The social care rumour mill is in overdrive. Despite the prime minister assuring the nation that he had a “clear plan”, the sector is now the subject of multiple proposals. While most concentrate on finding a solution to funding long-term care, there are also some fundamental suggestions around service structure and delivery. The most notable of these is that responsibility for social care could be transferred from local government to the NHS. It is a deeply flawed proposal.
The NHS and social care went their separate ways after the passing of the 1946 NHS Act and 1948 National Assistance Act respectively – the NHS centralised, free at the point of use and funded from general taxation; social care localised and means-tested.
The sectors are complementary in many ways and there has been no shortage of attempts to join them up through financial incentives, top-down edicts or locally integrated frontline teams. But the fact that these measures have been largely unsuccessful says something about differences and divisions.
The relationship between the sectors has typically been one of tension and mistrust rather than of shared endeavour. Over the years, the NHS has shifted many of its responsibilities for long-term care for older people to local councils (usually without transferring accompanying resources) while wrongly trying to retain control of long-stay provision for adults with learning disabilities, mental health issues and other complex conditions.
The privatisation of care provision added a further complication.
There is little disagreement that social care is on the cusp of collapse – it is failing to meet the needs and requirements of commissioners, providers, the workforce, users and carers. Proper funding is most certainly needed to resolve this predicament, but it is also clear that social care itself needs a new vision.
The Local Government Association and the Association of Directors of Adult Social Services have recently articulated the principles on which a new vision must rest, both emphasising the need for locally determined integrated care that achieves person-centred support, alongside a review of how the care market operates and the way the workforce is treated.
There is no reason to think that handing over the social care budget to the NHS will help to deliver on these principles. The response to Covid-19 has exposed a healthcare establishment with little or no understanding of social care, a shortcoming fatally exposed by the discharge of untested patients from hospital to care homes.
Hospital care will always be the prime focus of the NHS, and the absorption of social care into the NHS would not lead to a reappraisal of priorities. There may well be some greater service coordination but this would be geared to solving the problems of the acute sector, not social care.
The specific proposal that social care could become the responsibility of the nascent integrated care systems is notably inept. The NHS has been subjected to a bewildering array of unproven initiatives in the last few years: new care models, the vanguard programme, sustainability and transformation partnerships and now integrated care systems (ICSs).
ICSs are informal regional arrangements pursuing greater coordination within the NHS family; they are remote, unknown, unelected and unaccountable, with few links to local councils and even fewer to the voluntary sector and local communities. Incorporating social care into these bodies would not only fail to deliver on a new vision of support but would weaken local democracy to the point of collapse.
There is indeed a desperate need to “fix” social care, but an NHS takeover is nonsensical. Instead of asking if the NHS can fix social care, we need to start with a different question: how can people be best supported to lead the lives they choose? The answer is unlikely to be found within the NHS.