Politics as unusual
We’ve had all the technocratic reviews we need, it’s time for politicians to work together for the national good on social care
Today the Commons will debate the following motion:
“ this House calls for the establishment of an independent, nonpartisan Commission on the future of the NHS and social care which would engage with the public, the NHS and care workforces, experts and civic society, sitting for a defined period with the aim of establishing a long-term settlement for the NHS and social care.”
Joining Norman Lamb, Liz Kendall, Dr Daniel Poulter and a chorus of other voices calling for this new commission, NHS chief executive Simon Stevens last week called for political consensus on paying for elderly and social care. His intervention is important: he ties sucess of the NHS with the viability of the social care system. Vitally, Stevens recognises that the main obstacles to securing a viable future for social care are not technical or even financial, but political.
“2018 will be the 70th birthday of the NHS. That will be a fitting moment to seek, as the NHS turns 70, a new national consensus on properly resourced and functioning social care services”
The Barker and Dilnot Commissions, as well as recent work by the Health Foundation and the King’s Fund remain good guides to the reform our health and care systems need to enable them not only serve us today but to transform and meet the needs of the future. The options have been laid out and in my view, another technical review won’t get the results we need if we fail to pay attention to the politics. Let’s decide on a course of action and develop an accompanying shared story of change that can secure enough political commitment to see it through.
If we are going to build such a consensus, all parties need to think carefully and responsibly about the language they use when discussing the type of system we want, and how we hope to pay for it. There are traditions on both sides that can help do this. But Stephen Dorrell is right- doing the right thing on funding doesn’t mix well with crude sloganising. There are some familiar rhetorical and ideological tropes both sides could do with leaving at the door. I’ve presented two of these here in a deliberately exaggerated form: both reflect legitimate and reasonable concerns but they won’t help us create consensus.
“Hands off our NHS!”
One such trope conflates any institutional change in the health and care settlement with “privatisation” of “our NHS”. At its worst, this narrative is conspiratorial, imagining smoky rooms and secret handshakes between businessmen keen to profit from our suffering and mercenary politicians promising to slowly dismantle the legacy of Bevan.
This “hands off” narrative legitimises the deprioritisation of services which determine demand into the NHS — ring fencing NHS spend at the expense of public health, housing and infrastructure. The influence of this sloganising means we often fail to change the NHS to meet the needs of our changing country and address its institutional failings. “Hands off” is counterintuitively conservative and prioritises the institution over the wellbeing of communities.
Another familiar story exploits the emotional sensitivity associated with old age, death and inheritance for political advantage. At its worst, it portrays health and care reformers as big-state taxers, rubbing their hands together at the thought of robbing hard-working families of their legacy and rewarding slackers with free care.
Perversely, the status quo punishes those in the middle, meaning many have to sell their property to pay for care which is free for the poor and affordable for the rich. As our population ages, care costs will have to be paid, one way or another. This will happen either through pooling our resources or by paying out of our own pocket. There is very little to suggest that a private insurance market (£) will deliver peace of mind about the costs of care and access to assets tied up in pensions and property is too inflexible. Leading people to believe that they will pay less if nothing changes is disingenuous.
A narrative to unite?
So with our dearly held misconceptions left at home, how can we proceed? Can we find a narrative for change which appeals to both a search for fairness and the values of aspiration and tradition? I can’t pretend to have all the answers, but I’d like to suggest three stories we should be telling more loudly about a national settlement for care.
Coming together in a time of crisis — The welfare state and the NHS were built during a time of crisis. Although their establishment was by no means met with a complete consensus, there was a feeling that something needed to be done to address the risks faced by all following the Second World War. The looming collapse of the care market threatens both our collective institutions and the individual wellbeing of care service users (who often pay for their care privately). The broader financial environment further exacerbates the feeling of crisis. An old age managing various long term conditions awaits a growing proportion of us. A settlement for social care will be in the interests of the whole country.
Intergenerational fairness — Stevens, in his interview with the Guardian, rightly points out that access to care is inexorably linked to intergenerational fairness. In asking the wealthy to pay more toward a shared pot (possibly through limiting access to benefits for wealthier older people or through an extended inheritance tax) and by allowing more flexible access to assets tied up in property and pensions, the parties should appeal to the patriotism of baby boomers whose children may not have the same opportunities they had to own property and build up pensions.
Support for families and communities — the best social care works by building on people’s strengths. These could be personal interests, life experience, or vitally their connections and contribution in the places they live. Ensuring the sustainability of social care funding isn’t about just propping up services but about investment in the strength of families, informal carers, communities and their local civil organisations.
So can our political parties put aside their myths and political self-interest to build political consensus for a sustainable future for social care? I think they can, but only through a bipartisan approach which leaves the sloganising behind.