Social Care - Health Committee Contents

1  Introduction

The long shadow of the Poor Law has remained over social care to its detriment […] That long shadow brings with it the armoury of measures we are still familiar with: rationing, eligibility criteria and means-testing to sort out the deserving from the undeserving—Andrew Cozens, former President of the Association of Directors of Social Services[1]

1.  Many people at some time in their lives need one form or another of care and support. Family, friends and neighbours have always rallied round to provide this but such help can place unrealistic demands on carers and in many cases is simply not available.

2.  For centuries people have also relied on other sources of care. In the Middle Ages, charitable hospitals and almshouses gave such assistance; in 1414, the House of Commons declared that the hospitals of England were founded to sustain, among others, "impotent men and women out of their wits and minds".[2] Subsequently, care was provided under the Tudor Poor Law and then the New Poor Law of 1834, both of which were founded on a legal presumption of family responsibility. Provision varied greatly from area to area and was too often minimal and grudging, with "indoor relief"[3] carrying the stigma of the workhouse.

3.  The welfare state which was created in the 1940s, following the Beveridge Report, promised a radical break with the past, undertaking to provide "cradle-to-grave" care for all on the basis of need. This was epitomised by the creation of the NHS in 1948 as a universal, free, tax-funded service, run on a national basis. At the same time, however, a deep division was opened up for the first time between health and social care.

4.  The social care system which was created under the National Assistance Act 1948 did not represent a complete rupture with the past and still bore significantly the imprint of the Poor Law. In contrast to the NHS, social care was to be administered by councils, with significant local discretion, and substantially funded from local taxation. There was to be means-testing and charging for services. It was a residual or "safety net" service, predicated on the assumption (if not a legal presumption, as under the Poor Law) that care would as far as possible be provided by family members and other voluntary carers.[4] Many things have changed in social care over the past six decades, but the system today still retains those fundamental characteristics, which are increasingly ill-suited to modern needs and expectations.[5]

5.  Every year, nearly two million adults in England use social care services provided by their local council or commissioned on their behalf but more than 150,000 older people must purchase community support privately and almost 120,000 pay privately for places in care homes. At the same time millions of carers provide an immense amount of support with little or no help from the state and many thousands of people may be in need of help which they simply cannot obtain from any source. The system is widely seen to be failing and it has been clear for a long time that fundamental and lasting reform is necessary. The need for reform is made all the more pressing as an ageing population brings the prospect of rising demand for care and support.

6.  In September 1997, the then Prime Minister told the Labour Party conference: "I don't want [our children] brought up in a country where the only way pensioners can get long term care is by selling their home".[6] Subsequently, the Government appointed a Royal Commission on Long-Term Care, under Sir Stewart (now Lord) Sutherland, which reported in 1999 and made far-reaching recommendations on reforming the approach to paying for long-term care. However, the core recommendation, the introduction of free personal care, was not accepted by the Government (although it was implemented by the devolved administration in Scotland). In 2006, pressure for reform increased when Sir Derek Wanless published his review of social care for the King's Fund, proposing a "partnership" funding model as the way forward.

7.  In July 2009, the Government finally published a Green Paper, Shaping the Future of Care Together. This recognised the need to reform the current system of care and support in England, both to respond to demographic change and also to establish a more personalised and equitable service. For some time we had wanted to examine social care, but we decided to wait until the Government published its Green Paper. When it finally appeared, with a consultation period which was to run until 13 November 2009, we announced our inquiry. Our terms of reference were to look at options for:

—  future funding of long-term residential and domiciliary care for older people and people with physical or learning disabilities;

—  personalisation of social care services;

—  more effective, consistent and user-friendly social care services.

8.  There was surprise when, during our inquiry and while consultation on the Green Paper was still continuing, the Prime Minister announced to the Labour Party conference a policy for free personal care at home which appeared to cut across the Green Paper proposals. Fortunately, we were able to question witnesses about the Prime Minister's proposals in our oral evidence sessions.

9.  We received memoranda of written evidence from 61 bodies and individuals. We held a total of seven oral evidence sessions, hearing from academic and other experts on demography, social care funding and social policy; Baroness Young of Old Scone, the then Chairman of the Care Quality Commission; UNISON, the trade union representing many social care workers; the General Social Care Council; the Social Care Institute for Excellence; Skills for Care; representatives of independent sector social care providers; a representative of the insurance industry; advocacy groups representing people who use social care services and carers (Age Concern and Help the Aged, Counsel and Care, the Alzheimer's Society, Mencap, Mind, the Multiple Sclerosis Society and Carers UK); In Control, which is developing and promoting self-directed care; the National Director for Social Care Transformation; the President of the Association of Directors of Adult Social Services; and the Vice-Chair of the Local Government Association. We also took evidence from Rt Hon Andy Burnham MP, the Secretary of State for Health, along with officials from the Department of Health and the Department for Work and Pensions. We would like to thank all who gave evidence to us and our specialist advisers, Melanie Henwood OBE, an independent social care consultant, and Dr José-Luis Fernández, of the Personal Social Services Research Unit at the London School of Economics, for their expertise in helping us navigate the complexities of this difficult subject.[7]

10.  In the report below we look at:

—  The present social care system;

—  Meeting future demand and costs;

—  Shortcomings of the present social care system;

—  Plans for reform;

—  Achieving lasting reform; and

—  The way forward.

1   "Poor Law mentality must end", Community Care, 23 October 2003 Back

2   Nicholas Orme and Margaret Webster, The English Hospital, 1070-1570 (New Haven CT, 1995), p 119. The "impotent" included frail older people and disabled people. Back

3   "Indoor relief" was assistance given to the poor (including the "impotent") on condition of entering a workhouse (as opposed to "outdoor relief", whereby assistance as given, in cash or kind, to people living in their own homes). Back

4   In addition, sections 42 and 43 of the 1948 Act still gave local authorities the discretionary power to ask the spouse of a resident of a care home to make payments towards the cost of that residential care in addition to any sums already being collected from the resident for this purpose (the "liable relatives rule"). This particular Poor Law anachronism was only repealed in April 2009, under the Health and Social Care Act 2008. Back

5   We are grateful to Professor Pat Thane, of History & Policy, for providing us with an historical overview of social care (Ev 148-153). Back

6   Speech by Rt Hon Tony Blair MP to the Labour Party Annual Conference, 30 September 1997 Back

7   Ms Henwood declared her interest as Vice Chair of the General Social Care Council, Chair of the Advisory Group on Independent Living to the Multiple Sclerosis Society and a former member of Sir Derek Wanless's social care review team. Dr Fernández declared his interest as a former member of the Wanless team and the HM Treasury review of long-term care funding, as well as a current member of the King's Fund team updating the Wanless review and an adviser providing policy and quantitative analytical support to the Department of Health on social care funding. Back

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