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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