Nothing new under the sun?

1.    Understanding why we’re reforming adult social care: over time, different reform agendas have come and gone, each seemingly motivated by slightly different rationales for why you might want to reform adult social care in the first place.  This sounds a bit dull – but really matters: it depends what you’re trying to achieve and why as to how best to go about it.  In our previous policy work, we’ve identified a number of rationales for reforming care – each of which might take us in different directions:

• Maintaining social and public expectations that the state will provide a degree of collective support to its most vulnerable citizens – this can sometimes lead us to deliver a basic safety net, perhaps spending as little as we can get away with
• Supporting people to have greater choice and control over their services, and hence over their lives
• Enabling people to remain independent for as long as possible so that their needs do not deteriorate into a future/costly crisis – trying to use scarce resources well by investing in prevention
• Providing support to those in need so that they can contribute fully as active citizens, working, volunteering, participating in society on an equal basis 
• Reducing some of the negative impacts of poor social care on families and individuals who care for others (either because this is a good way to help ‘users’, because public services would bankrupt themselves if unpaid carers withdrew their support and/or because carers are citizens too)

The Commission ‘s draft principles and values suggest it is particularly interested in a system which supports people to contribute fully as active citizens – but being clear what success would look like and why is possibly half the battle.

2.    Being clear about what might be different this time round: looking back at previous reforms, there are a series of longstanding policy agendas which feel like part of a solution, but which haven’t always proved easy to implement in practice.  Common themes over the last few decades and beyond include:

• Personalisation: tailoring support to the needs of the individual and giving people greater choice and control over their services is fundamental – but there is a risk that we simply co-opt the new language and allow the old system to reassert itself, without a meaningful transfer of power 
• Partnership: working with others is key to supporting people with complex, joined-up needs, but we’ve struggled for decades to achieve genuine joint working in a system not designed with integration in mind.  The jury is still out as to whether we can improve outcomes and save money at the same time, and successive policy pledges have tended to over-promise and under-deliver 
• Prevention: providing support to help people stay healthy and well is much better than waiting for a crisis to occur – but we’ve tended to rely on relatively small-scale pilots which have failed to rebalance the system as a whole, and it’s hard to invest in prevention when they are still so many people with urgent needs
• Asset-based approaches: building on strengths and on the natural supports that we all draw on to live our lives feels much better than focusing on deficits (trying to ‘fix’ ‘what’s wrong’ with people) – but this is really counter-cultural, and pretty much every aspect of our current approach would need to change if we were genuinely to achieve this
• Strategic commissioning: adult social care was reformed on the basis of ‘markets’ many years ago, and is delivered by a ‘mixed economy’ of private, voluntary and public services.  The tools available to public service commissioners to shape what actually happens in practice still feel blunt and under-developed.

As it continues its deliberations, it will be important for the Commission to be clear on its vision for the future – but it will also be crucial to be clear about what will actually help to deliver this vision in practice.  Einstein is often credited with defining insanity as doing the same things over and over, somehow expecting different results – and this is a common experience when it comes to social care reform.

Reflecting on the history of our welfare state, it’s often only in a moment of crisis that radical change becomes temporarily possible.  Outside of these moments, the same ideas often go round and round.  It remains to be seen whether the combination of austerity and COVID proves to be just such a crisis, where what’s possible to think and do - politically, culturally and economically – suddenly changes.  Perhaps a key role for the Commission may be to argue that we’ve reached such a tipping point and, with others, to use its influence to make sure that things are different this time round.  Without this, the risk is that we repeat previous policy debates – trying to achieve many of the right things, but struggling to actually deliver these in practice.

Jon Glasby is Professor of Health and Social Care at the University of Birmingham, and Director of ‘IMPACT’ – the new UK centre for implementing evidence in adult social care. The IMPACT project is funded by the Economic and Social Research Council (ESRC) through UKRI's Strategic Priorities Fund (SPF) and the Health Foundation. (https://more.bham.ac.uk/impact/).  [email protected]  @JonGlasby

Jon Glasby writes in his personal capacity and his views do not necessarily represent the views of the Archbishops' or the Church of England.