Now that we know, courtesy of Theresa May, that people are not prepared to pay for social care in this life or the next, perhaps we should look at the problem in a different way. In all the discussion of ever more complex funding solutions, no one has explored how to make social care a better product, how to make it something that people might be more willing to buy.
I know we are now supposed to believe that government can do good things, but the state really is pretty useless at providing, rationing and managing social care. In the current system, those in need of care come as supplicants to their local authority. They fill in long and intrusive forms about their needs. Can you wash yourself? Can you put yourself to bed? Just how demented are you? These needs are then assessed and a carefully standardised, minimal service is doled out. Even if you pay for it yourself, you get what you’re given and like it.
There is no innovation or imagination in the services provided. There is no autonomy or choice. There are real issues of quality and as the private sector retreats and there is less and less competition to drive up standards. We have ended up with a classic state-directed system characterised by rationing and uniformity in which monopoly providers have no incentive to improve or personalise the service.
If you are deemed to be eligible for care at home, then you will get a 20 minute session to get you out of bed when the carer’s shift pattern allows it. If you are an early riser but the carer cannot come until 10am that’s tough, you just have stay in bed.
If you want to go to the lunch club and play bingo (and how many older people really enjoy such a fate?) you’ll have to be ready for the bus at 10.30am because they have to pick up 10 other people. You’ll probably spend two hours travelling five miles. And while the journey will be better than the destination, neither are going to be much fun and then you’ll do the two hours back. Who wants to spend the children’s inheritance on that?
There is an answer already in place, direct payments. This is the ability for the local authority to give money, hard cash, to the individual, or their carer, who then chooses and buys their own care. Hands are thrown up at the very idea, because people might spend it on bad things. One man spent his payments on going to the betting shop, parked himself there for the day, got a bit of company, felt better about life but the state sponsored do-gooders thought it should not be allowed, it was the bingo or nothing.
Most people, though, use direct payments to purchase fairly conventional services that meet their needs better than the state. Yet, despite being introduced 20 years ago, they are still only used at the margins. Social workers are suspicious of them and incumbent providers don’t like the competition. Yet they could transform social care by creating a true market where the private sector and charities have real incentives to look for new clients and develop new services.
All the evidence is that when things get miserable in old age, autonomy is still valued and valuable – and direct payments provide a scrap of choice. Those who receive them are more satisfied with the service and the money is spent more efficiently. If direct payments became the default provision, we can imagine a system emerging where there are care brokers in every High Street, or online, where care agents look at the money a person has and find them the services that meet their needs.
If the services are good, individuals will be more willing to pay a bit extra to top them up, to get some extras. They’d be more likely to see the value of taking out insurance if it could secure a quality product that they would have some control over. The poor would be empowered by becoming true consumers but the self-funders would also benefit from a broader more innovative market.
If most people had real choice in a diverse private market, if they could go to a Waitrose of social care, rather than the current take it or leave it public provision, the middle classes would become more willing to contribute. Over time, we could see a culture change where reasonably well-off people accept that social care is something they pay for, just as they pay for someone to do the garden or to deliver the shopping.
Until a cure for dementia is found, social care will remain a wicked political problem. It is never going to be much fun having to pay to manage your own decline but personalisation of services, more choice and privatisation will do more to solve it than sterile debates about funding caps and floors.