Beyond austerity: the National Care Service and a new social settlement

If Labour wants to go beyond opposing austerity and thereby appeal beyond the 25% of voters  affected directly, then it needs to propose policies that are relevant to the fears and dreams of specific sectors.  However, this needs to go beyond promising to do the same thing as the Tories only better, and policies should neither look like mere electoral opportunism nor be reducible to it: there needs to be a good reason for such promises.  And while it is important to defend the good in Labour’s record, new ground will need to be broken if there is to be a harvest.

The Tories have garnered votes from the older sector of the population who have gained financially and disproportionately.  But with social care in crisis, there is a potential opening for Labour.  Just as the 1948 foundation of the NHS responded to fears of illness and not being able to afford (medical) care, so Labour now could respond to fears of becoming old and frail and ending up either discarded, unsupported or surviving in a below standard service, staffed by ill-trained, badly managed staff on poverty wages.

So, the idea of a National Care Service (proposed towards the end of the last Labour government by Andy Burnham) is one whose time has come.  But that National Care Service needs to offer something distinctively new, overcoming the stigma and second class treatment so typically experienced by those who have to rely on formal care and support.   Bevan didn’t produce any “costed plans” for the NHS, and Labour should make it clear that this is a matter of caring for people, not saving money.  However, it could also indicate how the service would be funded and organised.  So from the outset any proposal needs to be explicit about values, show how it links with other fields of policy, and give some clues about organisation and funding.  As I see it, some of the dimensions would be:-

  • An end to the means test for social care funding and the government claw back of people’s savings. In my experience this corrupts assessments and understandings of people’s needs.
  • Funding would be by exploiting government’s ability to borrow at advantageous rates and/or the ability to spend money into existence (as per People’s QE if the conditions are right).  That’s very different from reliance on private finance, or indeed from the present arrangements where operators are allowed a 12% return on capital invested.  Colleagues from Manchester Business School have provided some comparative figures for capital expenditure for the residential homes sector.  “..reducing the claimed return on capital from 12 to 5% allows either an 18% reduction in price or a 40% increase in wages or some combination of the two benefits. If the starting point is an 8% cost of capital, the benefits are smaller but something like a 15-20% increase in wages is possible by low-cost public borrowing”. Link to report – see pp.  pp. 71-76.
  • Funding of all/most social care should be on the same basis as the NHS (i.e. with only the most minimal co-payments, if any) to be funded as above and via improved tax take (and reverting to a progressive direct taxation model), as well as by scrapping Trident, cancelling PFI contracts, stopping subsidy for private capital (rail, fossil fuels,/aviation,, nuclear power, etc)…… bold, practical socialism.
  • A new deal for staff – proper training and decent pay – the Keynesian multiplier will in part fund this through improved tax receipts and (managed, selective) economic reflation.  That supporting and caring for frail, vulnerable and complex people should be seen as less deserving than other jobs, speaks volumes about the accounting values of our neoliberal society.
  • But if Labour’s National Care Service is just a well-funded and staffed “care service” it will be a failure.   The 1948 welfare state was hardly a model of how to support people with disabilities or physically and mentally frail elders.  It separated them from society, subjecting them to regimes where professional fiat was the least of the problems – serious abuse and neglect were common, despite the commitment and strong service ethic of many workers in those services.  So what is needed is a transformation of care and support, fit for the changed society we now live in.
  • This means a new deal for older people with an emphasis on valuing and celebrating their contribution – with a “just enough” model of support – too much assistance is nearly as bad as too little: the trick is to get the level right, and this means using resources wisely and preventatively.  That would be  based on a neighbourhood model of domiciliary care as the first option, provided by public sector staff (but with new models of the public beyond local and national government bureaucracy).  Support for what though? Support to live a meaningful life, to pursue interests, to take part.  The proposal here means a downsizing of residential care, which is happening anyway as firms go out of business, but with a variety of other options developed.
  • In the longer term this means reducing the isolation and ghetto-isation of older people – new housing developments must include extra support schemes and be designed to allow the titration of support against increasing need, without the person having to move unless they want to, or it really is impossible to offer support safely and maintaining dignity.
  • To complement a truly inclusive approach, there is a need to support and fund intergenerational initiatives, based on old and young sharing time and activities together.  That would build on but go far beyond existing initiatives like literacy and numeracy volunteering in schools.  In a recent interview, Jeremy Corbyn described two of the volunteers in his leadership campaign, a hijab-wearing 18 year old showing a ninety year old how to use a mobile phone.  No doubt the older woman was also able to pass on a lifetime of practical intelligence.  How can we make this the norm, recovering something lost as our society became more specialised, more modern?
  • Social infrastructure can support much of this with emerging models such as co-housing and home-share.  This could help more older people stay in their own homes, offering accommodation in return for a level  of support – but being careful to match that support on a sliding scale with State-funded professional, formal input.

Much of this is not new: some of the thinking was there in the March 2010 White Paper “Building the National Care Service”, but I am proposing a change of emphasis. To summarise:

Firstly, although properly funded and organised services are vitally important, the problems of social support and care do not reduce to service provision: they have to do with the position of vulnerable people in our society.  They are citizens not “service users”, whatever their needs, and a socialist approach needs to begin with a hunger for social justice.  This is not about “independence”, the illusory self-sufficiency that (neo)liberal society so values (with its fantasy of dependency reduction through various magic and not so magic bullets), but about interdependency, or perhaps better, shared or pooled dependency, where we are all at various stages in a cycle of waxing and waning dependence and contribution.

Secondly,  older people, and others with disabling conditions are only part of the electorate.  Labour needs a Whole Policy approach, and the SHA needs to emphasise this – balkanising either/both health and social care (and prevention) from the organisation of society and economy as a whole is a recipe for failure inevitably leading to a discourse of affordability, compromise and efficiency.  If Labour’s new path means anything, it is a break from this.

Taking these two points together, it means a simultaneous emphasis on high quality, properly funded provision and a society that looks after us all, not just by offering a service, but through its very everyday fabric: part of what NEF call “a new social settlement”.

A very bold initiative, plausibly costed, with an inspiring model and vision, that responds to people’s fears while appealing to their dreams, could fill part of the policy gap between fighting austerity and offering a society a majority can believe in.

Mark Burton was for many years a manager of integrated health and social services in Manchester.  Now retired he works mostly on alternatives to the economic growth in public policy.