I am pretty sure that Ministers are surprised and dismayed at discovering how little ‘control’ they have had over care during this pandemic. For a long time it has suited successive governments to be able to hide behind local councils when difficult questions were raised about the inadequacy of our care provision and its funding, but this crisis has shown the downsides. Ministers are quite rightly being held to account for the catastrophic loss of life in care homes, but the reality is that there are few levers for them to pull and accountability for care is blurred.
In Whitehall, both the Departments of Health and Social Care and of Communities and Local Government have a stake. In addition to the role of local councils as assessors, and raisers and administrators of State funding, most care provision is in the private sector, split between a small number of large providers whose financial arrangements are complex and often domiciled abroad, and numerous small ones, including family businesses. Because State funded care has contracted due to budget cuts about half of care home residents now pay for their own care and so have no relationship with the State; this made some councils reluctant to pass on pandemic funding to care homes for their benefit. A further corollary is that little care data is collected centrally – the department doesn’t even have a list of care homes.
Perhaps not surprisingly, some commentators are now asking “who should run care, the NHS or local authorities?” This may be the wrong question today in the era of Integrated Care Systems, which bring together both. Perhaps the right thing to do now, consistent with the overall direction of travel towards more local integration between health and care, is to give ICSs responsibility for care, certainly for those older people who need both. Whatever happens, though, accountability must become clearer, with a line back to the centre, so Ministers can feel the pressure of their responsibility for overseeing a decent system of care. The fact is care needs to look and feel much more like a proper public service, as near to being free at the point of use as we can manage. A wide range of funding mechanisms is available, plus lessons from abroad. Whichever are chosen, though, they will entail all of us contributing financially in different ways, including older people.
I have said almost as much about the NHS as about ‘care’ here, and that’s because for older people with significant health and care needs – the group that has tragically died in such numbers during this pandemic – both are equally essential. What matters most is that they get excellent clinical input alongside great care – both highly personalised. For those with less significant needs and for disabled people of working age, among others, different conclusions may be reached. One size needn’t fit all and indeed that would be the antithesis of personalisation, but everyone matters and at all ages if we need care it should be there for us.