Never the twain should meet

 Combining health and social care services makes sense on the surface, but they have different objectives and priorities, argues Robin Jackson. He suggests that, to avert the looming crisis, we need to create a model that concentrates on social care rather than rely on merger

Social care is in crisis and, without radical changes in the very near future, I believe it will collapse.

Reforms introduced by successive governments have left it seriously underfunded and underperforming. It has become heavily dependent on the profit-oriented private sector and outsourced provision by powerful global companies which have frequently been exposed as incompetent and, on occasions, criminally irresponsible.

Many for-profit companies providing care have shown scant interest in maintaining adequately staffed facilities and an appropriately trained workforce. Companies have a strong incentive to keep running costs down by employing poorly qualified staff and maintaining less than full staff establishments.

This crisis will be made worse by merging health and social care.

The idea of merger appears to have arisen from the belief that the benefits of the two sectors are greater when they are combined into one rather than left as separate entities.

However, this is mistakenly built on the assumption that there are strong similarities between health and social care.

Why synergy fails

There is a belief that synergy inevitably confers advantages. However, it frequently fails because those seeking it focus too much on the financial and strategic aspects of merging and frequently underestimate the cultural aspects of the organisations being brought together.

In the one sector that one might reasonably have expected synergy to have a successful track record – mergers and acquisitions in banking – Leon Cooperman, a former Goldman Sachs partner, has confessed to being unable to identify one example where a merger has succeeded.

Defining the difference

The National Framework for NHS Continuing Healthcare has attempted to clarify the difference between healthcare need and social care need.

While there is no legal definition of a healthcare need, in general terms, it can be said that it is related to the treatment, control or prevention of a disease, illness, injury or disability, and the care or aftercare of a person with these needs, regardless of whether the tasks involved are carried out by a health professional.

In general terms – again, there is no legal definition – a social care need is one focused on providing assistance with activities of daily living, maintaining independence, social interaction, enabling the individual to play a fuller part in society, protecting them when their circumstances make them vulnerable, helping them to manage complex relationships and, in some circumstances, accessing a care home or other type of supported accommodation.

Social care needs are directly related to the type of welfare services that local authorities have a duty or power to provide. These include but are not limited to: social work services; advice; support; practical assistance in the home; assistance with equipment and home adaptations; visiting and sitting services; provision of meals; facilities for occupational, social, cultural and recreational activities outside the home; assistance to use educational facilities; and help to find accommodation such as a care home.

The essential characteristics of social care have been identified (Williams, 2003).

First, care of both the self and others are meaningful activities in their own right; they involve us all, men and women, old and young, able bodied and disabled. Therefore, care is an activity that binds all.

Second, in receiving and giving care, we can, in the right conditions of mutual respect and material support, learn the civic virtues of responsibility, trust, tolerance for human limitations and frailties, and acceptance of diversity.

Third, an ethic of care demands that interdependence be seen as the basis of human interaction; in these terms, autonomy and independence are about the capacity for self-determination rather than an expectation of individual self-sufficiency.

Fourth, it attributes moral worth to key positive dimensions of caring relationships such as dignity and the quality of human interaction, whether based upon blood, kinship, sexual intimacy, friendship, collegiality, contract or service; it recognises and respects diversity and plurality in the social process of care.

Finally, it argues against inequalities in the giving and receipt of care. It recognises these inequalities may be constituted through different characteristics, including sex, disability, age, ethnic origin, nationality, class and occupational status, sexuality, religion and marital status.

Care requires time, financial and practical support and the recognition

of choices. These extend beyond income maintenance, benefits and social services to include public space, transport and policies to address discrimination and poverty.

A department of social care?

To prevent a collapse of the social care system, I would argue for the creation of a single government department responsible for just social care.

Such a department would establish the principles and guidelines for social care. Furthermore, the operation of the system would be devolved to regional councils in a system comparable to that in Sweden, which existed in the UK before 1974. It’s worth noting that reorganisation in 1974 was intended to reduce the amount of money spent on public services and to ensure increased efficiency, neither of which was achieved.

The establishment of a central government department of social care can happen only if sufficient financial resources are made available. In my opinion, the best option would be to increase income tax in a discriminating manner – as in Scandinavia Ð or to introduce a social care tax. The UK is behind the overwhelming majority of western European countries in the amount allocated to social expenditure; it was the only rich EU country to cut welfare spending as a proportion of GDP between 2011 and 2014.

A strong case has been made by for introducing a hypothecated tax where the revenues from the tax go to financing a particular service such as social care (Keable-Elliott, 2014). This approach has a number of advantages:

Transparency – hypothecated taxation makes the link between revenues from taxes and government spending more visible

Accountability and trust – hypothecated taxes may help when the government is not trusted. With hypothecation, the government will have to follow a plan made in advance and will have no flexibility

Public support – the knowledge that the money paid on taxes will go directly to some needed service (social care) can help to reduce the dissatisfaction of the population with an increase in taxes

Protecting resources – earmarking can protect resources for financing social care from being spent on something else.

If taxpayers are aware that a dedicated amount is set aside to fund a particular service, such as social care, there is a high probability that they will be supportive of such a measure.

It would be incumbent upon the government to demonstrate that the hypothecated tax was being used for the purposes agreed.

Collapse and its consequences

Unless major reforms of the kind very briefly touched upon here are implemented, there is a high probability that social care in England will collapse.

The consequences of that for the social fabric of the country will be disastrous. For a society already characterised by increasingly sharp social divisions, the loss of an effective social care system to support the disadvantaged could well prompt civil unrest and disorder.

The problem has been that successive governments of all political persuasions have misguidedly placed their faith in solving problems by attempting macro solutions, none of which have worked.

If a genuinely caring society is to be created, then we need to seek micro solutions which foster localism and community endeavour and enable people to truly take back control of their lives.

If such action is not taken, there is a strong probability that an Americanised health and social care system will emerge, which fails the overwhelming majority of the population but has minimal impact on the moneyed few.

The kind of reforms briefly touched on here are unlikely to be brought about by any of the major political parties. However, as a result of the fractious and fracturing pressures within the different political parties over Brexit, we may see the emergence of a new progressive political alliance with a radical and strong community-oriented agenda. There is then a glimmer of hope.

You can download Robin Jackson’s full report, Reforming Social Care, published by the Centre for Welfare Reform at

Robin Jackson is an author and commentator on social care and learning disability and a visiting research fellow at the University of Hertfordshire

Keable-Elliott I (2014) Hypothecated Taxation and the NHS. London: CentreForum

Williams F (2003) Reforming Social Care.

Paper presented to the Annual Conference of the Finnish Social Policy Association, 24 October 2003