The Big Conversation on Care – What Should Good Care Look Like?

Social care is finally getting the national conversation it deserves.  The Big Conversation on Care is asking some very big questions: when we are older, disabled or seriously ill, what should we be able to expect?  Who should provide that support?  And, perhaps most difficult of all, who should pay for it?  For those of us working in care every day, these questions are far from theoretical.

At Right at Home Mitcham, Streatham & Dulwich, we see what good care can achieve for people and families across our part of South London.  We also see some of the pressures in the wider system and why finding a sustainable answer matters so much.

How did we get here?

Part of today's problem goes right back to the creation of the NHS.  Britain made a clear national decision that healthcare should largely be available according to need rather than somebody's ability to pay.  Social care developed very differently.

In England, state-funded care remained means-tested, with much of the responsibility resting with local councils. That distinction can sometimes seem increasingly difficult to explain.  If somebody develops cancer, much of their treatment will be provided by the NHS.  If somebody develops dementia and needs help several times a day with washing, dressing, meals, medication and simply remaining safe at home, they may have to pay significant amounts towards that support themselves.

Successive governments have recognised the problem. There have been commissions, reviews and proposals for reform, including plans to cap the amount an individual might have to spend on care.  Yet a lasting settlement has never really been reached.  In the meantime, councils have faced financial pressures, the cost of providing care has increased, recruiting and retaining good Care Assistants remains challenging, and demand continues to grow.

And now the demographic clock is ticking rather loudly.  We are living longer.  More people will reach their 80s and 90s, often living with several long-term health conditions at the same time.  That is something to celebrate – but it also means we need to think seriously about how we are going to support people in later life.  This is not a problem that is going away.

Good home care helps the NHS too

One thing that can get lost in the debate is just how closely social care and the NHS are connected.  Good home care can help somebody stay independent in their own home rather than reaching a crisis.  Care Assistants may be helping with meals, medication, mobility and personal care, but they are often doing something equally important: noticing when something has changed.  Perhaps somebody is eating less, seems unusually confused, is struggling to walk, or simply "isn't quite themselves".  Spotting those changes early and raising concerns can sometimes prevent a much bigger problem later.

Good home care is equally important when somebody has been in hospital.  A person may be medically ready to leave, but they cannot simply be sent home if there is nobody available to help them get dressed, prepare meals, take medication or move around safely.

So when good care is available in the community, it can help hospitals discharge people safely and promptly and, where possible, help avoid unnecessary admissions in the first place.

Get care at home right and you help families, GPs, hospitals and the whole health system.

Should personal care be free?

One idea now being discussed is personal care that is free at the point of need.  It is easy to understand the attraction.

Most of us would probably struggle with the idea that one illness is treated largely through the NHS while another condition could result in somebody spending a large part of their lifetime savings simply because they need help to live safely.  Sharing that financial risk across society has obvious appeal.  But there is an important catch.

Making care free of charge, does not automatically create more care.

We can see the same challenge in the NHS. Treatment may be free at the point of use, but if there are not enough doctors, nurses, appointments or hospital beds, people still have to wait.  Social care could face exactly the same problem.  Making a service free does not create a Care Assistant who isn't there. Nor does it make an underfunded care service financially sustainable.

So whatever system Britain eventually chooses, free at the point of use must also be properly funded at the point of delivery.

What can we learn from other countries?

We do not have to invent everything from scratch.  Other countries have already had to deal with ageing populations and rising demand for care. 

Japan faced these pressures earlier than many countries and introduced a national long-term care insurance system in 2000.  People begin contributing towards the system from middle age. Funding comes from a combination of insurance contributions and taxation, while people generally contribute something towards the care they eventually receive. 

The interesting principle is that Japan treats the possibility of needing long-term care as a risk that should be shared across society.  After all, none of us knows what later life will bring.  One person might need a little help with shopping and companionship. Another might eventually require several care visits every day.  Rather than leaving each individual family to face that uncertainty completely alone, the financial risk is spread much more widely.

Australia has taken a somewhat different approach, with increasing emphasis on helping older people remain independent in their own homes.  People are assessed according to their needs and can receive public funding towards support, with greater choice over the provider and services they use.

Like every system, Australia's has limits and pressures. But the principle of funding following the individual, rather than simply purchasing blocks of care on their behalf, is certainly worth exploring.

What should we actually expect from care?

It is also worth remembering that England is not starting with a blank sheet of paper.

The Care Act 2014 was introduced to create a clearer and more consistent approach to adult social care.  It established a national eligibility threshold, helping to tackle the old problem of a "postcode lottery", and put principles such as wellbeing, prevention, independence, choice and control at the heart of the system.  It also recognised the importance of having a diverse and sustainable care market, so people have genuine choice about the support they receive.  In many ways, therefore, we already know what good care is supposed to look like.

The challenge is making sure we have the funding, workforce and capacity to deliver it consistently.  And we can already see what good home care looks like every day.

For families arranging care privately here in Mitcham, Streatham, Dulwich and the surrounding areas, it can mean choosing a local provider they trust, getting to know familiar Care Assistants and having visits with enough time to focus on the person rather than simply racing through a list of tasks.  It can mean helping somebody get washed and dressed, preparing breakfast, supporting medication and still having time for a cup of tea and a proper conversation.  It means knowing someone's routines and preferences.  It means noticing when something isn't right.  And it means helping somebody continue living in the home, neighbourhood and community they know.

That is particularly important to us at Right at Home. Good home care should not simply be about completing tasks. It should support independence, dignity, companionship and quality of life.  The question, therefore, is not whether we know what good care looks like.  We do.  The challenge is how we make that standard of care available to many more people, regardless of who ultimately pays for it.

Time for some bigger ideas?

There probably isn't one magic solution.  Perhaps Britain needs a combination of ideas: long-term care insurance, a sensible cap on lifetime care costs, incentives to save for later-life care, greater investment in home adaptations and technology, more support for unpaid family carers and public funding that increasingly follows the individual.  Government would still have a vital role – setting standards, protecting vulnerable people, ensuring care is properly funded and helping to build a stable, skilled care workforce.

But people and families could have much more choice about how their support is provided and who provides it.  Above all, perhaps one simple principle should sit at the centre of whatever system comes next: wherever it is safe and practical, help people remain independent, connected and happy in their own homes for as long as possible.

That is something we believe very strongly at Right at Home Mitcham, Streatham & Dulwich.  Because social care can seem like somebody else's issue – right up until the day that you, your partner, your parents or somebody else you love needs it.