Adult social care: a journey back in time

Meenara Islam, Policy Fellow at the Health Foundation, reflects upon the history and progress of adult social care and integration.

Would it surprise you to discover that the origins of adult social care in the UK today lie in the Elizabethan era and the Poor Laws? It did me – I had never imagined that social care would pre-date the NHS by hundreds of years. As part of the Health Foundation’s Policy Navigator project, we have picked out key developments in social care policy over the past 500 years with a view to understanding how we have ended up with the system we have today.

The Poor Law Act 1601 compelled local parishes to levy ‘poor rates’ to fund public assistance to local people who were out of work. Outdoor relief in the form of food, clothing, and money - akin to today’s benefits payments - was provided.  In parallel, indoor relief was provided in the form of admitting the ‘impotent poor’ (those with physical disabilities such as blindness) to local almshouses, the mentally ill to hospitals and the ‘idle poor’ to workhouses.  

In 1834, the Royal Commission into the Operation of Poor Laws concluded that the provision of Poor Law relief was simply perpetuating poverty and that all able-bodied people and their families should stop receiving relief.  This was supplemented by the suggestion that the conditions of workhouses should be made so undesirable so as to repel those seeking relief, allowing the state to cut expenditure on alleviating poverty. These recommendations were realised by the Poor Law Amendment Act 1834, which became known as the ‘New Poor Law’. 

The notion of the ‘undeserving poor’ was apparent, and given the more recent debates around welfare reform and references to the ‘undeserving’ or ‘feckless’  poor, it is unnerving to see that this rhetoric has not moved on.

I’ve always had a mental picture of workhouses as the stuff of Dickensian nightmares – grim, dirty, overcrowded and cruel.  And they really were. In 1865, the unsanitary conditions of workhouses were exposed in a series of damning articles published by The Lancet, supplementing the growing public outrage against the way the poor and the sick were being treated. A chink of humanity came in the form of a directive for poor law unions to provide more comfortable accommodation for the elderly who needed assistance and allowed for spouses to share rooms.

In 1905, the Royal Commission on Poor Law and the Unemployed was established to review the poor law system of providing assistance. The ‘majority’ view delivered four years later suggested that too much outdoor relief was being provided and workhouses should be replaced with institutions to house separate groups such as children, the elderly and the mentally ill. In contrast, the ‘minority’ report, spearheaded by social reformer Beatrice Webb, argued for the complete abolition of the Poor Laws and instead called for the structural causes of poverty to be addressed. The Liberal government did not adopt recommendations from either report. However, the following years saw the introduction of some key social reforms in the form of the Old Age Pension Act 1909, the National Insurance Act 1911 and William Beveridge’s report  in 1942. The latter called for a national social insurance system which would look after people from the ‘cradle to the grave’, financed by the contributions of working people. Benefits would be provided to the elderly, sick and widowed to ensure a national minimal standard of living for everyone. 

Six years later in 1948 the state pledged to look after us from the ‘womb to the tomb’ with the establishment of the National Health Service and the National Assistance Act 1948. The latter formally abolished the Poor Laws and required local authorities to arrange accommodation for the elderly, frail, infirm and anyone who needed support, care and attention. In cases where individuals could afford it, they would be charged for the services they received whilst others would have their services paid for by their local authority if they could prove they had insufficient means to pay.

Strikingly, the radical reforms of the 1940s immortalised the strategic, practical and financial differences between health and social care.  The NHS was based on nationalised provision, universal access and health services were free at the point of delivery. In contrast, the 1948 Act firmly placed social care in to the realm of localised provision of services which were means tested, needs based, rationed and were chargeable for some. These are issues which have not disappeared.  And ever since, the NHS has been hailed as a national institution needing preservation, while social care has floundered over the decades and is seen as an add-on. 

Modern day reforms to adult social care were kick-started by reviews such as the 1999 Royal Commission on Long Term Care report. This review, chaired by Sir Stewart Sutherland, recommended that ‘personal care’ costs including help with washing, dressing and medicines management should be provided by the state with housing costs subjected to means-testing.  In 2011, the Commission on Funding of Care and Support, chaired by Andrew Dilnot, advocated an overhaul of the funding of the social care system to improve its sustainability and recommended the introduction of a lifetime cap on lifetime contributions. Finally, in 2014, the Care Act 2014 instigated widely supported reforms aimed at improving the fragmented social care system and the government did indeed bring in a lifetime cap (albeit at a higher rate than had been recommended by Dilnot) to be implemented in 2016. 

Despite these reforms, it seems that adult social care continues to be the poor relation of the health care system. Age UK earlier this year pointed out that despite rising demands for services, the funding available for social care services was declining, with the Nuffield Trust suggesting that spending on social care for older people fell by 15% in real terms from £10.6bn to £9.8bn between 2009/10 – 2012/13 (2012/13 prices, using the HM Treasury GDP deflators).

While there has been much focus on the projected NHS funding gap (estimated to be £30bn by 2020/21), the projected £4.3bn social care funding gap appears to have received far less attention. The NHS Five Year Forward View has acknowledged that achieving extra efficiency of an ambitious 3% (or even a more likely 2%) by 2020/21 will depend on prevention and sustainable social services alongside new care models and wider system improvements. But have we really learnt from history in the way that the system is approaching the increased focus on integrated services between health and social care?

The National Health Service Reorganisation white paper  of 1972 suggests that ‘Often what there is could achieve more if it were better co-ordinated with other services in and out of hospital’. Yet 43 years after these words were penned we have not cracked it. Yet.

The cynic in me asks: if it wasn’t widely acknowledged and accepted that the impact of bad social care would translate into increased pressures on the NHS would integration be on the agenda at all? 

Perhaps our main hope now lies in the plans to devolve NHS services to the Greater Manchester Combined Authority (GMCA). It’s a chance for the GMCA to show us how best to deliver co-ordinated, integrated and community public services, including health, public health and social care. As a coalition of local authorities, the GMCA will have considerable leverage – they can pull in all the other services they run such as housing, the environment and welfare to make a real difference.  However, there remain big questions about how the proposals will work in practice and whether changes to the administrative structures can compensate for more fundamental issues relating to budgets and differing entitlements between NHS and social care services.

While integration is all well and good – can we not just talk about improving social care services as an end in itself? What will it take for us to truly appreciate that this essential service is on the brink and requires urgent care and attention?