The Elder Interview
A new social contract for carers after COVID-19: An interview with the IPPR
Chris Thomas is a Senior Research Fellow at the progressive think tank, the Institute for Public Policy Research. His work there focuses on a variety of issues surrounding health and social care and he recently co-authored a report, Care Fit for Carers, which spells out five policy objectives needed to establish a ‘new social contract’ for carers in the wake of COVID-19.
Tell us a bit more about the work of the IPPR and your role there.
The Institute for Public Policy Research, or IPPR, is a charity and we’re the uk’s preeminent progressive think tank. What that means is that we undertake research on the practical ways that the country can be made fairer – more sustainable, more prosperous.
We use research, then engage with the public, with opinion formers with policymakers, with politicians of all parties – and of none. It’s very cross-party, but the emphasis is on working with anyone interested in making the UK a more progressive country.
My research focuses on health and social care. The IPPR hosts something called the Better Health and Care Programme. That’s a large initiative that looks to generate, in any given year, hard-hitting policy on ways that both the health system and the social care system can be improved.
For you, what’s special about social care? Why did that become your specialism?
There’s so much that I could talk about around what’s special about social care. When we interact with people in and around the sector, there’s a huge commitment which is often inspiring and a genuine opportunity to improve lives. This is not always the case in other public sector reform positions.
But really, when I think about it, there’s something about social care being on the frontline of the big societal challenges that we face. When we think about the rise in long-term health conditions, when we think about the ageing population, when we think about COVID-19, social care’s importance is really clear.
That makes it, in many ways, outrageous that we haven’t seen more commitment from Westminster. We’ve got a hugely important set of challenges but no commitment from political parties. There has been a deadlock for years that means, from our perspective, social care in 2020 is in a position not so dissimilar from health in 1948.
There’s a seminal moment here. That, if the right ideas – the right figures – can emerge that we can genuinely push forward bold reform and that’s a very exciting thing to work on.
For a long time, we’ve heard about an upcoming Social Care Green Paper. Can you give us your views on this?
It’s been a long slog hasn’t it. I think we first expected to see the Green Paper at the end of 2017. Then 2018. Past 2019. Now we’re more than halfway through 2020, we have a new Prime Minister, we’ve had a general election. It feels very uncertain.
The conversations that were originally the focus of the green paper have moved in many ways to different places. But I think it’s important to think about the positives when when coming into that conversation
The Government manifesto did talk about cross-party collaboration. It talks about a plan for social care. There weren’t huge amounts of detail but it did emphasise that it was a priority which is a genuinely good thing if it turns out to be true.
We know that there is interest – within a broad political spectrum – in state-based solutions. So when we’re thinking about what could actually come in a policy document, it feels like there’s a growing consensus around a state-based solution that targets improving care provision and potentially making that care provision universal and using general taxation to fund it.
Those are the kind of key tenants that we’d expect to be the basis now of the solution. To be fair – in 2017 that wasn’t necessarily the case we were still stuck in a kind of ring road conversation around insurance models and market-based solutions. So there has been some progress there and that could be the basis for genuinely good things.
The IPPR is a progressive think tank. What would you like to see in the Green Paper?
We need three things more than anything else. The first is a state-backed solution. Social care has struggled over the last few decades because it has not had delivery based in the same way as the NHS. From the 1990s onwards, there’s been a market-based system fragmentation and it hasn’t delivered for people.
Care has declined in quality and access has decreased so we need a system that puts the principles, such as universal based on the point of need, free at the point of delivery, at the heart of social care.
The second thing that we need is a clear sense of reform in the system – particularly in the provider models. We know that the transition to an increased number of private beds and particularly private beds that are provided by very big social care providers (the biggest five social care providers do provide around a fifth of the beds in the system) has an impact on quality.
This isn’t the case when you start looking at smaller providers – local authorities, social enterprises and non-profit organisations. We need the Government to have a plan to make sure the provider model is aligned with quality and what we know determines quality.
The last thing we need is around carer pay and progression. The COVID-19 crisis has shone a spotlight on how skilled and high value the work that social care workers do is. They’ve shown remarkable bravery and we recognised that in the eight o’clock clap for carers on Thursday evenings.
But the conditions that they work in are still far too poor. That’s pay – and we know that the pay for social care workers is very poor – but it’s also conditions, it’s also training, it’s also progression. We’d want to see the Government bring forward plans to make sure that the workforce has the right and the means to be put on a sustainable footing.
Could you walk us through how social care is currently funded?
It’s an incredibly complicated system for many people but the core components of the funding system are as follows. The central government provides local authorities with funding. Local authorities then use that funding to commission adult social care services.
For the most part, if you were then to try to access social care services that wouldn’t be free unless you had a very high level of need and a low level of income. So, often the onus is then on the individuals who pay the excess fees and these can be huge.
For 140,000 people in the country, at any given time, currently, those fees will be catastrophic or above £100,000 pounds. That’s the general system – it’s a changed system. In previous iterations of social care services, 30-40 years ago local authorities provided the majority of social care services directly.
Now there’s a commissioner relationship where your local authority commissions, for the most part, either a social enterprise, or charity, or a private sector organization to provide the care needed in that community.
So, what does that mean? Well, the first thing is that it has put a huge emphasis on the level of funding that the central government is providing local authorities with. We know that, during the austerity decade, the funding going to local authorities has been cut in the most brutal fashion possible.
The Local Government Association have made very clear that the impact of this is that they’ve now lost 60p in every pound of central government funding, which is a huge huge cut. That can only have consequences for people entering the care system in terms of either reducing the level of access that’s possible or reducing the quality. What we’ve seen, as funding’s got tighter, is that the quality of that access has declined.
What’s your opinion on how social care will be funded in the future?
Lots of options have been talked about and it feels that the best, the simplest, is to take what works. We know that the National Health Service has had a very successful model. It works on general taxation. People pay in and then care is delivered when they need it at the point of delivery for everyone – that’s a good working model.
The same would be possible for social care. There’s a couple of different options to do that through general taxation. You could think about income tax, for example.
Another option would be to pay more on National Insurance (NI) contributions. Through a relatively small contribution to NI we could radically upgrade the social care system and, of course, that would make sense because NI is about providing that safety net as you get older.
So that seems a good option. But the core component here is less about the details of what kind of tax and more about the huge onus on the Government to get the money in the system that’s needed for good access and good quality care.
What inequalities are there in the social care system?
The first thing is the Scotland/England dichotomy – you get free personal care in Scotland but you’ll have to pay in England. This is the first inequality that we should address.
There are other injustices too. If you’re diagnosed with many horrific, long-term life-changing illnesses, you may well get free treatment on the NHS. If it’s, for example, a cancer diagnosis and your first-line treatment will be delivered free through the NHS but if you get dementia and, as so many people now do – it’s fast becoming the leading cause of mortality in the country – the diagnosis rate is going up and up and up, you’re very likely to have to pay for your care.
That means that without free personal care the very principle of universal free health care is being challenged because huge amounts of society aren’t eligible for free care when they get that life-changing diagnosis.
The second thing free personal care does is it tackles a second injustice which is the scale of catastrophic care costs. We know, as I’ve mentioned, that huge amounts of people (140,000) pay over £100,000 for their care. Most people can’t afford that level. It means that they have to sell their house and that they have to forego other things that they’ve worked their whole life to build up.
Free personal care has a direct impact on that. It brings the figure down by 60,000 people – so 60,000 people avoiding catastrophic costs according to our modelling. Of course, 80,000 is still too high and the government should consider more action on that – a more generous means test, for example.
The final thing, and again this is something that’s been highlighted by COVID-19, is it provides us security in the future. We know that the population is ageing, we know that disease outbreaks like coronavirus are actually getting more and more likely, and we also know that the people that are at risk when that happens are the kind of people that are receiving social care, are in residential care homes.
Providing free personal care puts that system on a sustainable footing and means that we’re a lot more resilient in the face of the biggest challenges that we have in – not just the next few years, but the next few decades.
What’s your assessment of the Government’s COVID-19 response when it comes to social care?
We can split some of this into the things that went wrong before COVID-19 was even a condition and the things that then went wrong afterwards.
The first thing that we have to look at is the capacity that we entered the crisis with. The austerity decade was based on the logic of ‘if we make cuts to services but ask them to do broadly the same then those services will then go and cut the waste cut inefficiencies but, it won’t cut quality’.
What we’ve seen in COVID-19 is that in social care, where those cuts were really quite ferocious, those cuts did have consequences on the amount of care, the amount of training, the workforce – these things were just not in place in the way that we’d have wanted them to be in.
To give an example, we know in social care – because of pressures on pay and on training budgets – we have the highest turnover rates in the UK economy of any workforce. So, when demand spikes it’s really difficult to do the kind of things that you need to do.
Then you have the indication that there’d be a protective circle drawn around social care and of course, in fact, that didn’t transpire. We saw with PPE that promises were being made in March at prime minister’s questions that there would be protective equipment in the social care system for everyone that needed it.
It wasn’t there. The procurement wasn’t good enough. The amount that we were producing wasn’t uplifted enough and so social care didn’t get its fair share.
The same with diagnostic testing. That just wasn’t a system designed around social care, so people were put at risk. What does this mean? Well, it means that when push came to shove, the virus did enter that protective circle. It did breach it.
As we can see from the mortality statistics, the number of people in social care settings – in residential care homes particularly – that have died, then that number is much larger than it could have been.
Recent research between IPPR and Policy Exchange revealed that 31% of people were less likely to consider residential care in the wake of COVID-19. Could you talk us through that research?
The first thing to say is that the research was designed to test a hypothesis. That hypothesis was ‘is there cross-party support for a state-backed universal social care system a bit like the NHS, based on general taxation, available to everyone?
Certainly, the collaboration between the two think tanks indicated it was. We both previously had slightly different political views and endorsed very similar state-based solutions in the past. The government has pledged to that political collaboration. It hasn’t started yet but the indication was it was there
So could we demonstrate that in the public we found that, yes, actually there is huge consensus in the public? There isn’t now a split on what should happen with social care. Both Conservative and Labour voters reject private insurance models. They don’t think that private insurance is the way forward.
15% of Conservative (and 10% of Labour) voters support it. That’s not very much at all. Neither set of voters don’t want to see people selling their house to pay for their care. Only five per cent (and four per cent respectively) thought that that was appropriate.
Both Labour and Conservative voters want to see a state scheme funded by taxation. Over 60%, in both cases, thought that was the right way forward. Positively, over four-fifths in both camps wanted to see care workers paid properly. I suppose what that demonstrated to us was that there isn’t a divide in the public.
There isn’t necessarily a theoretical divide in policy development, so there’s no excuse now for political parties in Westminster not to sit down to get reform going. They have talked about doing that for over 12 years. it’s time for that deadlock to be broken.
What changes do you see to social care coming out of COVID-19?
The change is going to be monumental one way or the other. The optimistic account is that there’s been some really good change in terms of people’s perception of social care. We know that one of the big obstacles to change in the past in social care has been that politically the capital hasn’t been there.
People either don’t know what the system is or they don’t have a good understanding of what it does. It’s not on their list of priorities when the polling comes. They want to see more funding go into it but don’t want to pay more tax for it.
Through the crisis, we’ve seen that change. People have recognised how important social care is. They’ve seen more about what it does and we’ve had that embodied in the ‘clap for carers’, which has instilled almost like muscle memory in many people’s minds and just how important this is.
One of the changes could be that the political support increases, that the salience increases and that the accountability coming from the public also increases.
Then there are some negatives that we will almost certainly have to deal with. We know that the social care market is an unstable one. It goes back to even Brexit impact reports that social care, as a market, was so unstable that even relatively small shocks could cause significant disruptions in continuity of care.
We know that because COVID-19 has breached that protective circle that lots of people sadly contracted the disease. Many more than expected have died – because of this the residency rates in social care could go down – and it’s a market dependent on residency rates – so that could cause huge instability for the kind of providers that we have at the moment in the sector.
We also know that the costs that they’ve had to incur – in terms of buying in personal protective equipment, in terms of the uplift in operations, in terms of providing more intensive levels of care.
What we could see, and what the government really needs to be proactive on, is a growing instability in the provider sector and in the provision of care. If that was to collapse it it would be a disaster for hundreds of thousands of people.
There are lots of options, and one thing that was clear was that there are and there is now a growing sense of foreboding around residential care. Almost one in five from the polling feel less likely to go into residential care.
That’s obviously something that needs to be accounted for. Residential care provides a huge amount of the total sum of care in the country.
We need an intervention in perceptions, whether that’s to explore alternatives that might work for people in a better way to keep them in their home, and at the moment the facilities to keep people in that home are not particularly well funded – they could be stronger. Or, whether that’s to build faith in the residential care sector.
In particular, by making sure the financial stability is there, the care quality you receive in those homes are high and the people that do want to access it can access it.
There’s absolutely a need for more funding to go into the social care system. We know, and the Health and Select Committee have said this – and quoted this figure when opening an inquiry into funding social care as a whole – that there’s a £4 billion black hole.
That black hole only rises because the population is aging, because of COVID-19 and there are unexpected costs. We know that health needs are increasing. More people are being diagnosed with long-term conditions that need interventions.
There’s a need for new funding. The question is how that funding is put into the system and the commissioning relationship. There’s also an opportunity for the state to directly fund beds.
The IPPR has talked in the past about the 75,000 beds that we’ll need by 2030. Those could be directly funded by the Government. That would be one way to inject money into the system.
Equally, if the Government are looking at reforms, like state-based solutions, that will not increase as much as many people might think. But will come with a need to increase the amount of funding going in.
You recently released a report Care Fit for Carers. I’d wonder if you’d talk us through it?
What Care Fit for Carers reports on is two things. Firstly, a survey of healthcare workers during the peak of the crisis. What was happening during the peak of the crisis and how were they experiencing COVID-19?
The second thing it did was ask people – specifically in the social care sector and often in residential care homes – where things were looking worse, to describe their experiences in a lot more detail through a consultation.
The findings were quite stark. We saw the level of trust that the sector had in government to protect their health was low. There was a feeling that diagnostic testing and PPE were not being allocated in the right numbers or the right places – which was really worrying.
But there were other things too and what was really interesting was there was a national conversation around PPE and diagnostics but we also faced a looming crisis. Mental health was a huge part of that.
One in three people thought of having seen their physical health deteriorate, but one in two of their mental health deteriorating. Other things that were coming through were around security and welfare, particularly if they were working for private sector providers.
They would talk to us about pay and feeling that their financial security wasn’t there and people with children said that child care had become phenomenally difficult – particularly as their support network was now less available.
But, also, their shift patterns had changed. The hours had increased and people even talked about accommodation and the housing security they were facing, which was a really worrying sign of how deeply the problems were running
You call for a change in social contract for carers after COVID-19. I wonder if you could walk us through that?
A change in the social contract is right. What’s been really clear through COVID-19 is that the government sees it as a wartime event. Boris Johnson talked very explicitly about the invisible enemy and about the nation being listed.
He’s not the only one. Donald Trump, Emmanuel Macron have talked in similar ways in France and in America. What we know is that when there are wartime events, when people are asked to do things that are risky and uncomfortable and dangerous. When the welfare system is attacked in the way that COVID-19 has attacked it, that the social contract does need to change.
Often that means an intervention. We know that, after the war, homes fit for heroes was what people needed. Well in 2020, very clearly what we need is care fit for carers.
Again, an intervention targeted at the front line, at the people that sacrificed the most, based on the things they need, Not just because of COVID-19, but actually before because of austerity before that.
What does Care Fit for Carers mean? Well, we think there are five guarantees that are needed. The first is safety guarantees. It’s unacceptable that anyone would have to put their health and well-being unnecessary at risk to do their job. It’s avoidable.
We’re not into glorious sacrifice narratives when people’s lives can be saved. We need testing to be right. We need track and trace to be right. We need PPE to be right. That’s very important as a foundational policy, but then there are other things that we can do to both help protect people now and to also increase their capacity to continue looking after us in the long term.
We talk about a mental health guarantee. First and foremost at the moment some professions – in the NHS particularly, get a pretty good deal. But there’s not one-to-one group therapy or group therapy available for people in the social care sector. That needs to be improved.
We talk about a housing guarantee. That people, particularly those working on the frontline, shouldn’t be allowed to fall into rental arrears during this period. We know that’s happening.
We talk about a pay guarantee. We know that pay in social care is very low. We know that many people have not been paid the real living wage and we also know that their work in COVID-19 has shown that they aren’t the unskilled workers that sometimes Government policy has implied they are.
We need to see pay standards improved and we also recommend a 10% pay rise for everyone that’s provided that frontline COVID-19 response.
The last guarantee we talk about is child care. We know in Wales that the child care and provision for key workers was uplifted because people were struggling. It helps them stay in work and it’s a really good two-way policy that didn’t happen in England.
It’s an obvious way to provide support. it was a need that in our survey work people highlighted and it’s a way that we can guarantee people combined good work, with a good life.
Now you’ve penned the report, how are you going to move things forward with it?
We’ve had some really positive responses and we’ve had support from colleges from trade unions, from representative groups, and from charities. That’s really encouraging. IPPR’s role is to provide the research and the evidence that can inform decision-making. That can inform campaigning we’re really seeing that go forward
We obviously work with politicians and policymakers on shaping actions. We’ve seen the Labour front bench endorsing the mental health policy that we put forward and continue to work to make sure that the evidence that both they and the government need to make good informed decisions is still there.
We essentially need to think about what one of the big barriers has been to progress on some of these issues. If we look at the last 12 years, it’s been really difficult. Political parties want to do things that are priorities for people that they can get support from.
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