Social care must be reformed. If it wasn’t clear before the Covid-19 pandemic, it has become tragically obvious over recent weeks. So this is an opportune time to hear in the latest Holywell Trust Forward Together podcast from Deirdre Heenan, professor of social policy at Ulster University and joint author nine years ago of a major study into Northern Ireland’s health and social care system.
“The vast majority of people accept and want the NHS to be free at the point of delivery,” argues Deirdre. “Many are happy to pay increased taxation, or feel that the taxation system needs to be changed so that we can adequately fund the system – and have transfers within the system to support those less able to pay.
“Most people also believe that social care should be free, but there’s a lot of confusion out there… We know that health care is free at the point of delivery. We’re just not really sure about social care.”
Without adequate funding “we have a system that’s not fit for purpose,” says Deirdre. “We really need to think about how the system can be completely transformed and what principles will underpin that.”
There is also unhappiness, argues Deirdre, about the lack of transparency in the system and in how resources are allocated between the differing demands across the health and social care system. “It seems to me that much of the resource distribution happens at a high level: it happens at a central level. We have this commissioning through the health and social care board. It’s just not clear how decisions are made, how you can appeal decisions, and then how families can make their decisions around who’s going to do what. What level of additional care will we need? What level of care will we need to buy in? Because it isn’t clear who’s going to get what for how long.”
Much of this comes down to the lack of clarity about whether social care should be regarded as a public or a private service – or, if a mix of both, what the criteria should be for support from the public purse. “Most people believe that the NHS should be a universal service free at point of delivery. They’re slightly more confused about the issue of social care,” observes Deirdre.
Too often, social care is overlooked in terms of political priorities, leading to it being categorised as the ‘Cinderella’ service. Much of the sector has been privatised in recent years, with a parallel process of pay cuts. “If we are serious about wanting people to go into social care, to give social care prestige, to have career progression, we have to think about the level of professionalization,” Deirdre stresses.
All these pressures have come to a head during the Covid-19 pandemic and are much more deep-seated than the lack of personal protection equipment, which has put workers’, as well as residents’, lives at risk. There is also the parallel challenge of an aging population, more people living longer with serious disabilities and the new complication that many survivors of Covid-19 may themselves be left with new life-threatening problems that need ongoing care and support.
So how will social care be funded in the future? Should people’s lifetime assets be used for later years’ care? Should families contribute from their collective assets? Should a wealth tax be imposed? Should people be expected to contribute in advance through a mandatory social care insurance system? “People struggle with issues around fairness and equality when those sorts of examples are put before them,” says Deirdre. “So I think we have got to have that conversation to say this is how much you will get from the state regardless of your income.”
She adds: “What we do know now is that it’s this mix between the private, the formal, the informal and the public sector. And unless we discuss it, what we’re going to end up with is the worst of all worlds. I think now is the time to have the honest discussion about how we fund this in the future. The very worst thing is people sitting around worrying about what’s going to happen to them, or indeed what’s going to happen to their loved ones.”
A citizens’ assembly considered these challenges in the context of Northern Ireland. “I thought the idea was good,” comments Deirdre. “But to be honest, I think those debates around social care need to be led by experts. You need to have people who are at the forefront of policymaking. You need to have the organizations that are advocating for older people. And whilst the principles may have been right, I think you need to have the right voices there who understand that you cannot just wish for motherhood and apple pie… I just think that a lot of people here are talking about social care, are well-meaning, but may not be that well informed about what the realities of the system are.”
This latest podcast in the second Forward Together series is available here on the website of peace and reconciliation charity Holywell Trust. It is funded by the Community Relations Council’s Media Grant Scheme
Disclaimer: This project has received support from the Northern Ireland Community Relations Council which aims to promote a pluralist society characterised by equity, respect for diversity, and recognition of interdependence. The views expressed do not necessarily reflect those of the Community Relations Council.
Paul Gosling is editor of ‘Lessons from the Troubles and an Unsettled Peace’, author of ‘A New Ireland’ and ‘The Fall of the Ethical Bank’ and co-author of ‘Abuse of Trust’, the story of a child abuse scandal in Leicestershire. He is engaged by the Holywell Trust charity on peace and reconciliation projects and is Parliamentary Assistant to Sinead McLaughlin MLA, the SDLP’s economy spokesperson.