2 – How might the public own social care provision for older people?

In my last post I suggested that the nationalisation of social care would be a mistake. One of the main lessons we have learned from the Covid crisis, I argued, is that centralising a service that needs to be very sensitive to local and personal circumstances is not the optimum way to meet the very diverse needs of our society.

Today I want to explore other ways in which the public might own social care provision for older people[1]. I put it this way because ‘public ownership’ is too often seen as being synonymous with ‘state ownership’ and has consequently become insufficiently linked to the public.

There have been too many UK public service models that have systemically removed any rights from the public over their experience of services that are meant to be ‘theirs’. Too often the word ‘public’ before the word ‘service’ has denoted no ownership whatsoever. Rather it seems to invest the service with the right to push the public around. This does not encourage independence.

One of the cultural themes any future system must nurture is the right of older people to have a life full of choices and autonomy.  Telling older people where they must live strongly detracts from those rights. So whatever else we do in a new publicly owned system we must ensure that it enhances rights and independence and not restrict them.

Historically nearly all social care provision was owned by local government. That model grew out of the long history of local authority ownership of such provision from the Poor Law (1832 and earlier). Pre-World War II buildings from Poor Law days transformed into many of our post-war welfare state institutions. (As a child my local hospital, St Nicholas, had previously been a workhouse). In the 1950s many residential homes for the elderly were based in buildings that, since they were originally workhouses, had been built specifically to dissuade people from moving into them. It was a grim legacy on which local authority social care had to be built and it took several decades to move away from that reality. In no way was this history their ‘fault’ but it did mean that many elderly people in homes felt they were ‘in the workhouse’.

In 1962 Peter Townsend’s excellent survey of residential homes identified just how poor the experience was for many people in residential accommodation and argued for a much better social and cultural relationship between the homes and their local community. Looking at the normal experience then, it was an extremely poor service. (We must remember the demographics here – compared to today (50+ years on) there were many fewer old people and many many fewer very old people).

Early domiciliary care workers (called ‘home helps’ – which I knew about from my own early years as my mum was one in the 1950s) were also managed by the local authority. Insofar as both residential and care homes for poorer people were paid for by local government, authorities commissioned their own services. This meant that there was no real choice for older people.

There is a problem, for the near future, about how local authorities could be part of social care provision. As locally elected public bodies they are well placed to develop services which work in diverse localities, but their problem is that local government is – and is likely to be – the organisation that commissions care. This conflict in roles (commissioning from ourselves) has in the past reduced the choices for older people.

To provide social care for the future, local authorities must set up arm’s length public organisations to run social care provision. They could then provide one of a set of choices for local people, but for it to work the system will need to ensure service users’ rights. There will have to be clear standards and modes of working that do not lead, at the expense of public choice, to local authorities prioritising their own provision.

Choice and rights must therefore be the cornerstones of all social care. So for choice to mean anything the service user must have the right to choose between different options, meaning we will need other public service models of provision for social care.

In the past local authority care was not the only ‘not for profit’ care. Charities were, and still are, a very important part of social care provision. Since 1943 the Methodist Homes Association has played a significant role in innovative residential care. The Jewish Board of Guardians, founded in 1859 (with the same organisational name as the Poor Law) continues, through several reorganisations, to provide pioneering residential care. Over recent years as charities they (and many other charities) have been able to raise money to supplement the inadequate local authority fees for residential care.

In constructing a vision of public ownership for the future only a few hardened proponents of public ownership would say that charities should not play a role. They are wrong. Charities have played and will continue to play an important role in our society and have a role in publicly owned social care provision for the future.

In addition to arm’s length local authority provision and charities, there are other models which have become a normal part of our society.

My local authority gym and library is run by a charitable social enterprise called GLL. Under the brand name of Better they provide leisure facilities for 50 local authorities. For me as a consumer they provide a locality sensitive service and a national brand providing good back room services. A large public sector organisation not run by Whitehall. Organisations like GLL provide a template for large public service providers of social care.

The same is true for the many smaller organisations called Community Interest Companies. (CiCs). These organisations can generate an annual surplus but are legally not allowed to distribute it to shareholders – nor can they ever be taken over by private sector organisations. These legal constraints mean that CiCs provide a good public service model for many of the current small private sector companies providing social care. They can be run in a business-like way without distributing profit to others.

If we organise social care provision for the elderly through public ownership, these four very different public sector models: – local authority arm’s length bodies, charities, large social enterprises and CiCs will provide important diversity and increase the opportunity for public choice.

In a future post I will develop an additional model built around mutual aid – adding another option to the potentially rich diversity of public ownership.

[1] I realise that older people are only one part of social care provision and will return to the organisation of social care for younger people in a later post.