Who carries the can for adult social care?

According to its website, “the Department of Health (DH) helps people to live better for longer. We lead, shape and fund health and [adult social] care in England, making sure people have the support, care and treatment they need, with the compassion, respect and dignity they deserve.” One of the three Parliamentary Under-Secretaries leads on “care for the most vulnerable, mental health, adult social care, community care, injustices and vulnerable groups, women and children’s health, health and work [and] blood and transplants”.

That may seem a little confusing given that the DH's overall responsibilities can be divided more simply into three: medical treatment, adult social care and public health.  “Community care”, i.e. care in the community, is a subset of “adult social care” which also covers care homes – some of which are small enough to see themselves as being in the community. “Under the 1990 National Health Service and Community Care Act any adult aged 18 or over who is eligible for and requires services from the Local Authority has the right to a full assessment of their needs and the services provided should be individually tailored to meet those assessed needs." Adult vs. community care is not a useful distinction.

None of the 27 DH quangos is devoted wholly to adult social care although some, such as the Care Quality Commission which critiques both care and medical treatment institutions, have some involvement with it.  Of the 32 DH advisory bodies, only one, the Health and Social Care Advisory Panel, has some limited involvement in adult social care (“open data strategy”).

In summary so far, Whitehall’s responsibility for adult social care lies with the DH but it appears to have little capacity for exercising that responsibility.  The current fashion is to call for the integration of the NHS and adult social care.  Better linkage can indeed improve their cooperation at local level, like has happened in Manchester, but the NHS is already too big to manage and total merger makes about as much sense as merging the Titanic with an iceberg.

Much of the NHS' troubles flow from internal squabbles over how the money is spent.  At least it all comes from the DH.  In the case of adult social care however, Whitehall’s share of the funding comes from the Department for Communities and Local Government.  How crazy is that?  Suppose, for example, the DH decided to remove hospital bed blocking by transferring the savings to adult social care.  It would not happen because no self-respecting Whitehall department hands its money over to another department. The DH has responsibility for adult social care but not the finance or authority to meet that responsibility.  

Local authority expenditure in 2016/17 is budgeted at £94.1bn of which adult social care costs £14.4bn. and education costs £34.2bn.  The DCLG contribution is budgeted at 53% or £50.1bn. In other words if the total funding of adult social care and education was transferred to the DH and DoE respectively, with local authorities simply acting as agents, policy and resources would be aligned at no cost to the taxpayer.  The DCLG’s financial responsibility would be reduced to £2.4bn, and ultimately nil, which they would hate but who cares about them?

Adult social care is widely seen as an important and growing problem.  The Care Quality Commission reported “While so far the sector has been more resilient than some anticipated, we are concerned about the fragility of adult social care and the sustainability of quality.” The under-funding of adult social care is contributing to the difficulties of the NHS. At the national level, who carries the can for it?  In reality - almost nobody.  Yet this circle, as shown above, is not hard to square. If the Prime Minister could spare five minutes from Brexit, she could do so.