A season for change? Part three: Social care – a critical test

In brief

As political life resumes in earnest after the Summer break, Rich Bell explores – in a three-part series – the possibility and pitfalls of relational reform under the new Bernham government. 

In this, the final blog of the series, we argue that the approach the government takes to overhauling our creaking social care system in the coming year will provide vital insight into whether it will in fact pursue a meaningful project of relational public service reform.

In the previous blog in this short series, we explored Andy Burnham’s record of transforming frontline services in Greater Manchester and argued that the government’s emerging public service reform agenda could make a guiding focus on the power of human relationships a core feature of how the modern state works. We also considered how profoundly relational design and delivery approaches go against the grain of ways of working within Whitehall, and the scale of the challenge the new government will almost certainly encounter if it does seek to translate the principles of Live Well into a national approach.

There is, then, no guarantee that the new Prime Minister’s seeming commitment to relational reform will deliver meaningful change – even if there are good reasons to hope that it might. We won’t know for sure until the rubber hits the road.

One area of service provision where it will do so sooner rather than later is social care. Indeed, the approach that the government takes to overhauling our creaking social care system in the coming year will, in our view, provide vital insight into whether it will in fact pursue a meaningful project of relational public service reform.

Burnham has made it very clear that he intends to be the Prime Minister who finally grasps the nettle of social care reform. More to the point, we think he’s given us at least some cause to hope that he will do so in a manner which taps into the power of human relationships.

The PM has spoken movingly of his own family’s experience of the care system, and it’s notable that he now tends to describe it in markedly more human terms than was the case when he first attempted this task as Health Secretary. This rhetorical shift is lent credence by his record in Greater Manchester, where he used the powers and convening role of the mayoralty to pursue a preventative and whole-person model of care, marked by a significant emphasis on social connection and neighbourhood-based support.

Now, early indications are that he may be on course to take a similar approach nationally. Media reports suggest that his government will seek to direct a much greater share of social care funding towards community organisations, charities, and co-operatives. By virtue of both their social purpose and proximity to the communities they serve, these organisations are much more likely to possess both the inclination and the capacity to practise a relational form of care than the larger commercial providers that dominate much of the market.

Changing who provides care must, though, only be the first step on a bigger reform journey – one culminating in the creation of a system which treats relationships not as a by-product of care, but as the means through which it is delivered.

Such a system would be designed to enable care workers to get to know and earn the trust of those who they are charged with supporting – helping them to understand the individual’s unique needs and circumstances, to provide a more personalised and responsive form of support, and to take an asset-based approach. It would also actively support those in receipt of care to build and maintain meaningful relationships with friends, family, and neighbours, strengthening the informal support networks that so often prevent needs from escalating.

These are obviously desirable goals. Numerous government white papers have professed an ambition to mainstream the principles underpinning relational care models like Buurtzorg and Shared Lives across the system. But that very fact speaks to the reality that this is easier said than done.

Delivering on these aspirations will require considerable investment in social care and a sustained effort to improve the pay, conditions, and status of the care workforce – undertakings which will undoubtedly be difficult but are firmly on the government’s agenda. It will take active consideration of how social care can be made more relational, which we believe Louise Casey, who is leading the government’s commission on the future of the system, is well-placed to provide. It will also take careful thought and deliberate choices about how a reformed care system should relate to the NHS.

The Prime Minister emphasised during his July speech on social care that his new National Care Service will be “highly integrated” with the healthcare system. This is of course vital to the provision of high-quality care, but it is also not without its dangers. The gravitational pull of the NHS is enormous. Its institutional logic is immensely powerful, and much of it is necessarily technocratic. There is a very real risk that the creation of a National Care Service shaped to dock into the health system might lead to care becoming more integrated, more standardised, and even more professionalised, but no more human. As the Cavendish Review showed, past attempts to import the Buurtzorg model to the UK have stumbled exactly because it originated within a much less hierarchical and centralised health and care system than our own.

Whether the Burnham administration can resist that centripetal force – and ensure that integration strengthens rather than displaces the relationships on which good care depends – will, we believe, be a highly revealing test of its commitment to rewiring the state relationally.

Another, related test will be just how ‘national’ the National Care Service turns out to be. As was outlined in the first and second blogs in this series, relational approaches tend to take root and blossom when services are shaped to reflect the needs of specific communities and local people have some say in how they’re designed and run. We don’t need a National Care Service delivered locally – a model designed, planned, and managed from the centre and replicated, with only limited variation, in neighbourhoods across the country. We need a Neighbourhood Care Service funded and supported nationally – with provision shaped to reflect the circumstances of particular communities, and decisions about how care is organised made as close as possible to the people who rely on it, while central government provides the necessary investment, infrastructure, and standards.

The real, big test is this: social care reform is not about whether the government creates a new institution or succeeds in making the existing system more efficient. It is whether it can forge a system that enables people to live with greater independence, exercise greater agency, and build and maintain meaningful connections with those around them – and puts relationships at the core of how care is understood and delivered.

The Big Conversation on Care which Burnham launched last month is, arguably, itself an encouraging sign that this is a Prime Minister who is prepared to approach reform differently. The emphasis that his government is placing on listening to the views of those with experience of the care system and wider public, finding common ground, and working through difficult problems collaboratively could be understood as an attempt to model a more relational way of doing politics. Whether this approach can be sustained as the rough and tumble of politics ramps up is, however, another question – and there are some signs that the Whitehall machine is already struggling to turn Burnham’s ambition to engage in meaningful dialogue with the public into practical action.

Across these three blogs, we have explored the ways in which the Prime Minister’s ambition to foster a culture of encounter, rooted in “direct, compassionate interaction and relationships” between public servants and citizens and within communities, could be realised in practice through policy action. We have examined the ways in which he has sought to do this in Manchester, with some early success, and considered the extent to which his first steps in Downing Street suggest that it will shape his national policy agenda.

Ultimately, we don’t think the question is whether Burnham grasps the importance of relationships to effective public service delivery or to the health and strength of our society. Rather, it is whether he will be able to build his instinctive belief in the need to centre relationships in the work of social change into a political project capable of changing the principles and norms around which both the state and wider society are organised.

There can be little doubt that the odds are stacked against him in that endeavour. The habits and assumptions of a state organised around institutions, transactions, and professional silos run deep. Moreover, his own party tends to default to a binary conception of politics centred on the state and the market, leaving little room for the organisations and relationships of civic life.

Moving beyond these ways of thinking will demand more than good intentions or a more human approach to doing politics: it will require a sustained effort to change how power is distributed in modern Britain and to reorient our public services around the relationships that sustain us as people and as communities.

Nonetheless, having a Prime Minister who appears to feel the importance of human relationships in his gut surely represents a significant opportunity. The task before proponents of relational reform now is surely to come together and help his government give political and practical expression to an idea that does not always map neatly onto the way policy and government currently work.

To demonstrate that building a culture of encounter is not merely a romantic aspiration, but a goal that might sit at the very heart of its policy programme. That, by shaping his administration’s approach to devolution, public service reform, and our social care system to harness the power of human relationships, Burnham might build strong communities in every postcode.

The challenge is formidable. But the opportunity is real. Let’s make the most of it, together.

Go back to the series overview page.