Introduction

As set out throughout this book, it can be difficult to locate recent Conservative governments, not least because of stark differences between stated aims and subsequent realities. There have also been a series of unprecedented international events, which might have caught any government by surprise. Faced with these challenges, the Conservatives’ approach has largely been one of inaction: failing to address the very significant impacts of austerity and underdelivering on promises to reform long-term care funding. However, such inaction spans a number of governments: since the late 1990s there have been at least 12 adult social care White or Green Papers, reviews and strategy documents, with none of the funding proposals actually being implemented. While the latest version of these proposed reforms made it onto the statute books, it has since been delayed yet again (perhaps indefinitely), and it was in any case a pale imitation of the measures that were going to be introduced in 2014.

After summarising the legacy of the Coalition government (2010– 15), this chapter turns to events under Conservative governments since 2015. Throughout, the approach includes an unusual mix of elements of traditional Conservative ideology, a pragmatic recognition of the difficulties of genuinely trying to resolve some of the very thorny issues at stake and some slightly odd twists and turns en route. In the early 2020s, there is no doubt that adult social care faces even more challenges than in 2010, with recent policy overpromising and underdelivering. While similar underlying themes may well exist across all four nations of the UK, the details in this chapter focus on England.

The Coalition government, 2010– 15

In Bochel and Powell's (2016) edited collection, Glasby (2016) reviewed the Coalition's journey from ‘initial neglect to the Care Act 2014’. While social care hardly featured in the 2010 Conservative manifesto or the Coalition's Programme for Government (Cabinet Office, 2010; Conservative Party, 2010), a series of Liberal Democrat care services ministers developed and implemented the Care Act 2014.

Introduction: social care anniversaries

Although NHS anniversaries have been widely celebrated and form the basis of a number of detailed histories, adult social care has tended not to receive the same attention and focus. The National Assistance Act – the piece of legislation which many see as leading to the creation of the modern adult social care system – received Royal Assent on 13 May 1948, just weeks before the launch of the new National Health Service. In one sense, therefore, all the anniversaries set out in the opening chapter to this book could also be seen as joint anniversaries of both health and social care. This is very fitting, as health and social care have been so inextricably linked ever since – with a series of attempts to break people’s lives down into separate ‘health’ and ‘social care’ needs proving increasingly meaningless over time. However, the vast majority of previous accounts have focused solely on the NHS, and adult social care is rarely mentioned, even in passing. As a result, the history of adult social care is largely overlooked – and even people working in adult social care may know little about the origins and evolution of their current services and roles.

In many ways, the current adult social care system is based on the legacy of the Poor Law, with frail older people, disabled people and people with learning disabilities or with mental health problems initially supported within local communities, and then – as problems of poverty and rapid industrialisation and urbanisation increased – in infamous institutions known as ‘workhouses’ (see Payne, 2005; Means, Richards and Smith, 2008; Pierson, 2011; Glasby, 2017; Humphries, 2022; for an overview of the history and development of adult social care and of the social work profession). Faced with more need that they could ever possibly meet, workhouses were deliberately designed to be as a harsh as possible so that only people who were absolutely desperate would seek support, with everyone else doing all they could to remain as independent as possible (a principle known as ‘less eligibility’). After the Second World War, an attempt was made to distance modern adult social care from this controversial and unfortunate legacy, with a clear separation between national financial support for those on low incomes or unable to work (‘social security’) and practical care and support for people who are frail or disabled (‘adult social care’).

This book series arises from the Sustainable Care: connecting people and systems research programme delivered by a multidisciplinary partnership of 35 scholars in eight universities, funded by a UK Economic and Social Research Council Large Grant. It offers novel, internationally-informed interdisciplinary contributions based on work by linked research teams studying care systems, care work and care relationships.

The focus of the book series is timely and important. We hope it will inform and inspire scholars, policymakers, employers, practitioners and citizens interested in care. Books in the series offer new empirical, conceptual and methodological writing, in scholarly but accessible form, and aim to make an innovative and distinctive contribution to understandings of care challenges and how these can be addressed.

The books bring together data, practices, systems, structures, narratives and actions relevant to social care. Some relate specifically to the UK's unique policy, demographic, cultural and socio-economic circumstances, but all have clear global relevance. Similar concerns are salient around the world, especially in other advanced welfare states, where population ageing is profoundly changing age structures; developments in technology and healthcare mean more people who are ill or have long-term conditions need support at home; and ‘traditional’ gendered sources of daily caring labour are dwindling, as levels of female labour force participation rise, and family networks become more dispersed. The Covid-19 pandemic has amplified all these challenges.

Subject areas, disciplines and themes

The series critically engages with crucial contemporary debates about care infrastructure; divisions of caring labour and the political economy of care; care ethics, rights, recognition and values; care technologies and humantechnological interactions; and care relations in intergenerational, emotional, community and familial context. Within its overarching concept, sustainable care, its subject areas span social and welfare policy and systems; family and social gerontology; ageing and disability studies; employment and workforce organisation; diversity (including gender and ethnicity); social work and human resources; migration and mobility; and technology studies.

The new multi-disciplinary work on care we offer embraces progress in global scholarship on diversity, culture and the uses of technology, and engages with issues of inequality, political economy and the division of labour.

The Mental Health Act 1959 and A Hospital Plan for England and Wales in 1962 set a direction for mental health services away from inpatient and towards outpatient and community care which enjoyed support across the political spectrum. There has been a shift of focus over time from rights and recovery to marketisation, to risk and safety to modernisation and, finally, to well-being. There has been greater coherence in policy and consensus among staff in child and adolescent mental health than its adult counterpart, but service developments were hampered by chronic underfunding. Though, overall, it is probably fair to judge that mental health services in 2010 were both substantially more effective and significantly more humane than those prevailing in 1960, they have not fulfilled the aspirations held widely at the beginning of the period.

Seeking greater integration in the delivery of health and social care has been a longstanding aim of different governments over time, yet deepseated and seemingly intractable barriers remain. While the Coalition has stressed the importance of integrated care and introduced a number of new initiatives, it remains open to question as to whether health and social care are more or less joined up than they were in 2010. Against this background, this chapter begins by summarising the state of play at the end of the New Labour governments of 1997–2010 and the main reforms introduced under the Coalition government of 2010–15. After this, the chapter considers the emerging evidence about the impact of the Coalition's policies, and offers some initial thoughts on how such developments might be interpreted. Given limited formal evidence and the fact that the two authors have been actively involved in some of the policy debates described, the chapter draws on both formal and informal sources of knowledge, and seeks to combine a review of the published data with some more personal reflections. In the process, a ‘three stream multidimensional policy implementation framework’ is used to critique the implementation of integration policy by the Coalition (Exworthy and Powell, 2004). As the title of this chapter implies, it is relatively easy to make a rhetorical commitment to greater integration (in one sense, who would argue for greater fragmentation?) – but delivering this in practice is much harder.

Health and social care prior to 2010

In 1998, an early New Labour discussion paper on joint working between health and social care set out a strongly worded critique of what happens when potential partners fail to work together effectively. Although this is now dated, we quote this diagnosis of the problems to be solved on a regular basis, as it seems to us to so accurately reflect the practice realities that we observed at the time and the negative impacts that can still occur when frontline agencies fail to collaborate:

Introduction

‘Adult social care’ is a broad term to describe the practical assistance that is provided to people over the age of 18 who are assessed by a social worker as needing various forms of care and support. This can often be to do with activities of daily living, such as getting up, getting washed, eating and other personal care needs. Typically, groups of people using such services include older people, disabled people, people with mental health problems and people with learning difficulties, and traditional services have often taken the form of home care, day care, meals services and residential care. Whereas a qualified social worker would typically assess people's need for support, any subsequent services might be provided by social care providers in the public, private or voluntary sector. Given that so much care and support is provided within families, adult social care also works with family carers to help meet their needs and those of the person being cared for. However, issues such as child protection, work with so-called ‘troubled families’ and welfare rights advice would typically be provided by other services, and these are covered elsewhere in this book.

Of all the service areas explored in this edited collection, adult social care is arguably one of the most neglected and the least well understood. While the National Health Service (NHS), for example, is usually seen as a service that provides care to people when they are most in need, adult social care has tended to have a more mixed reputation, based on a combination of ‘care’ but also of state ‘control’. With origins in the Poor Law and in the workhouse, it is based, in part, on a history of stigma, of segregation and of potentially very intrusive attempts to distinguish between ‘deserving’ and ‘undeserving’ poverty (for an overview of the history and nature of adult social care, see Means and Smith, 1998; Means et al, 2002; Payne, 2005; Glasby, 2012). Whereas health services are provided free at the point of delivery to people we see as being ‘sick’, people who are somehow merely frail or disabled are left to rely on local authority adult social care services, which are means-tested and typically incur significant user charges.

Under the coalition government (2010–15), local authorities have suffered such massive funding cuts that one council leader has described the situation as “the end of local government as we know it”. While councils have tried hard to protect their social care spending as best they can, this has inevitably led to significant financial challenges, and to social care leaders struggling to make ends meet. All this comes on the back of new responsibilities under the Care Act 2014, changing demographics and policy pressures to develop more personalised services and to integrate care more fully with the NHS. While both personalisation and joint working with partners might be part of a longer-term solution, pursuing both goals at a time of austerity is incredibly difficult – and both agendas are arguably being implemented in less than optimal ways. Taking stock of these developments, this chapter looks at recent changes in adult social care, and argues that even more fundamental reform will be necessary in future.

In 2014, the House of Commons Committee of Public Accounts published its review of adult social care in England. In a boxed summary at the start of the report, the Committee concluded that (p 3):

The summary goes on to make recommendations around three main areas: ‘collaboration across bodies involved in the care system’; ‘better understanding of the capacity of the system to cope and for whether money really reaches the frontline services on which people depend’; and ‘the Government's oversight arrangements to reflect the overriding importance of quality of care in a sector where up to 220,000 workers earn less than the minimum wage and around one third of the workforce are on zero-hour contracts’ (p 3).

Throughout history, most revolutions fail in the first instance. Some never really ignite and others end with a whimper in a short space of time. However, even revolutions that seem to be ‘successful’ at the time often fail to bring about anticipated results. Sometimes this is because previous elites are unwilling to give up power and find ways of going with the flow in the short term, but quietly re-emerge near the top of the new system. ‘Turkeys do not vote for Christmas’, as the popular saying goes, and it is rare to find a ruling group that voluntarily gives up power. On other occasions, the different groups demanding change can have much in common at a superficial level when united by a common enemy – but ultimately have different aims and objectives that become more apparent after the common enemy has been defeated. At the same time, many of the initial revolutionaries are charismatic or powerful personalities that others want to follow – but the same traits can make it easy for people to fall out after the event and for previously coherent movements to fragment amid significant jockeying and personality clashes.

This is probably an overly grandiose way to start the concluding chapter to this book – but many of the contributors to this edited collection do appear to suggest that the personalisation agenda has not led to the revolution (or at least to the subsequent long-term changes) that many people seem to have been hoping for. For Victoria Hart, personalisation has ‘over-promised and has under-delivered’, while Peter Beresford describes various potential ‘traps’. For Simon Duffy, a key figure in the development of self-directed support, we have ended up with ‘a mixture of the good, the bad and the ugly’ at best – or ‘“zombie” personalisation’ at worst. Moreover, some of the changes that have taken place under the banner of ‘personalisation’ might not only fail to deliver the positive changes anticipated, but could also actually make things worse. Thus, Helga Pile warns of the negative impact that there could be for staff and service users, Lucy Series describes a worrying lack of transparency and a series of legal tensions around resource allocation and Colin Slasberg debates a potential threat to the universalism of the NHS.

For anyone working in or receiving adult social care services, the personalisation agenda is of fundamental importance. Different people may love it or loathe it – may be fully supportive, completely opposed and/or just confused – but the shifts in policy and practice that personalisation might imply are potentially far-reaching and certainly hard to ignore. Of all the changes that have taken place in adult social care (and increasingly in other sectors too), it is personalisation that stands out as one of the key themes of the past decade, and quite possibly as one of the key agendas of the next ten years.

Under New Labour, the government's Putting People First concordat pledged to achieve a ‘system-wide transformation’ in which people using services have ‘maximum choice, control and power over the support services they receive’ (DH, 2007, pp 2-3) and in which personal budgets are available ‘for everyone eligible for publicly funded adult social care support other than in circumstances where people require emergency access to provision’. Acknowledging the role of organisations such as In Control (see below) and a number of cutting-edge voluntary organisations and local authorities, the government recognised the importance of local and national leadership to help support and build on ‘the first stage in a unique attempt to co-produce, co-develop and co-evaluate a major public service reform’ (DH, 2007, p 5). Similar sentiments have also been expressed by the coalition government in A vision for adult social care (DH, 2010a, p 15):

Building on this, one of seven key principles of A vision for adult social care was ‘personalisation’, described as an approach in which: