Every so often it’s healthy to reflect on where things are and where they are going. At Northern Slant, we want to promote a conversation as to how Northern Ireland can ‘rethink’ certain approaches to policy and decision-making. What can we do differently? What can we learn from elsewhere or from emerging research? In this article, Dr Alexandra Chapman considers how we can rethink aspects of adult social care.

Social care for older people is a key issue for our society. We probably all know someone who either receives or provides care, so why has there been so little attention given to fixing its problems? Over the past year, we have seen a crisis in our care homes, limited support for unpaid carers and issues in workforce pay and conditions. While these are only some of the problems that have been magnified since the pandemic – they are not new.

For many years – in fact, since its inception – social care has never been treated the same as healthcare or given the same status. Many people believe that social care, like the National Health Service (NHS), is free to those who need it, but in fact it’s means-tested and is only provided free to people with low assets and savings. This leads to blurred lines and tension between the two services.

At the same time, the funding of social care has not kept pace with healthcare funding, nor has it increased in line with demographic changes, resulting in greater overall demand for services, impacting on those who need it the most. This is despite our health and social care system undergoing several fundamental and critical reviews setting out major changes of direction at various points the last 20 years. 

What do we want?

The Northern Ireland Life and Times (NILT) Survey asked the public about their attitudes to adult social care and their views about future policy in 2010 and 2015. The findings from both surveys show how a lack of public understanding and a low profile of social care contribute to a problem of low expectations and planning for future care needs.

There was little evidence that people have considered how they might fund their own care or support as they get older. Most notable is that 50% of people in Northern Ireland said that they hadn’t really thought about it. But, with limited knowledge about the social care system and the cost associated with it, it’s unfair to expect anyone to plan ahead particularly as most people’s first experience with the social care system often happens unexpectedly, at a time of crisis. 

The surveys also asked people where they would prefer to receive their care, such as in their own home or in a residential setting. 84% said their preference would be to stay at home and have paid care assistants help them. A large percentage of respondents, 72%, felt that spending on domiciliary care services (care provided at home) rather than residential care should be a priority. The survey results provide an important understanding of the public’s perception of social care and notably, the type of care people would like. 

How can the system change?

In 2018, the first Citizens’ Assembly for Northern Ireland met over two weekends to consider how our social care system for older people should be reformed to be fit for the future. A group of 75 citizens from across Northern Ireland came together to debate and deliberate on the type of social care system we want for our society and the ways in which it should change to ensure it can effectively meet our evolving needs.

One key recommendation by citizens was a move towards a more person-centred social care system that can provide genuine choice, be tailored to individual need and address a person’s holistic needs. There was also broad consensus from members that a valued and professionalised social care workforce is central to getting our social care system ‘right’. At the heart of this debate, better working conditions and pay were highlighted which could assist in recruiting and retaining staff. The value and economic contribution that unpaid carers make to the social care system was also recognised as invaluable to the sustainability of the system, and members strongly agreed that carers need greater support.

These recommendations provide the first real insight into a range of diverse and wide-reaching social care issues and reflect what the wider population of Northern Ireland, when fully informed about the issues, would like to see for our social care system now and in the future. It’s vital that these workable recommendations are carefully considered by politicians and policy-makers. 

What happens next? 

Northern Ireland is not alone, as the issue of how best to provide social care for older people has also been debated by governments in other parts of the UK for many decades. Looking to England, there has been some changes in how social care is delivered, and much of the focus is on a person-centred model of care where social care users are given the opportunity to be involved in their care planning and are given a personal budget which provides care users to control the money allocated for their care and support.

The direction of travel in Scotland is somewhat more inspiring, with growing calls for a National Care Service to be established on an equal footing with NHS, and that a Minister for Social Care should also be appointed. This call has been backed by several different Scottish parties. Regardless of future change, reform in any jurisdiction cannot take place without political will and significant investment. 

While there is widespread agreement that the system of social care in Northern Ireland is under unsustainable strain and that urgent reform is needed, there is no agreement on how it should be reformed. More recently, New Decade, New Approach agreement included reform to health and social care as a priority, yet action remains unseen and we continue to wait for change. With this being said, the evidence from the public shows that there is support to make innovative changes in social care to ensure it enables rights and capabilities and can be a vehicle for supporting independent living.

It’s clear that we won’t achieve the full potential of social care support without a new delivery system, and the public might be more willing to consider other models of funding than politicians realise. However, we need courageous leadership to help us take this next step together and we must be open to bold, radical thinking about what we as a society can do to ensure our social care system can work effectively for us all.  

The pandemic has shone a very bright spotlight on the problems in social care – many which are not new but have resulted from years of political neglect and under-funding. The past year has shown just how societies and communities can come together to support one another, particularly the thousands of unpaid carers. without them our social care system would have undoubtedly collapsed. It’s clear that doing nothing is no longer an option and there is no better time to act than now.  

More in our ‘Rethinking…’ series: