I originally wrote a version of this article for Labour Left in September 2012 following a very successful SHA meeting in Easington County Durham where some dispute had arisen about whether the quasi market in social services offered people more choice. In view of Lord Warner’s astounding support of section 75 quoting the success of competition in social care, it seems timely to reiterate some of the arguments disputing this.

The NHS and Community Care Act 1990 was introduced by the Thatcher Government and fully implemented in 1993. Lord Griffith’s recommendation was that money previously going to fund people in private sector care residential care, which had rocketed, should be passed to local authorities who would assesses and support people in choosing the care they wanted, which was generally to stay in their own homes. So the aim was to shift resources from residential care to care in the home. But of course Thatcher did not like Local Authorities, so the strings attached were that 75% of the budget had to be spent in the independent, i.e. private and voluntary sector, and local authorities had to stimulate the home care market in particular. The government said a wider independent market would give individuals more choice. But that is the very last thing it did. It gave commissioners more choice in who to commission from, but individuals had far less choice.

Many state funded recipients, who had been very happy with their local authority home care service had it removed to make way for a private sector provider. The voluntary sector could rarely compete on price. The individual was told which provider’s service they would receive. No choice. Such providers could supply a cheaper service to the local authority, because they employed their staff on zero hours, gave no training and were time based rather than task based. This meant that the time that the provider offered included travelling time for the worker which might be from one end of an area to the other. It was the individual receiving the service who paid for that by having the time spent on her or his work reduced.

If a person did not like the service they were receiving they could complain, but in the first instance that had to be to the provider. If still not satisfied, a complaint could go through the local authority process but even if the provider were changed, the local authority decided who the new provider would be, not the person receiving the service. Inevitably many complaints might be received about the same providers, but the local authority was between a rock and a hard place. Because contracts were block purchased, it was really difficult ending one with an established provider, as there was not room in the ‘market’ by that stage to encourage new more ethically and quality conscious providers. They were driven out by the price local authorities were paying.

Interestingly the growth of the home care market did not reduce significantly the number of admissions to residential care of older people, because as needs became more complex, it was cheaper to keep an individual person in a residential home, than provide a person with 24 hour care at home. That was your choice, especially if you were had no means outside of state funding and had complex needs: residential care, take it or leave it! If you were told you needed residential or nursing care then you supposedly had a ‘choice’ of home, but this again was a myth, as against the spirit of the legislation, many independent sector homes said they could not afford to provide care at the rate that the local authority paid, and so added ‘top ups’ where people had to top up £5 to £20 per week out of their pensions, or relatives had to do it for them. So where is the ‘choice’ without cost to the individual there?

I have written the above from the perspective of working in a local authority with a great public sector ethos, and many public sector resources that were devastated by enforced competition, so much so that on the eve of the implementation of the Act we were told we weren’t implementing competition quickly enough and so a ‘Task Force’ was sent in to help us. The probability is that Warner has never worked in a strong public sector. If not then he cannot compare like with like and should not be making such damaging comparisons.

I have written above about what happened in social care services in the past tense. In view of the Section 75 vote last night we must stop our NHS going down the same track.

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  1. Brian Cox says:


    This is a great summary and shows how we have developed the unbalanced and unsatisfactory situation we now have. One aspect of the original Griffiths plans for community care that was never implemented was that there should be budgets available at practitioner level to enable community supports and social alternatives to be funded to help people stay in their own homes and live a normal life. Choice in this situation could have been activated meaningfully and easily. Not so much a quasi-market as a practical means of supporting daily living.

    The experience of marketisation in social care is largely negative in my view and has worked against the interests of older people.

  2. ValHudson says:

    Thank You. Yes i agree about budgets never being devolved down to practitioner level Brian, but Thatcher’s government had us in a cleft stick Because practitioners could not give people choice, we were told peoples’ needs not being met, and thus Direct Payments. Now I’m not saying the latter were wrong, but how many people have to top up their DPs. you can see the same path being trodden in health and co-payments is even further moving us away from a universal service free at the point of use. That’s why Warner is wrong, and why privatisation has left social care demoralised scapegoated & underfunded

  3. Brian Fisher says:

    Val, how do you see personal budgets fitting into this?

  4. Matthew says:

    Thank you for the historical backdrop; very interesting. I hope that the many problems with social care will be addressed in Labour’s new commission/review

  5. Brian Cox says:

    You raise an interesting point. How will the SHA support the review and what can we contribute. I would favour making a strong case for integration of services based on natural communities and a social model of care but I suspect the easier policy option will be to go for something that the NHS can deliver. For instance I understand that recently Ed Milliband has suggested that nursing care homes for the elderly should be brought under the NHS. This would be a mistake I think.
    In the long term this wont solve the quality and sustainability issues.
    Do we have a SHA position?

  6. d3carehome says:

    Thanks for sharing. Very Intersting

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