As the government’s keenly awaited winter plan to protect social care in England dribbled out earlier this month, Sally Warren tweeted: “I can’t help but feel this is a missed opportunity to help the sector, those who work in it and those relying on it.”
As the policy director at the King’s Fund, she felt she was working with scraps in putting together the kind of authoritative commentary expected of the health policy thinktank.
By the time the plan was finally published at 9.30 that evening, a Friday, her views hadn’t changed. “It still feels very heavily like a ‘care homes for older people plan’ rather than a social care plan. There isn’t an awful lot that’s going to help this winter.”
Her assessment of the winter plan is that its extension of the infection control fund to support care providers through to next March, providing an extra £546m to pay for workers to self-isolate where necessary and to fund extra shifts to try to stop them working in more than one care home, was welcome but politically inescapable.
Critical to the impact of a second wave of the virus, she thinks, will be whether there is widespread transmission in the community, posing a severe risk to domiciliary care workers and thereby to the people they visit in their own homes. As “it now looks like there is”, social care faces “a really hard six months on the back of a first really hard six months”, she says.
“Added to that we have staff, working in a lot of different settings, who are already exhausted and quite traumatised because they have had to deal with a lot of grief. Many of their clients have passed away and that’s not something they can just take in their stride. What we are coming into is another peak, another kind of marathon if you like, and they have barely recovered from the last marathon they’ve been running. So I do think it’s potentially a real combined storm that could hit this winter.”
Warren has been at the King’s Fund since June last year, moving from Whitehall where she had previously been director of social care at the then Department of Health and later at the Cabinet Office. Her last civil service role was “director of EU exit preparedness and response” at the Department for Environment, Food and Rural Affairs. “Not great for my work-life balance and wellbeing,” is her only comment on the experience.
But if she expected a quieter life at a health thinktank, she reckoned without the worst pandemic for a century. The first wave of coronavirus proved devastating for social care in particular, accounting for some 26,500 excess deaths in care homes in England and Wales and a further 23,500 excess deaths of people at home, many of whom would have been in receipt of domiciliary care. Almost six in 10 of all deaths involving Covid-19 between March and July were people with a disability.
“I fear it’s going to be a really challenging winter,” she warns. “Covid has somewhat brutally exposed the fragilities of the sector, and those fragilities are because of a decade or more of funding squeezes – but also because of being ignored from a reform point of view.”
Above all, Warren is concerned that there is far too little focus on the more than 300,000 people in England who receive personal care at home, and on working-age adults who receive support and account for almost 50% of all social care state spending. “The evidence is clear that you need to help all of the sector, whether it’s care homes, supported living, housing with care or people living in their own homes,” she says. “I understand that they want to make sure care homes are protected, but that shouldn’t be at the expense of people who use social care and are vulnerable in other ways.”
She empathises with her former colleagues in the social care team at the Department of Health and Social Care who went into the Covid crisis with what she thinks must have been the smallest team for 15 years, following repeated cuts. That team is now being built up again, but she says it will be “a few months” before it is back to the size and strength of a decade ago. Many recruits will be new to the sector.
Warren puts the blame for the paralysis over long-promised social care reform squarely with ministers. “The reform issue is fundamentally a political and ministerial issue,” she says. “If you think about the amount of policy analysis done over the past 20 years, there is barely any aspect of the debate on which there have not been multiple detailed submissions to ministers. They are the ones who need to grapple with the difficult decisions that need to be taken, and that requires some political bandwith, which understandably recently has been missing.”
While she excuses ministers’ inaction on reform over the past six months, she is less forgiving about lack of progress between last July, when Boris Johnson claimed he had a plan all ready to go, and March this year. “There was a lot of time between last July and the pandemic where they could have set out a plan and I certainly now expect them to move forward with reform as soon as they have settled how to support the sector for the winter.”
Warren admits to being “quite taken with the logic” of a cap on individual liability for care costs and points out that, as it is already enshrined in legislation, it could be implemented easily and quickly. “The idea that all of us who can should plan and expect to meet some care costs later in life feels reasonable,” she argues. “What doesn’t feel reasonable is that we should have to plan for us being the unlucky people who incur quite catastrophic costs.”
Still just 42, Warren has already notched up wide experience in Whitehall, which she joined as a fast-stream graduate. She has had spells also at the Care Quality Commission and Public Health England (PHE), where she was its first director of programmes. She is angry at the way PHE has been singled out for retribution for failings in the national response to Covid without, she says, any “proper assessment” of what went wrong and any recognition of the facts that it is an executive agency under ministerial control and that planning for a pandemic appears nowhere in its mandate. “I do think it’s unfair and I think it’s particularly unfair that its staff found out about [the decision to scrap it] through media briefings rather than being told direct,” she says.
The initial pandemic response by ministers that everything could be directed from the centre was, she thinks, a misassumption that Covid was “a health issue” and therefore something to be dealt with in the same way as the NHS is directed from the top down.
“It’s hard to know without being in the room with ministers or inside their heads,” Warren says, “but they are relatively comfortable with NHS command-and-control mode. In a crisis the NHS definitely does that hierarchy thing – and does it very well – for good reason. That could be why they set out in the way they did and it hasn’t always been suitable, to put it politely.”
Education: St Bartholomew’s School, Newbury; University of Nottingham (BA history & American studies).
Career: 2019-present: director of policy, King’s Fund; 2017-19: director of food, then director of EU exit preparedness and response, Defra; 2016-17: director of social care, Cabinet Office; 2014-16: deputy chief inspector, Care Quality Commission; 2013-14: director of programmes, Public Health England; 2012-13: director of social care, Department of Health (DH); 2009-12: deputy director of social care, DH; 2008-09: joint programme director (integration), Hammersmith & Fulham council and primary care trust; 2006-08: deputy director for strategic finance, DH; 2004-06: private secretary to ministers, DH; 2003-04: policy team leader for foundation NHS trusts, DH; 2002-03: private secretary to cabinet secretary, Cabinet Office; 2001-02: lead manager for cancer services, Calderdale & Huddersfield NHS trust; 1999-2001: fast-stream policy generalist, DH.
Interests: Hiking, pilates, keeping fit, cinema.