Social care: who cares?

The answer is they should not be. The social care problem, which includes the trauma it is causing for the NHS, is not going to go away. It would, however, be foolish to pretend that this issue is easy – as illustrated by the fact that over two decades at least four serious independent reviews of social care and its funding, including a Royal Commission and the Dilnot review, plus at least a dozen green and white papers, have failed to produce a settled answer for England.

The four questions of the social care funding challenge

It is not easy because there is not one issue here, but four deeply inter-related ones.

First, how far should individuals and their families be responsible for paying for social care, against how far should the taxpayer meet the bill?

Second, a question that sounds similar but is in fact a different one, at what level of need should the state provide, and how generously?

Third, how can the much greater integration of health and social care that everyone recognises is needed be achieved?

And fourth – an issue that lies behind all three questions – why do we as a nation apply totally opposite arguments to the provision of health and social care? For most people, it is a matter of pride that the NHS seeks to treat everyone equally regardless of means. Yet when it comes to social care, the argument is that the state should not subsidise those with the means to provide for themselves – an argument that (a few prescription charges aside) is never applied to the treatment of cancer, diabetes or the need for a new heart, new hip or pretty much anything else the NHS supplies.

It is possible we won’t get to a sensible and settled answer to the first three of these questions until we have answered the fourth.

The inadequacy of the Conservative manifesto proposal

The initial Conservative manifesto promise was chiefly about the first question: how much should individuals (and thus by implication, their families) pay versus the state? Its inclusion was more bizarre because the party had already promised a green paper for the autumn, and already had, in legislation, but postponed the Dilnot proposals for a more generous means-test and a cap on lifetime total expenditure to 2020.

What the manifesto effectively did was take Dilnot’s more generous means-test (which would let people keep £100,000 of their assets), drop the cap (set at around £72,000), and throw in the idea that people receiving care in their own home should pay with the value of their home (down to the £100,000 floor). Half-baked is putting it politely – leaving aside the sheer administrative complexity of the last part of that proposition.

Working towards a sustainable solution

So, what could the Government do? And what should it do?

Well, it could go back to Dilnot and meet the cost of that: several billion pounds over the years which would have to come from tax rises or cuts elsewhere – borrowing would not solve the problem. But while Dilnot tackles the question of how much the individual should pay, it wouldn't increase the quantity of social care provision. That is decided by the needs test – how great do an individual’s needs have to be before they get help? – not the means test. And the ever-rising level of disability that is needed before an individual gets the taxpayer’s help has been one of the key drivers of the current social care crisis. Tackling that would require yet more money, and the apparent loss of the abolition of the pension triple lock and of the reduced winter fuel allowances make that even more difficult.

So, what the Government should do first, in its humbled state, is reach out across party divides to build as common an answer as possible to these questions. In practice, if only the politicians could resist shouting “dementia tax” or “death tax” at each other, there has been more communality in their assorted answers to the “who pays” question (including the idea that there should be a cap and that housing wealth will come into it somewhere) than they will publicly admit. And there is at least 20 years of common ground that social care will, one day, have to be sorted.

Silence is not an answer. If the Government seeks only to stay shtum, social care will come back to bite it, and hard.

In November, the IfG will launch a project exploring new ways to address the long-term funding challenge facing health and social care. If you are interested in this work, please contact Research Manager Nick Davies: nick.davies@instituteforgovernment.org.uk