Social care is the nightmare that won’t go away

Having seen so many commissions on social care come and go, and so many policy proposals announced and then dropped, the temptation to be cynical about yet another commission is almost overwhelming. You might think that a government with a huge majority and access to all those previous reviews might actually decide to do something rather than set up yet another review.

The issue of the ruinous social care costs that many older people will face is the most familiar. Sir Andrew Dilnot described as a “tragedy” this government’s abandonment of the long fought for implementation of his plan —published all the way back in 2011 —to limit the costs that individuals should face. Until that plan was abandoned I had thought we had the political consensus that Baroness Casey is tasked with seeking. Apparently not.

Around one in seven 65-year-olds can expect to spend more than £100,000 on their social care. That’s because provision is subject to an extremely harsh means-test. If you have assets of more than a paltry £23,250 you are simply not eligible for any support. If that’s the problem, we know the answer. You can limit the total amount that anyone should spend on social care over their life. You can also make the means test less harsh. That is, the state can provide social insurance.

That’s what Dilnot recommended, what the last government, after multiple delays, said they would introduce (but only after the election) and what this lot abandoned. One can quibble over what the lifetime limit on payments should be — the previous government suggested £86,000 — but beyond that the answers are there. The cost would be about 0.25 per cent of national income each year in the longer term, less in the short run. No further commission is needed to opine on this.

Cost is going to be the elephant that stalks this review. Even our current, miserably mean, system involves local authorities paying out some £25 billion of public money. Just maintaining it will mean spending rising more than 3 per cent a year above inflation. It is hard to imagine serious reforms that don’t cost at least as much, on top of this, as the proposals just abandoned on cost grounds. Casey’s biggest challenge is not going to be getting agreement on what needs doing, it’s going to be getting agreement on how to fund it. Yet if history is anything to go by the Treasury will not let her near that crucial question.

These are not the only issues though, and it is true that a broader policy direction is needed. Almost exactly half of the £25 billion goes not on the elderly but on those of working age who need (often intensive and expensive) care. This is where demand and spending has risen most. Despite a growing older population, the number of over-65s receiving state-funded care in England has fallen over the last 15 years as eligibility criteria have been tightened. To receive state-funded care you don’t just need to be poor, you need to be in very serious need. The need threshold for support is just as important as the means test.

Then there is the role of local government. Social care is currently arranged and funded through 153 local authorities in England. Adult social care is much the biggest thing these authorities are responsible for, taking up more than 40 per cent of their non-schools budgets, a fraction that has grown rapidly over time as deep cuts have been imposed on other services. But the grants received by local authorities from central government no longer reflect their needs. And the capacity of different local authorities to raise additional revenue via council tax is unrelated to social care needs.

I am afraid, Baroness Casey, that you will not be able to sort out social care without getting deep into the bowels of local government finance. And if the logical conclusion of the government’s stated desire to move to a “national care service” is to take responsibility away from local authorities then that will leave our local government even more enfeebled and leave us with an even more centralised state — directly contradicting a stated desire for more devolution.

Then there is the structure of social care provision itself. Local authorities may fund it, but care is overwhelmingly provided privately. The vast majority of care home beds are provided by an independent sector made up of many small providers and a small number of big ones, often owned by private equity. Casey will need to determine whether this provides value for money and whether alternative models are possible. Care homes, by the way, charge you much more if you are paying for yourself than they charge your local authority if you are publicly funded. Not only does the state not support you in your hour of need, you literally end up subsidising the state. Again, I thought we had consensus on remedying this. Also abandoned by this government.

And that is just the start. Employing some 1.5 million people, the social care system is heavily dependent on immigrants to staff it. It won’t work without a coherent workforce strategy, which may well cut across other government priorities.

As a result of all this, people’s experience is often appalling. Only half of those requesting support receive any. Navigating a hopelessly complex system with inconsistent provision and a hazy line between free healthcare and paid-for social care is a nightmare. Tens of thousands more will suffer this nightmare as yet another commission gets going. Many will have to spend a lifetime’s accumulated assets when they had every right to expect that they had escaped that fate until this government abandoned the changes that would have spared them. Justice delayed will, for them, be justice denied.

This article was first published by The Times, and is reproduced here with kind permission.