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Why the UK has struggled to reform social care


From Labour’s 2010 “death tax” to the Tories’ 2017 “dementia tax”, UK political parties have long sought to reap electoral advantage from demonising rivals’ prescriptions for funding the care of elderly and disabled people.

This toxic history may explain the Conservatives’ reluctance to spell out in detail how they would restructure a broken social care system in this election campaign, but they appear to have postponed, rather than evaded the question.

Boris Johnson, whose Conservatives are expected to win the most seats in Thursday’s ballot, according to opinion polls, has promised talks within the first 100 days of a new administration aimed at finding a solution that can attract cross-party support.

Yet many remain sceptical that consensus can be achieved, particularly in Britain’s polarised political climate. Despite the urgency of the problem, politicians have for years tended to substitute analysis for action.

Unlike the UK’s cherished taxpayer-funded National Health Service, which provides care free to all, social care is tightly means-tested — a fact of which even many Britons are unaware until personal or family circumstances provide a crash course in its complexities.

J9H6CB London, UK. 2nd June, 2017. Liberal Democrats protest outside the Conservative Party HQ against the proposed Dementia Tax by Prime Minister Theresa May. They held up mock national estate agency boards called
Theresa May’s ‘dementia tax’ became a major political issue during the 2017 general election © Vibrant Pictures/Alamy

Through a decade of austerity, which disproportionately affected the budgets of local government, which oversees social care, the gap between demand and resources has yawned ever wider. This has had a knock-on effect on the NHS, with patients well enough to be sent home trapped in hospital beds due to a lack of community support, straining an already seriously overstretched system.

During the past 22 years, the question of how to improve the social care has been explored in 12 “white” or “green” papers or major government consultations, four independent reviews or commissions and a number of parliamentary inquiries, according to a tally by the Nuffield Trust think-tank.

Over the same period, other countries have confronted the issue: Germany and Japan, for example, both introduced social insurance systems to ensure that no one is unable to afford the care they need in old age.

There are multiple reasons for the contrasting stasis in the UK, but those who have been involved in some of the attempts to find an agreement highlight a deep institutional reluctance by the Treasury, the UK finance department, to countenance an expansion in the scope of the state.

Sally Warren, director of policy at The King’s Fund health think-tank and formerly a senior civil servant working on social care, noted that the current system is “so tightly progressive in that there’s only a very small proportion of people at the extreme ends of the need and assets scales . . . that get helped”.

Ms Warren argued that one solution would be for those at the top of the wealth spectrum to pay a higher proportion of the cost of the reform through the tax system. This could allow social care to become “a universal service, or a basis of a universal service, like the NHS, with wealthier people contributing more to it through the tax system”, she said.

Some analysts see a degree of common ground emerging between the two major political parties, despite the discouraging history. While Labour’s manifesto went into more detail about its plans than that of the Tories, Richard Sloggett, formerly one of health secretary Matt Hancock’s closest advisers and now working on health and social care for the Policy Exchange think-tank, argued that, “with both parties accepting a state backed solution to address the social care crisis, the basis of a deal exists”.

The two parties also appear united on the need for some form of limit on an individual’s personal liability for care costs. Last weekend Labour committed to a ceiling of £30,000, even more generous than the one proposed by a 2011 commission led by the economist Sir Andrew Dilnot, which would stand at £46,000 in today’s prices.

While the word “cap” does not appear in the Tory document, the party’s pledge that no one should have to sell their home to afford care suggests some form of ceiling on personal contributions would be set.

Politicians’ consensus may founder on where the additional revenue needed should come from but a shifting public mood may yet insulate them from a voter backlash.

An Ipsos MORI poll last month found that care for elderly and disabled people is now on a par with crime in the list of voter concerns, only exceeded by the NHS and Brexit. Also notable has been an apparent shift in people’s willingness to pay higher taxes for better care.

A survey conducted by the same pollsters for the Health Foundation, a charity, recently found that almost two-thirds of people — 62 per cent — believe that any government decision to increase spending on social care should be funded by some form of tax increase, a rise from 51 per cent in May last year.

The scale of the problem is vast. Total spending on adult social care by local authorities in 2018/19 was £22.2bn. Anita Charlesworth, the foundation’s chief economist, has calculated that as much as an extra £12.2bn a year would be needed by 2023-24 to meet demand, increase care workers’ wages, and return access to, and quality of, services to 2010/11 levels.

These figures may increase dramatically in the coming decades as the vast “baby boomer” generation gradually succumbs to the ills and indignities of old age.

At least as significant, although often overlooked in the debate over social care, is the rise in the proportion of spending devoted to younger disabled adults rather than the over-65s. Jill Manthorpe, professor of social work at King’s College London, said one of “the hallmarks of greater advances in medicine and care and social attitudes has been that more people with disabilities have survived into adulthood”.

She said that in some areas more than half of requests to local authorities for social care now came from working age adults, while they are actually falling from older people — yet the debate had all too often been framed by politicians as “the debate about older people’s social care”, Prof Manthorpe added.

In a recent presentation on social care, Andrew Dilnot suggested it was time to “just get on with it”. If the next government heeds his words it will have broken one of the longest losing streaks in public policy history.



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