Fourteen years later, this topic continues to attract lively discussion in fringe meetings if not on the main stage at party conferences. With £1 billion less in councils' social care budgets this year and with demand rising, the need to sort out how we pay for and deliver social care remains as urgent as ever.
The coalition government got off to a flying start, fulfilling the pledge made in its programme for government to establish an independent commission to report within one year. And the spending review settlement for social care was more generous than many expected (though undermined by a 27 per cent cut to local government). Andrew Dilnot's report has commanded an impressive and unanimous welcome from all parts of the care sector, as reflected in our recent Dilnot to Delivery conference. Consensus even broke out among the politicians, with initial talks held between health ministers and their Labour shadows. But many question whether Dilnot has run out of steam, with the Treasury baulking at the £1.7 billion+ price tag and political nervousness in the wake of the stalled NHS reforms. The result: the announcement of a further public engagement exercise – the third in four years – and the promise of a 'progress report' on funding alongside a White Paper on social care reform by Easter.
The mood music emerging from this year's party conferences is decidedly mixed. Many in the Liberal Democrats aspire to promote the positive case for social care reform with the same enthusiasm with which they resisted those aspects of the NHS reforms they saw as negative. Alongside a political strategy of creating distance between their policies and those of the Conservatives this could create fresh strains within the coalition. Labour too have supported Dilnot, having publicly committed to work consensually to achieve a cross-party solution, though some voices demand a stronger policy position. Within Conservative ranks there remains overall support for Dilnot, but with some continuing to lean towards the use of private insurance as a means of shouldering a larger share of future costs. The all-party consensus is fragile.
On the economic front, hopes that an improvement in public finances would take effect from 2014 are being dashed by deepening uncertainty in the Eurozone and beyond. The public spending tap will not be turned back on any time soon. Yet the government has found more than £1 billion – apparently outside the spending review – to freeze council tax and ensure a weekly 'entitlement' to have our rubbish bins emptied. So, as we argued in our updating of the Wanless report last year, it is priorities rather than affordability that is the primary issue – additional resources can be found.
As yet social care does not reverberate enough on the political Richter scale to make an impact on priorities. At least 10 million people have direct experience of social care – a quarter of the adult population of England, whose collective voice has yet to be used as a social movement. More could be made of the economic benefits of investing in a relatively low paid sector where extra money will quickly create a multiplier effect and could enable carers and disabled people to hold down employment. The NHS will face the growing impossibility of meeting the Nicholson challenge and developing integrated care without an adequately resourced social care system. There is much more to do in translating the Dilnot framework into a comprehensive programme for change. But the remaining question is not 'can we afford it?', but 'how we can we afford not to?'