The long-awaited social care Green Paper, 'Shaping the Future of Care Together', published on Tuesday, was first promised in an obscure paragraph in the October 2007 pre-Budget report. It was an inauspicious start for what could be one of the most significant social reforms of the post-war era.
Social care funding is one of the great unfinished pieces of business of the Blair government, which came to power promising to solve a problem that had defeated its Tory predecessors. It set up its one and only Royal Commission to deliver the answers – the only problem was that the Royal Commission failed to produce an answer the government could live with (although the Scots adopted a version of it).
The issue was revived in 2006, when The King's Fund commissioned Sir Derek Wanless to undertake a review of the funding of social care for older people in England. The view at the time was that it would be 'politically courageous' for politicians to tackle this issue.
But government and opposition views have moved on and politicians have been courageous. Launching the review of social care, Gordon Brown described it as a 'once in a generation' opportunity and he may be right – one thing is certain, the current system is unsustainable and is already failing thousands of the most vulnerable members of society.
Courage is badly needed. Social care has always been an unloved child of the welfare state – the beneficiaries are relatively powerless, and the fact that much of its funding and delivery is the responsibility of local government means that it can appear one step removed from national political concerns. Unlike health care it is often below the political radar.
And it is complex. Whichever solution is chosen, social care will need more resources devoted to it. Even if it becomes more efficient and we find better models of care, the demographic realities mean that costs will rise. In economically straitened times, this becomes an even more unpalatable truth.
Some fundamentally hard decisions need to be made to achieve long-term solutions, and they can only be made through public debate and a political consensus – regardless of who is in power.
Behind the well-crafted words and clearly set out options of the Green Paper lie some very tough questions that will have to answered if reform is going to be delivered.
First, is there an appetite to reform the benefits system? We know that Attendance Allowance is popular but probably not well targeted. Those who are eligible for it will need to be reassured that any new system will provide the freedom and flexibility enjoyed by current recipients.
Second, do we know enough about what constitute effective models of care? There must be a move, as in health care, to focus funding on interventions that are effective.
Third, do we need the same system for all ages? The Green Paper has included working age adults with disabilities in addition to older people. It suggests with some justification that different approaches can be taken for different groups but it does raise issues of age discrimination and questions over the affordability of a free system for those of working age that does not impact on current benefits.
Fourth, are we prepared to give up local control in exchange for a national care system? In both the government’s consultation, and the Caring Choices programme led by The King's Fund in 2007, it was clear that a consistent national system and an end to a postcode lottery was seen to be far more important than local flexibility. However, this does have significant implications for the future shape and function of local government.
This then is the moment for us to settle these issues and, if we can, to reach some form of consensus that will create a lasting settlement – it is too important an opportunity to let go.