Social care: manifesto debacle shows need for wider debate

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Governments of all political persuasions over the past 20 years have made bold promises to reform the way social care is funded. All have discovered that this is easier said than done despite the mounting human and financial costs, including the effect on the NHS. The events of the past week suggest the next government will find it no less difficult.

The Dilnot Commission was the coalition government’s attempt to resolve the conundrum. Its central recommendation – a cap on how much people would be expected to pay over their lifetime from their own savings and assets – was accepted and included in legislation. But 10 weeks after the 2015 election, implementation was postponed until 2020 and then, in last week’s Conservative manifesto, it was dropped altogether. However, within days, Theresa May has confirmed there will be an 'absolute limit' on lifetime care costs after all, although she gave no indication about the amount.

Who should pay?

Depending on this, a cap would offer welcome protection for those facing very high care costs – especially in conjunction with a proposed 'floor' whereby no one would be left with savings and assets of less than £100,000. These measures would help to achieve a fairer balance in how costs are shared between the individual and the state. But it does not tackle the bigger question affecting thousands of disabled and older people with few or no assets who are wholly dependent on local authority funded care budgets, which have been cut by £5.5 billion over the past six years.

The question of where the money comes from is crucial. The Conservative Party wants to means test pensioner winter fuel allowances and for the first time include the value of property in working out what people pay towards care at home, as is currently the case with residential care. This faces up to the tricky issue of intergenerational fairness – why shouldn’t relatively wealthy baby boomers draw on their unprecedented property and pension wealth to fund their care rather than working age people who have borne the brunt of austerity? The absence of costings makes it hard to assess how much more the Tories would invest, over and above the extra £2 billion announced in the Spring Budget. It will mean thousands of people paying more for home care but will be complex and challenging for councils to implement and risks unintended consequences. These might include discouraging people from seeking help, placing a greater burden on unpaid carers, and driving increased use of hospitals and long term care.

Fault line

Although all parties are committed to further integration of health and social care, none of their proposals will remove the historical fault line between the NHS that is free at point of use and funded through taxation and social care that is heavily rationed, means tested, and reliant on high levels of self funding. As the Barker Commission concluded, this is neither sustainable nor equitable – develop cancer or heart disease but not dementia and your house and savings will be intact.

Fundamental reform is needed not only of funding but in the way services are delivered to offer better outcomes for people and to tackle the mounting workforce problems facing the sector. All of the manifestos fall short in setting clear, credible, and costed proposals that address the scale of these challenges.

The NHS will never work properly without an adequately funded and well designed social care system that recognises far reaching changes in demography, wealth, and increasing acuity of needs and comorbidity. When the heat and noise of election campaigning has subsided, a green paper early in the next parliament could offer a fresh opportunity to engage with the public on the issue, presenting a range of options and choices to achieve a social care system that is fit for the 21st century. All parties agree this is necessary. Their current policy differences are a reason for promoting that debate not an excuse to avoid it.