A collective groan greeted the rumour that the government will announce yet another royal commission on social care. The fear is that it just kicks this problem into the blue yonder; it was Harold Wilson who jibed that royal commissions “take minutes and waste years”, which can be politically convenient.
The world of the NHS and local government needs a resolution to the care crisis: 250,000 people wait for a care assessment and almost 30,000 a year die waiting while councils go bankrupt because of soaring care cases and NHS beds are blocked for lack of care in the community. Everyone concerned already knows exactly what is needed: urgent funding and a pay and career path to attract new care staff.
There have been, according to the King’s Fund, at least 12 green papers, white papers or reviews on care reform, the Dilnot commission from 2011, along with five independent reviews since the last Sutherland royal commission in 1997 – and all of them have been ignored. Their conclusions were filed away on the too-difficult shelf. It’s easy to see why there are reports of havering and wavering within government. This is known as a “third rail” issue: “you touch it politically and you get fried”. Ask Theresa May after her 2017 mid-election disaster when her care policy was denounced as a “dementia tax”, or Labour in 2010, whose sensible plan was weaponised as a “death tax”. All the alternatives for real reform are, in their own way, politically toxic.
Labour’s manifesto committed to a “national care service, underpinned by national standards” and the employment rights bill in parliament this week includes the first fair pay agreement for care workers. So far, the only decision has been (rightly) to ditch the old coalition government-era plan – not yet implemented – to cap individual care costs at £86,000, with the state stepping in to pay above that (costing an immediate £1bn). There is to be a 10-year plan for health and social care: it must include the rising needs of care for younger adults with disabilities, which is often costing half of councils’ care budgets.
Reform is an administrative as well as political nightmare. Owing to another Thatcher privatisation fiasco, there are about 18,500 care providers, mostly very small homes or homecare services, but 13% are owned by private equity chains, and the proportion owned by local councils has been estimated to be as low as 3%. There are several organisations representing them, so when it comes to pay negotiations with these very different interests, it won’t be easy. Care was privatised because the cost of running private, rather than council, care is lower for all the usual reasons: worse pay and conditions, zero-hours contracts and cheaper pensions.
But the political dilemma is the same as ever: who pays? It still comes as a shock to many families to find it is not free, like the NHS, except for those without means. Any assets or property have to be used to pay the bills: half the residents in care homes pay for themselves, the King’s Fund tells me, as do a third receiving care in their own home. The lottery of life sees one in seven people paying more than £100,000. Pooling that risk seems the obvious answer, as Andy Burnham, then health secretary, proposed in 2010: everyone with means on retirement would pay in, say, £30,000 (or a lien on their home) and never pay again. But that was politically explosive. The Tories are already running with “Labour’s war on the old”.
Why not free care for all, paid from taxation like the NHS? Campaigners point out no one asks what your home is worth if you need cancer treatment. But not only would that be unaffordably expensive in these stricken times, it would mean taking taxes from the working young to pay for the old in order to preserve the assets of the old who already own most property. An extra national insurance levy hypothecated for care would do the same. Some on the right argue for paying into a private insurance system, but the King’s Fund points out that insurers say there is no market: people won’t buy it, even if there were a cap to limit liability.
That’s why nothing has changed all these years. Making the old lose their property and savings is detested; any new solution that abides by that principle will just shine new attention on it. And there really is no other solution. Although Covid showed people how much social care matters, it’s not a high public priority: unlike the NHS, most families only encounter its random chaos for very few years. Yet doing nothing at all is no longer an option either, as council bankruptcies are imminent.
That’s why a royal commission would, ultimately, be a very good idea. There are no new facts to unearth, no new solutions, but it would open up necessary public discussion and oblige everyone to confront the inevitable. There could be citizens’ assemblies and discussions around the country. Laying out every option, it would oblige the opposition not just to rouse anger against any particular proposal but to choose a realistic one itself. The plan needs to be conducted in two parts: an immediate emergency plan to keep social care going now, reporting ahead of this spring’s spending review – and then a longer term plan for reform and restructure.
The name in the frame for this tough job is Louise Casey, a tough nut who would take no nonsense from those pretending there is a pain-free way out. A royal commission would need her ferociously rational style of argument to make plain that savings and property are there to be used for your care in old age. She is the sort to dare ask the public to step back and consider national priorities. How should we spend whatever state money is available? Would you spend it on preserving the property and inheritances of better-off old people, or should it go to children, on early years, schools, further education and apprenticeships to invest in the country’s human capital for the future?
Polly Toynbee is a Guardian columnist
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