The social care crisis is out of control – and Priti Patel’s curb on migrant workers will push costs higher

By 2010, 75 per cent of people with moderate needs were already being denied free care. The situation is untenable, says Vince Cable, yet the solutions are very costly and politically controversial

Patel has sparked nationwide debate on how new immigration measures will affect the social care sector (AP)

We are told that this government will bravely go where others have feared to tread and solve the problem of funding adult social care. This is a subject that can quickly disappear into arcane debates around financing mechanisms but has a profound effect on very many vulnerable people and their families. At its heart is a simple but difficult question: who pays for the cost of looking after the growing numbers of elderly people, especially dementia sufferers, who cannot care for themselves? Should it be the elderly themselves, out of their savings or insurance if they have any? Or their families? Or the rest of us through taxation?

Our collective unwillingness to confront this question has resulted in confusion and frustration on several levels. In particular, it has exposed the arbitrary line rationing what is and isn’t available through the universal free service of the NHS.

Cancer, strokes and broken limbs guarantee world-class health treatment, free of charge. Alzheimer’s or Parkinson’s do not qualify. You can get free treatment for bowel cancer and a colostomy bag fitted on the NHS, but cleaning up after an incontinent dementia patient is someone else’s problem. The state will pay if you crack a hip getting into the bath, but not to help you take a bath safely if you are infirm.

These arbitrary distinctions have translated into separate bureaucratic and political responsibilities. So the much loved NHS, with tight but relatively generous funding, gets to do the healthcare while severely cash-strapped councils have to take responsibility for social care and administer means tests to extract funds from those who can afford to pay.

Because local authorities cannot organise domiciliary care or residential accommodation quickly enough, there are thousands of people who need care and support, but are otherwise healthy, sitting in hospital blocking beds needed for the sick. In December 2019 there were 148,100 “bed days” taken up by patients who were physically ready to move on. Around 60 per cent of these bed days were attributable to stresses elsewhere in the NHS, but 30 per cent were caused by blockages in the social care system.

The pressures are growing. The numbers of dementia cases alone are expanding at over 3 per cent a year – from 800,000 now to a projected 2,000,000 in 2030 – but the capacity to care for them is static or declining.

Some families take responsibility for caring for their loved ones. There are 350,000 full-time carers; 110,000 have given up their jobs. But most families are not in a position to provide round the clock care, and statutory responsibility then falls on the local council. Because of severe financial pressures, councils have to cut costs and contract to low-cost providers who in turn hire the cheapest labour. Caring is not just poorly paid, but emotionally and physically demanding and often unpleasant. Unsurprisingly there is a big turnover of staff (450,000 a year) and many vacancies, around 100,000. Immigrant workers keep the system going.

At present, the ideal solution of good support for those living at home is undermined by skeletal domiciliary services, run by harassed, underpaid, staff, many from overseas. For those forced into the diminishing supply of care homes, there is a choice between what are in effect luxury hotels – comfortable, yes, but eyewateringly expensive – and very basic accommodation, often smelling of urine.

Even before the financial crisis and subsequent austerity, there was a serious strain on the social care system. Bed blocking was rife, even then. Councils were resorting to increasingly stringent means tests; by 2010, 75 per cent of people with “moderate” care needs were denied free care. Adding to the problems, politicians have weaponised the care issue, and have shown great skill only in kicking the can down the road. The last Labour government tried to win cross-party agreement for a supplementary inheritance tax, which was shot down as a “death tax”. The coalition government established the Dilnot Commission, which recommended maximum liabilities for those able to pay for care, backed by insurance. But the subsequent Conservative government never implemented those recommendations, and Theresa May later made compromise proposals that were immediately dismissed as a “dementia tax”. It almost cost her the 2017 election.

What these failures exposed was the fact the social care problem is about two different issues, with two different sets of motives. The first is about how to ensure, in tandem with the NHS, that there is adequate social care for all those who need support. The second is about how to level the odds in the lottery which presently exists around inheritance. This starts with whether you are related to someone who owns property at all, and where that property is (Hampstead being somewhat more profitable than Hull). And the bonus ball, or lack of it, is determined by whether the elderly benefactor lives independently into their dotage, or if they are struck down by dementia.

If the government is serious about either issue, the solutions are very costly and the likely funding mechanisms are politically controversial. The Kings Fund estimates that it would require up to £6bn a year merely to restore the level of care to 2010-11 standards. But it would potentially require another £10bn to make social care like NHS care, free without a means-tested contribution. In total that is equivalent to raising the basic rate of income tax by 2-3p in the pound. A fairer tax on inheritance would clearly be preferable to such a significant hike in taxes on income but would agitate Conservative voters.

Another probably fairer approach in the long term is to introduce social insurance, to ensure we’re all covered for the catastrophe risk of needing prolonged social care. But of course, that doesn’t pay for the legacy problem of those already old who would not have paid into the new scheme. A reasonable compromise could involve the introduction of social insurance, backed up by a big injection of cash into local social services, combined with free palliative care for those with terminal conditions.

Whatever solutions are arrived at, the costs will rise considerably if Priti Patel is successful in keeping out foreign carers. Britain is a nation of highly skilled workers, who cannot readily give up their jobs to care for relatives. If the home secretary has a vision of the future in which families are expected to care for their own – and we become a nation of carers by choice or necessity – she is even more naïve than she is right-wing.

We can only hope that some Conservative MPs who recognise this will amend the coming Immigration Bill so that care workers are recognised as a shortage occupation. Without them, the country is on track to move from a crisis in social care to a full-scale collapse.

Sir Vince Cable is a British politician who was leader of the Liberal Democrats from 2017 to 2019