The road to social care reform is paved with good intentions – but Streeting must deliver

Editorial: The health secretary is right to commission a social care review, but this time we need more than words

Not the sort of man to slumber into the new year for long, health secretary Wes Streeting has launched the first step towards Labour’s promised “National Care Service” – prospectively, the Starmer administration’s complement to the post-war Attlee government’s National Health Service.

A manifesto commitment delivered – or leastways started – with the appointment of the protean Louise Casey to head a commission, the review, in Mr Streeting’s words, will “finally grasp this nettle and set our country on the path to building a National Care Service that meets the urgent needs of our generation, guarantees quality care to all who need it, and lasts long into the future”.

“Consensus” across political parties and carrying the broadest possible political support is the means to this end. Yet it is fair to say that there is already a consensus – and one that has been operating for some decades now – doing nothing, which has proved cheaper and less troublesome for politicians with a developed instinct for survival.

Inertia, muddling through and miserly reforms to the system have, in fact, been the preference of the nation for a quarter of a century.

Tony Blair appointed a royal commission on long-term care for the elderly in 1997. It reported two years later that “this is a complex issue and there are no easy solutions”. The commission, chaired by Stewart Sutherland, a distinguished philosopher, couldn’t achieve much consensus even among its members and suggested sharing the costs of care between the “taxpayer and individuals”.

But even in those less austere times, when growth delivered tax revenues for public spending increases, the Labour government chose not to spend significantly more on social care. There were good reasons for this – and they remain true today, despite the commission warning that Britain faced a “demographic time bomb”.

The fiscally explosive device was also ticking by the time David Cameron and Nick Clegg formed their coalition government in 2010, and they asked Andrew Dilnot, well versed in such matters, to look into it. The Dilnot report of 2012 remains the best piece of work yet completed, and even made it as far as a statute. But it is also one that six successive prime ministers chose not to activate.

Even the much-derided proposal that Theresa May put forward at the 2017 general election had more going for it than its nickname – “the dementia tax” – suggested. It was poorly researched, and clumsily presented, but as a rough compromise, leaving people with at least £100,000 of their assets and being able to settle the bills after death, so never having to be forced out of their own home, was a rough and ready line of social equity.

The problem with all of the proposals in recent decades is that they constituted compromises of one kind or another, and thus succeeded in alienating some section of public opinion, and its political agents. Given that raising taxes to fund comprehensive and universal social care for all is unacceptable on a variety of grounds, then a choice must be made as to who pays for what – and when.

The present division between the cost of “accommodation” and “nursing care”, with a means test attached, is itself a compromise that grew out of the Sutherland commission. But it is uncomfortable, illogical and messy. The idea of selling a family home to pay for long-term care remains repugnant, not least on the grounds of fairness. Why should someone of modest means be financially “penalised” for suffering a long death from dementia when their next-door neighbour in hospital with cancer would not? Or when their other neighbour can pass everything on after a sudden fatal heart attack?

The dilemmas facing Baroness Casey and her colleagues, therefore, will be formidable but nothing new – and she need not spend the next few years reinventing the social care “wheel”. The trade-offs have been thoroughly explored and the benefits of social insurance demonstrated in the Dilnot report. If all she manages to do is to bring it up to date and recruit some cross-party support for it, then she will have discharged her duties admirably.

It should not take as long as some are predicting, even if getting buy-in to the new scheme will take time and patience. We wish Baroness Casey and Mr Streeting well in their quest to fix social care; but all should also be prepared to consider the more modest, piecemeal and provisional solutions that have had to suffice thus far.

History suggests all too powerfully that electorally, rather than morally, there are always more important things for politicians to spend public money on than social care – however lofty their words.