It's been almost a year since Boris Johnson said he would not wait to 'fix the problem of social care that every government has flunked for the last 30 years'. With a green paper detailing the government's plan finally due, we'll soon learn whether the Prime Minister is as good as his word. We'll also see whether Johnson succeeds in avoiding the pitfalls encountered by his predecessors. Might he tumble into the same trap that blew up Theresa May's bungled snap election?
The wrecks of those previous attempts – sent out with such high hopes – are plentiful. Talking to the politicians in charge of those efforts from three different parties and five administrations for Engage Britain common themes emerge. From Andy Burnham to Nick Timothy, would-be reformers have seen the 'problem of social care' as a series of inter-linked systemic failures. An underfunded service increases demand on the NHS, while the means-test complicates delivery and generates iniquities.
The nub of the political problem has been finding a way of increasing funding but also mitigating, if not eliminating, the impact of the means-test and costs which can be catastrophic for individuals and their families. And while the politicians may have advanced different solutions, each blames a lack of public understanding of the current system as a major factor in their failure.
Norman Lamb, the former Liberal Democrat care minister, was the most direct about political dynamics which mean that the NHS is seen to deliver a better rate of political return on investment:
'[The NHS] always dominates politicians' attention: NHS – politically sexy, no-one understands what social care is. It feels rather old fashioned. It’s not clear from what it says on the tin on what it actually amounts to.'
When push comes to shove, it’s always the NHS that wins out. When David Cameron cooled on the package based on Andrew Dilnot’s report he raided billions of pounds previously set aside for its implementation to fund the 'long-term plan' for the health service, according to one of his senior ministers.
Lamb says the public barely blinked when Cameron killed off the Dilnot plan that limited liabilities at £73,000 after he had ditched his coalition partners following the 2015 election. 'No-one had any idea what the Dilnot cap was out there in the public, so it was incredibly easy for the Tories to ditch (it) once they got rid of us.'
There’s a dry irony here. It was, of course, the Tories that had most recently politicised the means-test when George Osborne and Philip Hammond led the ‘death tax’ charge against Burnham’s proposals for an estates levy. Lord Lansley, who commissioned Dilnot and was a strong advocate of his proposals, said Osborne was deeply hostile, resisting particularly his efforts to raise revenue to pay for the whole package that included means-testing winter fuel allowance.
May’s objections to Dilnot were more fundamental. Allies said she had a 'visceral dislike' of a scheme that passed on the costs of insuring very large inheritances to those much less well-off. Her own version led famously to one of the great unforced errors of modern political times. The inversion of Dilnot was designed to protect voters with relatively modest assets that the Tories were targeting.
They were described by one of those involved as 'that kind of striving middle who had had unglamorous jobs, worked hard, not gone on big holidays, had not had credit cards, have saved money and given a bit to their children. Those people who had probably been on joint incomes of today's money in between £20,000 and £35,000. They had built up an asset, which would be something like £100,000 that would normally be the value in their home, and we said that we thought that's what we should be helping to protect.'
The proposals were approved after being subject to extensive focus-tests, according to one person closely involved:
'It was tested in considerable detail...The feedback we got was that the public wasn't across the issues didn't really understand how social care works, but when it's described to them, they liked it.'
May was told, ‘It’s fine, go with it. It shows you are being grown up’.
It was, of course, very much not fine – as Tory candidates quickly attested, doorstep conversations on the financial consequences of a dementia diagnosis rarely ended well.
'The biggest clanger we dropped was to tell people something that already existed,' confesses a well-placed source.
What if the problem isn't that the public don’t understand the system? Could it be instead that policy-makers have never taken time to appreciate how people experience what the state, for its own convenience, calls ‘social care’?
There are questions which we are all likely to face at some point in our lives. What do we want for ourselves and our loved ones as we grow older? What do the transitions between the health and care services feel like? A richer understanding of questions like this might enable us to uncover what we value, what we are prepared to pay for and how.
Asked to give their advice to today’s reformers, those that have gone before all urged Johnson to be bold. Several also said he should address the fundamental question of what we want from our care system.
'What are we trying to do with social care?', asked Norman Lamb. 'We're trying to make people's lives better…we're trying to enable people to continue to live independent lives even when they have sort of disabilities or conditions that make that difficult. It's supposed to enable people. But often, we allow people to become trapped..in care homes when they don't need to be or to have no control over the care that arrives in their own home from some awful agency based in some other part of the country.'
'It's not just to sort of contain people in institutions, it must be fundamentally to give people a good life, and not to just extend life for the sake of it, but to give people the opportunity of a good death as well.'
May’s former chief of staff Nick Timothy thinks the issue of funding can only be tackled as part of a broader debate about fairness and the growing demands on the state:
'I think a non-compulsory insurance [system] doesn't work and compulsory insurance is basically a tax. But, as a country we need to have a much bigger, and more serious debate about demands on the state, what they cost and what the likely trends in future growth will be. And what that means for how we raise our taxes. Because I don't see a future in the coming decades where the overall burden of taxation is going to be lower. We need to decide who is going to pay what.'
These are not conversations best held in the heat of electoral battle or in Westminster alone. But for our sake and the benefit of future generations, we need them to happen. To 'fix' social care, we need to allow people to navigate the inevitable trade-offs and trust that they can come up with ways forward that both improve lives and are politically sustainable.
Unless people on the frontline are brought into the room where the next set of policies are made the chances are very high that there’s another wreck in the bay all too soon.
Francis Elliott is Director of Advocacy at Engage Britain. The full version of this paper and information on Engage Britain’s health and care project is available at engagebritain.org