Grass

I heard superwoman on the wireless.

Dame-Go-To… aka… Louise Casey… HMG’s fixer.

She did what everyone else, who is given the job of producing a review or an inquiry does… told us how difficult the problem is.

Her task, fixing social care… that political orphan everyone knows is broken…

the system is complex,
fragmented and
under severe strain.

Correct, but the solution? Difficult? Not really.

Parliament has already given us the toolbox.

The Care Act 2014 created;

a national eligibility framework,
gave people clear rights to assessment,
required councils to maintain local care markets and
a mechanism for people to defer the cost of care by placing a legal charge on their home so it can be settled from the estate later.

In other words, the practical components needed to run a coherent system, already exist.

If I know this and I’m sure from practical experience, you may know this, for sure, Dame-Go-To knows this.

The cross-party agreement she says will be difficult, has already happened. The Care Act 2014 was one of the rare pieces of social policy where a broad political settlement was reached.

It emerged from the 2011, Dilnot Commission on Funding of Care and Support and passed Parliament with relatively little partisan conflict.

The principles were clear:

national eligibility rules
a duty on councils to support the care market
deferred payment mechanisms against property
and a lifetime cap on care costs

The settlement might be imperfect but was politically significant. For once, the parties had broadly agreed.

What followed was not political disagreement about the design. It was Treasury resistance to the cost of implementing it.

Another national review risks doing something quite different from building consensus…

… it risks reopening a settlement that had already been achieved, at a time, now, when the political environment is far less stable than it was in 2014.

Now, the party system is more fragmented, fiscal pressures are greater and cross-party policymaking is harder, not easier.

In that context, a new review may actually undermine the fragile consensus that once existed, because it invites fresh arguments about structure when the real question has always been financial; as Roy has argued elsewhere, all solutions lead to social care.

With a cost-of-care-cap set at ~£70k the cost to HMT might be around £1.3bn…

… which over time could be adjusted as the population ages and the economy fluctuates.

It also recognises this is an insurance issue…

… most people will need little or no formal care. A minority will require expensive long-term support. Local authorities are too small to carry the risk. It’s job for HMG.

A dedicated capped contribution becomes and insurable risk for individuals.

Otherwise, reverting to tax-only funding means putting up taxes, 4p to cover ~£30bn… not a goer.

What the Care Act cap does is insure the nation against the unlucky minority.

Only a small fraction of care users, ~10–15% generate the majority of lifetime costs, usually through long periods of dementia or frailty.

The policy was never about subsidising everyone; it was about pooling the risk of the few catastrophic cases that no family can reasonably plan for.

The other thing we know for sure is; don’t set up a national care service. I will take years and cost billions, and definitely…

… do not merge health and social care.

Health will take years to recover from Covid, waiting lists and Streeting’s bonkers reforms and sackings.

Social Care is fragile at its best, and…

… two turkeys won’t make an eagle.

The existing Better Care Fund would allow health and social care joint-funding to create a ‘home first budget’ and technology is improving to provide meaningful virtual care, bringing costs down.

All this is available now and leaves us with the question… why get Dame-Go-To revved-up and ready for a Cook’s Tour?

The machinery and mechanisms for reform are on the statute book.

Meanwhile, we already know social care is the system’s main constraint, and that without fixing it hospitals will never get the flow to do Streeting’s one job of cutting waiting lists.

The Casey review and her timetable looks less like policy development and more like a classic kick it into the long grass.

News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
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