The path to social care reform: four key questions

Andy Burnham has made history this week as the first modern Prime Minister ever to have previously headed up the Department of Health. Since his last stint in government, the name of that department has been changed to reflect its responsibility for social care, and it is social care, not health, where Burnham has chosen as one of his first priorities in office. His early announcements suggest a bold ambition: a national care service that would “operate on the NHS principle”, a willingness to confront the tax rises needed to improve care, and a plan to accelerate the Casey Commission so that it reports before the end of the year. 

But Burnham knows better than most the perils that lie ahead. As Health Secretary in 2010, his proposal to raise money for a new National Care Service was branded a “death tax” by opposition parties despite having secured cross-party support, and reform retreated into the long grass. Several other politicians have since had similarly bruising brushes with the politics of social care reform. One of them – Boris Johnson – even stood on the steps of Downing Street on taking office and vowed to fix social care once and for all, yet reform amounted to little. So, what questions does Burnham need to grapple with in the short term to make sure his promises don’t follow the same trajectory of those that have gone before?

Four vital questions

There are four key questions that stand out right now.

What does he mean by “NHS principles”? Most people will interpret NHS principles as free as the point of delivery, and that was the eventual ambition of the Labour Party’s 2010 white paper. However, it is not yet clear if Burnham means that all care should be entirely free, or that there should be some universal free elements balanced with some individual contributions. After all, even in the NHS, there are exceptions to the free offer, with people paying out of pocket for things like (price-controlled) prescription charges and dental treatment. 

If the aim is to provide entirely free care for all who need it, that would take England from having one of the most threadbare systems in the world to one of the most generous. Even in the most generous system we have identified (Denmark), care is free but accommodation in residential care is not. Most other countries among those we have studied have some sort of universal offer to all, but share the remaining costs between state and individual according to means. As our recent work demonstrates, there is a wide continuum of approaches deployed across the world, which reflect public expectations, public finances and deeply rooted societal attitudes to fairness and the role of the state. 

Can he build public support? Enduringly low public awareness of what social care is, and how the system works now, has made building support for change (and the inevitable financial contributions) difficult. Getting the public onside, and thus reducing the inherent political jeopardy, will be essential if plans are to survive beyond the next election. When looking at other countries, reform only became possible when a groundswell of public support for change switched social care from a political hot potato to a vote winner. Burnham and his team need to position social care as an essential part of our society and economy, something that we all benefit from and see the value of investing in. 

Which prompts the next question: what of the Casey Commission? Burnham reiterated his call for Commission timelines to be sped up, possibly reporting by the end of the year. The original timeline was for an interim report in 2026 and a final report by 2028. Baroness Casey has previously indicated that the Commission will move more quickly than stipulated where possible, so this may be feasible. The bigger issue, though, is what does that mean for the Commission’s public conversation that is about to be launched? 

The Conversation is aiming to unpick public attitudes to fairness, to understand what people want in a care system and ascertain what they expect from the state. This is intended to build a solid foundation on which to determine the principles of a new system and to start to enhance public understanding. Accelerating that process demonstrates an understanding of the urgency of the issue, but Burnham will need to walk a careful tightrope between expediency and building public support.

And then the final, and potentially most tricky, question: can he find the money? The amount he will need to find very much depends on the ultimate ambition of the system, its design, and where the line is drawn between state and individual responsibility. £18 billion has been cited in the press. That number is a projection of the cost of making the current system largely free at the point of use. However, Casey’s conversation may lead us to different territory – a system that is reimagined, not just a more generous version of how things are now. 

Inevitably, any advance on what we have now will need more resource than we are currently putting in. Burnham, and his Chancellor, will face a stark choice: reallocate money from somewhere else or look for new sources of revenue. The quantum of cash is not the only issue. The growing reliance on local council revenue, propped up by sporadic injections of cash from central government, is increasingly unsustainable and exacerbating inequalities. A new approach that pools the risk of high costs across the whole population, administered nationally, would be more sustainable. Designing that to be fair across generations and different population groups will need careful thought, as we have written about before. 

Beyond the technical considerations of making reform happen, there is now an opportunity to ask some really fundamental questions as a society about what social care is for, what we want from a system of support, and how that system should work not just alongside other parts of the state but alongside our lives. Baroness Casey, in her speech to the Nuffield Trust in March, talked about social care needing a “Beveridge moment” – a moment to explicitly design a system that works. It would be a wasted opportunity if reform boiled down to just expanding what we have now. 

Social care, when it works well, enables people to live a meaningful (or ‘gloriously ordinary’) life. At present, the dysfunctions within the system – from the labyrinthine eligibility process, to the inconsistency of access, to the unstable provider market, to the workforce vacancies and low pay, to the enormous responsibility falling on the shoulders of unpaid and largely unsupported carers – too often make living that life feel like a battle and a lottery. Burnham has shown that he’s committed to making this a priority for his term in office. There will be tough choices and difficult moments ahead but let’s hope, for all our sakes, that he can make some tangible progress and set social care on the path to reform.