Will it be 23rd time lucky for social care reform?

Following fevered speculation over many days, Andy Burnham on 29 July gave his first speech on social care since taking office. He had already signalled his commitment to grasping this issue and has repeatedly promised to spend political capital on getting it right. He has now reconfirmed that he is serious about finally reaching a solution for this long-running political sore, and pledged to put things right for so many people across the country who are being let down by the current system. 

Burnham has under three years before the next election to prove that he can deliver positive change, but he knows better than most how difficult the task ahead is likely to be. His original reform plans in 2010 soon became embroiled in a toxic political debate that set the scene for the next 15 years of policy failure. 

Since the original Royal Commission in 1997 that called for an urgent solution to the challenges of an ageing society, there remarkably have been 22 separate attempts at reform. If Burnham is to be 23rd time lucky, he will need to tread carefully and avoid the pitfalls of the past. So what could be different this time?

Three key announcements

Instead of leaping to an eye-catching solution or specific offer, he set out three key announcements: bringing the Casey Commission forward; a focus on the social care workforce; and finding common ground across the political divide. 

Almost more important than what he said was how he said it and what he didn’t say. He notably steered clear of announcing a funding solution, despite much prompting from journalists in the audience. Some may accuse him of avoiding the most difficult decision of all, but experience from the past and from other countries suggests it is a wise approach. 

Previous debates about social care reform have very quickly descended into political mud-slinging about inheritance and tax, stunting any productive conversations about what’s needed and feasible. 

At the root of this is enduringly low public awareness of what social care is and how it works. A third of people believe it to be free as part of the NHS, and many get a nasty surprise when they find that isn’t true and that it can, in fact, be ruinously expensive. Even the most seasoned experts in the field find navigating this labyrinthine system stressful and confusing.

This time, Burnham has framed the debate around the fundamental questions that have never been explicitly explored before, which the Casey Commission’s conversation will unpick. What should social care do, who should get access to it, and where should the balance of costs lie between the state and individuals? By building public and political consensus around these questions, the final question of who pays and where the money should come from – while still not simple – will be informed by a good understanding of public attitudes to fairness. 

Treading a tightrope carefully

In our recent work looking at where other countries draw the line between state and individual responsibility, it’s clear there are a number of options with varying degrees of state generosity, but all are grounded in agreed and explicit concepts of what is acceptable and fair in that society. 

In bringing forward the Casey Commission, the Prime Minister has demonstrated he is aware of the urgency of the issue. But he needs to tread a tightrope carefully. Political acceptability will largely be fed by public support. If he expedites the Big Conversation too far, he may jeopardise the process of bringing people along with him.

Getting from where we are to having a fully functioning and fair system involves a huge shift and will undoubtedly take time, and full implementation will stretch into the next parliament. Whether success is achieved or not is as much a test of the maturity of opposition parties and our political system as it is of Burnham’s leadership. But he will need to stand strong in the face of turbulent headwinds. 

There will be difficult choices ahead, but there is also a cost to inaction. From the people unable to access the care they need to live a meaningful life, to the unpaid carers struggling to juggle caring and work and other commitments, to those who don’t yet need care but one day may do so – there is a moral, social and economic argument for making tangible change. We all have skin in this game. It’s in all our interests for Burnham to be 23rd time lucky.

*This blog was originally published in the BMJ on 30 July and is reproduced with permission.