1 August 2011 | By Polly Toynbee and David Walker
The Dilnot report is the latest attempt to find a solution to the social care funding crisis. To avoid the fate of its predecessors, it has erred on the side of compromise. But in doing so it has avoided tackling the prickly issues of varying quality of care and huge wealth disparities
Andrew Dilnot’s social care report could have provided a rare moment of national fiscal honesty. It could have said, clearly, that in the end we will get what we pay for. We have the national capacity to make increasing longevity a virtue and create a country where those who need care get it. But that involves accepting that there’s no such thing as a free lunch or a get-out-of-jail-free card in funding the rising cost of caring. Dilnot’s Commission on Funding of Care and Support in England falls quite a way short of forcing us – or the present government – to face these facts of life.
The harsh truth about the future facing us was instead highlighted by the Office for Budgetary Responsibility. A few days after Dilnot’s report was published, Robert Chote and his colleagues came out with their hair-rising projections of the cost of ageing.
No country for old people seemed to be the message – unless we agree, across generations, within families, that we have to stump up.
Dilnot is a clever man with an astute sense of the politically possible. The economist, broadcaster and principal of St Hugh’s College, Oxford, points out: ‘Sutherland reported in 1999 in favour of free care, when Labour had a large majority and public finances were good. If it wasn’t going to happen then, how much less likely is that option now?’
So, experienced in the ways of Westminster, Dilnot has delivered a report crafted for maximum agreement all round. This is partly as a result of sidestepping crunch questions such as: do we have enough care of acceptable quality? His report is about paying for existing standards, not improving them. Another question avoided is why society, and families, shouldn’t have to put property into the pot and use the astonishing build-up in housing wealth in recent decades to pay for care.
Dilnot was commissioned in July 2010 to fulfil an explicit pledge in the coalition agreement between the Tories and Liberal Democrats, after social care had risen, briefly, up the list of hot election topics.
In the dying days of Gordon Brown’s administration, he had promised a grand-sounding National Care Service, with free care at home for all with ‘critical’ needs (but no details on how it was to be paid for). Dilnot embodies the coalition’s response.
The Tories had slammed Labour’s plan as a ‘death tax’, that would need to be paid for by snatching away basic inheritance rights. So a new plan was needed that bailed out homeowners and their expectant relatives.
As a result, Dilnot is not so much about care as easing public resentment at paying for it. Why should old people in need of care be forced to pay every penny of their savings over £23,000 and to sell the roof over their head, ran the complaint. The fickle finger of fate leaves some spending years with Alzheimer’s in residential care so expensive that after a lifetime of thrift they have nothing left to hand on to their children, while others are lucky enough to drop dead after a short illness paid for by the NHS in an NHS hospital.
Not fair, says the Daily Mail, the coalition and others in regular campaigns on behalf of middle-aged children denied their inheritance.
If that is indeed the most pressing problem, then Dilnot has come up with a neat solution. As you might expect from the former head of the Institute for Fiscal Studies, his recommendations are tightly costed, judicious and practicable. No-one need ever fear paying more than £35,000 of their savings if they are unlucky enough to need care: the state will pay the rest.
That cap should attract the insurance industry, which has backed off offering terms for an open-ended risk. Dilnot says: ‘Now we’re opening the door to feasible policies, so people can insure against the risk of losing that £35,000.’
He spoke movingly to us about a visit to a dementia unit. ‘What kind of models of economic rationality and statistical probability could ever capture the humanity of the care I witnessed? Call this the confessions of a repentant economist,’ he said. Determining who might need such care and when is chancy and unpredictable. Demographers say the number of people aged over 80 will double by 2031, to 5 million, but they cannot predict what proportion will need care.
Plainly, many more will, and not just in the UK. Longevity has been rising fast across the western world and social care is a Cinderella in other European countries too. Despite moral panic about heartless modern families, most caring is – and will go on being – done by families themselves. Two million people identified themselves as carers in the 2001 Census, a fifth of them providing care for 50 or more hours a week. Less than 1% of those aged 60–79 live in communal establishments, the proportion rising for the over-80s. Only two out of five of those aged 95+ are in care homes.
Strip away the politically motivated exaggeration and the compression of time – the UK is ageing much more gradually than other countries – and you are still left with the basic proposition that if society is going to age with comfort or fairness, we (collectively) will have to pay more.
Care has always been a dark territory, below the social radar. It is small beer besides the two-thirds of the NHS budget spent on patients above official retirement age, or the 59% of the benefits budget spent on older citizens. Care is ‘a mess’, as one senior Whitehall official pithily characterised the interplay of family, council and state responsibilities. Dilnot smooths the path a little, but his report would leave in place a jungle of eligibilities, ‘hotel’ charges and disability and attendance allowances.
As he was completing his work, scandal broke. Shocking pictures from a BBC Panorama programme about the mistreatment of adults with disabilities at Winterbourne View, a privately run unit, melded in the public mind with the sudden bankruptcy of major care firm Southern Cross, with its 31,000 residents in 750 homes.
Until then, few people had realised the extent to which the care home industry had become a target of private equity, stripping away the property values and leaving the rest of the business financially vulnerable.
Meanwhile, the inadequacies of the resources of regulator Care Quality Commission were exposed, its inspections cut by 70%. A year ago ministers promised to repeal the regulatory state; now Tory MPs were calling for the CQC to take on more staff and get tough. Dame Jo Williams, the chair (and a co-commissioner on the Dilnot report, along with former health minister Lord Warner) said she shed tears at the Panorama programme.
That is why, Dilnot says, we have to have a national system for England. ‘One where people with identical care needs in Lewisham and Lancaster are treated differently cannot be right, either morally or in terms of the expressed wishes of the public.’ Dilnot’s focus is on finance and, paradoxically, local authorities’ tasks of assessment and commissioning provision might in theory be easier, if his proposals for a uniform and predictable financial pathway through care were accepted.
But his plan implies a new national body to oversee it. English councils, which are to be subject to a statutory duty to provide information and assistance, would be left sweeping up. Dilnot takes us no further forward on questions about the quality of care or its availability.
Social care is the largest item of spending under direct council control. Across England, families are becoming increasingly aware of councils tightening assessments and seeking savings on their care budgets. The same councils might have to pick up the pieces from the collapse of Southern Cross and other companies that teeter on the edge.
The underlying problem is this: not enough money is paid privately or publicly to provide a decent standard of care either at home or in residential homes.
So who should pay more, and how? Older people have unmet needs – but as a group they also have means. They own property. Seven out of ten people aged 70-plus own their homes outright. House prices peaked at an average of £221,000 in January 2008 and, after falling, recovered to £212,000. It is a store of wealth that is remarkably buoyant – and phenomenally under-taxed, by international comparison.
The generation that needs care has accumulated wealth that has enormously inflated in value in past decades, to the detriment of younger people. But, politically, tapping into that well of wealth is dynamite. Dilnot is a sort of damper down, doing the opposite – guaranteeing the older generation that they can keep more of it, with an even bigger chunk of the bill picked up by younger taxpayers. He bows to the British conviction that granny’s home is our castle.
Many taxpayers expect the state to foot the bill for any care requirements they might have. Just 14% would be willing to pay higher taxes, and fewer than one in ten would be willing to sell their home to pay for care – according to a recent survey by Anchor, a non-profit provider of care homes.
To the charge that his plan is regressive, Dilnot replies that the true injustice is currently to the poorest savers as assets over £23,000 are included in means-testing for financial support. His recommendation is to increase this to £100,000 to level the playing field. He adds that the average house price figure is misleading: many older people have properties worth only around £120,000.
This classic ‘wicked issue’ slips below the radar because responsibility is shared not just between central and local government but between different bits of the social security system, between households and the state, charities and statutory providers. Fay Wright, a research fellow at the Institute of Gerontology at King’s College London, points out the ‘terrific ignorance’ of the public about the costs of care and the administrative system and how sporadic debate has been. That might be because caring is a vast archipelago in which some families never have problems and others manage very well.
Ironically, social care exemplifies the choice and personalisation extolled in the government’s recent public services reform white paper. Families are mostly left on their own to provide care for dependent relatives and many do. The trouble is that, for many, choice is onerous and expensive and they demand help. But relatives’ complaints never acquired political traction; carers were too various and widespread to form a movement.
So will the Cameron government now pick Dilnot up? Let us assume that Andrew Lansley, shell-shocked after his abortive attempt to sell his vision of the NHS, remains health secretary.
He called the report ‘immensely valuable’. But it is still a counter-intuitive proposition: he is urging a Tory-dominated government to expand the welfare state. Lansley’s formula was predictable: ‘We have to consider carefully the additional costs to the taxpayer of the commission’s proposals against other funding priorities.’
So far, however, the response to Dilnot has been deafening silence. Not his fault, it is a clearly written document and rich in evidence. But will the public, ever, link their own family and personal circumstances to the question of taxation, wealth and housing?
As things stand, Dilnot risks joining the other social care reports on the shelf – the royal commission chaired by Sir Stewart Sutherland that provided Labour with a blueprint, Derek Wanless’ study for the King’s Fund, all the work over the years from the Joseph Rowntree Foundation.
Although Dilnot says he doesn’t expect his recommendations to be implemented until the economy revives, sometime after the next election, it might take more campaigns by irate families losing their inheritance and families’ growing fears of what lies ahead. Most will have more caring to do: in two decades’ time, two-thirds more adult children than now will have parents who need care.
Dilnot’s report is useful. His arithmetic is precise, his scheme elegant. But his report is no Beveridge, prompting a great national conversation about welfare and responsibility. We are stumbling into our older years and have yet to deliberate among ourselves – within families, as much as within politics and policy – whether this will be no (comfortable) country for elderly people to spend their remaining days in.
