Interviewed by Laura Kuenssberg yesterday, Andy Burnham talked of a universal social care service, free at the point of use, on “NHS principles”. There’s been a lot of discussion about this pledge being kicked the other side of the general election, but less about whether these principles are actually the right starting point.
The starting point is presumably free domiciliary care at home and/or free care provision in a care or nursing home. In Scotland, which the PM referred to obliquely, free provision excludes non-care support such as help with shopping and housework at home, or accommodation and food costs in a care home. So, not quite the same as the NHS (you don’t pay for your food in hospital), but universal nonetheless.
(Incidentally, for all Burnham’s commitment to devolution, he seems to be less happy with the differences that may result from it. He said, “There is free personal care elsewhere in the UK. I don’t think it’s right that people in England don’t get the same.”)
Costs could be as high as £18.5 billion a year (around seven per cent of current health budgets) for a fully comprehensive care system by the mid-2030s, according to Health Foundation estimates, though Burnham said he expected the eventual numbers to be lower than that. For example, the Health Foundation estimates that a Scottish-style system would cost around £7.5 billion a year.
Care desperately needs sorting out, but I think the commitment to “NHS principles” risks locking us into an expensive and unsatisfactory system (which may not be sustainable for health costs either, though that’s another argument). At the margins, it could lead to crazy situations. One anecdote: a friend’s mother received continuing health care funding (available for the most seriously ill people) from the NHS for her live-in carers, plus visiting ‘domiciliary’ carers. Rather than continuing to deplete her savings at a rate of nearly £10,000 a month, friend’s mother started accumulating cash, as pension and investment income came into her bank account, without anything to spend them on (food was also supplied, through a tube, by the NHS).
It’s a mad story, but just an extreme example of what “NHS principles” could mean. Is the aim of social care reform really to take all the financial burden of paying for social care from individuals and placing it on general taxation, a huge extension of welfare provision? Or should it be about protecting people who need care from catastrophic costs (and taxpayers from catastrophic tax rises – more than 2p on the basic rate of income tax to generate £18.5 billion a year), while requiring those who can pay to make a contribution? Universalism is laudable, but it comes at a price when it protects the wealthy as much as the poor.
Since the Dilnot Commission 15 years ago, various permutations of ‘cap and floor’ have been explored to balance protection with private responsibility. Currently you receive care for free if you have assets valued at less than £14,250, and pay some costs if your assets are worth less than £23,250. These are pretty low sums (and include your house, if you have moved into a care home). Theresa May proposed raising the threshold, so that you would not have to pay care costs if you had less that £100,000 of assets. Boris Johnson’s equally unimplemented plan proposed instead a cap on costs; nobody would pay more than £86,000 over their lifetime on care.
One can quibble about the numbers (maybe both should be a bit higher?), but these approaches seem about right. Cap and floor are complementary: May’s floor protects poorer people; Johnson’s cap limits the impact for everyone. Almost anyone who has assets pays a bit, but nobody has to pay everything. Even the worst affected person (someone who starts needing care with precisely £186,000 in assets) retains more than half their wealth to pass on to the next generation. The approach still costs money, around £4 billion a year by the middle of the next decade, but is both cheaper and fairer (and the legislation is already in place).
But these, and other well-intentioned but complex proposals, have fallen foul of political sniping, wilful misrepresentation and flip-flopping changes in (Conservative) government. So you can see why Andy Burnham wants to opt for a model that people understand: “I am talking about a system that works on NHS principles because that is the only way you can make it work.”
That may make it work in presentational terms, for the purposes of a conference-eve interview, but I do hope the Prime Minister will in due course present a policy that protects people, but in way that is proportionate to their needs and to their ability to pay their own way.
