Donning the Cap?

Social care for older people is one of those issues that every political party professes to care about, but none is willing to tackle. At election times, it is ritually acknowledged as important, then sidelined by voters and politicians alike.

The one exception to this was the 2017 election, when Theresa May's Conservative Party had a rare moment of political courage and came up with a proposal that was at least rational and and thought through. They were duly punished, for reasons which we'll come back to, and which probably explain the timidity across the spectrum.  This time round main parties' manifestos are artfully evasive - all but conspiring to avoid the subject - but point the way to a possible consensus in the next Parliament.

Before considering the parties' proposals, such as they are, it is worth looking at how social care operates at the moment. Unlike the NHS, the glamorous sibling that carries us through critical moments of our life and is never far from TV screens whether in dramas, documentaries or new bulletins, social care for the elderly lurks in the shadows. It's one of those things best not known about it, until you have to learn a lot in a hurry (I have, so this rant is all a bit parti pris).

Care today, gone tomorrow
If an older person needs help living in their own home, with everything from moving around, to washing and dressing, to using the loo, the local council's social services department will appoint carers to visit up to four times a day to help out with those tasks ('domiciliary care'). If needs are more severe, you may have to go into a care home, or a nursing home with more specialist medical staff.

Costs mount up quickly: four visits a day can cost £400-500 per week (£26,000 a year), while residential care can cost twice as much. And, if you have capital assets above £23,250, you will have to meet those costs (or make your own arrangements). If you have less than £14,250, the council will pay all your costs. If you are receiving care at home, and own that home, you won't have to include that in your assets; but if you are in a care home, it will be included, unless you have a partner or dependents living there.

There is one big exception to all this - 'continuing health care' (CHC). A 1999 court decision held that all the care needs of a particular severely disabled adult were in essence 'health care' needs, and should therefore be funded in full by the NHS, at home as much as they would be in hospital.  CHC is a big cost for the NHS, more than £3 billion per year, and getting it involves an undignified argument about precise levels of enfeeblement with clinical commissioning groups who will fight hard to avoid assessing patients as eligible.

The inequitable split between means-tested social care and universalised health care was one of the things that sunk Mrs May's modest proposal in 2017. She proposed that people would be required to pay for social care until their assets reached £100,000 - a much higher threshold than currently, but this time including the value of property (which would not have to be sold until after death). But why should someone with dementia have to impoverish themselves - or rather eat into their children's expected inheritance - while someone with cancer would receive their treatment free, the critics asked? Dementia Tax, they shouted! After that, the deluge, a hung Parliament, and all the fun that has ensued.

Caps and consensus
Which brings us to the parties' manifestos this time round. The Conservatives' is triumphantly vague, allocating around £1 billion a year extra to budgets for adult social care (currently just over £21 billion), and promising to build a consensus for reform.

Beyond that, there is a promise that "nobody needing care should be forced to sell their home to pay for it". As discussed above, there are only a few circumstances today where people are forced to sell their homes, and giving the same exemption to a £50 million mansion as to a £50,000 flat seems a little arbitrary.

The Daily Mail, which has campaigned vigorously against people being forced to sell their homes, might be more enthusiastic about the Labour Party's plans for universally free personal care for over-65s (except, you know, socialism, Corbyn etc). But Labour's plans are themselves unclear: the  Manifesto promises a 'National Care Service' providing free personal care to the over-65s - but then talks, confusingly, about eligibility criteria and lifetime cap of £100,000 on individuals' payments towards their care.

The idea of a cap on costs goes back to the 2011 Dilnot Commission, which recommended a cap on lifetime costs of around £35,000. It certainly makes more financial sense than universal free provision, which has been priced at £6 billion a year. The fact that Labour's spending plans show the cost of social care reform as £2 billion suggests that capping costs, rather than free provision, is the real plan.

It is one idea that might even attract cross-party support. The coalition government's 2014 Care Act provided for a cap to be set, and a cap of £72,000 was proposed for 2020, but the idea has been quietly dropped, as the long-awaited Green Paper on Social Care continues to be, erm, awaited. The idea of a cap also appears in the Liberal Democrat manifesto, bashfully buried at the end of a waffly paragraph about 'sustainable' and 'joined-up' funding.

A cap is essentially a form of social insurance: we don't know whether we will need care when we get older, so the state insures us, but will levy an 'excess' of up to £100,000 from those who can afford it.  It is perhaps more surprising to find such a measure in a Labour manifesto. On its own a cap is deeply regressive, hitting the poorest hardest, while allowing the rich to retain the bulk of their wealth. Admittedly, the Dilnot Review recommended that the cap be combined with a means-tested threshold, so people would not have to pay anything if they had less than £100,000 in assets (as reflected in Mrs May's fateful 2017 proposal).

Such a cap and threshold approach would protect the poorest, but still privilege the rich over the moderately wealthy. While 30 per cent of people leave less than £100,000, so would be not have to pay anything towards care costs, 55 per cent of people leave between £100,000 and £500,000, so would take a significant hit. It might not be as much as they would pay without a cap, but voters may not see it like that: nobody plans to lose in the lottery of long-term care.

The parties' proposals leave a lot of issues unaddressed. The quality of care provided by carers rushing from appointment to appointment can be highly variable, and the working conditions and pay are so poor that the profession tends to attract the dedicated or the desperate. In much of the UK, care agencies are dependent on workers from overseas, so Brexit and a change in the immigration regime may be an additional threat. But half-hidden within the parties' manifestos is the germ of a consensus, a potential route through the treacherous terrain of funding services that few of us plan to use, but most of us will.