No government in my lifetime has been dealt a worse hand than Keir Starmer’s. Austerity-broken public services, an empty Treasury, a jittery bond market freaked out by Liz Truss and then stricken by the arrival of Trump 2.0 with his bully-tariffs. Now Britain’s ally is setting the Middle East on fire in a murderous war, exploding oil and gas prices. This needs repeating regularly, lest anyone forgets the obstacles blocking this government’s best intentions for change.
One of those good intentions in the Labour manifesto was the creation of a national care service. Louise Casey, respected troubleshooter, was given a commission to review adult social care and solve its impossible dilemmas. She showed her thinking in a blistering speech last week.
With her trademark brutal honesty, she laid bare the chaos in ramshackle care services on the verge of collapse, as near-bankrupted councils fail to cope with the “seismic challenge” of soaring dementia cases. With all the wars and crises around the world, it was practically overlooked. It shouldn’t be.
Later this year comes Casey’s first report on creating a national care service out of the 18,000 mostly private providers in England, ranging from tiny family businesses to chains owned by profiteering private-equity firms. A new service will try (yet again) to bond with the NHS, ending warfare over shifting expensive responsibilities from one to the other: the NHS says that about 12,000 beds are occupied by patients fit for discharge, while councils complain that those with clear medical needs are being shunted out of the NHS and into social care.
In her letter to the health secretary, Casey says dementia should be regarded not as “an inevitable part of ageing” but as “a clinical matter”, a disease – its sufferers treated as patients “with neurological, health conditions”. That revolutionary re-categorisation would mean a gigantic shift of responsibility and funds across the divide from council care to NHS budgets.
But the administrative nightmare is the easy bit. Casey’s final report in 2028, a year before the next election, will propose how to fund social care. That killer question has defeated 22 major reviews since 1997. This is a political third rail: you touch it and you get fried. Few know much about how the care system works now. When it’s spelled out that in England those with assets over £23,250 must pay, sometimes having to sell their homes, there is outrage. Many expect care to be free, like the NHS. But it requires a lot more money – and why shouldn’t better-off older people pay for their own care?
‘Politicians dare not confront voters so abrasively.’ Louise Casey. Photograph: James Manning/PA
In 2009, the then health secretary, Andy Burnham, had an excellent plan for all with enough assets to pay a lump sum into a pool on retirement – about £20,000 – which would cover all future care needs. Contributions from those who died before needing care would cover others’ costs. No family would have to suffer a catastrophic financial outlay. The Tories immediately weaponised it as a “death tax”. Theresa May suffered a mid-election disaster in 2017 when her reasonable funding plan was similarly seized on by Labour and blow-torched as a “dementia tax”. Casey calls for cross-party agreement: can she embarrass them into better behaviour?
A decent care service needs to pay care staff NHS rates with NHS-style careers: many home care workers still earn below the minimum wage after paying their costs, Casey has found. Care can be callously inadequate and a 2024 study found that nearly 30,000 died waiting for any care at all in the prior year.
But all money-raising schemes are anathema to governments and voters. Free universal care paid from taxation would add to the huge burden of the smaller cohort of working taxpayers paying for the booming needs of the old, who all the while are sitting on property the young can’t afford. As ever, the ballooning value of housing owned by my generation, making us property-rich without trying, lies at the root of so many social dilemmas.
Here’s the barrier: the country is in no mood to pay more tax, as YouGov finds in its latest poll. At the 2024 election, only 28% thought tax and spending was too high: that has risen to 45%, with only 20% saying it’s too little. Social care is a very low priority for spending: the Kings Fund reports that just 3% put it among their top issues. Gone is the brief Covid moment when people seemed to understand the importance of its relationship with the NHS.
But here’s why Casey’s commission has a good chance of not following all the others into the “too difficult” graveyard. There’s the sheer force of her character and determination to launch a national conversation. She openly says she wants to “challenge” the general public, demanding “a mandate from the people” on who pays and “where we draw the line” on what to expect from families and the state. Politicians dare not confront voters so abrasively: she has no such inhibition over what has been such a vote-loser until now. “It is a moment of reckoning,” she warns.
She has given the government notice that she has vastly extended her remit. “If they thought I was just finding a bit of cash,” she tells me, “this past year has shown me how much further this reaches, with its mishmash of pots of funding.” Pulling on the social care string, she unravels the knitting. It can’t be resolved, she says, without reforming the “hollowing out of local government finance”, NHS provision, family wealth and housing and other fundamentals. She never does timid – and her record is formidable.
She takes as a model how the last Labour government tackled the politically “impossible” reform of public pensions. A commission of independent experts, including Adair Turner and the late John Hills, forced the public to face incontrovertible facts about the crisis ahead: the pension age was extended without French-style riots and with automatic enrolment into workplace pensions. “They, too, ignored their original remit and went much further,” she notes. She, too, has a Labour government intent on leaving a similar long-term legacy on social care.
There is no magic bullet for this problem, but if anyone can force the public to confront the cost of rescuing collapsing social care, Casey has the best chance yet – even in these difficult times.
Polly Toynbee is a Guardian columnist
Guardian Newsroom: Can Labour come back from the brink? On Thursday 30 April, ahead of May elections, join Gaby Hinsliff, Zoe Williams, Polly Toynbee and Rafael Behr as they discuss the threat to Labour from the Greens and Reform – and whether Keir Starmer can survive as leader. Book tickets here or at guardian.live
