25 October 2024

Andrew Dilnot: “Social care is an insurance problem”

The former warden of Nuffield College, Oxford on the fate of his proposed reforms and an ageing population.

Shortly after the 2015 general election, the newly appointed social care minister, Alistair Burt made what he has since described as “one of the most difficult phone calls [he] had ever had to make”. The call was to Andrew Dilnot, who had led a commission four years previously which looked at how the UK might make its social care provision more equitable.

The Dilnot reforms, as they have since come to be known, included a lifetime cap on care costs and, under the coalition government, had been due for implementation in 2017. Burt’s phone call brought news the reforms would be delayed until 2020 at the earliest.

Today, almost ten years on from Burt’s “difficult” phone call and nearly 15 years since the commission, the Dilnot reforms have been delayed indefinitely. They were put on ice for the foreseeable future by the Chancellor, Rachel Reeves, at the end of July, shortly after the general election, in a move which Dilnot viscerally told BBC Radio 4’s Today programme had “failed a generation of families”. Reeves blamed a £22bn financial “black hole” left by the previous government. Speaking to Spotlight from his office at Nuffield College, Oxford – where he was the warden until his retirement at the end of September – Dilnot said: “At the time, I thought this is a tragedy, and I still think it’s a tragedy.”

For Dilnot, who has worked tirelessly as an advocate for social care reform since his time at the helm of the commission, successive governments have failed to make good on promises made to some of the most vulnerable people in society by not following through with adequate social care reform. It was not the first time, he said, that the “promise was not to be trusted”.

It was in 2010 that the incoming prime minister, David Cameron, invited Dilnot to lead what became the Commission on Funding for Care and Support. Dilnot – alongside the former health minister Norman Warner and former Care Quality Commission chair Jo Williams – set to work. “We spoke to a very wide range of people, both within the sector and outside,” Dilnot explained, “and had input from economists, political scientists and philosophers.”

Once completed, the commission offered four recommendations: a more generous means test, so that more people would become eligible for state-funded care; a cap on the lifetime amount a person might spend on social care; the continuation of the disability living allowance and attendance allowance; and a new national threshold for care eligibility, ending local variability between council areas.

The reforms were welcomed across the political spectrum. The government and the opposition, led by then Labour leader Ed Miliband, spoke warmly of Dilnot’s recommendations. But progress towards implementation was typically slow. And ultimately disappointing. Dilnot describes the coalition’s attempt at reform as a “less generous version of our proposals than we would have liked”.

The Care Act 2014 included the implementation of the lifetime cap on care and a readjustment of the means test. Both were due to come into effect in 2017. That was until Burt’s 2015 phone call. Progress since has been rocky. It encompasses Theresa May’s “dementia tax” (which Dilnot said “wasn’t at all the right way forward”) and Boris Johnson’s health and social care levy, a 1.25 per cent rise in National Insurance, which became the sole victim of Liz Truss’s infamous tax cutting mini-Budget.

But when he first outlined these proposals almost 15 years ago, did Dilnot have any inkling they would prove so difficult to enact? “I could imagine a shorter time line, but I also thought, honestly, when you take something like this, there’s probably a one in three chance it will happen,” Dilnot said. “[The new Labour government] haven’t ruled out coming back to this. That’s what I’m working on hardest at the moment.”

[See also: More cash won’t save the NHS]

Dilnot’s expertise has not always been in social care. He was previously the director of the Institute for Fiscal Studies (IFS) between 1991 and 2002, and is an economist by trade. “My main area of focus was the tax and social security systems,” he told Spotlight. “I hadn’t done an enormous amount of work on social care when I was at the IFS.” He explained he went into the commission with an “open mind”.

Now, over a decade on, Dilnot knows more than most about the extent of the crisis in social care. Successive governments have struggled to find a workable solution. Part of this, according to Dilnot, is linked to how we approach and view social care – his background as an economist is clear in this approach. “You and I are both likely to need social care before we die – 80 per cent of us will. But we have no idea how much of it we will need,” he said. “Some people will need nothing, some will need a small amount, and a small number of people will need an enormous amount. That’s an insurance problem.”

Dilnot explained that no private healthcare provider would be willing to insure that far ahead – it is simply too risky. That is why the state must step in. “The state can do this because it is something we can do together. We can change the rules so that the state can provide that risk-pooling,” Dilnot explained. This is essentially what Dilnot’s reforms aimed to do – to make care more accessible to more people by making state support more generous and available. “By doing nothing, we’re condemning those who use the sector, who work in the sector, to continued unbelievable strain.”

Indeed, despite his reforms’ rocky history, Dilnot is confident of their eventual success. The rising cost of care and increasing number of people living into old age will make change inevitable. “We talk about the burden of ageing as though it’s bad to live longer,” Dilnot said. “It’s bizarre. The alternative to living longer is being dead, which, on the whole, is not what people would prefer.”

With the government currently in a fiscal deadlock, and side-stepping key decisions over social care reform, it’s unlikely change will be imminent. But this parliament still has almost five years left to run. Dilnot remains positive. “I’m not confident that it will happen this year, or next year. But in the end, I’m confident that something with this broad characteristic will happen.”

This article first appeared in our print Spotlight report on Healthcare, published on 25 October 2024.