As a former adviser on social care reform to a Conservative prime minister, allow me to explain why Andy Burnham’s proposals on the issue – which I don’t know about, since he hasn’t revealed them – are wrong. Hints have been dropped, and a speech is planned for Wednesday.
Burnham is committing himself to tackling the problem that brought David Cameron to my ward at the John Radcliffe Hospital in Oxford. He came in response to concern from a Witney constituent about delayed discharges. As ever, more than half my ward was occupied by patients termed ‘medically fit for discharge’. They were in hospital beds because the queue for carers at home, or for a care home bed or other supported accommodation, was long.
Most of my patients are the frail elderly, so I work on wards that see more of these delays than most. Across acute hospitals in England, roughly one bed in nine is occupied by someone with no medical need to be there but who cannot be immediately discharged elsewhere. Back when Cameron visited, the figure was about one in 40.
Making social care free would not make it abundant
Social care was seen as a terrible problem even in those sunnier years. Gordon Brown had appointed Burnham as Secretary of State for Health. His proposals were bold. He set out a vision for a National Care Service (NCS) much like the NHS, with personal care free at point of delivery for all. One of the proposed funding mechanisms was gleefully seized upon by his opponents as an additional death tax. In the general election that soon followed, Labour lost.
If Burnham is serious about tackling the ever-growing problem of social care, its costs and its availability, then you have to respect his courage. Even if you expect his tenure to do a great deal of damage to the country before imploding as rapidly as Starmer’s.
One can admire a man’s courage without admiring his sense. And there is every suggestion that Burnham’s approach to social care will be calamitous. When he was health secretary, the NHS was still generally lauded, and his idea of an NCS was politically disastrous even then. Resurrecting it now, when the NHS is widely seen as failing, even by those on the left, is no obvious winner.
Burnham seems determined to accelerate the Casey review, hoping it will provide the architecture for a service operating on what he calls the ‘NHS principle’. There is much to be said for a cross-party settlement, but little reason to expect one.
Fundamentally, the country must decide whether it wishes to follow a Scandinavian model, with the state providing ever more, and taxes rising ever higher to match, or an alternative where costs also fall on individuals and their families. Japan and Germany do better than us by pooling risk through compulsory insurance, limiting benefits and requiring individual contributions. My bias is obvious: I believe outcomes follow incentives. This is a conservative viewpoint, the modern left-wing one being that incentives don’t matter as much as kindness and decency, a faith in which I was once fully invested as a young member of the Labour party.
Making social care free would not make it abundant. Rationing by price would simply be replaced with rationing by queue, with the inevitable added bureaucracy and endless political fights over funding ever-rising demand.
The physicist Wolfgang Pauli was once asked to give his opinion on a junior colleague’s work. He read their paper, and concluded that it was not even wrong. Thus far Burnham has done little of substance: nothing good enough to be wrong on any national scale, unless you count his willingness to avoid the big issues. Wednesday may change that. A separate proposal to exempt existing care workers from tighter settlement rules already indicates where one pressure point lies: a care system that cannot staff itself without migrant labour. His own party has promised to restrict immigration, which polling shows is now the wider public’s greatest concern.
Burnham cannot make reforms to social care – he cannot even suggest them – without provoking some of his own backbenchers, whether by new taxes or new charges. Come Wednesday Burnham might say very little, postponing the moment when he must make more open enemies in his own party. We are likely to see more clearly what Burnham the prime minister is made of, and even those of us who suspect the answer will be very bad indeed for Britain must hope that we are somehow wrong.
In the meantime, I would like to remind Cameron that some 15 years ago, strolling down my ward in his suit without observing the NHS’s rule about arms being bare below the elbows, he asked my advice about how to fix delayed discharges in the NHS. ‘Fix social care,’ I explained. When he asked how, I said he must have lots of people working for him with good ideas.
A further 15 years of life has not enhanced my estimate of my own ideas, but it has certainly diminished my faith in those of politicians and civil servants. That incentives shape outcomes is a basic and much-ignored truth. Little would demonstrate its neglect more clearly than building a National Care Service in the image of our failing NHS.
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