Dilnot: social care commission should report by end of 2025, not 2028

The new commission on social care reform should deliver final proposals by the end of this year, not by 2028, as planned, according to the author of the last major review of the sector.

Andrew Dilnot told MPs that a host of challenges facing people who need care, families, care staff, councils, providers and the NHS had gotten worse because of a failure to reform the system since his commission reported in 2011.

The economist was speaking to the House of Commons’ health and social care select committee in the wake of the government’s announcement of a commission – headed by Baroness (Louise) Casey – to draw up proposals for adult social care reform.

Casey, a former senior civil servant who has led several other public service reviews in recent years, is due to issue an initial report next year and her final conclusions by 2028, a timeframe heavily criticised by sector leaders.

Casey ‘should report by end of 2025’

Dilnot, who led the last social care commission, in 2010-11, said Casey should be able to deliver her recommendations by the end of this year, and would only be prevented from doing so by a lack of political will from government.

“I think Louise Casey will very quickly work out what needs to be done,” said Dilnot. “And I think she should say what needs to be done as quickly as possible…I think it would be perfectly feasible for the government to expect by the end of 2025, [to be able to say] ‘actually, we know what needs to be done’.”

He added: “It really is a matter of political courage and political decision-making. We know things can happy very quickly once a government, a House of Commons, decides to get something done.”

What Dilnot recommended

Dilnot’s 2011 report made two key recommendations:

• Increasing funding for the existing means-tested system, to address unmet and under-met need.
• Extending the means-test to enable more people to take advantage of state-funded care and capping people’s total costs for their personal care, to insure the population against catastrophic care costs.

The first recommendation fell foul of the austerity policies of the 2010s, but the coalition government legislated to enact the second through the Care Act 2014. However, its implementation, due in 2016, was first delayed and then ditched altogether by the Theresa May government.

It was then revived in modified form, in 2021, under Boris Johnson, but its implementation was delayed again before the plan was scrapped by the current Labour government on attaining power last year.

Dilnot’s list of costs of failing to reform social care

Dilnot said the priorities for reform remained the same but the need to take action had become more urgent since his report, listing several costs arising from a failure to act:

1. The potentially large and unknowable costs faced by individuals. “I’ve often likened needing social care to being in a shop with no prices,” said Dilnot. “Because you know how much it will cost each week or month for your partner, your mum or your grandma to be looked after, but you don’t know how long it’s going to go on for.”
2. Self-funders paying more for their care than local authorities.
3. People having to build up savings in case they need a lot of care. “80% of 65-year-olds will need social care before they die, but the amount they will need is unknowable and most of them actually won’t need very much and a small number will need an awful lot,” Dilnot said. “But in the current system all of them are faced by needing to set aside a lot of money in case they are one of the unlucky ones. So, a significant cost of inaction is that many people, not with especially large amounts of income and wealth, are setting aside money that they won’t actually need because there is no pooling of the risk.” 
4. Premature loss of function and loss of life arising from unmet need.
5. The difficult decisions families face about, for example, making home adaptations now or saving money should a loved-one need care in future.
6. The impact of informal care on people’s ability to work and function.
7. The direct effects on the NHS of inadequate social care. “If you are an elderly person with significant social care needs, you’re very likely to have some continence challenges,” Dilnot said. “That’s quite likely to lead, if you don’t have a downstairs loo, to you falling down the stairs and ending up in hospital unnecessarily.”
8. The indirect impact on the NHS. “Because there isn’t good social care that we can get people into when they need to leave the NHS, we have NHS hospitals that have many people in them who don’t need to be there,” said Dilnot. “The frustration that causes to clinicians is extraordinary.”
9. The impact on providers. “The lack of a functioning market means that there are very low returns to innovation and investment and so not much innovation and investment going on,” said Dilnot. “[Providers] are squeezed – we have endless stories of providers handing their contracts back to local authorities because they simply can’t make things work…This could be an area where we could see economic growth if we had a sensible model. We don’t so we can’t.”
10. The impact on care staff. “Staff are under really intense pressure and are not paid enough and have every few opportunities for career progression,” Dilnot added. “All of that is a function of the model we have.”
11. The impact on local authorities. “The inadequate funding of social care means all other services that local authorities provide are being squeezed and the decisions that local authority staff are asked to make would try the wisdom of Solomon,” he told MPs. “If any of you wants to experience a really stressful period, go and sit alongside somebody who is making decisions in a local authority about how to allocate resources to people who desperately need care.”

Asked by MPs why his reforms had not been implemented, Dilnot said: “Somehow, for reasons I don’t quite understand, not enough people make enough noise about [social care], so it feels like an easy thing to pull back on.”

He added that, while there had been consensus on what needed to change in social care, there had not been sufficient agreement on how this would be paid for.

‘Tiny amounts of money’ required to reform care

This is despite spending on adult social care – roughly £30bn a year currently – amounting to just 2% of total public spending – and the reforms that Labour scrapped last year being due to add a further £5bn a year to costs over the long-term. This compares with a £22.6bn increase in annual NHS funding, from 2023-24 to 2025-26, announced by Labour last year.

“So these are tiny amounts of money compared to overall levels of public spending and very small amounts of money compared to the amounts of money that have been added, with enormous support, to the health service budget,” he added.

Dilnot said that, while improvements to the current means-tested system should be funded through general taxation, there was a case for exploring a different way of resourcing an expansion of people’s entitlements to social care.

He said the health and social care levy – a 1.25 percentage point supplement to national insurance, introduced by the Boris Johnson government, in part to fund social care reform, but then scrapped under Liz Truss – was “quite an interesting idea”.

“I think that one of the things that Baroness Casey will undoubtedly want to look at is whether there’s an argument for something like that,” Dilnot added.