Dr Reva Gudi is GP and healthcare leader in Hayes, Middlesex, she is also a former Conservative parliamentary candidate, and serves as a local school governor and charity trustee.
“Doctor Gudi, I’m frightened I’m going to be sick in the middle of the night. What should I do?”
My patient was elderly, frail and lived alone. She asked me this during a home visit, late one evening. Clinically, she didn’t need to go to hospital, but I knew she would struggle alone until the morning. It wasn’t really a question about the NHS. It was about growing old, and the safety net politics has promised for decades but never properly built.
I have been a GP for twenty-six years. I live in a three-generation household, with elderly in-laws, and for most of my professional life I have cared for the oldest and frailest people in my practice.
Visiting them at home, looking after them in care homes, watching what ageing does to the individual – to the husband who becomes a full-time carer, the daughter juggling work and daily visits, the son wondering how long the family savings will last – I have seen it all. I have seen the loneliness that settles over people even when family is close, and the guilt we often carry.
That is why I welcome what Andy Burnham has done this week. The headlines have focused on speculation about a so-called “death tax”, missing the more important development: the Prime Minister has not announced a funding mechanism. Instead, he is attempting to bring the main parties together, has commissioned Baroness Louise Casey to lead a national conversation, and is asking an honest question: what should social care look like, what should individuals contribute, and what should the state guarantee?
Whatever political views we hold, we should welcome that conversation. Not because anyone has found the answer, but because after decades of reports, abandoned reforms and stalemate, the country has another chance to look for one. The mistake would be to arrive only with objections.
We should arrive with solutions.
The current social care system is unfair, unsustainable and opaque, in the face of rising demand and unmet need.
England must clearly decide what social care is for, who should pay for it, and what citizens should expect in return. Instead, it has evolved into a confusing mixture of council funding, local government revenue, central grants, means testing, NHS support and unpaid family care worth an estimated £184bn a year.
The capital limit deciding whether the state helps at all has been frozen at £23,250, with a lower capital limit of £14,250, since 2010: rationing by stealth. Twenty years ago, roughly one older person in twelve received council-funded care; today it is roughly one in twenty-seven.
Nobody voted for that.
A number was simply left untouched while costs rose around it. The OBR already projects adult social care spending will climb towards 1.8 per cent of GDP in the coming decades, whether or not government names a tax to meet it.
A patient with cancer is treated free at the point of use. A patient with advanced dementia may spend their final years watching the value of their home disappear to pay for equally essential care. I struggle to explain why one illness is a collective responsibility while the other becomes a personal financial risk.
Yet the answer is not simply to ask taxpayers for more money. The state is already involved – expensively, inefficiently and opaquely – so the question is not whether government has a role, but whether it plays it well. Any lasting settlement should rest on a simple principle: people provide for themselves wherever they reasonably can. Families care for one another wherever possible, and government steps in when the risk becomes too great to bear alone. Frailty in old age is one of those risks. We are a compassionate country, and a compassionate country prices such risks honestly and pays for them in a way that lasts, rather than pretending inaction is free – much as we already insure our homes and cars. Social care deserves the same.
The debate usually presents several broad choices: general taxation, simple but competing against every other priority at each spending review; a Dilnot-style cap, protecting families from catastrophic costs but leaving gaps; a flat levy on estates, attractive-sounding but simply redistributing unfairness; and private insurance, which works for rare, unpredictable risks but has never taken root for care in old age, because those most likely to need it are those insurers are most reluctant to cover.
Rather than one imperfect model, we should take the strongest elements from each and build a statutory National Care Insurance Fund.
Contributions should come not only from earnings but also from employers, pension income above a protected threshold, income from investments and property, and a progressive supplement on larger estates – banded in addition to inheritance tax, not a flat charge regardless of size – with spousal transfers, charity exemptions, farms and family businesses protected.
Some will call this a tax on top of a tax. It is not the same tax twice: inheritance tax buys nothing in return, while this contribution buys a legally enforceable entitlement to care. Nor could it be carved from existing inheritance tax receipts, which already fund other spending, rise and fall with house prices rather than the cost of care, and at roughly £8.5bn a year would barely cover the fund alone. Younger workers alone should not carry the burden of an ageing society; broadening the base addresses intergenerational unfairness rather than entrenching it.
In return, Parliament should guarantee, in law, an entitlement to free personal and nursing care. Accommodation costs should remain, since care homes provide housing as well as care – the average English care home costs around £1,300 a week, roughly two-thirds of that is on accommodation and food rather than care itself – but those costs should be capped and tapered by income, so no family faces unlimited exposure.
That is not free care. It is guaranteed care.
I will not pretend such a settlement comes without cost. It requires higher contributions, and before asking for them, the government must show that every pound is spent wisely. After more than two decades in the NHS, I know we do not always achieve that: extraordinary clinicians deliver extraordinary care alongside duplication and organisations rewarded for activity rather than outcomes. Any new funding settlement should sit alongside an equally ambitious commitment to reform how public money is spent. The two are inseparable.
To be clear, this is not a question about whether reform is needed. The case for change is settled. It is a question of mechanism: how best to deliver care that is free at the point of need while keeping the system fair, sustainable and transparent. The proposal I outline offers a credible route. If others can demonstrate a better way of achieving the same outcomes without raising further taxes, I would welcome that debate. I have yet to see one.
Taxation, however, should never be the only answer. Government should make it easier for people to prepare for later life themselves: tax incentives for long-term care savings, encouragement for employers who wish to contribute towards future care costs, and greater recognition for unpaid family carers, who save the state billions every year.
Some reforms should not wait for Baroness Casey’s final report: updating the frozen capital limits, publishing consistent eligibility standards, and requiring councils to commission care at rates reflecting its true cost. None solves the funding challenge alone, but each would show government is serious.
Whatever else is said about this government, asking the question before naming the answer is the right order of operations. The opportunity now is a settlement that can command support across parties and survive changes of government. We have had enough reports, enough reviews, enough promises. The people I have looked after do not care whether it is described as Labour, Conservative or Liberal Democrat. They care whether it works.
I did not arrive at this from a Treasury spreadsheet, but from decades of looking after the elderly in their homes, in care homes, in conversations with families trying to do right by the people they love. People who have contributed throughout their working lives should not spend their final years wondering whether illness will cost them everything they own.
We are living longer. The chances are that you, reading this, will need care yourself one day, or will watch someone you love need it. If this generation of politicians can build a settlement based on responsibility, contribution, sound stewardship and protection against catastrophic costs, then for once the promise debated in Westminster will reach the elderly lady I visited, still wondering what she should do if she became ill in the middle of the night, and give her, and millions like her, the answer they deserve.
Dr Reva Gudi is GP and healthcare leader in Hayes, Middlesex, she is also a former Conservative parliamentary candidate, and serves as a local school governor and charity trustee.
“Doctor Gudi, I’m frightened I’m going to be sick in the middle of the night. What should I do?”
My patient was elderly, frail and lived alone. She asked me this during a home visit, late one evening. Clinically, she didn’t need to go to hospital, but I knew she would struggle alone until the morning. It wasn’t really a question about the NHS. It was about growing old, and the safety net politics has promised for decades but never properly built.
I have been a GP for twenty-six years. I live in a three-generation household, with elderly in-laws, and for most of my professional life I have cared for the oldest and frailest people in my practice.
Visiting them at home, looking after them in care homes, watching what ageing does to the individual – to the husband who becomes a full-time carer, the daughter juggling work and daily visits, the son wondering how long the family savings will last – I have seen it all. I have seen the loneliness that settles over people even when family is close, and the guilt we often carry.
That is why I welcome what Andy Burnham has done this week. The headlines have focused on speculation about a so-called “death tax”, missing the more important development: the Prime Minister has not announced a funding mechanism. Instead, he is attempting to bring the main parties together, has commissioned Baroness Louise Casey to lead a national conversation, and is asking an honest question: what should social care look like, what should individuals contribute, and what should the state guarantee?
Whatever political views we hold, we should welcome that conversation. Not because anyone has found the answer, but because after decades of reports, abandoned reforms and stalemate, the country has another chance to look for one. The mistake would be to arrive only with objections.
We should arrive with solutions.
The current social care system is unfair, unsustainable and opaque, in the face of rising demand and unmet need.
England must clearly decide what social care is for, who should pay for it, and what citizens should expect in return. Instead, it has evolved into a confusing mixture of council funding, local government revenue, central grants, means testing, NHS support and unpaid family care worth an estimated £184bn a year.
The capital limit deciding whether the state helps at all has been frozen at £23,250, with a lower capital limit of £14,250, since 2010: rationing by stealth. Twenty years ago, roughly one older person in twelve received council-funded care; today it is roughly one in twenty-seven.
Nobody voted for that.
A number was simply left untouched while costs rose around it. The OBR already projects adult social care spending will climb towards 1.8 per cent of GDP in the coming decades, whether or not government names a tax to meet it.
A patient with cancer is treated free at the point of use. A patient with advanced dementia may spend their final years watching the value of their home disappear to pay for equally essential care. I struggle to explain why one illness is a collective responsibility while the other becomes a personal financial risk.
Yet the answer is not simply to ask taxpayers for more money. The state is already involved – expensively, inefficiently and opaquely – so the question is not whether government has a role, but whether it plays it well. Any lasting settlement should rest on a simple principle: people provide for themselves wherever they reasonably can. Families care for one another wherever possible, and government steps in when the risk becomes too great to bear alone. Frailty in old age is one of those risks. We are a compassionate country, and a compassionate country prices such risks honestly and pays for them in a way that lasts, rather than pretending inaction is free – much as we already insure our homes and cars. Social care deserves the same.
The debate usually presents several broad choices: general taxation, simple but competing against every other priority at each spending review; a Dilnot-style cap, protecting families from catastrophic costs but leaving gaps; a flat levy on estates, attractive-sounding but simply redistributing unfairness; and private insurance, which works for rare, unpredictable risks but has never taken root for care in old age, because those most likely to need it are those insurers are most reluctant to cover.
Rather than one imperfect model, we should take the strongest elements from each and build a statutory National Care Insurance Fund.
Contributions should come not only from earnings but also from employers, pension income above a protected threshold, income from investments and property, and a progressive supplement on larger estates – banded in addition to inheritance tax, not a flat charge regardless of size – with spousal transfers, charity exemptions, farms and family businesses protected.
Some will call this a tax on top of a tax. It is not the same tax twice: inheritance tax buys nothing in return, while this contribution buys a legally enforceable entitlement to care. Nor could it be carved from existing inheritance tax receipts, which already fund other spending, rise and fall with house prices rather than the cost of care, and at roughly £8.5bn a year would barely cover the fund alone. Younger workers alone should not carry the burden of an ageing society; broadening the base addresses intergenerational unfairness rather than entrenching it.
In return, Parliament should guarantee, in law, an entitlement to free personal and nursing care. Accommodation costs should remain, since care homes provide housing as well as care – the average English care home costs around £1,300 a week, roughly two-thirds of that is on accommodation and food rather than care itself – but those costs should be capped and tapered by income, so no family faces unlimited exposure.
That is not free care. It is guaranteed care.
I will not pretend such a settlement comes without cost. It requires higher contributions, and before asking for them, the government must show that every pound is spent wisely. After more than two decades in the NHS, I know we do not always achieve that: extraordinary clinicians deliver extraordinary care alongside duplication and organisations rewarded for activity rather than outcomes. Any new funding settlement should sit alongside an equally ambitious commitment to reform how public money is spent. The two are inseparable.
To be clear, this is not a question about whether reform is needed. The case for change is settled. It is a question of mechanism: how best to deliver care that is free at the point of need while keeping the system fair, sustainable and transparent. The proposal I outline offers a credible route. If others can demonstrate a better way of achieving the same outcomes without raising further taxes, I would welcome that debate. I have yet to see one.
Taxation, however, should never be the only answer. Government should make it easier for people to prepare for later life themselves: tax incentives for long-term care savings, encouragement for employers who wish to contribute towards future care costs, and greater recognition for unpaid family carers, who save the state billions every year.
Some reforms should not wait for Baroness Casey’s final report: updating the frozen capital limits, publishing consistent eligibility standards, and requiring councils to commission care at rates reflecting its true cost. None solves the funding challenge alone, but each would show government is serious.
Whatever else is said about this government, asking the question before naming the answer is the right order of operations. The opportunity now is a settlement that can command support across parties and survive changes of government. We have had enough reports, enough reviews, enough promises. The people I have looked after do not care whether it is described as Labour, Conservative or Liberal Democrat. They care whether it works.
I did not arrive at this from a Treasury spreadsheet, but from decades of looking after the elderly in their homes, in care homes, in conversations with families trying to do right by the people they love. People who have contributed throughout their working lives should not spend their final years wondering whether illness will cost them everything they own.
We are living longer. The chances are that you, reading this, will need care yourself one day, or will watch someone you love need it. If this generation of politicians can build a settlement based on responsibility, contribution, sound stewardship and protection against catastrophic costs, then for once the promise debated in Westminster will reach the elderly lady I visited, still wondering what she should do if she became ill in the middle of the night, and give her, and millions like her, the answer they deserve.