Dilnot Warns NHS-Style Social Care in England May Take Decades to Deliver

A universal, NHS-style social care system for England could take many years, or even several decades, to become a reality, according to Sir Andrew Dilnot, the economist who led a landmark review of the sector more than a decade ago. Speaking to BBC Radio 4's Today programme, Sir Andrew said the direction of travel set out by Prime Minister Andy Burnham suggested a system in which social care, including residential costs, would be entirely free at the point of use. He cautioned that the price tag attached to such an ambition would be "very substantial," and that the prospect of meaningful reform now appears more distant than previously implied.

Adult social care covers the state support that helps people live independently, ranging from help with washing and dressing at home to placements in residential homes. Unlike the National Health Service, however, social care in England is not free when people access it. Instead, eligibility is means-tested, and individuals with assets above a certain threshold are expected to fund their own care. That structure has left many families facing bills that can run into tens of thousands of pounds, and it is precisely this arrangement that Burnham has signalled he wants to replace.

In an interview with the BBC's Sunday with Laura Kuenssberg, Burnham outlined the principles behind his proposals, saying they would mean "everyone contributes, everyone is covered." He declined to rule out tax rises as a way of paying for the system, and promised to flesh out his vision in a conference speech on Tuesday. At the same time, he indicated that any changes would not be introduced before the next general election, because he intends to honour the commitments made in Labour's 2024 manifesto, which ruled out increases to national insurance, income tax and VAT.

The timing question is central to Sir Andrew's concern. He noted that if the proposals were to be included in Labour's manifesto for the next election, that document would not appear until 2029 — 30 years after Sir Tony Blair established a royal commission on social care, and more than 15 years after Sir Andrew's own commission published its findings. The next general election is not due until August 2029, although the prime minister could call one earlier. On that timetable, Sir Andrew said change "is now further away" than had been suggested when Burnham first promised a new national care service for England in July, shortly after taking office.

Sir Andrew's intervention reflects a long and largely unsuccessful history of attempts to overhaul the system. His own commission recommended a lifetime cap of £35,000 on the amount any individual would have to pay towards their care. The recommendation was accepted by the Conservative-Liberal Democrat coalition government led by David Cameron, but implementation was pushed back to 2020, with Cameron citing pressure on the public finances. The cap was subsequently abandoned by later Conservative governments, and the reform agenda stalled.

Other efforts met similar fates. Theresa May's government withdrew plans to require people receiving care at home to pay the full cost if they held assets worth at least £100,000, after opponents branded the policy a "dementia tax." Earlier, when Burnham served as health secretary under Gordon Brown, his proposal for a national care service envisaged funding through a compulsory contribution levied on people's estates after death. Opponents labelled it a "death tax," and the plan was shelved after Labour lost the 2010 general election.

The funding puzzle remains the biggest obstacle. The Health Foundation has estimated that a universal social care system in England, with the government covering all support, could cost around £18.5bn a year. Burnham said on Sunday that he believed the true figure would be lower, but he has not explained how he would raise the money. Sir Andrew said he thought an NHS-style system could cost "well in excess of £18bn," although he suggested a Scottish-style model might come in at roughly half that amount.

Scotland offers a partial template. There, state-funded personal care is available to all adults assessed as needing help with tasks such as eating and bathing, but accommodation, food and everyday living costs remain subject to means testing. Sir Andrew pointed out that even under the Scottish approach, people in residential care still face "very substantial bills" — precisely the outcome Burnham has said he wants to avoid. In England and Northern Ireland, people with assets worth more than £23,250, including the value of their home, are not entitled to council help with care costs, while Wales also operates a means-tested system.

The political difficulties are compounded by the question of how to pay for reform without breaching manifesto commitments. Darren Jones, a Labour MP and former minister, told Laura Kuenssberg that scrapping the pensions triple lock was "an option that the government should consider alongside others" as a way of funding social care reform. The triple lock guarantees that the state pension rises by whichever is highest of average wage growth, inflation or 2.5%, and maintaining it was also a Labour manifesto pledge — making any change politically sensitive.

Sir Andrew said he would "love to see such a scheme," in which all social care is government-funded, but warned that "the cost would become very, very large." He added that an alternative approach — capping the amount people must pay towards their own care — "could still work well for elderly people" and might prove more achievable than a fully universal system. His own proposed cap of £35,000 was intended to protect people from catastrophic care costs while still requiring some contribution.

Burnham's promise of an NHS-style system carries significant political risk as well as potential reward. By implying that social care would be "entirely free," Sir Andrew argued, the prime minister has set an expectation that would be extremely expensive to meet. With the details still to be set out, and delivery potentially pushed beyond the next election, the debate looks set to continue along familiar lines: broad agreement that the current system is unfair, deep disagreement over who should pay, and little consensus on how quickly change can be delivered.