The Promise That Never Comes
In July 2021, Boris Johnson stood at a podium in the House of Commons and declared that he had a plan to fix social care — a plan that had eluded every prime minister since Tony Blair. He called it a landmark reform. He promised it would mean no one would ever again have to sell their home to pay for care. He gave it a funding mechanism: a 1.25 percentage point rise in National Insurance, later rebranded as the Health and Social Care Levy.
Photo: Boris Johnson, via cdn.mos.cms.futurecdn.net
By October 2022, the care cost cap — the central plank of that reform, lifted almost wholesale from the Dilnot Commission's 2011 recommendations — had been delayed until 2025. By January 2023, under Rishi Sunak, it was delayed indefinitely. The levy itself was reversed before it had meaningfully reached the care sector. The plan that would fix everything had, like every plan before it, quietly dissolved.
This is not a story about one government's failure. It is a story about the structural impossibility of social care reform under the current political economy — and about the real human beings left to absorb the consequences of that impossibility year after year.
What the Dilnot Commission Actually Said
Andrew Dilnot's 2011 commission produced one of the most thorough and reasonable pieces of social policy analysis in recent British history. Its central recommendation was elegant in its simplicity: cap the lifetime amount any individual would be required to contribute to their own care costs — originally proposed at £35,000, later revised to £86,000 under the Johnson scheme — after which the state would assume responsibility. The principle was insurance: spreading the catastrophic, unpredictable cost of care across the whole population rather than concentrating it on the unlucky few whose needs turned out to be severe.
Photo: Andrew Dilnot, via assets.publishing.service.gov.uk
Dilnot estimated the cost at between £1.7 billion and £3.6 billion annually — significant, but not extraordinary in the context of a national budget measured in hundreds of billions. He described it as affordable. Independent analysts broadly agreed. The policy sat on shelves through the Cameron, May, and Johnson governments, surfacing periodically as a manifesto commitment before being quietly reburied by Treasury opposition and political timidity.
The Johnson cap, when it finally arrived, had been watered down in ways that disproportionately disadvantaged those with fewer assets — precisely the people the original proposal was most intended to protect. Under the revised scheme, means-tested local authority contributions would not count toward the cap, meaning that poorer recipients would effectively never reach the threshold at which the state took over. The reform had been hollowed out before it was even implemented, and then cancelled before it could be tested.
The Means-Testing Catastrophe
In the absence of reform, the existing system has continued to impose its brutal logic on hundreds of thousands of families every year. In England, anyone with assets above £23,250 — including the value of their home — is required to fund their own residential care in full. The average annual cost of a care home place now exceeds £40,000; for nursing care, it frequently surpasses £55,000. The average length of stay before death is approximately two and a half years.
The arithmetic is unsparing. A family home worth £300,000 — modest by London and South East standards, significant elsewhere — can be consumed by care costs within five to seven years of a parent entering residential care. The wealth that a working-class family spent a lifetime accumulating, often the only substantial asset they possessed, is transferred not to their children but to the care sector — frequently to the private equity-backed care home operators who have come to dominate the market.
This is not a fringe experience. Age UK estimates that approximately 40,000 people a year are forced to sell their homes to fund care. The emotional and financial devastation this causes to families is poorly captured by statistics. It is experienced as a kind of double bereavement — the slow loss of a parent to dementia or physical decline, accompanied by the simultaneous loss of the family home that represented security, continuity, and identity.
The Workforce Nobody Wants to Talk About
The political debate about social care focuses overwhelmingly on funding and on the asset-protection interests of middle-class families facing care costs. What receives far less attention is the workforce that delivers that care — and the conditions under which they do so.
There are approximately 1.5 million people working in adult social care in England. The majority are women. A disproportionate share are from Black, Asian, and minority ethnic backgrounds, and a significant proportion are migrants. Their median hourly wage hovers fractionally above the National Living Wage — lower, in real terms, than supermarket shelf-stackers in many parts of the country. Zero-hours contracts remain prevalent. Travel time between home visits is frequently unpaid. Staff turnover in the sector runs at approximately 28 per cent annually — a figure that reflects not individual fecklessness but the rational response of workers who can earn more and be treated better almost anywhere else.
The consequence is a chronic staffing crisis that directly degrades the quality of care received by the elderly and disabled people who depend on the sector. Care workers who are overworked, underpaid, and undervalued cannot deliver the attentive, dignified, personalised care that good social care requires. This is not a moral failing of individual workers — it is the systemic output of a sector that has been systematically undervalued because its workforce lacks the political leverage to demand otherwise.
A genuinely reforming government would recognise social care as skilled work, establish a national pay framework that reflects that, and fund it accordingly. The Nuffield Trust and others have estimated the cost of professionalising and fairly remunerating the care workforce at several billion pounds annually. It is a cost that, set against the social value of the work, is transparently worth bearing. It is also a cost that no government has yet been willing to impose on the tax base.
Why Reform Is Structurally Almost Impossible
The political economy of social care reform is, on honest examination, extraordinarily unfavourable. The people who most need reform — elderly, often cognitively impaired, frequently isolated — are among the least politically powerful actors in British society. Their families, though numerous, are diffuse and not organised as a lobbying force. The care workforce, predominantly female, migrant, and low-income, has limited industrial power.
Against these weak interests sit formidable structural obstacles. The Treasury's perennial resistance to long-term spending commitments. The private care sector's interest in maintaining a system that generates reliable returns on invested capital. The political toxicity of any tax increase that can be framed as a burden on working people. And the fundamental difficulty of a policy whose benefits accrue slowly and diffusely — preventing future catastrophe — while its costs are immediate and visible.
Labour has spoken about social care reform in careful, measured terms. The government's planned review of the sector is welcome as far as it goes. But the history of such reviews — Dilnot was himself a review; the Care Act 2014 was a response to a review; every parliament since 1999 has commissioned or received a review — suggests that another process of deliberation, however well-intentioned, is unlikely to break the cycle unless accompanied by a political commitment to implement whatever it recommends, regardless of Treasury resistance.
That commitment requires political courage of a kind that has been conspicuously absent from this debate for a quarter of a century.
Social care reform has been promised by every government and delivered by none — and until Westminster treats the dignity of elderly and disabled people as a non-negotiable political priority rather than a fiscal inconvenience, the families forced to sell homes and the workers paid poverty wages will keep paying the price for that cowardice.
