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

A sweeping proposal to remake adult social care in England along the lines of the National Health Service could take many years, or even several decades, before it becomes a reality, according to the economist who led the last major attempt at reform. Sir Andrew Dilnot, who chaired a commission that recommended overhauling the system 15 years ago, told the BBC that the timeline now appears longer than previously suggested, and that the political focus has shifted to an even more ambitious vision than the one he once put forward.

Speaking on BBC Radio 4's Today programme, Sir Andrew said Prime Minister Andy Burnham seems to want social care to be entirely free at the point of use, including the cost of residential care. He cautioned that the price tag for such a system would be "very substantial," and noted that because Burnham intends to seek a mandate from voters at the next general election, meaningful change "is now further away" than the government has implied.

Adult social care covers state support that helps people live more independently, ranging from help with washing and dressing at home to care in a residential setting. The crucial difference from the NHS is that social care in England is not free when people need it. Instead, it is means-tested, which means many older and disabled people are left to pay large bills themselves, in some cases selling their homes to cover the cost of care. That divide between a free health service and a charged care system has been the central grievance driving reform efforts for more than two decades.

Burnham, who became prime minister in July, first promised a new national care service for England in a speech shortly after taking office. In an interview with the BBC's Sunday with Laura Kuenssberg, he suggested his plans would mean that "everyone contributes, everyone is covered," and he declined to rule out tax rises to pay for the scheme. He said he would set out more detail in his conference speech on Tuesday, but also indicated that any changes would not be implemented before the next general election, because he wants to honour the commitments made in Labour's 2024 manifesto.

That manifesto included a pledge not to raise national insurance, income tax or VAT, which severely constrains how a new universal care system could be funded. The next general election is not due until August 2029, although Burnham could call one earlier. Sir Andrew pointed out that if social care proposals are ultimately written into a Labour manifesto for that election, the timetable would fall 30 years after Sir Tony Blair launched a royal commission on the subject, and more than 15 years after his own commission reported its findings. The repeated delays, he argued, illustrate how difficult it has been to turn consensus on the need for reform into action.

The funding question took a new turn when Labour MP and former minister Darren Jones told the BBC that scrapping the pensions triple lock was "an option that the government should consider alongside others" as a way to pay for social care reform. The triple lock guarantees that the state pension rises each year by whichever is highest: average wage growth, inflation, or 2.5 percent. Keeping it in place is itself a Labour manifesto commitment, so any move to abandon it would carry significant political risk, particularly among older voters who rely on the pension as their main source of income.

Under the current system 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. Wales also operates a means-tested system. Scotland is different: 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 are still means-tested. Sir Andrew said that even a Scottish-style model would leave people in residential care facing "very substantial bills," which is precisely the outcome Burnham says he wants to avoid.

The Health Foundation has estimated that a universal social care system in England, with the government funding 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," though a Scottish model might come in at roughly half that amount. He added that he would "love to see such a scheme," but warned that "the cost would become very, very large."

Sir Andrew also argued that a system in which the amount people must contribute towards their own care is capped "could still work well for elderly people." His own commission proposed a lifetime cap of £35,000 on care costs, a recommendation accepted by the Conservative-Liberal Democrat coalition government led by David Cameron. However, implementation was pushed back to 2020, with Cameron citing pressure on the public finances, and the cap was eventually abandoned by later Conservative governments. The episode has become a symbol of how reform proposals in this area have repeatedly stalled.

Other attempts have met similar fates. Theresa May's Conservative government dropped plans to make people receiving care at home pay the full cost if they had assets worth at least £100,000, after opponents branded the policy a "dementia tax." Earlier, when Burnham served as health secretary in Gordon Brown's government, his proposal for a national care service suggested funding it through a compulsory contribution from people's estates after death. Opponents labelled that a "death tax," and the plan went no further after Labour lost the 2010 general election.

The history matters because it shapes how the current proposal is likely to be received. Any system that spreads the cost of care across the population raises questions about who pays, how much, and when, and those questions have repeatedly proved politically toxic. Burnham's approach appears designed to avoid naming a specific funding mechanism until after an election, while still signalling a universal entitlement. Whether that strategy can survive contact with the Treasury, the electorate and the passage of time is the central unanswered question.

For families currently navigating the care system, the practical consequences of delay are immediate. People who need support often find themselves means-tested, negotiating a fragmented market of private and council-funded providers, and facing the prospect of losing savings or property to pay for care. Sir Andrew's warning that an NHS-style system could be decades away suggests that the gap between the health service and social care, which many campaigners regard as unfair and arbitrary, is unlikely to close soon. His comments also imply that the ambition set out by Burnham may be harder to deliver than the prime minister has suggested.

What happens next will depend largely on the details Burnham sets out in his conference speech and on whether Labour is willing to revisit its tax and pension pledges. Darren Jones's intervention on the triple lock shows that some within the party are already looking for ways to fund reform, even if that means reopening difficult manifesto commitments. Sir Andrew, for his part, remains a supporter of universal care in principle, but his message is one of caution: the goal is desirable, the cost is enormous, and the political path remains as uncertain as it was 15 years ago.