From Dilnot to the Dementia Tax

Why social care reform keeps going wrong

10 June 2026, Green Templeton College

Download the slides for this talk

Simon Bottery’s lecture, which was followed by audience discussion in person and online, discussed some of the findings of his 2026 report with Dan Wellings for the King’s Fund: ‘Not my priority: How the public sees social care (and what can be done about it)’. The report pulls together and analyses existing data on public perceptions of adult social care in England, highlighting the apparently paradoxical truth that, while there is widespread dissatisfaction with the current system, there is also very little public pressure for reform, while plenty of precedents in the last fifteen years demonstrate that attempts to improve care provision carry a high risk of failure and unpopularity for any political leader who advances them.

The existing social care system does not match what most people say they want. Studies have indicate that a large majority of people in the UK believe that the balance of responsibility for paying for adult social care should rests more with the state than the individual.[1] However, the UK system is unusual internationally for the strictness of its means testing, and for requiring that adults who don’t meet the threshold for support pay all their care costs.

Perhaps unsurprisingly in these circumstances, public satisfaction with social care has declined  sharply in the last twenty years. However, regularly collected data from the Ipsos Issues Index shows that this dissatisfaction has never translated to a widespread sense that social care is a high-priority issue for the public. Asked to list the issues which they consider the most important (without any suggestions or prompts), only between 1 and 10% of people surveyed typically raise social care. Even at moments when the care system is in the headlines, this proportion has never been higher that 20%.

If it seemed likely in 2020 that the disastrous situation in care homes caused by the Covid-19 pandemic would shake off apathy and drive public demand for system reform, this did not happen. Attention to social care during and after the pandemic has been limited, and quickly diverted to other issues, such as the NHS, the economy, immigration.

The first part of the lecture outlined multiple connected factors associated with this lack of attention. First, the general population is not well-informed about the current social care system. What Prof. Mary Daly in her comments on the lecture labelled ‘care literacy’ is not widespread outside of practitioners and researchers. Only a small percentage of the population (around 3%) are users of care services at any given moment, and the subject has associations with ageing and death which make it a difficult or unappealing topic to many people. An audience member suggested that, in addition, conversations around care are sometimes suppressed by taboos or discomfort around money and inheritance.

Most people get their information about care secondhand from friends and family, or from the media, and so these taboos and silences lead to important misconceptions. In particular, a significant proportion of the UK public—around a third—believe that legal responsibility for paying for adult social care rests with the state, and that care is free at the point of need. A similar proportion think that social care services are provided by the NHS. The impression is widespread that social care is primarily about personal care for vulnerable older people when, in fact, half the national cost of social care goes on the care of working-age adults. Simon made the point that progressive principles highlighting ‘outcomes, choices, control’ for people, which are established and familiar in the legislation and the field of provision, are unfamiliar and opaque to the public.

The Q&A at the end of the talk raised further specific limitations regarding the capacity of directly experienced voices to be heard in public discussions on social care. For example, the point was made that service users are disproportionately likely to be vulnerable or near the end of their lives, and so are less likely to become activists as a result of their experiences than, say, people who have experience of maternity care. While Simon and others suggested that carers and care workers could be mobilised to draw attention to the issue, one audience member commented that people working in the care field are often first- or second-generation immigrants to the UK or precarious workers, and that this may reduce their power and resources to influence public debate.

In this low-information, secondhand discourse, Simon explained, the way people hear about care systems and reform may help to push these issues down their list of priorities. Simon’s analysis of Ipsos Issues Index data since March 2011 indicates that any ‘peaks’ (which never go beyond a low level) in the public’s prioritisation of social care are largely driven by national political activity, such as government reports and proposals for reform. Crucially, these are overwhelmingly presented to the public in terms of costs and funding: who is going to pay for care, and how? This framing of reform is immediately contentious, particularly for those who believe the existing system to be significantly more generous to individual care users than it actually is. The long history of trumpeted and then abandoned proposals for reform in the UK, as well as, he suggested, the overuse of a language of ‘crisis’ for too long a period, may also have encouraged a sense of fatalism about adult social care: the public does not perceive it as an issue that can realistically be addressed by government.

All this makes political leaders perceive social care reform as politically costly, even if they recognise it as good policy and even as popular in the abstract. Simon quoted the Former Secretary of State for Health and Social Care, Wes Streeting, as expressing a general consensus: “general election campaigns are where plans for social care go to die”.

Simon acknowledged the depressing picture painted by this research, but in the second half of the lecture highlighted some possible routes to change. These, he argued, could take three possible forms: public pressure; the reframing of adult social care as the solution to another, more highly prioritized, issue (as in Japan, where care reform has been motivated by the desire to get informal family carers into the paid workforce); or as the result of strong personal leadership by an individual person in power. He focused on the first of these.

Stimulating public demand for care reform seems a distant prospect but Simon pointed out that there are signs of a large ‘warm’ constituency who might be converted into more actively pushing for change. Although people rarely identify care as a high-priority issue unprompted, many will select it from among a list of suggested issues. That is, people do care about care, although it is not at the front of their minds. This warm constituency is likely to include the relatively large number of people who have some experience of the social care system:  the professional care workforce, informal carers and families of care users. As one audience member pointed out, an increasing number of people are caring for family members, and it may be possible to “tap in to the public’s increasing experiences of having to care for their family themselves, and the lack of support they experience with this”.

Simon’s recommendation is for a change in how people and institutions within the care field talk about social care reform, to make a narrower, and thus more credible, case for change which engages with the public’s existing knowledge, feelings and priorities. This, for Simon, means moving away from language and concepts which are inaccessible to people outside the field, and towards:

• A focus on tangible things: the equivalent of ‘more nurses’ or ‘new hospitals’ for the NHS.
• A focus on benefits rather than costs and payment systems.
• Building on (real and perceived) links between social care and the NHS, which is a much more prominent public priority. Discussion following the lecture picked up the wider relationship between care and the NHS and the need to ensure that the NHS sees social care as more than ‘discharge facilities’. Reference was also made to the possible impacts of change within the NHS, including the Ten Year Health Plan and its shift from emphasis on treatment to prevention.
• Using metaphors and other language for talking about social care which are meaningful to the wider public: Simon was critical of the language of care as social ‘glue’ as well as that of a care ‘crisis’. Suggestions from audience included ‘scaffolding’ and ‘investment in social infrastructure’. Even the term ‘social care sector’, one audience member commented, may be misleading, as it is made up of many providers, large and small, and formal and informal.
• Striving for cross-party political consensus, however challenging this may appear.

Questions and comments after the lecture, in addition to those already mentioned, raised:

• The potential of learning from other countries’ history of care reform, with example given from Japan and Singapore.
• The role of, and strategies for, care providers in communicating with the public and policy-makers.
• Increasing ownership of care homes by private equity, as well as the power of private contractors and subcontractors, and associated issues of corruption and fraud, in the adult social care sector, with examples given from China and Canada. Simon noted that this is rarely mentioned as an issue by the UK public.
• The increasing support needs of carers, and the additional pressures of increasing the retirement age for women who may have to continue in paid work when they would otherwise be providing family care.
• Concerns about the quality of care, and about ‘postcode’ variations in care as well as variations according to income and wealth. Would the public be receptive to calls for a national, nationalized system needed to match what the NHS does in a different field?

 

Ruth Scobie, Green Templeton College, Oxford

[1] E.g. Ipsos MORI (2018), ‘Understanding public attitudes to social care funding reform in England’ report prepared for the Health Foundation and the King’s Fund; Ipsos (May 2025), Public perceptions of health and social care polling for Health Foundation. See Simon Bottery and Dan Wellings (2026), ‘Not my priority’, 20-22.