What did the King’s Speech say about the new government, and what next on social care?

Matthew Taylor

So welcome to Health on the Line. Later in this edition, we'll be speaking to Sam Freedman, public policy expert, author, commentator, podcaster, all about the King's speech and what we know so far about the way that Labour is going to approach health policy. But one of the big issues already is, of course, social care, a subject that wasn't really addressed properly during the election campaign, but in many ways has come back to the forefront of public attention since. 

Now, there's almost no one better I could talk to about this than my guest for this initial conversation on Health on the Line, Natasha Curry, who's deputy director of policy at Nuffield Trust, and social care is one of her areas of expertise. 

Natasha, welcome. 

Natasha Curry

Hi Matthew. Happy to be here. 

Matthew Taylor

Let’s just start where we are in relation to social care. Obviously, you could talk about that for a long time. There's so many different dimensions to it. But what does the picture look like at the moment and are there particular aspects of social care that you're particularly concerned about? 

Natasha Curry

Yeah, well, as you say, I mean, it's a really complex picture and we could talk about it for a long time. I think it's fair to say the new government's inherited quite a complex and fragile system. And as the survey that was published last by the Association of Directors of Adult Social Services showed there's deep concern amongst councils about how much funding they have to meet the rising needs. So we've seen an increase in need over the last 15, 20 years, people coming forward needing social care. That's led to long waits for care assessment and care packages. So we're seeing a high level of unmet need in society as people are struggling to get public funding.

The sort of generosity of the system in terms of how much wealth income savings you can have before you access public funding has not changed since 2010. So the system has become meaner, if you like. And as the funding for local authorities has been squeezed over the last decade or so, council had to make very difficult choices. So we're seeing fewer people being eligible for publicly funded care and other people self-funding facing very high costs for their care.

Alongside that, we see providers of care, so care homes and home care agencies struggling financially to make ends meet because of the low fees paid by local authorities. And those providers are struggling to recruit the staff they need because of the rate of pay that they're able to offer, by use of insecure contracts. So there's a whole load of instability and different issues within the system, which means that it's in desperate need for a comprehensive, far-reaching reform.

Matthew Taylor

And this position of social care, Natasha, one of the things that happens as a consequence is it makes the borderline between social care and the NHS even more challenging. And there was a recent survey, wasn't there, from ADAS that talked about one element of this, because often from a health service perspective, we talk about the lack of social care, meaning that people are stuck in hospital. But ADAS was identifying a different element of this, which is that the pressure on social care when people are released from hospital with complex and intense needs.

Natasha

Yeah, indeed. Health and social care, obviously two independent systems that have to work well together. I think the focus of political and policy debate has very much been on social care, creating pressures for the NHS in terms of that discharge bit. Actually, as you say, there's also a flip side of that with the NHS shifting more tasks, more care onto social care, which is now really struggling. So we see that. That's manifested in point of discharge in both systems with people coming out of hospital with higher and more complex needs and social care needing to extend or increase the size of packages that people are needing. 

I think the kind of narrowness of the focus on just discharge is a little problematic because it tends to lead to sort short-term solutions, for example, buy more care home beds, which are not necessarily what we need in social care in the longer term.

Social care is keeping people well, keeping people independent, reinvesting in those fundamental services. You can then keep people well for longer, which should then have an impact down the line on the NHS in terms of fewer people hitting the system or hitting the system in such a complex state. 

Matthew Taylor

Yeah, well, so that takes us to some of the really concrete choices the government faces. The specific reference to social care in the King's Speech, which I think was very welcome, was trying to do something about the social care workforce, in particular about pay and conditions for social care workforce. And that kind of coincided, didn't it, with your report from the field report on options to improve the way in which we look after care workers, pay them and their conditions. 

Now, at the heart of what Labour's proposing is a national framework for pay in the care sector. I think that's entirely welcome, but it's almost certain, isn't it, to make the affordability question even more difficult? 

Natasha Curry

Yes. Obviously, any sort of reform will come with a price tag, and we're not clear where that extra funding will come from. I think the sector welcomed the announcement of a fair pay agreement in social care. We know that the workforce is a key pressure in the sector and that low pay drives a lot of that instability and providers are struggling to recruit and retain people. So it's right that we focus on that. 

What that fair pay deal looks like eventually is yet to be decided. I mean, there are a number of options that we looked at in our work, ranging from just better enforcement of the national living wage that we have at the moment, because we know that especially home care workers are not always paid travel time, for example. So there's more we could do with what we've got - ranging through a sector specific minimum wage where social care has its own sort of minimum to a sort of pay scale, which would look more like what you have in the NHS. And there are many considerations about what's best, depending on what the government wants to achieve and how ambitious it wants to be. 

But I think eventually to retain and recruit the right people in social care, we need to be moving more towards that sort of sector pay scale which rewards experience, not just setting at a higher minimum, but that would be a long-term sort of ambition, I think. 

Matthew Taylor

One of the things I think that people who are not experts in there might forget is that the platform is already burning in terms of additional investment here because the last government delayed the implementation of a cap on social care and improvement in the kind of means testing, but that's going to happen, supposed to happen, I think next year, and it's going to be extremely expensive. And it has led the county councils network, I think, call on the government to postpone it even further. Isn't that right? 

Natasha Curry

That's right. The cap on care costs, which would basically give people a lifetime maximum, what you pay towards your care. That was passed into legislation in 2014, actually, as part of the care act, but was delayed and then abandoned. It was then put back in an amended form in legislation in the health and care bill in 2022, but its implementation was again delayed. The intention is, and the government has stated that they're still committed to this, is to implement it by next October, 2025. That would put a limit on care costs at £86,000 for the individual and also raise the means test, which is the generosity of the amount of money and savings assets you can hold while still being eligible for social state-funded social care. 

So that's one element of the system. We don't know yet how the government intends to fund that. It's not obvious. They said it was baked into finances. I think we need to wait for the spending review to see that. 

But of course, that's just one part of the challenge or one of the challenges that the social care sector faces. So it would increase the generosity of the means test, cap the cost, but it doesn't necessarily expand the amount of care and the number of people working in the sector or the fees that providers are paid. So I think we want to see those reforms introduced as part of a whole comprehensive strategy towards a more functioning system. 

Matthew Taylor

That brings me to my last question. And it's almost surreal this debate, isn't it? I mean, we had the Liberal Democrats promising a great deal in relation to care during the election,  and good luck to them for raising the issue; it seemed to help them. We've had Labour in the King's speech promising to improve the paying conditions of social care staff. But nobody wants to talk about how we're going to pay for this. And I think many of us had hoped that a new government might say, right, we're going to grasp the nettle, we're going to do some difficult things early to pay for social care. And hopefully by the time we get to the next election, it's bedded in, people have accepted it. But instead, we're getting talk of another royal commission or another inquiry.

Natasha, speak freely. Do you think we need a royal commission, another inquiry? 

Natasha Curry

In short, no. I think there been so many reviews, inquiries. There was a royal commission in 1999. We have a good grip on what the problems are. And I think there's quite a high consensus in the sector politically about the vision towards where we want to be and where we want to move to. What's lacking is the plan of how to get there. And a major part of that plan is how we're going to fund that. 

And so I think the government now has an opportunity, as you say, that you and they have a big majority. I think it's time for political bravery. mean, having a cross-party consensus, you know, ideal for longevity, but they have this opportunity to be quite brave and to bed in the foundations of a functioning system. And part of that is raising revenue and funding properly. 

I think part of what's held politics back in the past is that there's generally a low public awareness of what social care is, the fact that it's not funded as part of the NHS. People assume it's free. So having that sort of debate with the public has been difficult in the run up to elections. We're now post -election, but I think there's an exercise to do in raising public awareness and having that debate with the public. But then we need some political bravery and leadership to then put in place the foundations of a functioning social care system. 

Matthew Taylor

Natasha, it's been great to talk to you. Thanks so much for joining us on Health on the Line. 

Natasha Curry

Thanks for having me.

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Matthew Taylor

So after that fascinating conversation with Natasha Curry about a particular set of public policy challenges, let's turn to a broader assessment of what we've learned so far about how Labour is going to approach health and care policy, with Sam Feeman.

No sooner have we had an election than it's down to the core business for this new government, with a King's Speech setting out 35 bills that in the government's words are taking the brakes off Britain to achieve economic growth. 

But with the NHS top of the electorate's priority list, what do these bills do for the health of the nation? What do we need to see in the early days of this government? What's in? What's out? And is legislation really the question for the health service?

Well, to unpack some of this over the next 30 minutes or so, I'm delighted to be joined by Sam Freedman, author, senior advisor to the education charity ARC, former advisor to Michael Gove and also co-presenter of his own policy focused podcast, The Power Test. Welcome, Sam. Thanks for joining us today. 

Sam Freeman

Thank you very much for having me.

Matthew Taylor

Sam, let's just start off with the King's speech as a whole. We can obviously talk about health in particular, but I'm interested, you know, it was a pretty voluminous thing in terms of the amount of stuff that's going to be coming down the legislative pipeline, a mixture of legacy material from the previous administration and new stuff. What was your general view of the King's speech? 

Sam Freeman

There was nothing in it that was sort of wildly unexpected.

could categorise the bills into three buckets, think. One of which was, as you say, things that were left over from the last administration bills that Labour wanted to take forward and largely had bipartisan support, like the smoking bill, which I'm sure we'll talk about in a bit. 

And then you've got a category of sort of fairly minor, what you might call performative legislation, which is designed to make a political point. I think this sort of having the OBR legally required a report before any major fiscal announcement certainly fits into that category because it basically allows you to make a load of headlines about this trust, but it doesn't really make much difference to anything in the real world. 

And then you've got probably the most sort of new and important set of legislation, which are things that were in the manifesto that are relatively straightforward to do. I say relatively because nothing's easy, but things like rail nationalisation, which is actually already 40 per cent complete. Or the devolution bill or things like that which are not particularly legislatively complicated compared to other things that they will want to do in the future. So essentially this is, it wouldn't be quite fair to say this is all the easy stuff because there's some important things in there, but it's the easier things and a lot of the more difficult legislation, more tricky decisions are being held off as you'd expect because it's only two weeks into a new government and they need time to figure out their answers to a lot of those questions. 

But there's a lot of stuff in a lot of it is either quite small or quite easy or stuff that was going to happen anyway under the last government. 

Matthew Taylor

So do you think it tells us anything about this new government? You kind of said it's more or less what we would expect. Do you think there was anything in the content or the signalling that told us something new about how Labour was going to govern? 

Sam Freeman

No, I mean, think what it tells us is that there's not going to be some dramatic post-election change in tone or beliefs, and that's not really surprising.

I never thought that there would be. This is very much they're doing what they said they were going to do. I think what's quite interesting is there's a lot in here on growth and there's some big messages around growth. There isn't very much in there on public sector reform, not just in health, but across the board. And that was something that was missing from the manifesto, I felt. There was ambition around public services and a diagnosis of what was wrong with the current state of affairs. But not much in the way of sort clarity around what Labour wanted to do to change things. And I think that still feels like there's a big picture to be filled in and this King's Speech didn't really give us that picture. 

Matthew Taylor

It's interesting, I think, when you look back on the last two times we've seen a significant change, we've seen a change of political control in government. And when we look back on that, we can see the mistakes that were made. 

So if we look back on 1997, I think there would be a kind of consensus that Labour didn't really fully use the political capital that it had after ‘97. Tony Blair certainly believes and has said that he got into the difficult, tough issues too late, three or four years down the line. 

If you look at 2010, and you might not agree about this, were involved in that government, my sense was that again, Number 10 was slightly asleep at the wheel. was the kind of Steve Hilton's kind of interesting, but in the end not particularly kind of effective way of doing things. it felt like the Treasury really was in charge and marched around Whitehall saying to people, well, you can do what you like, but you've got no money. And that kind of led to a certain lack of coherence. Obviously, it was a coalition as well. 

When you look at this government, do you have any sense, of what is the thing that you think we might look back on and say, well, that was the thing they got wrong? 

Sam Freeman

I think my worry, and this has always been my worry for the last couple of years, is the way that they're treating the fiscal situation. We're in a pretty deep fiscal hole. Public spending plans are not realistic. The politically sensible thing that they've done, and it has worked clearly politically, because they've got a big majority in the House of Commons, was to say, we're not going to put up taxes, we're not going to borrow more money. The only solution to this is economic growth, which in the medium to long term is true but in the shorter term is probably not true. 

And I don't think they can leave it two to three years before making some pretty hefty investments across the public sector. And if they're not willing to do that, then I think they will come to regret that when it comes to the next election or the next term. And you will get a sort of, why didn't we, there was no actual way to solve these problems without making some additional investment. Why didn't we take that difficult choice early on? 

So I think the sort of critical point for me in the first year of this government is not going to be so much this King's speech, but more of a budget or autumn statement that we get in September, October, which will tell us how they're feeling about that sort question of public finances. 

Matthew Taylor

I want to follow up on that point that you've just made and we'll come back to some of the elements of the King's Speech in a minute. 

So, I think our view in the Confed about this kind of money question that almost certainly had the Conservatives won the election they'd have had to put more money in this year. We've had the lowest kind real-term settlement that we've had for many, many years. If we don't put more money in, at the very best, we'll see a stagnation of performance over winter, probably a deterioration. And at worst, we could have a full-on winter crisis. 

And also, one thing we've learned is that if you don't put money in for winter reasonably early, you don't use it very effectively. So, Labour's running out of time to be able to invest in a way that'll make a difference to enter. 

Then secondly, there is this bigger structural deficit in the health service. I most people would say about £3 billion gap between what the health service is expected to do and what it can afford to do. And the choice there for Labour is if they plug that gap, people might say, well, this is a departure from fiscal responsibility. This is pouring money into the kind of ‘begging bowl’, to use West Streeting's term.

The problem is if they don't do that, then when they do put money in, say next year in the context of a ten-year strategy, a comprehensive spending review, what will happen is quite a lot of that money won't go on reform and innovation and change, it will simply go on stabilising the system because of that deficit Labour's inherited. So if you were in the room with Wes Streeting and Rachel Reeves looking at these two questions of the forthcoming winter and that structural deficit, what kind of advice would you be giving them?

Sam Freeman

So, I mean, I think that what's happened pretty consistently for a very long time with health service funding is that you've had secretaries of state at NHS England saying we want to invest in primary care, we want to invest in infrastructure and IT. Money being sort of, in theory, put aside to do that and then being cannibalised to deal with winter crises, acute hospital problems, et cetera.

I think the danger of saying you kind of want to do reform onto a system that is in serious deficit is that that will just keep happening. You'll keep sort of creating little pots of money to do your reform and then they'll keep getting cannibalised because you have this kind of basic structural deficit. 

So I kind of think you need to accept the hit and you need to do the bailout first up and then you say we can build on this platform to do reform so that aren't repeatedly in this situation in the future. And I think a lot of the things that Wes Streeting has said and have been said for many, many decades by everybody in the health profession are entirely accurate in terms of how you do that. It's just how can you do that when you're already in crisis? 

You've got to get out of the crisis first, at least out of the most severe elements of the crisis, before you can then seriously say this is how we reform the system. And if you don't do that, you're just going to get stuck in the same trap the last government got stuck into.

Matthew Taylor

Let’s go back to the King's Speech. We have the smoking of vapes bill being reintroduced and Rishi Sunak will always and should always get the credit for having introduced that bill the first time, even if he ran out of time. We've also got promises in relation to junk food and energy drinks. 

Tell us both about the policy and the politics of this focus on kind of reducing harms. 

Sam Freeman

I think the interesting thing about this is the last government were quite schizophrenic about it. They would sometimes do things in this kind of policy space. We saw the introduction of the sugar tax, for instance. And then they sometimes would rail against proposals for other harm reductions as being nanny-statism and so on. And there was no sort of clarity around the strategy, kind of depending on who ever happened to be giving the speech on the topic and what their kind of personal ideology and who they were trying to appeal to.

I think with Labour it's much clearer that where their ideological position is, they're much happier intervening with state intervention on harms. And I suspect we will see quite a lot more of it over the coming years. And actually it's pretty in tune with where most people in the country are. For all of the headlines about nanny state, actually the British public are fairly authoritarian and are quite happy with interventions, even considerably stronger ones than them being proposed here. So I think they're kind of on a political winner. Whether they are policy successors will depend on the design of the policy. 

I think the smoking bill, I still think the issue with it is going to be when you get a bit further down the line and when you have sort of 26 year olds being allowed to buy cigarettes and 25 year olds not being allowed to buy cigarettes. And it's just going to be a bit weird. So I think you're going to get to a point quite quickly where it becomes a question of why don't you just ban this rather than sort of mess around with this sort of one year progressive model. 

On energy drinks and junk food, I think we need to see the details. There's literally no detail as to what that proposal is at the moment, so we need to see more. But I think generally what this is telling us is that Labour are going to be much more content to adopt the nanny state label and realise that it's actually politically quite salient. 

Matthew Taylor 22:36

Of course, Sam, one of the kind of legacy bills in the King's Speech is in terms of the Mental Health Act. Now, it's kind of legacy because it was all drafted before the election, but it had been postponed by the previous government. Warmly welcomed, I think, by most of the mental health world. But some issues, I think, about the resourcing that needs to go with this act in order to ensure that it succeeds. 

What's kind of view of the mental health challenge that the government faces? 

Sam Freeman

If you look at the bill, it's based on something like, again, the last government had been taking forward on the 2017 review. 

I think if you look at the data, you're already starting to numbers of detentions drop away anyway, kind of as a result of, I think, probably some of the messaging around that review and sort of a wider understanding of the challenges of detention and the lack of benefits in many cases. 

The King's Speech notes make clear that implementation of the measures in the bill will be dependent on increased staffing. There are plans, I think, to increase staffing, but there's a long lag time because you need to train people and I know there's been challenges around getting applications for mental health roles, certainly for younger people. 

So I think this is one where the legislation is welcomed by everybody and we'll go through on the nod in terms of parliament, but where all of the actual challenge is going to be in implementation, staffing and again, cost. 

Matthew Taylor 

So a second area that is of interest, I think, is this model of change that Labour may have for the health service. Because on the one hand, we hear talk of Alan Milburn coming back. We see the focus on reducing waiting lists with a national programme to do that. That hasn't been unveiled yet. And that sounds like the way of running the NHS we are used to over the years, quite centralised, quite dirigiste, quite target driven, associate that with new Labour in the past. 

But at the same time, another really big theme in Labour’s manifesto and in their first two weeks has been devolution. We've seen the combined authority mayors come into Downing Street within the first few days of the government. We've seen Angela Rayner promising that even those areas that don't have combined mayors will be part of Labour's commitment to devolve. And of course, if you talk about devolution, you talk to mayors and council leaders, one of the things they want to be able to influence is health and health policy and health spending in their areas. 

So what's your kind of sense, of how one balances this kind of instinct, this NHS model of kind of top-down target-driven ways of working with this commitment to devolve, given how incredibly important health is to local economy, local quality of life? 

Sam Freeman

I think this is the absolute crux of NHS reform at the moment and exactly where the last government ran into serious problems. 

You had the introduction of integrated care systems, which are supposedly supposed to do some of this devolution, to do some of this decentralisation and to integrate local government more in decision making and public health more into decision making, all of which is totally logical. But their reaction to the acute crisis in hospitals over the last few years has been to move back towards that kind of do-reduce-new-Labour model because they know that's what works to stop waiting this continue to go up, even if not get them down yet. 

So you've got this sort tension right at the heart of the NHS model now, which is kind of structurally built in due to the introduction of integrated care systems. And I haven't seen clarity from Labour as to which side of that they want to fall on. And if they keep trying to do both, you're just going to keep getting this kind of tension within ICSs where they're both trying to do integration and trying to respond to top-down instruction from NHS England. And it's just not doable. You can't do both of those things. 

You have to decide. You could make an argument for both directions. You could say, for the next few years, we're going back to the new Labour model and we're to do a very centralist and we're going to absolutely hammer these waiting lists down. We know it worked. It worked 15 years ago with the right kind of investment. And then we can worry about integration and public health and so on and so forth. 

Or you could go the other way and say, we're going to do integrated care properly. We're going to genuinely devolve. We're going to bring the mayors more into it. We're going to sort of make the mayors chairs of the integrated care boards. We're going to really go with devolution. You could try that less tested, but there's a good argument that could work as well.

Trying to do both of them, I think, is where you're going to get into real trouble because they're just in contradiction to each other. 

Matthew Taylor

Yeah, and I think that's absolutely right, Sam. And I think for me, Paul Corrigan, who was the last guest we had on this podcast just the day before he announced he was going into work on the ten-year plan, he kind of implies, well, one method, the former method is right for the kind of short term, and then you can move to a longer-term approach. Now I can see that. It sounds logical. There are two problems with it that I run past you, Sam. 

The first is if you say to the health service, you know, these integrated care systems, they're great, but actually they're not really relevant for the things that we, the Secretary of State cares most about, like cutting waiting lists. That sends a signal into the system, which could be destabilising. 

And then the second element of this is, of course, we've seen this in the health service. If you have a today plan, and a tomorrow strategy, the problem is that tomorrow never comes. Do you recognise those kind of dangers? 

Sam Freeman

Yeah, I mean, think that's exactly right. again, I think this is the history of certainly the last 15 years, if not before, is that there's always a desire, there's always a rhetorical ambition to shift more money to public health and primary care. There's always a rhetorical ambition to invest more in infrastructure and IT. Always rhetorical ambition to decentralise, devolve more frontline autonomy. And we never quite get to any of those things because there's always a crisis. 

And the question is, can you ever get to the point of where the system is working well enough that you can do all of those things without doing all of those things? You're sort of caught in a paradox. And if you really believe those are the right approaches and the right way to solve problems, you kind of have to go there now and take a bit of a risk. But that's a huge political jump for Wes Streeting to take when they've got a very concrete commitment to introduce 40,000 more appointments a week, et cetera. The easiest way to do that is in a very centralised fashion. 

You can see why it's a tricky question for them, but what I worry about is they fudge the answer rather than coming down clearly on one side or the other. 

Matthew Taylor

Which takes me very neatly to the thing that I'm really itching to ask you about, which is there's a fascinating piece by Robert Shrimsley yesterday in the FT about Labour's model of government and this notion of insurgent government that as the government need always to seem like you're kind of still in some ways outside the establishment. 

This has become a kind of former government we recognised. And of course, it immediately made me think of Michael Gove. And it made me think of the ‘blob’, which for those people who don't recollect this, this was Michael Gove's description of the kind of education establishment, the education equivalent of organisations like the NHS Confederation or the BMA or the Royal Colleges or the think tanks. 

And Michael Gove saw those institutions as the problem. They were the barriers to the kind of radical changes that he wanted to institute. On the right, people loved this; of course, in the blob, it was much less popular. 

The Shrimsley article suggests that Labour has a similar kind of inclination and that what that might mean for those of us in the health blob is that we have to be very careful of looking like we're kind of adopting predictable position of resistance to radical change. 

What's your perspective on this Sam? 

Sam Freeman

Yeah, it's a really interesting question. Having worked with Michael, having been sort part of that part of government, my sense was always that it was unnecessarily aggressive way of doing it. Using phrases like ‘the blob’; it would alienate people who you could actually win over through argument onto your side. He kind of broadly agreed with a lot of the things you wanted to do.

But that doesn't mean that there isn't an element of truth to it, that you do get sort of sector inertia, special pleading, et cetera. And if you just sort of say, the sector's always right, then you won't get anywhere either. So I think what you need to do is identify people within organisations, within the sector that you're working in, you get it, you want to drive change, you have good ideas for reform and champion them and build them up so that you're not sort of looking like it's purely a bunch of politicians, you have no expertise demanding things, but you do have a clear theory of power and theory of change. 

I think a lot of critical failure comes from the fact that you have politicians who don't understand how to drive change in a sector. They might have some idea of what they want the end goal to look like, but they don't get how you get there. And I think one thing Michael was good at, and I think he got better at actually later on, is understanding how you do drive change in government departments. 

And it's neither by of slagging off the civil service and calling them the blob and demoralising everyone. But it's also not by just agreeing to whatever they say. 

It's about finding the right champions, putting them in the right places and backing them and winning support for their ideas. 

Matthew Taylor

And I think with that comes an implication for those of us who are trying to influence the government that you need to make arguments that feel like they're based in fact, analysis, desire to make things better, not just a kind of defensive resistance. Or the use of arguments that based apparently on protecting vested interests. 

Sam, there are so many other things in the King's Speech, but I think we'll address those in other podcasts around mental health and around children. 

But I want to end with you, because we're running out of time, on the big thing that's largely not in the King's Speech, which is social care. 

So there is social care commitment in the King's Speech. And actually, it's a great commitment in terms of the social care workforce, but it will actually significantly increase social care costs. If we have national negotiation of social care wages and we get rid of some of the unsavoury practices around the employment of social care workers, it will increase costs. So it makes the issue of how you fund social care even more difficult. And yet we hear to our consternation the possibility of a royal commission.

And I'm sure that you would greet that in the same way as everybody else, which is to say, why? What on earth is this royal commission expected to uncover that hasn't been uncovered by all the other inquiries and commissions and citizens’ juries? 

What's going on social care? And again, surely the right thing for the government to do is to recognise that there's a problem and to do something bold and get it done so that by the time you get to the next election, it has ceased to be so controversial. 

And just to add to this, and sorry, such a long question. The Darzi review, the audit, it's very difficult, isn't it, to see how an audit of NHS performance doesn't surface that one of the challenges is length of stay and that length of stay is connected to, it's not entirely about, but it's connected to these social care issues. 

So it's hard in a way to see how the Darzi review is not also going to say, you know, social care is a big problem. So what's going on social care Sam, do you think?

Sam Freeman

I think this goes back to what I was talking about earlier on, which is my big concern about this government overall, is the fear of engaging with the public finances. The only reason I can see that you would do a royal commission when we've had endless numbers of reports on this topic is to put off having to spend money, bluntly, because you don't want in the first spending review to have to commit X billion pounds, which is the only way, especially given, as you say, the changes to employment rules, that you're going to make any progress on social care alongside, of course, lots of other reforms and changes. 

I think you're seeing this across government. I think, you we saw a task force on child poverty set up this week. I'm not sure we really need a task force to say, you know, get rid of the two child limit, don't put arbitrary caps on benefits. Yeah, I'm sure there's more you could do beyond that, but there's some pretty obvious basic stuff across a lot of policy areas that we know the government can do and which we know ministers know about and understand. But which would cost money and they don't want to, but they can't commit to yet because the treasury is currently going around, why are we trying to find more savings? 

So this is why keep coming back to this is actually for all of the conversations about reform, for all of the conversations about good intentions and policy, unless they grip this money issue early, I think they're going to find in three or four years’ time that they haven't been able to deal with a lot of problems that causing public frustration and they kind of wish they'd bitten the bullet on tax earlier – because doing it later makes it harder to blame the conservatives. 

Matthew Taylor

And it's not just biting the bullet on tax, it's also biting the bullet on how the other ways you might raise money. It always feels to me that the future funding of social care has got to be related to the fact that we've got the wealthiest set of pensioners that we've ever had. 

Sam Freeman

Exactly, biting the bullet on that sort of question of what brought down Theresa May May in 2017 as well. It's all of these difficult financial trade-offs that the last government put off and put off and put off. 

And at some point a government is going to need to engage with, despite the fact that they're going to be very electorally challenging. The sooner they do that, the easier it is to blame the last lot. And the more time you have before the next election just to, for the improvements that result, so become a parent. 

Well, Sam, thank you so much. It's been a brilliant conversation. I'm certain we will invite you onto the podcast over the coming years as we see how the Labour government unfolds. Maybe you'll invite me back onto the Power Test as well. Who knows? 

Sam Freeman

Absolutely. We can keep talking to each other on lots of different topics. 

Matthew Taylor

Thank you, Sam. 

Sam Freeman

Thank you very much.