A Sisyphean task for health and social care?
The recent appointment of Camilla Cavendish to advise on the future of social care, including potentially handing it over to the NHS to run, has made me ask myself whether that would actually ‘fix the crisis in social care’ as the Prime Minister has promised he would do. Is it also the right thing to do for the NHS, social care and, most importantly, the people of Britain who rely upon both?
There are three main areas for consideration when determining whether social care and the public would fare better under the control of the NHS.
The provision of social care is often described as a postcode lottery, dependent upon the funding and priorities for each local authority, but the Care Act 2014 gives a national eligibility criteria that all councils must apply. How much people pay towards the cost of their care and support, in the form of client contributions, is also determined nationally through the use of the Fairer Charging Guidance. It is also worth noting that, despite having a ‘National Health Service’, there remains a lottery in respect of our access to that healthcare with vast differences in provision and treatment thresholds between local clinical commissioning groups and A&E performance and hospital waiting lists between provider trusts.
Funding While the acquisition of social care by the NHS would swell its budgets by more than £22bn to approximately £150bn, it would not, on its own, solve any of these problems. The bigger challenge to address is the shortfall in funding for social care which, as a result of the injection of one off grants, has fallen to a mere £1.2bn this year (according to the Local Government Association), but will be back up to £5.5bn if nothing is done. Essentially there are three main options:
Local taxation – the current approach:
While some funding comes from central government to local authorities specifically for social care, the vast majority is funded from locally determined Council Tax and means tested client contributions. As the income from client contributions is already maximised, the only remaining options under this approach would be increasing central government funding through additional taxation (which is unlikely to be a vote winner), or by further increases to the locally determined and collected Council Tax. Again, this option is not popular but, for central government, has the advantage of being levied by someone other than them.
A similar approach to the American method of funding healthcare would also be problematic. The insurance companies are not overly keen as there is an untested actuarial calculation to be made which would leave a significant level of financial risk with them. The alternative would be to increase premiums to a level that would mitigate that risk but would be unaffordable to many. If the insurance scheme was optional and premiums were high, uptake would be low and mainly by those individuals who already currently pay for the full cost of their care. If insurance was mandatory, it would just be another form of national taxation delivering less than optimum value for money because of the profit margin that the insurance companies would need to top-slice.
This is by far the easiest method to address the funding shortfall but for a Government it is also by far the least popular option, which is probably the reason why responsibility has remained with local authorities for so long. There are numerous options for raising the necessary funds, from VAT to National Insurance and Capital Gains and Inheritance Tax but, at a time when the Government is undoubtedly going to have to raise taxes to pay for our nation’s response to COVID-19, will they be bold enough to raise it even further ? If and when that current funding gap is addressed, how much individuals should pay towards the cost of social care (if anything), is the next issue to be resolved if there is to be true financial parity with the NHS.
Continuity of care and a familiar face are absolutely critical to delivering a personcentered approach, but the now (in)famous example, used by Camilla Cavendish, of the elderly man visited by 102 different carers, will not be resolved by simply merging social care with health. Most of social care, in the form of home care and care homes, is provided by the private and voluntary sector. The constant challenges of recruitment and retention that these organisations face as a result of low pay and zero hours contracts will not simply go away because of a change of paymaster. In order to deliver the much wanted continuity of care, providers need to be paid a fair price for the care that they deliver and this will not be achieved by simply changing the name on the pay cheque. It will require a significant injection of funding whether they are commissioned by the local authority or the NHS, particularly after enduring the hardship (and expense) of COVID-19.
There is, of course, also the issue of trust and confidence. While the relationship between local authorities and the care providers that they commission may not be perfect, it is considerably better than the relationship currently enjoyed with the NHS. Independent sector care providers feel a high level of distrust and disdain for the NHS and central government, particularly when you add the issues relating to the availability of Personal Protective Equipment and the delay in the implementation of weekly COVID testing for example.
It is commonly known that the idea of bringing social care under central control is not a new one. Ten years ago Andy Burnham, then Secretary of State, set out his vision for a National Care Service, where everyone would contribute and everyone would get their care for free when they need it.
In the last 20 years there have been over a dozen Green and White Papers and commissions, all of which have concluded that joint working and integration between health and social care with the common goal of providing a high quality, cost effective and seamless patient-facing service is a good thing. Since then, none have been implemented and the issue of sustainable funding has never been addressed. Will it be any different this time, or will we just continue to push the boulder up the hill?