A centralised, free-at-the-point-of-use NHS and council-run, means-tested social care aren’t working together – and patients are paying the price.
Neil Kinnock was on the radio at the weekend, talking about his hero Aneurin Bevan with the journalist Matthew Parris and one of Bevan’s biographers, John Campbell. Any conversation about Bevan’s life is mostly about the NHS and so it was this time, too. But it was a useful reminder of how, among all the battles fought over its creation, among the fiercest was the question of replacing a patchwork of local provision with a single centralised structure that tried to guarantee that everyone got the same level of care wherever they lived. At that the point the radical, big-government approach petered out. Social care was left where it always had been, with local councils.
Now the Institute for Fiscal Studies (IFS) has published a study looking at the difference in social care provision across England that raises the question of whether it too should be centrally funded. After all, whether it’s soaring demand for A&E or delayed discharge from hospital, the impact of inadequate or ill-designed social care services on the overall state of the health service has become the stuff of daily headlines.
Then there is the ageing population. Although we are all healthier in old age, the need for care doesn’t track changing demography exactly: men’s life expectancy is growing faster than women’s, so there are more old couples looking after each other rather than relying on formal care.
George Osborne’s response to the incipient social crisis was to set in motion plans to shift the entire cost of locally incurred spending to local taxes, with a system of equalisation that has yet to be explained. He introduced a social care precept allowing an increase of up to 2% in council tax to be spent on social care.
Since the amount councils can raise through council tax depends on their tax base, these changes are – as the IFS points out – hitting poorer councils much harder than well-off ones, even though in theory, the introduction of national criteria for eligibility for paid-for social care should mean a reasonably equitable approach. The IFS study found that cuts in social care were much steeper in metropolitan areas such as Greater Manchester, Tyneside and Greater Birmingham, which typically have significantly higher levels of need, than in the south of England (although that may be partly because there are more older people in the south).
But the distinction between what we pay for and what we expect wider society to support is more than just a matter of an arbitrary geographical divide. We are so familiar with it that we rarely ponder the palpable inequity between providing free care for, say, a cancer patient, regardless of their wealth, while charging someone with dementia who also has some modest assets.
Because social care is provided locally, the national focus is always on the NHS. So although last month’s budget made another £2bn available for social care, it is being delivered in a way that ties it in to supporting the kind of services that will ease pressure on the NHS. Councils rightly argue that keeping older people well is about much more than care homes and providing a bed clearance service for their local hospitals. It’s about wellbeing in the widest sense of the word, and the NHS’s provision of community services like stroke rehabilitation also have a significant role to play.
In some ways, NHS England chief executive Simon Stevens’ sustainability and transformation plans with their objective of integrating health and social care in ways that meet local priorities are an attempt to synthesise the national with the local. Yet there is such an inbuilt conflict between a free-at-the-point-of-use NHSand means-tested social care that it is hard to see how they can continue to coexist.
It comes at a high cost to patients. When hospitals are in effect incentivised to shovel the old lady who’s had a fall out of bed and off their books pronto (I exaggerate, a little), leaving her local authority to pick up the bill for getting her back on her feet, it seems the two arms of care that ought to be wrapped protectively around her are instead locked in a standoff. It is more arm-wrestling than hand-holding.
The government now promises (another) green paper on paying for social care in the autumn. But successive plans, each of which points to more central government funding, have crashed and burned on the runway. Oh, for a Bevan (and a Clement Attlee) with the courage and determination to sort it out.
Anne Perkins is a leader writer