In his first speech as prime minister, Boris Johnson made the bold promise that his government would “fix the crisis in social care once and for all”. It’s a political minefield: Theresa May’s so-called “dementia tax” – the suggestion that potential Conservative voters would have to sell their homes to pay for care – helped her to lose her majority in the 2017 election. England’s adult social care system has long been in need of reform but successive governments have struggled with how to design and in particular fund a system that provides quality care, is fair and is palatable to the electorate.
As an attempt to embark on this, the government has now published a white paper: Integration and Innovation: working together to improve health and social care for all. A main thrust of this, commendably, is to promote communication between hospital and community care – “removing barriers”, with “different parts of the NHS joining up better” and “dynamic partnerships” being created with local government. However, the history of the NHS is littered with top-down reform plans, not least the recently jettisoned Lansley reforms, and the government will face difficult, possibly intractable, problems but also opportunities.
Issues in social care provision
One of the underlying problems in social care provision is a lack of adequate funding. In addition to the impact on social care itself, this has had clear knock-on effects on NHS services. Research by the Health Foundation found a direct link between cuts to funding and an increase in the use of A&E services by over 65s, while those care homes able to provide an enhanced care package reduced emergency admissions by 23 percent. Cuts have also led to a shortage of appropriate care home places to cater for patients who would otherwise be able to leave hospital. To relieve pressure on over-stretched NHS services, any solution to the care crisis will have to be adequately funded.
Public concern stretches beyond funding, however, to the quality of care. Neil Heslop, chief executive of the Leonard Cheshire Disability Charity, highlighted his frustration that “disabled and older people are still having to endure the indignity and disrespect of receiving flying personal care visits … 15 minutes is nowhere near enough to do these essential tasks if you need support”.
Currently, the Care Quality Commission (CQC) monitors quality standards in social care homes. However, with private ownership of the majority of care home beds (83.6 percent), there has been no clear leadership to adapt and develop social care policy to meet the needs of our changing society.
Efforts to integrate a means-tested and largely private social care system with the NHS, free at the point of need, have previously faltered and adult social care services have been fragmented, leading to incidences of poor care, abuse and neglect. The current proposals for greater integration between the two types of systems will have to deal with their basic “cultural and structural differences”.
Providing an integrated National Care Service
While fraught with difficulties, greater integration of health and social care clearly offers an opportunity to improve things. The Labour Party’s pledge in its recent manifestos has been to create a ‘National Care Service’, with an emphasis on public sector provision via local authority funding. But if we accept that integration of services is desirable, then integration of budgets may be the necessary underpinning for this to work.
A combined budget for the NHS and social care is one of the funding options outlined in a February 2018 Health Foundation working paper. There are drawbacks, such as the risk of social care funding losing out to acute and emergency care, but the paper quotes a Local Government Association prediction that an integrated system could result in efficiency savings of as much as 7–10 percent or £1bn a year. Whilst a single budget would not provide a guarantee of adequate social care funding, it would seem to be a fundamental prerequisite for the provision of better quality ‘joined-up’ adult care.
Within a National Care Service, commission of service use of social care homes could be carried out by the well-established 84 NHS foundation trusts. Based on reviews from the CQC, foundation trusts would provide services to care homes based on quality, not price. This would create a market where care homes were driven to provide better quality care in order to compete, and where our over 65 community would receive adequate care based on needs, rather than where they live.
Another conclusion that we might hope will be drawn from the integration of services is that as people grow older, they have the same right to social care as health care. The right to free personal care, a key aspect of Labour’s National Care Service blueprint, is already recognised in Scotland, which has operated a needs-tested (not means-tested) model for people aged over 65 since 2002. Domiciliary care is provided free and people who require care in a residential setting receive a flat rate from local government and an additional amount of money if nursing care is required.
However, while an integration of services should lead to improvements, there is a risk that private companies will be allowed to increase their participation in health and social care through managing the provision and communication between hospital and community care. Labour and other opposition parties will doubtless be on guard for this.
The lack of concern in addressing the social care crisis has been damaging to British people and so the fact that the government is taking the issue on is to be welcomed. Whether or not they will live up to Labour’s standard that social care should be “a universal public service that provides the dignity, security and compassionate care that people need to live their lives” remains to be seen.