It’s time to face facts. A health service with a ring-fenced budget and free at the point of use is not likely to work well with a social care system funded through local authorities and heavily means-tested. And indeed, the evidence we collected for the interim report, including meetings with stakeholders and first-hand testimony from those who have to grapple with the two systems, proved that too often the present state of affairs does not work well for patients and their carers. Additionally, both parts of the system are under financial pressure, which means that even the present unsatisfactory situation may not be sustainable.
The Dilnot reforms to social care funding are a step in the right direction. But for many people the costs of social care will remain high, with access to public funding limited to those with high needs for care and low incomes.
It is the Commission's belief that the nature of illness and care today has changed so much since 1948 that the original settlement establishing the NHS and social care system urgently needs to be re-visited. Our stake in the ground is that England should move towards a single, ring-fenced budget for health and social care that is singly commissioned, and within which entitlements are much more closely aligned. Inevitably, this leads to questions, two of which we will address in our final report: how should entitlements to publicly funded health and social care be aligned? And how should this be financed?
In addressing these questions and considering the options, we have used – and will continue to adhere to – some key criteria. Any new settlement needs to be equitable (similar needs today do not receive equal treatment), to be efficient in terms of value for money, to be financially sustainable, and to strike an appropriate balance between collective and individual responsibility. Crucially, it must deliver better care for patients and carers and be a system they can understand.
We are looking for responses that discuss how the boundary between eligibility for public funding might shift. In the past this boundary has been less fixed than many assume, and it ought to move in response to the changing nature of care needs.
We are looking for views on how the new settlement could be financed. In round numbers we spend about £150 billion – or 10 per cent of our national income – on health and social care, about a fifth of which is paid for by individuals and families. In addition there is a lot of unpaid care, and we want to consider whether these carers should be better supported.
Some options for funding are set out in the interim report – and range widely from big tax proposals, to changes to tax or benefits for the elderly and increases in user charges for health care. We are clear, however, that we would only support higher user charges if these were linked to an improvement in entitlements. A couple of options – a wholesale switch to social insurance and tax relief on private medical insurance – have been ruled out as not meeting our criteria. But otherwise we are open-minded and would welcome other funding suggestions.
These are uncomfortable choices. But the health and social care systems are currently structured and funded in a way that is both inequitable and financially unsustainable. We need to act now to develop a clear vision for health and social care in the 21st century.
This blog is also featured on the Guardian website