The closing months of 2012 offered little cheer. In November, the Care Quality Commission’s annual assessment of the state of care services warned that the increasing complexity of conditions and the growing number of people with more than one condition were affecting the ability of providers to deliver person-centred care. Then, the Audit Commission’s Tough Times 2012 report found that although most councils were coping with cuts, stresses were starting to show with many planning to make big reductions in adult social care spending. In a similar vein, our own mid-term assessment of the coalition’s health policy concluded that whilst NHS performance is generally holding up, cracks were starting to emerge. In December the Chancellors’ Autumn statement raised the spectre of at least four more years of austerity and a further 2 per cent cuts in local government grant (on top of the 28 per cent already announced in the last spending review). The numbers of people receiving publicly funded social care is already plummeting and little is known about what happens to people who fall outside the system.
Against this bleak backdrop, the spending review promised for the first half of 2013 looks to be the bloodiest yet. An outcome that sees the NHS continue to be protected from real-terms cuts will come with a heavy price of even deeper cuts in local government spending, of which the biggest controllable item is adult social care. The drumbeat of support for integrated care as a response to these pressures will grow louder still in 2013 – yet the boundary of health and social care will be where financial and service pressures will be at their fiercest. The potential impact of the welfare reform changes for health and social care has yet to be quantified. There are real worries that the financial squeeze on providers will compromise efforts to tackle poor quality care epitomised by Winterbourne and the Mid-Staffordshire Hospital (Francis) inquiry.
And what about social care? The wettest winter on record has not stopped the grass growing around the Dilnot report. The coalition’s mid-term review is expected to reiterate commitment to its principles, but it will be for the spending review to determine the level of cap beyond which the state will pick up the tab for individuals’ social care costs. A cap as high as £75,000 will seriously diminish the impact, especially on those with modest assets who suffer the most under the current system.
Government handwringing about Dilnot has helped divert attention from a bigger set of questions about how we pay for care that will become more urgent in 2013. The first and most fundamental question is what level of resources we need to fund good health and care services (which is not the same as projecting the future costs of our existing, dysfunctional system); the second is to what extent these costs should be shared between the individual and the state (the question Dilnot was asked to consider in relation to social care). The third, and probably the most contentious question, is where the money comes from (in terms of re-prioritising existing public spending, changes to taxation, or new forms of taxation, insurance or charging).
These questions are just as valid for the NHS as they are for social care, yet history has bequeathed very different answers, crafted in the different world of the 1940s. As a result, means testing, co-payment and self-funding are firmly embedded in social care to an extent many would consider unthinkable for the NHS. A generally benign post-war economic climate has meant that the consequences of these differences could be fudged, ignored or in some cases camouflaged by policy complexity (for example, by creating the concept of continuing health care). Demography and austerity has put paid to that. And rising levels of people with more than one illness will defy efforts to compartmentalise needs into ‘health’ or ‘social’ care categories.
Our Time to Think Differently programme aims to stimulate ideas and debate about fundamentally changing the way services are delivered and funded. In 2013 pressures on local authority and NHS budgets will become so great – and the clamour for better co-ordinated services so loud – that it will be increasingly impossible to duck the big questions about what kind of health and care system we are willing to fund, how this can be achieved and where the money comes from.