It is inconceivable that the NHS will be able to balance its books and maintain current standards, let alone implement new commitments like seven-day working, with such a small increase in its budget. And even if councils take advantage of new powers to increase council tax, social care faces a funding shortfall of approaching £3 billion by the end of the parliament. Something will have to give.
This kind of reasoning lies behind the decision of Stephen Dorrell, Norman Lamb and Alan Milburn to join forces to call for a cross-party commission on health and social care. Their initiative follows work at The King’s Fund by the independent Barker Commission, which proposed a new settlement to end the historic divide between health and social care by moving to a single ring-fenced budget and a single commissioner of local services. The Commission argued for a new funding model to provide adequate resources for social care as well as the NHS, and to align entitlements between health and social care.
The Commission proposed that health and social care should account for 11–12 per cent of GDP by 2025 based on international comparisons and affordability. It argued that most of the funding should come from public sources and outlined a menu of options for raising these funds. In doing so, the Commission acknowledged the difficult choices that would need to be made between these options, and the desirability of implementing a new settlement over a decade or more.
The deafening silence of the major political parties in response to the work of the Barker Commission hints at the challenges they face in confronting these important but difficult issues. All the more welcome, therefore, that three former senior health ministers have come together to underline the seriousness of the pressures facing health and social care and to argue for a cross-party approach in tackling them. While we at the Fund are sceptical about the benefits of simply repeating the analysis carried out by the Barker Commission and other independent reviews in previous years, if this initiative can add fresh impetus to the debate then we would welcome it. The way in which a cross-party commission works will be critically important to its success, if indeed it goes ahead.
Three things matter. First, the urgency of the issues facing health and social care means that the commission should be required to report within 12 months. This is not the time to consign issues that matter hugely to the public to the long grass, particularly when much of the groundwork has already been done by the Barker Commission and others. Using a commission as an excuse for delay would be the worst possible outcome.
Second, we do not believe that a royal commission is the right approach. Instead, the government should appoint a credible and respected individual with cross-party endorsement and terms of reference that are manageable within the time available. Such an individual would need support of the highest order to analyse the issues and come up with recommendations.
Third, there should be a requirement for the commission to engage with the public and NHS staff. The future of health and social care is too important to be left to experts, and now, more than ever, the views and voices of people giving and receiving care need to be heard. Surveys, meetings, focus groups and other methods all have a part to play in informing the work of the commission and lending legitimacy to its findings.
In making these arguments we are aware of the experience of previous reviews, from the Guillebaud Committee in the 1950s onwards. History teaches us that reviews set up with government support, most recently exemplified in the work led by Derek Wanless in the 2000s, stand a better chance of success than those that lack such support. And while a commission might create a rod for the back of a chancellor focused on reducing the government’s deficit and debt, it could equally offer a legacy for a prime minister whose stated commitment is to govern for one nation.