The proposed NHS and social care commission should report quickly and engage with staff and the public

Following the government’s Spending Review, the NHS has just over two years at best to stabilise rapidly deteriorating finances and declining standards of patient care. At that point the harsh reality of planned real growth in funding of only 0.2 per cent in 2018/19 (and even less the following year) will have to be confronted.

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.

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#545688 Guy knight
Self employed

Why not remove the internal market, remove all the administration, create an intergrated service and the savings will I'm sure provide the funding the NHS is being starved of under the current arrangements. Simple common sense!

#545693 Pearl Baker
Independent Mental Health Advocate and Advisor/Carer

I agree to the first comment. 'Integration' by a 'pooled budget' in use in many areas with great success. In Torbay 'pooled commissioning budgets enabled providers to create health and social care co-ordinator.

#545694 Roland Dunn
Tech Manager
Own Organisation

- Norman Lamb: flat out denied that any privatisation of the NHS is happening at a LibDem hustings in 2015 election campaign in Haringey.
- Alan Milburn and Stephen Dorrell both up to their necks in winning private contracts for private health companies.

If there's to be any "review", it should explicitly exclude these three whose own motivations for such a review should be significantly questioned (particularly Milburn and Dorrell).

#545697 George Coxon
Various. Inc independent Health & social care advisor
Many !!

No one likes being ignored, dismissed, or undermined. Equally no one likes saying important obvious and inspiring things that don't lead to being taken seriously or action. It is also true that persistence and being calmly assertive with a credible reasoned voice is essential. There is a view (and I subscribe to it) that you must say the same thing at least 7 times before you penetrate the 'yes but' and self interest driven world of stubborn short sighted resistance. I vote for a Big Conversation Day akin to that being promoted by Dyning Matters in May (excellent organisation incidentally). The Big Conversation on sustainability of H&SC must involve not just NHS staff but social care staff too. Great blog. I'm not counting but I think we all need to keep saying this a few times more yet!

#545708 Duncan Kennedy
Company Director
Audit Ready

A really good blog highlighting the need for a national debate involving all. My worry is this message will fall upon deaf ears. The current administration is solely fixed on dealing with the deficit. Austerity for all. Jeremy Hunt’s apparent approach is my way or the high way – anyone with a modicum of sense can see that forcing a seven-day service on the NHS currently is not the most sensible thing to do. I don’t see the political parties ever putting aside their differences; not in this parliament. It appears to me the DH is hoping the Carter review is going to flush out wastage, find a stash of cash under the pressure mattress and make our buck go even further. In reality this is misguided. Investment and integration needs to be made at either end of the patient pathway i.e. prevention and social care. Transformation is neglecting parts of the system that have been under resourced for years. If we can defer demand by reducing the numbers of people needing to access the service (public health matters!) and support people in well-resourced nursing homes (older people clinical hubs) then just perhaps…….I would also advocate a national strategy to develop health awareness within the nation by linking up with the education system i.e. include health issues within the national curriculum, such as exercise, healthy diet etc. If not then I come back to Chris Ham’s introduction. Something has to give!

#545715 Stephen Smith

What will give is the weakest point in the dam. Pay-as-you-go GPs is just the beginning of the eventual privatisation that can hardly be resisted by the general public. Unless a real effort is made with public NHS reinstatement (incl. reform & integ) the privatisation will be progressive and irreversible. There is a day of action on the 11th March nationwide & including Westminster.

#545716 Terry
Member of the public

I have always looked at The Fund, and yourself, as trying to lead the way through endless repetitious actions in the NHS to get results.
To do this we really need some tough talking from you. Not ill thought out or simply trying to make a point for the sake of it, but really letting us, the public, see that we are supported by somebody 'real' and indeed enough is enough.
You have the facts so please use them strongly and if it embarrasses so be it. You have to be ill to understand this thrust well but please do it for the rest of us as well.

#545728 Julie Gildie
Full-time undergraduate student in Health and Social Care
Bangor University

I welcome the involvement of the public rather than so-called 'experts' - many of whom simply occupy 'ivory towers' without any knowledge of, or intention of, discovering what goes on on the front-line.

There is little doubt that where health and social care are concerned 'business as usual' is no longer an option. However, I would not want to see seemingly endless re-organizations/reviews etc which are (usually) very expensive and which lead to yet further costly and meaningless change.

#545729 John Kapp

I agree with Duncan Kennedy above that the answer is education of the public in self care, such as mass commissioning and providing the NICE recommended Mindfulness Based Cognitive Therapy (MBCT) 8 week course that has turned drug dealers into missionaries (see papers on section 9 of www, The Better Care Fund, and the Childrens Mental Health Transformation Plan funds should be used for this, and every £1 spent can save £7 in primary care attendance, hospitalization, benefits, and criminal justice, so it is a no brainer that can be implemented right away.

#545764 Dr Jon Tuppen
GP partner

In my view it is highly probable that modern healthcare is simply unaffordable. Health care is a service industry dependent on the workforce. All parts of the NHS have suffered pay restraint for the last 5 years. GPs have suffered year on year reductions in take home pay since 2005-6 amounting to a 25% reduction in real terms. At the same time relentless pressures and stresses of work has exhausted the last vestiges of goodwill which has held the NHS together. Industrial unrest or people simply leaving the care professions has arrived. The only immediate solution open is for market forces to act on pay.
Health inflation is the other major factor in the need for more resource. Factor in the inflationary pressures of the next generation of genetic healthcare. My feeling is that this will outstrip the medical inflation of the last 20 years.
Some hope that there will be compression of illness into the last few years before death. 32 years of experience tells me we are accelerating away in the opposite direction. People live with multiple long-term conditions for many years. Guess what - they complain and seek medical answers for those conditions and doctors and nurses feel duty bound to try things even if the evidence is poor.This all inflates costs.

Together I think 11-12% of GDP is far too conservative. What will society allow to be cut from other public expenditure?

Medical inflationary pressure needs to tackled - Technology must be intelligently tamed . Medical education at both under- and post-graduate has moved more and more to sub-specialism. Clinical skills and ability to deal with uncertainty are being replaced by fancy diagnostics and technology .
Health professionals and the public need training in living with risk. Old fashion, more holistic generalists are needed. Nurses and carers need training and empowerment in empathy and care not degrees in theory.
Systems need to support this approach. Anything other just adds to inflationary pressure.

Whilst I support the integration and sharing of budgets, I fear that without an independent commission and root and branch retraining of health professionals and public it will be yet another redesign that is not given a fair chance to live within a very finite resource which is outstripped by desire.

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