Raising the levy: will the new health and social care tax work?

Throughout my (long) career I have watched successive governments edge towards the reform of social care funding only to run out of time, get distracted or decide it was all just too difficult after all. Yesterday’s announcement indicates that this government will go where its predecessors have feared to tread by putting forward concrete reforms of social care financed by a new (or newish) tax. This is on top of a major health bill currently before parliament and significant reforms to public health. The objectives of all this change are threefold: to deal with the long-term challenge to social care access and funding; to help the NHS and social care to recover from the Covid-19 shock, including improving health itself; and to support the efforts to integrate health and care services.

Will it work? Well, we really need to await the full detail in the Spending Review to make sure everything on the money side is as it appears. But with that material caveat in mind, here is a first assessment.

'...social care has been allowed to drift into such a perilous state that there is (at the very least) a question mark over whether this is enough to truly ‘sort’ social care.'

On social care, the proposals combine the Dilnot ‘cap’ that sets £86,000 as the maximum an individual can be expected to pay toward their care over their lifetime; increases in the means test, below which all social care is free (rising from £14,250 to £20,000); and increases in the means test, whereby the public sector will pay some but not all costs (rising from £23,250 to £100,000). Along with some other elements of reform and support, this is expected to cost £5.4 billion in total over the next three years. This is easily the biggest reform package for a generation (at least) and may be enough to move the challenge of social care funding from the level of strategic and fundamental into the more operational. But the holistic challenge facing the service is still a big one: social care has been allowed to drift into such a perilous state that there is (at the very least) a question mark over whether this is enough to truly ‘sort’ social care. There will also need to be a forensic assessment of the final Spending Review package to make sure there isn’t some devil in the detail of local government finance and an understanding of how funding will continue to flow after the next three years are up. This may sound pessimistic, but for those who have lived and breathed the (absence) of social care reform, it’s merely realistic. On the optimistic side, there is still scope to increase social care’s share as part of the Spending Review.

'The failure of successive governments to grasp the nettle of workforce planning risks overtaking social care reform as the most enduring blot on the face of public policy in England.'

All this is paid for by a new health and care levy, mostly made up of an increase in National Insurance payments of 1.25 per cent, but also from extending this levy on people working beyond retirement age and a similar increase for those earning dividends. This will raise £12 billion a year over the next three years (for the whole of the United Kingdom). Clearly this is a lot more than the sums dedicated to social care (the £5.4 billion for social care is the total over three years), which by default means the NHS takes by far the larger share. For the NHS, this extra money aims to bring the elective backlog back under reasonable control but also to put the NHS back on a sustainable footing, recognising the challenges facing general practice, mental health and other services. When added to the existing growth already guaranteed to the NHS this is a very significant investment (usual caveats on the Spending Review apply, not least how much goes to the NHS and how much to the Department of Health and Social Care). However, as the funding gap recedes, without an accompanying workforce plan, this will not deliver the goods. The failure of successive governments to grasp the nettle of workforce planning risks overtaking social care reform as the most enduring blot on the face of public policy in England.

Lastly, there is a promise of yet more reform to come with a new White Paper later this year that will look to support and accelerate integration between health and social care, including new system-wide outcomes measures and new freedoms for local leaders to design structures and incentives. It also promises (with some irony given the previous paragraph) to improve workforce planning across health and social care. Whatever one thinks of this forthcoming White Paper, it does leave a question mark over the health and care bill currently making its way through Parliament, also promising better integration across health and social care.

Before these announcements, successive governments appeared to have learnt two lessons in health and care policy making: avoid social care reform and (since 2012) avoid major NHS legislation. This government has emphatically ‘unlearnt’ both. A single day has brought announcements of social care funding reform, a new NHS funding deal, taxation and more proposals on integrating services. If they only add a proper workforce plan to this mix, they’ll have the set.

Of course, then the challenge will be to make all this reform actually work.