Background
1948 Hospitals were given to the NHS. What we now call social care was left with local authorities.
This organisational structure persists to this day.
Hospitals were given to the NHS. What we now call social care was left with local authorities.
This organisational structure persists to this day.
2014 People are living longer with more complex diseases that require co-ordinated health and social care.
The distinction between health care and social care is being eroded by these changing needs and new ways of meeting them.
People are living longer with more complex diseases that require co-ordinated health and social care.
The distinction between health care and social care is being eroded by these changing needs and new ways of meeting them.
For better services, spending will have to increase and become more joined up. But how could this be done and where should the money come from?
The King’s Fund set up the independent Commission on the Future of Health and Social Care in England, led by Kate Barker, to explore these issues and to come up with recommendations.
Here we present the problems the commission identified and the changes it proposes.
Problem 1: the system is unfair
Most health care (major and minor) is free at the point of use. Social care is heavily rationed and means tested.
This leads to situations where people with dementia have to pay for their own care while people with cancer don’t. Both cases involve significant care needs but they get very different levels of assistance from the state. There is not equal treatment of equal needs.
Problem 2: the funding is separate
The NHS budget is ring-fenced, comes mostly from national taxation and must be spent on health. Publicly funded social care is paid for by local authorities through a mixture of central government grant, council tax and user charges. Levels of spending vary across the country.
Deciding who pays for what is a constant source of friction which can impact on people who are caught between the two systems.
Problem 3: the system is not co-ordinated
The organisations that commission health and social care - 211 clinical commissioning groups for hospital care, emergency care, community care and mental health; 152 local authorities for social care; and NHS England for primary and specialist care - are not aligned.
This creates inefficiencies with financial and human costs. For example, 3,000 beds a day are occupied by people who are fit to leave but are stuck in hospital while funding or assessment is resolved.
Change 1: commission health and social care together
Remove the barrier between health and social care. Have a single, ring-fenced budget and commission both together.
Change 2: create simpler pathways with more personal control
Design simpler pathways through the current system that respond to changing levels of need.
Use a new care and support allowance and personal budgets to give people more control over the support they receive.
Change 3: increase provision of ‘free’ social care
Make all social care for those with ‘critical’ needs free at the point of use.
Extend this to ‘substantial’ social care needs as the economy improves.
By 2025, provide support for ‘moderate’ needs as well.
These changes offer a big prize – a more integrated service, simpler pathways through it and more equal treatment of equal needs. But this has to be paid for somehow, either from the public purse or out of people’s own pockets.
This new settlement will be more efficient and achieve better outcomes for people – but it will cost more overall.
The hard choices: how should we pay for this?
These changes should not be paid for by new NHS charges, nor should they be funded privately or through insurance.
Instead, this increased access to social care should be paid for by public finance, and much of the cost should be borne by those who can most afford it (wealthier people) and those who will benefit from it the most (older people).
How can we afford it?
Prescription charges Make prescriptions much cheaper but remove most of the exemptions. Potential saving of £1 billion.
Make prescriptions much cheaper but remove most of the exemptions. Potential saving of £1 billion.
National Insurance Restructure National Insurance to collect more from those over 40, those over state pension age and high earners. Potential extra revenue of £3.3 billion.
Restructure National Insurance to collect more from those over 40, those over state pension age and high earners. Potential extra revenue of £3.3 billion.
Contributions from older people Limit Winter Fuel Payments and free TV licences to older people on low incomes. Potential saving of £1.4 billion.
Limit Winter Fuel Payments and free TV licences to older people on low incomes. Potential saving of £1.4 billion.
Wealth and property taxes Review taxes on wealth and consider reforms to inheritance tax, wealth transfer tax, capital gains, property tax, etc.
Review taxes on wealth and consider reforms to inheritance tax, wealth transfer tax, capital gains, property tax, etc.
Overall, the government should assume that public spending on health and social care will increase from 9.6% to 11–12% by 2025. The commission believes that in the long run this is affordable and sustainable.
That sounds like a lot of extra money but it’s still less than other similar countries spend on health care alone.
What do you think?
- About the new settlement the commission is proposing?
- How it could be achieved?
- How it should be paid for?
Tweet using #barkercomm or comment on Chris Ham's blog, Now is the time to create a combined health and social care system.
This is an abridged version of the final report. Download the full version, including all 12 recommendations.
Comments
I like the principle that money raised by National Insurance (NI) is regarded as Insurance and is spent on health & care services, unemployment & pension benefits. if we need more for these (in my opinion, essential) services then we increase NI contributions. However, these contributions need to be "ring-fenced" for these activities and not spent on other items or disappear into general government expenditure (including Defence, Foreign Aid, etc.)
As we aware that we could benefit from these NI contributions in the future, we would probably be more willing to pay them and they could be levied across the whole income spectrum, say as 12% of all sources of income. Avoidance should be minimised and no exemptions permitted - 12% at £25,000 pa and 12% at £250,000 pa and 12% on dividends, 12% on capital gains, 12% on selling your house (even the primary residence).
Eventually we will realise what we need & where it is spent, perceive the benefits and find that we can raise the money at say 10% or ....
Demnark decentralised its health service to put it mainly under local authoirty control with (according to various international bodies ) huge success. We should see waht we can learn from them. But it has to be real decentalisation not an NHS or central government seeking to retain control while in reality just dumping blame.
As a member of the public I find such endless findings, good as they may be, cast a very big shadow on the ability of managers and policy makers to actually manage the problem and importantly to 'bite the bullet' whilst all the while the public are suffering as this farce is endlessly rolled out.
I recently met the Chairman of hospital Trust in England where I worked for over 20 years and mentioned that people in his domain were leaving ALL lights on in the corridors and mini-nightingale wards for hours in summer day light even in these days of austerity , to which he shrugged his shoulders and said, "one cannot micromanage in the NHS "!
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