Squabbling over Social Care Costs

Last week, the Department for Health and Social Care (DHSC) updated its 2012 guidance on who should cover the costs of those needing health and social care. A simple matter, you may think: the NHS pays for healthcare and local authorities pay for social care.

Well, not quite. 167 pages of “guidance” reveal a massive bureaucratic process whose costs should be devoted to the care itself. Many elderly people have both health and social care needs and neither public purse wants to pay for the care they need. In extreme cases, the patient dies before the squabble is concluded and care is provided.

The basic guidance is that “where an individual has a primary health need and is therefore eligible for NHS Continuing Healthcare, the NHS is responsible for commissioning a care package that meets the individual’s health and associated social care needs.” (p.6, my italics).

A complication is that the NHS is not great at providing social care so it either does so expensively (e.g. keeping people in hospital) or has to contract it out—normally to the local authority, but in theory the private sector could meet the need.

The public purse squabble starts at the top: although the DHSC is nominally responsible for social care, they do not pay for it. The money comes to local authorities from council taxes and the Ministry of Housing, Communities and Local Government who have no particular interest in social care. This is crazy. It would just need a flick of a switch to transfer central funding to the DHSC.

Under the current multi-pocket arrangement of paying for care, the expensive drugs for a lucky few are, in effect, funded by evicting frightened old people from their care homes because the local authority has run out of money or needs to use it for other purposes.

Unsurprisingly, in this context, the new DHSC guidance notes are written from the perspective of the NHS. The objective appears to be the avoidance of having anything to do with social care and especially not to pick up the bill, unless it is to free up a hospital bed. In other words, the guidance notes appear to be an elaborate means of refusing to pay for Continuing Healthcare.

They use two devices: a multidisciplinay team (MDT) and a decision support tool (DST): “Determining whether an individual has a primary health need involves looking at the totality of the relevant needs. In order to determine whether an individual has a primary health need, an assessment of eligibility process must be undertaken by a multidisciplinary team (MDT) (refer to paragraphs 119-123) which must use the national Decision Support Tool (DST) (refer to paragraphs 131-141).”

One might think that a good way to determine if someone has a primary healthcare need would be to ask their GP but not in the wonderland of the DHSC. Instead a committee of people with other territorial, the MDT, interests should be formed. It is very unlikely to include the GP who will be too busy to participate in these buck passing games. There is also the risk that the GP will say their patients have healthcare needs. The CCG (Clinical Commissioning Group) does have to sign off on the MDT’s findings but they too are mainly driven by trying to keep within budget.

Best of all is the DST which is a sophisticated, modern measurement technique based on the Texan methodology for weighing pigs. A plank, with a basket on each end, is placed across a tree. Once it balances, a pig is placed in one basket and stones progressively added to the other. When the plank balances again, they guess the weight of the stones. The DST works in much the same way: needs are broken into 12 “domains” each of which is assessed (by non-doctors) along with how it mat develop in the future.

To decide whether it is primarily a health problem (and the NHS should pay), the MDT is required to see if social services could cope, with the NHS doing the medical bit. The purpose of the whole charade is to dump NHS problems onto local authorities. According to one senior GP: “In practice, very few people seem to be awarded continuing healthcare, hardly surprising since virtually everyone’s primary need in life is social care.”

From both a national and an individual point of view, this may be a good thing. Social services look after people far more economically than the NHS and none of us want to live out our lives in hospitals.

Three things are wrong with these “guidelines”: the DHSC is partisan because it pays for the NHS but not social care (it should pay the share from the public purse of both); they needlessly bureaucratise what should be a simple matter thereby taking funds away from any kind of personal care; and squabbling over who pays the bill does nothing to bring the two sides of care seamlessly together.

The DHSC agrees that health and social care should be seen together but their twin green papers on these subjects are now long overdue. It is high time DHSC practised what it preaches.