The 2019 Conservative manifesto committed to building “a cross-party consensus to bring forward an answer that solves the problem, commands the widest possible support, and stands the test of time. That consensus will consider a range of options but one condition we do make is that nobody needing care should be forced to sell their home to pay for it.” (p.17) Such a policy is constructive if a bit thin on specifics. It follows Norman Lamb’s proposal to take the NHS and social care out of politics, something Mrs May had rejected for three years. Progress. We must get away from each party tarring and feathering each other’s proposal as a “dementia tax” or “death tax” or some such. Any strategy for the NHS or adult social care needs to survive changes of government.
In 2011, the government rejected the independent Dilnot Commission report and has produced no Green Paper since. Ironically, the main objection to the Norman Lamb proposal has been that it would take too long. This paper shows how cross-party consensus could be achieved and a Green Paper (for England) published within three months.
Adult social care, unlike the NHS, currently assumes funding by those who need it, with local authorities paying for what they cannot afford. Today’s basic problem is that local authorities cannot afford to do so either. According to the BBC Reality Check, in 2015, 30% of those needing help received none, family and friends helped 37%, 12% paid some or all and 21% were helped by local councils. In 2015-2016, 57% of the 1.8m requests (28% from 18-64 year olds and 72% from those older) were rejected.
The Ministry of Housing, Communities & Local Government (MHCLG) “alongside the council tax precept, gave local authorities an additional £0.4bn in 2016/17, £2.3bn in 2017/18 and £3.4bn in 2018/19, and will give an additional £3.9bn in 2019/20. These temporary grants made up 8.9% of adult social care spending in 2018/19.” But as they were temporary grants, the ability of councils to plan ahead was limited. In any case they were far too small.
Estimates of Local Authority costs are consistently around £20bn towards adult social care in 2016-17 but according to the NAO, the public purse was also responsible for £34bn and £120bn for “Incapacity, disability and injury benefits” and “total health spending” respectively The last figure lies within the NHS costs and implies that two thirds of the NHS budget is devoted to care, not cure. This is clearly debatable but, with NHS bed occupancy at over £1,000 per treatment day and £300 per recovery day, compared with £70-80 per day in an LGA funded care home, limiting the NHS to cure would release serious money for care being provided by local authorities. Delayed discharges from hospital is a well-known problem that has received some attention and improvement, e.g. through the Better Care Fund arising from NICE guidance in 2015, although this could be seen as excessively bureaucratic. In 2016, the NAO estimated the annual England and Wales cost at £0.8bn. Of course the problem has been created by the cuts in adult care funding reducing the adult care beds available. Over half of all hospital beds were occupied by those aged over 65 but no records appear to exist to distinguish between those where cure is feasible and those simply requiring care. Given the huge disparity in costs per bed, this is the key question any strategic review needs to consider, namely how to limit the NHS to “cure” and provide the resources for local authorities to deal with “care”, and, indeed, how the two should be distinguished.
It has been argued that, due to their overlap, the NHS and adult social care should be integrated. The trouble is that NHS England is already five times as big as it should be. As and when NHS England is reduced to manageable units (the size of NHS Scotland say), that could be considered. Meanwhile integration might be considered for Northern Ireland and then Wales.
Finally, the current funding arrangement has taxpayers’ money doled out by the Ministry of Housing (MHCLG) whilst policy and strategy are allegedly set by the Department of Health and Social Care (DHSC). This makes no sense and adds to the perception that the NHS is favoured at the expense of adult social care to the disbenefit of both. So, what is to be done?
The Dilnot, and other such committees, have been made up of experts: not the politicians who have to live with what is agreed. The three main (English) parties need to feel they own the result.
The three party leaders du jour should agree a one-per-party triumvirate to resolve, i.e. take out of party-politics, adult care strategy, future funding formulae and the role of the DHSC. It should also have a neutral chairperson and handful of expert advisors.
Since this is similar to the Liberal Democrats’ own proposals, it is hard to see how they could refuse. A Plan B will be required if Labour does.
On the day of the announcement, the terms of reference (“Who pays?”) should be published and the door opened (for two weeks only) for proposals of 1,000 words, or less, to add to the Dilnot and other proposals already being considered.
Party leaders should be able to replace their representatives where they wish so to do.
The committee should list solutions they consider feasible and score them against (weighted) criteria such as cost.
By the end of month two, preliminary conclusions (green paper) should be published.
By the end of month three: a Government White Paper—acceptable in principle to the three parties, but capable of fine-tuning by Parliament—should be published.
Simples!