Hospitals were given to the NHS. What we now call social care was left with the local authorities
This organisational structure persists to this day.
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.
In order to maintain care overall, spending will have to increase and become more joined-up across the NHS and social care system. 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.
Problem 1: it’s 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 similar health burdens 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. 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.
Problem 3: it’s not co-ordinated
The organisations which commission health and social care are not aligned: 211 CCGs for acute hospitals and community health; 152 local authorities for social care; NHS England for primary and specialist care.
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 stuck in hospital while funding or assessment is resolved.
The commission concluded that tinkering with the existing system is not enough to address these problems.
We need a new settlement for health and social care to meet 21st-century needs and aspirations.
What would this involve?
Change 1: commission health and social care together
Remove the barrier between health and social care. Have a single ring- fenced budget for both, and commission both together.
Change 2: simpler pathways, more personal control
Design a simpler path through the current system that responds 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 care for those with ‘critical’ needs – health and social – free at the point of use.
Extend this to ‘critical’ and ‘substantial’ needs as the economy improves.
By 2025, provide support for ‘moderate’ needs.
These changes offer a big prize – a more integrated service, a simpler path 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.
The 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 (the wealthy) 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
How can we afford it? 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
How can we afford it? Contributions from the elderly
Limit winter fuel allowance and free TV licences to older people on low incomes.
Potential saving of £1.4 billion
How can we afford it? Wealth and property taxes
Review taxes on wealth and consider reforms to inheritance tax, wealth transfer tax, capital gains, property tax…
Overall, the government should assume that public spending on health and social care will increase from 9.6 per cent of GDP to between 11 and 12 per cent by 2025.
That sounds like a lot of extra money but it’s no more than other similar countries. The commission believes that in the long run this is affordable and sustainable.
This still compares favourably with Canada (11.2 per cent), France (11.6 per cent) and the Netherlands (11.9 per cent).
What do you think?
About the settlement the commission is proposing?
How it could be achieved?
How it should be paid for?
Tweet using the hashtag #barkercomm or leave a comment at www.kingsfund.org.uk/commission
This is an abridged version of the report. To download the full version, including all 12 recommendations, go to www.kingsfund.org.uk/commission