Hamish Dibley

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Sticking-plaster perspectives: health and social care integration

Beware of sticking plaster solutions

Beware of sticking plaster solutions

Today’s King’s Fund inspired Barker Commission on the future health and social care in England calls for a new health and social care settlement, proposing the merger of NHS and social care systems. It calls for a new approach that redesigns care around individual needs regardless of diagnosis based upon a single ring-fenced budget with one commissioner per local area. Obviously, this has fundamental structural implications for the NHS as well as central and local government.

Alas Barker makes the same ‘back-to-front’ thinking mistake as the Dilnot review (and the government’s response last year) into funding social care. Both publications start from the wrong perspective: that to achieve genuine health and social care integration and serve peoples’ needs requires more not less resource.

The argument contained in the Barker report boils down to an out-dated and fragmented system being unable to meet the expenditure pressures of an ageing population with rising number of people who have long-term conditions. Merging NHS and social care systems therefore can create a fairer, free at the point of use system or ‘equal support for equal need’. Well up to a point.

Barker’s proposals advocate for a phased approach over time to ensure financial affordability. What this means is that it is proposed that social care eligibility criteria remains in place with only the fewest people with the highest ‘critical’ needs receiving free care.

Subject to economic improvement, coverage could be extended to those with ‘substantial’ needs. A new ‘Care and Support Allowance’ would offer ‘choice and control’ to people with ‘low’ and ‘moderate’ needs but would not remove the principal of means-testing.

Yet, the existence of eligibility criteria does not save money. The longer a person waits for care, the more likely it is that their condition(s) will worsen. It simply stores-up greater problems, resulting in no support for large numbers of people that only creates larger costs over time.

Dilnot meanwhile represents the worse kind of sticky-plaster solution, based on dodgy data of projected demand for services, out-of-date unit costs for domiciliary and residential care and misguided behavioural assumptions over people’s willingness to take out care insurance.

Its accepted proposal, the cap-cost model for social care, to be introduced in 2016, is unlikely to lead to a market for pre-funded care insurance. Economic modelling undertaken did not take into account variation but instead utilises the ‘average of averages’ for both residential care stay and care costs. Moreover, the care cap and means-tested threshold simply entrench fragmentation and disconnect between health and social care services.

Taken together these two reviews seemingly have a blinkered focus on funding allocation that assumes more care demands equal more resources and that there is no bad money or waste in health and social care activities, processes and systems. This is an entirely false assumption to make. Given the publication of the Barker Commission and resulting obsession with bandying around funding cap and eligibility threshold figures perhaps we could focus on a few telling ones?

During the lifetime of the current government spending review the NHS will provide £7.2 billion of support to local authorities for ‘health-related needs’ in the provision of social care. We presently spend £111 billion on the NHS and £17 billion on social care. We know that typically 70 percent of patients in NHS hospitals have social care, not acute medical, needs. We should be asking ourselves if we actually have a funding crisis or whether we have a failure to intelligently lead, manage and spend crisis.