Careless vistas

So many prime ministers have pledged action on social care before recoiling, that I really wanted to celebrate the PM grasping the late summer nettle of reform. But he seems to have  brushed casually past it while racing after shimmering mirage of making the NHS “the envy of the world”. Providing a ‘cap and floor’ for personal contributions to care is a good thing. It will reduce anxiety and help protect inheritances for many moderately well-off families, though using workers’ national insurance contributions to do so seems pretty well the least appropriate way of achieving that.

Or almost. State-provided adult social care (which London Councils estimate is 65 per cent of home care and 54 per cent of residential care) is currently funded by London’s boroughs, drawing on government grants, and the dysfunctional ugly twins of local government finance – council tax and national non-domestic rates.

Paying for social care accounted for more than 50 per cent of London borough service spending in 2018/19 according to Centre for London analysis (excluding public health, education and police services). London’s older population and younger population with care needs are both forecast to grow over the next decades, so the costs will rise. When he was chief executive of Barnet Council, Andrew Travers drew a ‘Graph of Doom’ showing social care (including children’s services) gobbling up the whole borough budget by 2030. The £3 billion or so (out of a total of £36 billion) left for reform of the system over the next three years would only just close the funding gap in London. It’s pretty thin gruel.

Even putting the matter of funding levels and taxes to one side for a moment, it makes no sense for the service to be delivered this way. People value social care, and see it as a critical service, but also look to councils for housing, planning, waste collection, street cleanings, park, libraries and schools.

The current model also creates an unhealthy tension between the NHS and social services, as older people are shunted gracelessly between home care, hospitals and residential care. I have heard anecdotes about councils employing full time lawyers to argue against hospital discharges into their care, and (full disclosure) I am personally in the middle of an unseemly haggle with the NHS and social services about who should be providing my mother’s care.

The row over the miserly allocation of funding to social care improvement, compared to the sums lavished on the NHS, illustrates the point. It is artificial to distinguish between the care provided to an old person at home and the care she receives on a hospital ward, not least because if you get the former right, you are less likely to have to pay for the latter.

I am generally all for devolution, but I think this may be the exception. The PM announced that the “NHS and social care systems need to be brought closer together” and talks of “integrated care systems”, but we have been hearing soft phrases like that for years. I think we need to be bolder, and nationalise funding for adult social care.

This does not necessarily mean nationalising care homes and care agencies, though in some cases that might be desirable or even necessary. It should mean tighter regulation to ensure decent pay and more consistently compassionate care.  In many cases, services would be provided pretty much as they are now (the NHS is far more used to operating through third-party providers than it was in the past), but decisions would be taken in a genuinely integrated way, where budgets allocations were not the issue.

This is not intended as a criticism of borough social services departments – London has some pioneering boroughs like Hammersmith and Fulham, who are I think the only local authority who levy no charges for home care, regardless of care recipients’ savings.

And the NHS is far from perfect; it has a lot to learn from social services about the management of long-term conditions, which often seems to take second place to the more life-affirming business of ‘curing’ people in hospitals. There would still be a role for local authorities, in managing interfaces with housing and other services, in promoting public health and preventative services, and in acting as champions and advocates for their residents – perhaps through continuing to play a part in assessments of need.

There are elements of today’s announcement that should be celebrated, but it is still tinkering with the system rather than seeking to transform and upgrade arrangements that date back 70 years. There has been a lot of talk about better joint working between the NHS and local government, but progress has been limited in London.  I’m afraid that the consequences of missing the opportunity for more fundamental structural change – or at least beginning a debate about it – will become increasingly apparent in the next few years.

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