Health and social care

It’s not all about the money


Photo by Cristina Serí on Unsplash

In his latest column for The Municipal Journal, Jonathan Carr-West examines how to achieve a successful reform of social care and reflects on why progress has stalled in the decade since the publication of the Dilnot Report.

There was great excitement last week at the prospect that the Government would be announcing plans to reform the funding of social care. In the end, to the surprise of absolutely nobody, this announcement was deferred. The great game of waiting for social care reform goes on (and on, and on).

Last month it was a decade since the Dilnot Commission proposed a fixed cap on an individual’s liability for care costs in the hope that this certainty would create a viable insurance market. It is nine years since we, at LGIU, ran an inquiry for the Local Government All-Party Parliamentary Group which concluded that we needed integration of health and social care and that money needed to be diverted from NHS budgets to prevention.

None of these things has happened.

There has been progress in recognising the problem: back in 2012 it was still possible for the minister for care to claim there was no funding gap in social care. That wouldn’t happen now. But progress towards solutions? Not so much.

All the talk this week was about funding, with suggestions that care would be paid for by an increase in National Insurance. I’m not going to add to the debate about whether that is the right choice or not, but I think it is dangerous if we let this discussion become exclusively about funding. Of course it’s important: the Local Government Association estimates there will be a £3.5bn funding gap by 2025 and in the annual finance survey we run with The MJ, councils consistently tell us it is their biggest long-term financial pressure.

But there are three other areas we need to think about if we want additional funding to be effective.

First, we must consider how care is actually delivered. We need a shift towards outcome-based commissioning.

Back in 2012, three-quarters of councils agreed this was essential for the future but still the majority of care is commissioned on a task and time basis. We need to commission providers – in-house or external – in a way that makes them focus on outcomes and allows them to be creative. This is more cost-effective and delivers better outcomes for care recipients.

Second, we need to urgently improve the lot of the care workforce. Care is only as good as the people who deliver it. Care workers are some of the unsung heroes of our society but too often they are badly paid and working on precarious contracts. We need to improve their conditions while building career pathways and esteem. They should not be the poor relations to clinical staff.

Third, we should be clear about where care sits in the system. Everyone is agreed that health and care need to be integrated but there is a growing argument that this should mean rolling care into the NHS. Some in local government have even argued that the sector would be better off without the costs of care.

This would be a mistake. Demographic shifts mean that more of us will require care for longer.

This has two consequences. It means an onus on prevention and that in turn means care needs to be integrated, not just with health, but with housing, planning, leisure and a whole raft of local services.

It also means that more care will be delivered by the community (this is already where the majority of care happens), so we need better alignment between formal and informal care and we need care to be part of the overall ‘curation’ of communities that is local government’s key role.

All this means care has to stay local. Does it also mean we should localise health? Or recognise that the NHS is not, in reality, a national monolith, but already a patchwork of local trusts, commissioning groups, providers, etc, and place these within a framework of local democratic control? Maybe. But that might be an argument for another day.

Jonathan Carr-West is Chief Executive of LGIU. This article was first published by The Municipal Journal.


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