Reform is more than funding: response to Health and Care funding plans

Finally, the long wait is (almost) over. Today the UK Government has announced plans to reform the funding of social care through a 1.25 per cent increase in National Insurance. However, it appears that initial monies raised will primarily benefit the National Health Service.

It has been just over ten years 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, and we can see that thinking reflected in today’s announcement. A cap will be placed on lifetime expenditure and the asset floor below which someone pays nothing will be raised, and there are promises of means tested assistance between them. We have to ask ourselves why on earth it has taken the decade since the Dilnot recommendations to deliver essentially the Dilnot recommendations.

We are still waiting, though, on a promised plan for health and care integration, but there are some indications of a single pot of funding and shared health and care records. But there is still little promise of significant and needed reform to social care.

The paper published from Number 10 Building Back Better: Our plan for health and social care states:

We expect demographic and unit cost pressures will be met through Council Tax, social care precept, and long-term efficiencies; the overall level of Local Government funding, including Council Tax and social care precept, will be determined in the round at the Spending Review in the normal way.

The normal way is not good enough and has not been good enough for a long time.

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. The language today still seems to prioritise the NHS’s responsive services and does not reflect the importance of place, community, prevention and local accountability to adult social care.

The talk from Government over the summer was and still is, mainly about funding and the nature of the funding through National Insurance. While we will not yet add to the debate about whether this is the right choice, this cannot simply be a debate about funding. While money is at the root of the problem, additional funding to support much-needed relief for those facing catastrophic care costs – on its own – will not create solutions.

As we described in our recent briefing on Adult Social Care after Covid-19: Adult social care was already in crisis before the pandemic for reasons that are regularly described by ADASS, think tanks such as the King’s Fund, NHS bodies, national charities and select committees. These include:

years of council budget cuts;
increasing needs of older people and adults of working age;
increasing cost pressures; fragile care markets and high vacancy rates;
no workforce plan or pay that recognises the contribution of workers;
the absence of resources to invest in prevention and early intervention;
prioritising the NHS with adult social care “treated as an afterthought”.

Today’s announcement for additional funding lacked little additional detail on these crucial areas for reform and after years of waiting for a social care green paper, surely there would have been enough time to advance some proposals about these crucial areas?

There are three 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 outcomes-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.

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