It just does not add up, and even the expensive experiments in funding places like Manchester to try and make integration work, have failed. We need a different model, but we are a long way from achieving agreement to ditch the current one: so its got to get worse. Election pledges are meaningless in such a crisis. Unity is impossible (Independent) when our politicians cannot think long term. Chaos results (Guardian) Whatever options are chosen, they will not solve the long term problem of sustainability.
The Times view on health and social spending: Tax for Care 4th September 2021: Boris Johnson intends to sort out social care with a tax rise. He must not allow the NHS to suck up the extra cash without reforming itself.
Boris Johnson could well have a tough week ahead with the prospect of breaking two eye-catching manifesto promises. Faced with a choice between abandoning his pledge to fix the crisis in social care and breaking his pledge not to raise income tax, capital gains tax or national insurance, the prime minister looks set to choose the latter. Meanwhile the price of fixing the crisis in social care looks likely to be the jettisoning of a second manifesto promise in the form of the pension “triple lock”. Mr Johnson has concluded that not only is he too personally identified with the social care pledge to walk away but the pandemic has given him cover to raise the taxes needed to pay for it. He is betting that the public will reluctantly accept paying more as part of a broader plan to tackle the backlog in the NHS.
There’s a compelling argument for addressing the social care crisis, a problem that has been neglected by successive governments for more than two decades. Not only does the current system cause distress to individuals and families who find themselves hit by sky-high bills for care. But the crisis in social care is also adding to the pressures on the NHS as people who could be looked after in their own homes end up in hospital. The reality is that the private sector has been unable to develop a workable form of social care insurance and in effect only the government can underwrite this risk.
Of course it does not follow that because the state must be the insurer that national insurance is the right way to fund the reform, as the government is proposing. The link between national insurance and entitlement to access to the NHS and most state benefits has long been broken. Today it is essentially just another tax, and specifically one that falls on those in jobs and excludes those above state pension age. What’s more, the threshold for paying national insurance is lower than income tax so it falls disproportionately on lower paid workers. That is why the triple lock is likely to be abandoned. Not only will this save the Treasury up to £5 billion a year, it will help reassure younger taxpayers that they are not being asked to bear the cost of a benefit that will go primarily to the old.
That may make raising national insurance an easier sell politically, though it is sure to be deeply unpopular with many Tory MPs. But it still leaves open the question whether the government’s plan will work. That is far from clear. One concern is that the money raised will be insufficient to fund both reform of social care and clear the backlog in treatment caused by Covid. The Treasury is reported to want to limit the increase in national insurance to 1 per cent, which would raise about £10 billion. But NHS leaders have said they need £13 billion to clear the backlog while most estimates put the bill for fixing social care at a minimum of £6 billion. Sajid Javid, secretary of state for health and social care, is reported to be pushing for a 2 per cent hike in national insurance.
That points to the wider risk that the extra money will go to the NHS, leaving little for social care. When Tony Blair’s government raised national insurance to boost funding for the NHS, half the money ended up on increased salaries. Ominously, this new plan appears to ensure the new money for social care will only become available once the NHS backlog has been cleared.
Meanwhile the government looks likely to set the cap on social care costs well above the £50,000 recommended by Sir Andrew Dilnot in his 2011 review, leaving many families facing heavy bills. Mr Johnson should insist the extra money provides a durable solution to the social care crisis from day one. He should further demand the NHS delivers savings through greater efficiency reforms. Why bear the political pain of breaking two manifesto commitments if the plan turns out to be just another ruse to kick social care reform back into the long grass?
Times letters 4th September.
Sir, Fixing our broken social care system and tackling NHS backlogs undoubtedly comes with a multibillion pound price tag (“Javid wants 2% tax rise to fund social care amid cabinet split”, Sep 3). Although increasing national insurance contributions (NICs) is thought to be politically acceptable to voters, it is the wrong tax to use for this purpose. NICs are more regressive than income tax because the rate charged drops at higher earnings levels. Employees earning less than £967 a week pay NICs at a rate of 12 per cent but this drops to 2 per cent on earnings above this level. In addition, NICs are not levied at all above state pension age, so even the one million people in work over the pension age are exempt. It is hard to see why a tax rise to fund services that will largely benefit the retired population should be funded solely by the working-age population and with an easement for higher earners. Finding the necessary money through income tax would be a far fairer solution.
Sir Steve Webb,
Partner, Lane Clark & Peacock; pensions minister 2010-15
Sir, Your report indicates that the government is finally willing to increase spending to reform England’s social care system. Our analysis shows that a lifetime cap of £50,000 on individual care costs would particularly benefit those living in red wall seats. But debates on how to raise the money risk blocking reform. Increasing national insurance contributions would hit younger and lower-paid workers disproportionately; a more broad-based and progressive tax would be fairer. Properly reforming the system, which means improving care as well as capping costs, might cost an extra £12 billion in 2023-24. This sounds a lot but equates to only about a month’s NHS funding or 0.6 per cent of GDP. If it chooses to, the government can afford to provide better care for vulnerable people.
Anita Charlesworth, director of research
Hugh Alderwick, head of policy, the Health Foundation
Sir, It is good that the prime minister intends to keep his promise to “fix social care” but he will snatch defeat from the jaws of victory if his reforms are underfunded. Those involved in social care agree that a cap on care costs would not be enough and that new funding is needed to stabilise the provision of care and strengthen the workforce. Given that the idea is apparently to share the money raised with the NHS, at least in the short term, it is highly unlikely that a 1 per cent increase in national insurance contributions would generate enough funds. This means that the extra funding required will either have to be raised by some other means, such as through government borrowing, or that the national insurance levy that ministers seem agreed on will need to go appreciably higher.
Caroline Abrahams
Charity director, Age UK
Sir, It is right to raise national insurance contributions. I would also make these contributions compulsory after pensionable age. Many of those in their later years are fairly wealthy and are no doubt using more of the services available to them. I know that we have all paid for this care during our working years but I see no reason why a small contribution should not continue to be made by those who can afford it.
Chris Dodd
Ullesthorpe, Leics
Sir, There is no shortage of care workers. There is only a shortage of care workers willing to work for the low wages on offer.
Samir Sirdeshpande
Walton-on-Thames, Surrey
Steven Swinford, Chris Smyth and George Grills report in the Times 3rd September: Sajid Javid calls for 2% rise in national insurance to fund social care = Cabinet split over plans to increase tax
The King’s Fund : Adult social care funding and eligibility our position 26th Feb 2021
Rand Europe – an Exconomic think tank – Funding Options for the NHS and Social Care in the UK
The Nuffield Trust: How to fund social care?
The Health Foundation 2018: Social care funding options. How much and where from?
The Good Care Group: how to access social care
It was meant to be the experiment that saved the NHS. Instead of having GPs separated from hospitals, and hospitals separated from social care, everyone would work together. It would be cheaper, better, more efficient and less bureaucratic. Everyone would win.
And they had the perfect place for it. Greater Manchester ticked all the boxes: it was well connected and densely populated. Its health authorities were used to working together. Its elected mayor, Andy Burnham, used to be secretary of state for health. It was handed £450 million in extra funding to make the new system work. “Greater Manchester now has a unique opportunity for innovation and improvement in health and wellbeing,” said Simon Stevens, the then head of NHS England, when the project was launched in a blaze of publicity in 2015. “The eyes of the country will now be on what this new partnership can deliver.”
The problem is that it hasn’t delivered. At all.
For the past few months my colleagues at the Centre for Policy Studies think tank have been examining the performance data on healthcare integration in the years leading up to the pandemic. In Manchester in particular the record is dismal. One of the key justifications for integration is to move patients more swiftly from the NHS into social care. Yet, as we show today, incidents of delayed transfer of care — “bed-blocking” — were on average 65 per cent higher in the years after integration than before it.
In fact, despite self-congratulatory progress reports, Manchester’s new healthcare system was, before the pandemic hit, on course to miss every concrete target it had set itself. In healthcare circles the region has gone from a poster child to an awkward embarrassment. The extra hundreds of millions have vanished down the drain…..
Across the 13 pilot areas in England, our research found no sustained improvement in performance. If anything, we found the opposite, with delayed transfers of care averaging out at 24 per cent higher since 2016, versus just 9 per cent for the rest of the country…..
The reason these findings are so alarming is that the NHS is charging pell-mell towards integration. The new Health and Care Bill parcels the system in England into 42 “integrated care systems” like that of West Yorkshire. The proposals are less controversial than Andrew Lansley’s similarly sweeping reforms of 2012, largely because they have been developed by NHS administrators rather than politicians. But, as the National Audit Office warned in 2017 and our report confirms, there is no compelling evidence base to show that they actually work.
Integration as a principle makes obvious sense. Indeed, one of the few benefits of the pandemic has been the way it forced parts of the healthcare system to work more effectively together. But the idea that another fearsomely complicated, top-down reordering of the NHS will deliver the same benefits in peacetime is, ultimately, a form of faith-based medicine……..
All of which leaves our politicians, and the NHS, in a horrible situation…..
But while the evidence is still patchy and preliminary, our research, and the similar problems in Scotland, suggests that we still haven’t got the recipe right. It turns out that asking separate bureaucracies to hold hands and sing Kumbaya is as likely to entrench the status quo, and protect incumbents, as to push through change.
Similarly, its proponents say the reform will save money by stripping out a layer of administration. But that was precisely the promise made in Manchester — and, indeed, precisely the justification Lansley gave when creating that same administrative layer in the first place. You tend to end up with the same people, sitting in different chairs.
All of which leaves us back where we started. Everyone accepts that health and care need money and reform. But there can never be enough money, and we are still struggling to find the right reforms.
The UK Governement keeps pushing money in this direction: Better Care Fund increased to support health and care integration (extra £6.0m) and 25th August in Business News Wales: £2.5m Funding Boost for Social Care and NHS Projects
Update 12th September 2021: This is about inheritance, not the quality of care – Dominic Lawson in the Sunday Times 12th September
The Economist 11th September 2021: Boris Johnson at last grasps the nettle of social-care reform. Mr Johnson’s choice is unjust and wrong. It should have gone in other directions, removing the triple lock on pensions and taxing property would be fairer,
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