The social care funding gap – caused by the cuts since the Conservatives came to power in 2010 – is about £12 billion a year. But the part of the Johnson Plan that introduces the cap on care payments does not actually put any more money into social care.
Instead it subsidises private payers so that the about one in ten people who currently pay more than £86k in care fees (before they die) will not do so after 2023.
Clearly, this is welcome news for those people, but they are not the people suffering most from the social care system at present.
The people who are suffering most are working age adults with mental health problems (mostly learning difficulties) and poor, elderly people (with wealth less than £23,250). About £25 billion of public money is spent on these two groups of people: just under a half on the 300,000 working age adults and a little over a half on the 550,000 elderly people.
Spending on these two groups of people needs to increase because inadequate local authority fee rates mean that services are contracting, and care workers are paid very low wages and are often poorly trained. This situation is unlikely to change as a result of the Johnson Plan.
In fact, the Plan can be seen either as an underwhelming response to the severe health (NHS) and social care difficulties or, more positively, as the first step to more thoroughgoing and much needed reforms of a health and care system that is creaking dangerously at the seams.
Part of the answer needs to be to pool budgets for both health and social care and give integrated care organisations the responsibility for spending money to optimise outcomes for patients (moving money, for instance, from expensive hospitals to preventive and pre-emptive out of hospital care (high risk care management programmes).
The current integrated care systems are a step in the right direction, but they have no statutory rights over local authority (social care) budgets or policies. They need to be given these rights in a ‘merger of equals’.
Adult social care and NHS services within the Integrated Care Systems could be merged immediately. The merger is not a takeover of the NHS by local authorities, nor vice versa, but a new integrated, patient-centred service: managing the cultural challenges of a ‘merger of equals’ is a key task
The funding of social care also needs a sustainable solution: a cash injection in the short term and an hypothecated tax in the medium term. Merging adult social care and the NHS locally will trigger an opportunity for a more thoroughgoing reform and modernisation of local government.
The Johnson Plan to raise national insurance contributions will collect £12 billion a year, nearly all of which will have to go into the NHS to pay for the backlog in surgery – and that is likely to be true not only in the short term but in the longer term as well. But, it could be seen as the first step on the road to reform:
- The integration of health and social care is long overdue and should happen forthwith.
- Real operational integration, and efficiency savings, will mean that funds will have to be pooled and allocated based on the best return to improving health outcomes.
- This in turn leads to the logic for an hypothecated tax. In the case of local authority funding, this will likely require legislative change.
- Adult social care is about 20 per cent of local government spending – and as much as 60 per cent in some local authority organisations and integrating it with NHS services into a new Health and Care System (an expanded ICS) makes the remaining services increasingly marginal.
- This is exacerbated by a dwindling funding base for local authorities.
- Underpinning this greater emphasis on devolution and ‘place based’, customised solutions to local problems, is the growing recognition that too many communities in the UK have lost cohesion which, in turn, further fuels inequality.
- Decentralisation and devolution, then, make sense in every domain – health, social and economic.