The 2019 election will be held at a time when the NHS and social care are typically under strain. David Rowland outlines a number of key policies that the manifestos should include if the various crises in the sector are to be addressed by the next government.
Unless the UK dodges the virulent strain of flu which hit Australia earlier this year, the upcoming election is likely to take place against a backdrop of TV footage of over-stretched NHS hospitals and the possibility that a deal to save hundreds of care homes for older people from closure could fall through. So, how should the party manifestos respond to the various crises in health and social care?
A commitment to a substantial increase in funds for the NHS
As was the case in the 2015 and 2017 elections, all the major parties will be under significant pressure to commit to a significant increase in funding for both the NHS and social care. To date, there is no clear consensus on the amount of additional funding which is needed to enable the NHS to deliver high quality universal care. The injection of an additional £20.5 billion into the NHS by 2023/24 is regarded by many as a sticking plaster to cover a wound to the service caused by eight years of austerity.
To equip the NHS to deal with an ageing population, to upgrade its crumbling facilities, and to enable it to meet public health challenges such as obesity will require much more on top of this additional £20.5 billion; the parties will need to be honest with the voters about how much more is needed and how it is going to be paid for.
A workforce strategy which is linked to a wider labour force strategy
Merely providing more money to the NHS is not sufficient. Any party which is serious about addressing existing problems must also commit to producing a workforce plan which is designed to meet the huge numbers of unfilled vacancies in the NHS and social care, especially after Brexit when recruiting workers from Europe will be more difficult.
Any workforce strategy for the NHS and social care must, however, not be separate from a wider labour force strategy – as has traditionally been the case – but should instead form part of a radical plan to prepare the UK’s workforce to meet the challenges of an ageing population, de-carbonisation, and automation. Care work is high-value, low-carbon work, but caring is also an activity which robots or computers will struggle to undertake. As a result, workforce planning for the NHS and social care should form part of a strategy to re-equip the economy and the labour force to meet the UK’s 2030 target on reducing carbon emissions and the replacement of traditional work with artificial intelligence.
Providing additional finances for social care to address the quality deficit
Calculating how much is required to address the crisis in social care is more problematic as this is a crisis of quality, access, and entitlement. As things stand, funding for social care has declined by 13% between 2009/10 and 2015/16. Currently, one in five care homes in England are rated as inadequate or requiring improvement, whilst the workforce which delivers social care is often paid below the minimum wage and the turnover rate is on average 30%. In addition, the market which delivers adult social care – primarily care home and home care services – is so fragile that the government’s impact assessment on a no-deal Brexit estimated that it could fall over if hit with a small increase in inflation or a nasty strain of flu.
Tackling the inequities in terms of access to state funded social care
But it is the entitlement to state-funded social care which is the most pressing political issue. Over the past decade, those eligible for state-funded care have diminished in number considerably – to the point where over half of the £15 billion in income which goes into the private care home industry is now from private payers rather than local authorities.
Even if the care needs of an older person are deemed by local authorities to be sufficiently serious, they still are unable to access free care if they have assets or income over £23,250. As a result of house price inflation, more and more people are now required to pay for social care out of their own resources – a major inequity which all parties will need to address once and for all.
In the absence of the government’s promised Adult Social Care Green paper, a growing political consensus has emerged which recognises that the only way of addressing the inequities inherent within the current social care funding model is to make elements of this free to those deemed to be in need, irrespective of their income and wealth. In July 2019, the House of Lords Economic Affairs committee recommended that personal care should be free to all and funded from taxation – an endorsement of the conclusions of the 1999 Royal Commission on Long Term Care. Any party which does not include a commitment to a similar scheme may suffer at the polls.
Whether the funding for this new scheme comes from income tax – which places an additional burden on working younger people – or from a tax on inheritance or wealth – which is likely to be dubbed unhelpfully by the media as a Death Tax – is a question which all the major parties will inevitably face but which can no longer be dodged. Taxing inheritance to pay for free personal care is likely to be less regressive and will also help to address the wider inequalities which result from the nation’s accumulated housing wealth cascading down the generations.
Major structural reform of the social care market
But again, simply pumping more money into social care will not solve all the problems unless it is accompanied by structural reform. As our new research shows, hundreds of millions of pounds which flow into the care home sector each year leaks out to offshore investors in the form of debt repayments and rental fees. Unless these leaks are plugged before any additional taxpayer money is poured in there can be no guarantee that it will reach the frontline.
Plugging these leaks will require a new law to make care home companies fully transparent in how they use the income they receive and it should be accompanied by the introduction of new regulatory requirements to ensure that any company which is licensed to provide social care is tax registered in the UK and satisfies certain tests regarding their financial sustainability.
A capital investment strategy for all aspects of healthcare backed by public capital
The parties should also commit to a ten-year capital investment strategy but this will need to go beyond patching up run down NHS hospitals; it must also incorporate the provision of social care and mental health facilities.
For far too long, care homes and mental healthcare facilities have been excluded from our common understanding of public infrastructure. Instead, successive governments have relied on private financiers and the market to provide care facilities which provide investors with a return. Yet these also often fail to meet the needs of those who use them, producing bigger and bigger facilities at the expense of care quality. Breaking away from the use of private finance to build infrastructure – a policy which locks in high costs for decades to come – doesn’t just mean ditching the use of the Private Finance Initiative in the NHS: it also means making low-cost public capital available to invest in care homes and mental health facilities.
And these new facilities should be planned as part of the overall health infrastructure for the UK and not just seen as an adjunct to NHS hospitals as is currently the case. The use of public capital to build new care facilities should also be used to require developments which are green in terms of their impact on the environment, but also through using nature and wildlife in their architecture to promote health and wellbeing for the people who use the services and the professionals who work there.
A democratically accountable administrative structure
Because the last two parliaments have shied away from a re-organisation of the NHS infrastructure after the debacle of the 2012 Health and Social Care Act, it is now the case that the law which governs the constitutional arrangements for the NHS is now so obsolete that many of the administrative units which are responsible for delivering healthcare in England lack a firm basis in law.
The market-based experiment encapsulated in the 2012 Health and Social Care Act may have been officially abandoned, but a substantial proportion of health care in England is still delivered through a myriad of thousands of independent contractors who are paid £29 billion each year by hundreds of public authorities, few of whom have the capacity to hold the contractors to account for their use of public money. Ending the wasteful contracting culture across the NHS by substantially reducing the number of providers and commissioners of services would put the NHS in a better position to co-ordinate health and social care provision in a much more efficient way.
Any new administrative architecture must also abolish the division between health and social care so that the care needs of individuals are addressed holistically rather than according to an abstract bureaucratic category.
In addition, the provision of healthcare by public bodies must be democratically accountable so that it is clear to all citizens who decides what healthcare they are entitled to; there must also be clear opportunities for citizens to shape the provision of services in their local areas.
The re-emergence of population-based planning for healthcare is to be welcomed but planning decisions should be undertaken by accountable public officials and not by unaccountable private companies.
Reaffirming the values of the NHS as a service based on need rather than entitlement
One of the more pernicious aspects of the Brexit debate has been the attempt by some to recast the NHS as an institution which is there to serve only a part of the population living in the UK – a ‘British NHS for British people’. This has led to a wasteful and iniquitous regime of charging which has, without doubt, led to many people being denied access to life-saving healthcare whilst burdening NHS trusts with the responsibility of checking the entitlement of patients. The fact that the government has recently spent £1 million on a programme to help educate NHS trusts to prevent them from charging the wrong patients shows that the relevant regulations are a high-cost way of restricting access to healthcare – a fundamental human right – and need to be scrapped.
About the Author
David Rowland is the Director of the Centre for Health and the Public Interest. Prior to this he worked within healthcare professional regulation in the UK as the Head of Policy at three national regulators.
All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science. Featured image credit: Pixabay (Public Domain).