Having upset junior doctors with a bad tempered contract dispute, Jeremy Hunt was a surprise reappointment to Health by Theresa May. Junior doctors are now planning five consecutive days of strikes in September, amid calls for increased taxes to pay for an NHS which is braced for widespread cuts. Yet Mr Hunt risks even more bruises – this time from GPs and dentists. This is due to his refusal to confirm they will get more than the 1 per cent public sector-wide pay cap in the forthcoming pay review period.
What Hunt should urgently be looking at is the imminent crisis in social care. But Number 10 is winning him no friends on this front. A senior policy adviser suggested that the elderly should sell homes to pay for care – a policy Hunt is on record as being against.
Amidst this ever increasing background noise, and with a second term ahead of him, the Health minister now needs to signal his strategic vision and clear sense of purpose for both health and care systems. He said he was “thrilled” to be back in the top job in Government. We need to see some raw enthusiasm from him. We need him to galvanise the country to reshape what our health and care system could be. Cometh the hour, cometh the man, and boy has the health and social care system’s hour cometh.
We urgently need a new deal for health and social care together. It must tackle the three most significant issues – the long-term funding arrangements for both health and social care, the ongoing definitional skirmishes between “health” and “social” care and the expected role of local communities and each individual citizen.
There are is increasing momentum for an overarching, strategic review that engages the nation in a conversation about the future of our health and social care system – and about their role in it.
1. We need to get real about money
Brexit has thrown fiscal forecasts into disarray. Where previously there was a handle on the future of public finances (very tight), now the only certainty is uncertainty – plus the certainty that the £350m a week bandied about by Leavers is very unlikely to materialise to bolster the NHS’s bottom line.
Hospitals are in dire financial straits. No amount of “re-sets”, inspection programmes, rating regimes, threats or pleas will change one fundamental fact – the money available isn’t sufficient for the level of demand. Key waiting time targets are already being regularly missed and there are fractious disputes between hospital chiefs and NHS management about clinical care quality and safety in light of the budgetary restrictions placed on them.
There is some evidence that the British public are getting to grips with the idea that the NHS needs more funding, and that this could mean paying more tax. The British Social Attitudes Survey reports there is an upward trend in willingness to increase taxes for public spending (including health). After a decade of decline, the proportion of people willing to increase taxation for public spending has increased from a low of 32 per cent in 2010 to 45 per cent in 2015. The opposite has happened amongst people who would prefer to keep taxation and spending the same: after a high of 55 per cent in 2010, this has declined to 45 per cent in 2015. Higher taxes specifically for the NHS are widely accepted (41 per cent), with more support to a new tax tied to health (24 per cent) than through current taxes (17 per cent).
A new deal should commit to a figure, a percentage of GDP, that would allow a closer fit between funding, demand and expectation. A new deal should also consider what is the appropriate mix of public funding versus potential individual contributions.
2. We need to talk about “care”
It is now widely accepted that far from operating in distinct, unrelated spheres, health and social care are part of the same ecosystem. No longer is it the case that people get sick, get better, or die. The success of longevity means people living longer with chronic illness. The distinction between “NHS continuing care” – free at the point of use – and social care – paid for and stringently means tested – is blurring. It is no longer an accurate or helpful representation of the kinds of care needed and is leading to a strong sense of unfairness about entitlement to help in old age.
Added to that, social care funding is in crisis and this under-resourcing is having a knock effect on hospitals. Our research found that hospitals are set to waste up to £3.3bn over the next five years caring for people who don’t need medical treatment, in part due to lack of capacity in social care. Simon Stevens, the chief executive of NHS England, has explicitly acknowledged that social care plays a key role in ensuring that quality healthcare can be delivered within budget and it should be first in line for any additional funding.
In this context, where health and care are two sides of the same coin, it is nonsensical that the Minister for Care has been downgraded to parliamentary under secretary. Social care needs someone with power to make real change.
A new deal should address eligibility and equal support for equal need. In the context of intergenerational fairness, a new deal should assess the full package of seniors’ entitlements (eg winter fuel allowance, pension tax arrangements, free prescriptions) to increase transparency and aid shifts in resource to the publicly-funded care budget.
3. We can’t count on the family silver
There is now a huge question of intergenerational equity. More young people are being priced out of home-ownership permanently. The advent of “Generation Mortified” – fortysomething renters – suggests that lifelong private renting is likely to become increasingly common. The assumption to date has been that the family home will form the bedrock of funding for social care in old age (as holding assets above £23,500 disqualifies you for publicly-funded care). With lower levels of home-ownership in future, more people will be eligible with consequent impacts on forecast budget requirements.
4. We’re having our cake, and we’re eating it
We know we are the fat man of Europe (even if we’re not in Europe anymore). Obesity is placing huge demands on the health system and stresses on personal wellbeing. There is much the state can do to help citizens lead healthy lives. There is a strong argument for much more assertive – draconian even – action from the top given the scale of the challenge and our human frailty in the face of cake. But, we as individuals, families and communities must also play our role. No one can lead a healthy life for you, and there is now a need for a conversation about health as part of citizenship.
There is no shortage of reviews, inquiries and commissions dating back as far as the early years of the NHS. But it is policy that turns these well intentioned recommendations into reality. In response to these major trends, and as defining agenda of his second stint in office, it is timely for Hunt to establish an broad ranging inquiry that would spark a national conversation and establish a new deal on health and social care.
Emily Crawford is principal research consultant at ResPublica.
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