In a message to Tory party activists on 24 March, the Prime Minister said “it is vital that we slow the spread of this disease so that we reduce the number of people needing hospital treatment at any one time. That way, we can protect the NHS and save more lives.” Not only was the logic impeccable, but it was also a rare example of Boris Johnson telling the truth; or at least part of it.
It would be unreasonable in the extreme to expect the state – whichever political party controls it – to provide a health service that permanently maintains the capacity to handle a pandemic. However, the NHS ought to be given a fighting chance to cope without the nation having to be closed down, millions of livelihoods put at risk and hardship imposed on countless people. The government – and particularly Johnson and Health Secretary Matthew Hancock – are already coming under severe criticism for having failed to act swiftly. It was clear in early February that a pandemic was coming out of China: the government did not equip the NHS, particularly its clinical staff, to deal with the approaching crisis. But the failure to maintain a health service capable not just of carrying on during a pandemic, but able to avoid meltdown even in a serious flu epidemic of the sort that might occur in any winter, dates back long before the advent of this administration, or the birth of this virus.
Since the 1980s, governments have known the United Kingdom had a steadily ageing population, and that a growing number of people over 80 would have a serious impact on the ability of the NHS to function in accordance with public expectations, even in normal times. More than 12 million people are over the age of 65; nearly 5.5 million are over 75; nearly 600,000 over 90. In the next 20 years the numbers over 85 will more than double, to around 3.2 million people.
It was in recognition of these trends that Tony Blair set up a Royal commission in 1999 on care of the elderly, and that the Brown administration spoke of establishing a National Care Service, to prevent the NHS from having to look after elderly people who were not sick, but were unable to manage for themselves. That notion evaporated with the 2010 election campaign.
The Cameron government, on taking office, asked the economist Andrew Dilnot to inquire into how social care for the elderly could best be funded. It was recognised this was essential, not merely to ensure the sort of care for the elderly expected in a civilised and prosperous society, but to ensure the NHS could do its job. In default of proper social care provision, NHS hospitals would, in effect, become the front line of an improvised national care service, with severe consequences for its ability to handle other duties and, in particular, any periods of excessive demand.
Dilnot reported in July 2011; and presented what the King’s Fund characterised as “a credible and costed way forward” for social care policy. But his report also warned the government “it must move quickly to undertake detailed work on its recommendations and honour its pledge to publish a White Paper followed by legislation in 2012.” What Dilnot proposed was relatively modest: the additional public spending required was 0.25 per cent of GDP. It recommended a cap of £35,000 on the cost of care to be met by any individual with over £100,000 in assets, with residents of care homes contributing between £7,000 and £10,000 a year to meet their living costs, with the state providing the additional resources. This would have encouraged a great expansion of residential care, thereby removing a massive and growing burden from the NHS.
Legislation for a £100,000 cap was passed by the end of the Coalition parliament. However, on winning the 2015 election the Conservatives announced that the introduction of the cap would be postponed until at least 2020. The Treasury, then under George Osborne, would simply not commit to the extra funding necessary. It regarded care of the elderly as an insufficiently high priority and, with it, the ability of the NHS to function as intended and as the government claimed it could. The result of this political decision was to cause NHS clinicians to worry, with the onset of each winter, about the service reaching breaking point because of the usual ration of winter ailments. Because of an inadequate social care sector many hospitals already have a contingent of elderly patients who lack only a safe place for them to be discharged to. That is a part – a large part – of what lies behind Johnson’s plea to “reduce the number of people needing hospital treatment”.
There are already many lessons to be learned from the way the government has handled this crisis. An honest administration would institute a full public inquiry when this is over, not so much as to apportion blame for poor decisions, as to prepare better for the inevitable arrival, be it in years or decades, of the next such pandemic. But we should be in no doubt that the massive strains placed on the NHS because of the failure of successive prime ministers to prioritise social care have to be removed. The health service needs all the help it can get, even in a good year. But in the next bad year ministers must be aware that another long-term lockdown, with its severe economic consequences, simply cannot be an option, and they are unlikely to be forgiven if their lack of strategic thinking helps force one.