RESPONSE TO BARKER COMMISSION ON SOCIAL CARE

by Dr. Ros Altmann

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This response is from Dr. Ros Altmann, Expert on Older People’s issues, former Government Policy Adviser and former Director-General of Saga.

The responses are framed from the perspective principally of the care needs of older citizens. They are not directly relevant to children’s care, however the high-level principles are similar and can apply to all age groups.

Questions

• Do you agree with our conclusion that a new settlement in health and social care is needed?

I absolutely agree that we need a new settlement in health and social care. One striking feature is epitomised in this Consultation itself, which is only consulting on changes to the system in England – rather than for the whole country. The other parts of the United Kingdom need to be aligned too, in order to have a sensible settlement for both health and social care. Currently the NHS operates nationally, but social care is only controlled locally, varying across the countries of the United Kingdom and from council to council. Indeed, the arbitrary distinction between what counts as a health need – and receives full funding from taxpayers – and what is considered a social care need – and receives no funding from taxpayers in most cases – is confusing and unhelpful – and differs depending on where you live in the UK. In reality, it has become something of a lottery as to whether or not society pays to look after people who are unwell, depending on the nature of their incapacity. If someone needs care, they are not ‘well’ in some way. The current divisions are quite arbitrary.. A social care need is ultimately a health need – and if people who have care needs do not receive help at an early stage, they often present with more severe health needs later – and this costs the NHS significant sums which could have been avoided.

• If so, do you support our proposition for a single, ring-fenced budget for health and social care that is singly commissioned, and within which entitlements to health and social care are more closely aligned?

I do agree that a single, ring-fenced budget for health and social care is needed and should be commissioned by a single source. The current system which sees medical experts commissioning health care, while local councils are responsible for social care, merely adds to confusion and resentment among the general public. Indeed, it would make far more sense for GPs to commission social care – and perhaps ‘prescribe’ electronic aids for infirm patients, or monitoring equipment at their home, or even prescribing a social care visit on a regular basis to help prevent falls and emergency hospital admissions. People do generally trust their GP and, if the GP says they need certain interventions, they are likely to accept this more readily than if their family have to persuade them. The current system has perverse incentives. Even for those whose care could be funded by local councils, there could be a much higher cost to taxpayers because the NHS may have to pay more than it should. If an older person, for example, is admitted to hospital, they cannot be discharged unless the council social services assessment has been made. Once they are discharged, the council may have to pick up some cost, which can cause delays in the assessment, during which time older people stay in hospital for longer than necessary, at significant cost to the NHS (while potentially saving money to the council) and sometimes the patient may become more unwell, either through acquiring a hospital infection or losing the capacity for independence or neighbourly support network that was working well. All of this ultimately costs society more and damages patient welfare.

• Should the aim be to achieve more equal support for equal need, regardless of whether that support is currently considered as health or social care?

The aim should be to ensure patients can be looked after and receive the optimal interventions that can save money overall in the management of their condition. That often means focussing spending on social care when needs are only low or moderate, which can prevent needs becoming substantial and the knock-on extra costs that this imposes on the NHS if someone has an accident, a fall, or becomes ill due to lack of care at home. Currently, council care funding only starts once needs become substantial, which leaves many with moderate needs and no means to pay without the care that could really improve their quality of life and keep them safer and healthier for longer. This requires an assessment of the impact of all medical and social care interventions to be carried out in an integrated manner. For example, a heart monitor at home or hand rails to help someone live at home without having to go to doctor’s surgery and remaining safer could be a wise investment for the NHS to make in the care of older people. This could be commissioned by GPs, just as they might prescribe medication. Intervention at the early stage of care needs could ultimately save significant sums in medical costs further down the line. It is understandable that cash-strapped councils are cutting back and tightening qualification criteria for social care funding, however this could turn out to be rather short-sighted and runs the risk of increasing costs to the NHS and care system in future, as well as negatively impacting the health and wellbeing of older people denied earlier care.

• If so, should social care be more closely aligned with health care (that is, making more social care free at the point of use)? Or should health be aligned more closely with social care (that is, reducing the extent to which health care is free at the point of use)?

Social care should definitely be more aligned with health care – but the sad financial reality is probably that not everything can be free at the point of use, either in healthcare or social care. The current artificial distinction, however, is prolonging the air of unreality in our health and care systems and results in sub-optimal outcomes from the perspective of both individuals and the public purse. The NHS will have to admit sooner or later that some aspects of its current provision can no longer be afforded and some charging for certain services is inevitable. Politically, that is really difficult because the electorate does not realise the extent of the social care funding crisis that looms in the coming years. So much waste in healthcare needs to be controlled, but these will be difficult decisions. These could include charging for missed appointments, increasing the age at which prescriptions are free, asking for some payment for certain technological aids, closing some hospitals (very politically toxic), restricting some treatments (to be decided on a political basis, with a detailed analysis of cost-saving.) With a rapidly aging and growing population, the current financial model of the NHS is not sustainable and neither is the model for social care funding. More will need to be paid for by individuals and encouragement of saving for care needs is long overdue. There are presently no incentives offered to help people save for care. There are no products for care saving either – this needs to be urgently addressed. The Dilnot reforms will not solve the problem, particularly as the level of the cap is set so high and the payments do not even start to qualify for the cap until social care needs are assessed as substantial. It is important that social care funding starts when needs are moderate, to avoid much higher costs later. Medical prescription of social care, which can be considered as a valid medical treatment alongside medicines or other therapies, needs to be considered.

• Do you think that adequate funding for health and social care requires:
  – increased charges in the NHS? If so, for what?

Charging for things such as missed appointments and perhaps a small charge for all appointments. Charging for interpreters. Charging for some cosmetic treatments. Increasing prescription charges and increasing the age for free prescriptions.

• increased charges for social care? If so, for what

Currently, social care charges for private payers are not particularly low. It is not clear, however, why care for the elderly should be charged for while care for other age groups is often free. A reassessment of care for all ages is needed.

• cuts to funds from other areas of public spending, re-allocating it to health and social care? If so, from what

The health and social care budgets should be combined, with social care services incentivised to save money on healthcare and vice versa. There are not cost saving incentives between the services at the moment.

• an increase in taxation? If so, which taxes would you favour increasing

That has to be a political decision. Ultimately, NHS spending is unlimited. With no control on the costs and expenditure, the NHS being free at the point of need could overrun its budget and taxpayers just have to carry the cost. It seems that more cost control, efficiency savings, less waste, more streamlining and a national system of both care and health may help rather than the current confusing arrangements which cause unnecessary concerns or distress to people and their families.