A. Richard Humphries, Assistant Director, Policy – The King’s Fund responds.
Social care wasn’t a big issue in the 2010 election campaign; cross-party talks about how to pay for it ended in an acrimonious political row about the Conservative’s ‘death tax’ poster. But the sense that something had to be done about social care returned after the election with some specific pledges in the Coalition’s programme of Government. The centrepiece was a commitment to establish an independent commission to consider how to pay for care.
Nearly five years on, how has social care fared? Arguably, the Coalition has made more progress in five years than the previous Government did in 13. The independent commission, chaired by Andrew Dilnot, reported within a year. To the surprise of many, his central recommendations were not only accepted but also embodied in legislation that will be implemented from April 2016.
To make any headway at all on an issue that has eluded all previous attempts at reform – and in the toughest fiscal climate in living memory – is a big achievement. It establishes a symbolic milestone in social care policy – that the State places a limit on how much the individual should pay for care and extends to care and support needs, the protection from catastrophic costs that we have always enjoyed for health care needs. The Coalition should receive credit too for the most comprehensive and ambitious overhaul of social care legislation since 1948. The way that the Government has engaged with the sector and its stakeholders to ensure the passage of the new Care Act is a model of good practice in policy development that contrasts sharply with the experience of the Health and Social Care Act. To consign the 1948 National Assistance Act to the history books is an achievement of which any modern Government could be proud.
Undermined by spending cuts
However, the Coalition has undermined much of the good it has done by deciding in the 2010 Spending Review to protect NHS spending from real-terms cuts but leave social care exposed to the impact of a 40 per cent real-terms fall in financial support to local government. The transfer of some NHS funds has helped a bit, but not enough to prevent a 17 per cent fall in spending on social care for older people (see figure 1).
Figure 1: Growth in population and changes in spending on adult social care, 1997/98 to 2012/13
The sharpest service reductions have been in community-based services, like home care, that are vital to supporting people at home and avoiding admissions to hospital and long-term care. Since 2009, 25 per cent fewer people are getting publicly-funded social care.
Cuts on this scale to most other public services would elicit political and public outrage. It seems ironic that, although the Government has given priority to protecting universal benefits for older people (such as winter fuel allowances) irrespective of need or wealth, it is older people who arguably are least well-served by the sharp deterioration in access to essential care and support. Public spending on older people is not coherent.
As the financial ratchet on local government tightens, doubts grow that the Care Act will be adequately funded. The funding reforms will be complex to administer and hard for people to understand. In the absence of accompanying action to address the underlying funding position, relatively few people will benefit from the changes. As the gap between demography and resources continues to widen – to an estimated £4.3bn by 2020 – the National Audit Office is right to warn that no-one knows how much longer services can carry on absorbing these pressures.
In the meantime, the deepening fault-line between universal NHS care that is free at the point of need and social care that is rationed to people with the highest needs and lowest means is not sustainable. That is why we, at the King’s Fund, endorse the recommendations of the Commission on the Future of Health and Social Care in England for a new settlement in which there is a single ring-fenced budget for social care as well as health.
The Election and party policies
As the election draws closer, the NHS may attract the loudest political noise but recent pressures in emergency care have highlighted the crucial inter-dependency of social care and the NHS. The coalition has done well to pass the Care Act, but bigger change is now needed. In an ageing society social care has become too important to play second fiddle to the NHS.
As the election is very near, the main political parties have announced policies relating to health and social care. Although specific manifestos haven’t been published at the time of writing, a brief roundup of the main parties’ policies is below.
Conservative Party Policies
- Continue to ring-fence the NHS budget, with a real-terms increase in health spending from 2015 to 2020.
- All patients to have access to comprehensive care, including to a GP from 8am to 8pm, seven days a week by 2020.
- A ‘truly seven-day’ NHS including expansion of hospital services at weekends.
- Committed to implementing the NHS Five Year Forward View ‘in full’.
- 5,000 more GPs to be trained by 2020.
- Spend an extra £1.25bn on mental health services in England over five years, to treat more than 100,000 young people by 2020.
- Cap redundancy payments to NHS and other public sector staff at £95,000, except for those earning less than £27,000 a year.
Labour Party Policies
- A national health and care service based on ‘whole person care’ which brings together physical health, mental health and social care, with health and wellbeing boards overseeing commissioning and Monitor given a new role to drive integrated care.
- Repeal key aspects of the Health Social Care Act and make the NHS the preferred provider of services, with a statutory exemption for the NHS from EU procurement and competition law.
- A cap on profits made by private companies providing NHS services in England.
- Introduce an annual £2.5bn Time to Care fund to pay for 20,000 nurses, 8,000 GPs, 5,000 care workers and 3,000 midwives.
- Guaranteed appointments with a GP within 48 hours and a maximum one-week wait for cancer tests and results.
- Set maximum limits on levels of fat, salt and sugar in food marketed to children.
Liberal Democrat Party Policies
- Increase NHS spending by £8bn a year by 2020/21, in three stages.
- A Manifesto for the mind promise to spend £3.5bn more on mental health care in England over the next parliament. This represents an additional £2.25bn on top of the £1.25bn pledged over five years in the 2015 Budget to improve access to talking therapies and reduce waiting times.
- Promote integrated care by pooling health and social care budgets and giving a stronger role to health and wellbeing boards.
- NHS mergers no longer to come under the jurisdiction of the Competition and Markets Authority and commissioners not to have to put all services out to tender.
- Introduce an annual £250 bonus for carers looking after someone for at least 35 hours a week over a 12-month period.
- Increase frontline NHS spending by £3bn a year, with social care funding for older people increased by £1bn a year.
- Make NHS-approved private medical insurance compulsory for all visitors to the UK and for migrants who have been resident for fewer than five years.
- Replace Monitor and the Care Quality Commission with ‘county health boards’ made up of locally-elected health professionals.
- Introduce a statutory ‘licence to manage’ for NHS managers, overseen by a professional regulator on the same footing as the General Medical Council.
- End hospital car parking charges in England.
Green Party Policies
- Repeal the Health and Social Care Act and ensure ‘a public NHS’.
- Introduce an ‘NHS tax’ to increase funding to the approximate EU average, abolish prescription and other user charges, and expand free NHS dentistry.
- Abolish foundation hospital status, reducing the amount of income that these trusts can earn from treating private patients.
- All promotion of tobacco and alcohol products, including sponsorship, to be banned.
- Introduce free social care for all people over 65 years of age.
National Health Action Party Policies
- Introduce an NHS Reinstatement Bill to abolish competition in the NHS, end the purchaser-provider split and restore the Health Secretary’s duties to provide universal and comprehensive health care in England.
- Guarantee a minimum four per cent annual rise in NHS spending, increasing it to at least 10 per cent of GDP, with the money to pay for this coming from general taxation, including a 1p rise in income tax until cost savings could be realised elsewhere.
- Abolish prescription charges for NHS services.
- Impose a moratorium on accident and emergency and hospital closures and reconfigurations where these do not have the support of the local population and affected staff.
For more information on the King’s Fund’s General Election 2015 content, visit www.kingsfund.org.uk/election
Richard Humphries is Assistant Director, Policy at the King’s Fund.