By Ghandi’s test, that the true measure of any society is how it treats its most vulnerable members, we have surely failed, writes Niall Dickson, chief executive of the NHS Confederation.
For a generation, successive governments in England have presided over services that have left growing numbers of older people without the care and support they need. It is the half-hidden scandal of our welfare system which never seems to have attracted enough political or public attention for anyone to tackle it.
Estimates vary but at least 1.4 million older people who need basic support with bathing and getting in and out of bed, the most fundamental activities of daily living, are not receiving the help they need. And it hits all but the wealthy – half of all home owners are not confident of having enough money to fund their own care, even if they sell their home.
We have a means tested system which excludes individuals with modest means and a publicly funded system which has been cut so severely, that only those with the most severe needs are eligible for any kind of support. And again, in some places they have more than 1000 clients waiting to be assessed for care, some of whom will be in the urgent category.
For those providing services, whether in people’s own homes or in residential care, public funding is sometimes so woeful that they are handing back contracts. And in most areas, private pay users in effect subsidise those who are funded by the local authority. For providers, public funding is not enough to create a viable business, and it is imperative that they attract private payers who pay substantially higher fees. This means that in more deprived areas where there are not enough better off clients, the local care market does not work and more people end up in hospital for lack of any alternative.
The funding story is not complicated – in the last ten years the demand for social care has risen exponentially. The so-called tail of morbidity among a growing older population – the number of unhealthy life years - has increased alongside more healthy years. At the same time, funding has not only failed to keep up but has been cut – we have seen an 11 per cent cut in real terms funding in the last five years alone. Not for the first time, central government has been willing to see local government services suffer to an extent they would not have allowed in areas where they have direct responsibility.
You could argue that this is hardly an auspicious moment to call for fundamental reform, both for the funding and the delivery of social care, but we cannot ignore the continued cost of doing nothing, and the perpetuation of a system that is unsustainable, damages lives and threatens to undermine other areas of public service, not least the NHS.
It is also about political expediency. Failing to act could mean another major social care provider collapsing, it could mean the emergence of another major scandal like Winterbourne View and increasing noise from the army of relatives and unpaid carers who see the daily impact of a failed system.
To be fair, the Prime Minister has had other priorities, but it is surely reasonable to remind her that she came to power promising to be the leader who would finally resolve the crisis in social care. Two years on and even civil servants struggle to keep a straight face as they announce yet another delay to the promised Green Paper which was supposed to set out the route to reform.
That is why the NHS Confederation has brought together a coalition of 15 health organisations to launch Health for Care, to campaign for a fair long-term funding settlement for social care in England. The government has declared that it will deal with this as part the spending review, which will be carried out later this year. This is then the time to convince the political class in general, and Treasury Ministers in particular, that they cannot duck this issue again.
This is one part of the public sector arguing for more funding for another part and that is unusual. But it reflects deep frustration within the NHS at the appalling way in which social care has been treated and the impact this is having on the health sector. It is also prompted by the experience of the NHS front line, where the human tragedies of the social care deficit are evident, and by the growing realisation of how dependent health services are on an effective social care system.
A lack of care and support packages in communities has led to thousands of patients being stuck in hospital when they no longer need to be there. It is no exaggeration to point out that the much-trumpeted NHS Long Term Plan will fail to deliver if we do not achieve a social care settlement.
That means funding at a level to enable social care services to operate effectively. The report we commissioned from the Institute for Fiscal Studies and the Health Foundation concluded that this would require a 3.9% real terms uplift every year for the next ten years. This is above the NHS uplift, but it would be unacceptable for social care to receive anything less than the 3.4% the NHS has been promised.
Alongside money, we have a significant workforce crisis in the sector. The status of the work in this sector remains shockingly low and it is hardly a surprise given pay rates that providers are having to compete with supermarkets. With around a third of social care workers in London coming originally from other EU countries, the immediate challenge is obvious.
At the same time, Ministers need to address the central issue of widening eligibility. Whatever system is chosen for raising the money for care, eligibility should be based on need and must be widened to make sure that those with unmet or under-met need have access to appropriate care and support.
Let us concede, this is a politically fraught area. The Conservatives’ plans for reform had to be hastily dropped during the 2017 general election having been dubbed a ‘dementia tax’, while Labour’s plans during the 2015 election were labelled a ‘death tax’. None of this is helpful. As was achieved in the 1990s pension reforms, we should be seeking to achieve political consensus on the way forward for policy reform that will last for many years.
We have reached a point where we cannot go on like this. Dare one say it? This is another area where time is running out. The Green Paper and the Spending Review provide an opportunity at long last for this Government to do the right thing.
Niall Dickson is chief executive of the NHS Confederation. Follow him on Twitter @NHSC_Niall. This blog was first published in the New Statesman and it is the first in a new series of NHS Voices blogs about the new Health For Care campaign.