Distinction between ‘sick’, ‘frail’ and ‘disabled’ has to go

Getting the green light for NHS treatment - but who pays? Flickr/Martin Kliehm

Since the 1940s our welfare state has been built around the assumption that it’s possible to distinguish between people who are “sick” and people who are merely “frail” or “disabled”.

While we consider the first group should have their health needs met for free by the NHS, the others are deemed to have social care needs that should be met by local councils, and often subject to means-testing and charges.

At various stages this has involved a series of demarcation disputes as to which side of the health and social care divide people should fall – and therefore who pays.

At its most ridiculous, this has led to debates about whether someone needs help to have a bath for “health” reasons (when it would be provided by a nurse free of charge) or for purely “social” reasons (when it would be carried out by a home carer and the person would be charged).

Next time any of us takes a bath, perhaps we could reflect on whether it’s a health bath or just a social one.

While this particular debate seems foolish, the same boundary issues exist throughout the health and social care system - for example debates about the difference between means-tested long-term care and free NHS continuing care is just a less blatant version of the bath scenario. But of course, ever since the 1940s we’ve also been learning the hard way that people do not live their lives according to the categories we create in our welfare services.

So while having a £3.8 billion budget pooled between the NHS and social care, as announced in the Chancellor’s spending review last week, is a helpful step forward, it’s also just a small percentage of the total £110bn NHS budget. It’s important that we transform the whole system rather than just the services paid for out of this pooled fund. But many of the barriers are longstanding and deeply ingrained.

Even if such a distinction between health and social care once made sense, it seems increasingly unfit for purpose at a time when most people using services are frail older people with multiple chronic diseases (asthma, diabetes, heart problems, breathing difficulties, depression etc).

In a difficult financial climate, the risk is that different agencies have a vested interest to cost-shunt, rather than take a step back and agree that both their budgets are scarce public resources and that we need to decide jointly how best to spend this money on behalf of local people.

Like many seemingly common sense statements, the reality is more complicated.

One of the reasons that the health and social care divide has lasted for so long is that these issues are genuinely difficult to solve. Arising out of these separate categories of health and social care are different organisations with different budgets, different catchment areas, different legal frameworks, different cultures, different IT systems and different ways of training and educating professionals.

Day in day out, we ask people who work in frontline services like nurses and social workers to try and integrate their work, which is a bit like trying to put a square peg into a round hole.

To make matters worse, many of our current incentives encourage senior leaders across health and social care to focus on internal, single-agency issues rather than on looking across the local area and reaching out to other partners. Because of this, a lot of collaboration happens in spite of the system rather than because of it.

There is much debate about creating more integrated care – but perhaps the only genuine solution is to ask ourselves if the underlying distinction between health and social needs to be rejected and rethought. Perhaps in future a bath should just be a bath, irrespective of who provides it.