Foundation essay: This article on the relationship between health and social care in the UK by Bob Hudson, Professor of Applied Social Science at Durham University, is part of a series marking the launch of The Conversation in the UK. Our foundation essays are longer than our usual comment and analysis articles and take a wider look at key issues affecting society.
Despite moves to prioritise social care alongside the NHS, funding shortages - as well as other NHS reforms - could well have a dramaric and grim impact.
The government has promised more money but as the Association of Directors of Adult Social Services recently calculated, a further £800m will be cut from social care budgets this year, which may go some way to explain why the qualifying criteria for the £72,000 cap on care costs in 2016 has been set so high.
Integrated care, a key part of the new Health and Social Care Act, is being marketed as the answer to a financial crisis in healthcare – that somehow it can square the circle of increased demand, higher expectations and diminishing resources. But put alongside the government’s other enthusiasm for competition and market-led provision, the picture looks less rosy.
There is perhaps one unexpected benefit in all this – an opportunity to consider whether the whole health and social care system actually works and to change it, and there has been no shortage of reviews and inquiries.
A group of MPs in the Commons Health Select Committee is currently holding an inquiry into how the new act should be implemented. Politicians across the spectrum are also looking to incorporate ideas from the US and the King’s Fund think tank announces today that it is setting up its own commission on the future of health and social care in England.
Roll up, roll up! It’s integration time
Central to all of these initiatives is the search for the holy grail of “integrated care”. The Labour Party was first out the blocks this year with Shadow Health Secretary Andy Burnham emphasising the need to focus on what he called “whole person care” which will encompass people’s physical, mental and social needs.
Labour leader Ed Miliband followed this up with a major policy speech in April, where he announced the setting up of an independent commission to advise the party on how best to achieve this goal.
Not to be outdone the Conservative Health Minister, Norman Lamb, announced the creation of a number of local “integration pioneers” and invited councils, leaders of new health and well-being boards (where leaders from health and social care already now have to come together) and voluntary organisations to come forward. These pioneers will be granted new freedoms to work in partnership and be offered national-level support including dedicated account managers.
And now the government has further upped the ante by declaring that health and social care will somehow be “joined-up” by 2018 and potential financial penalties if patients have to recount stories to too many professionals. There are also plans for an NHS co-ordinator for all vulnerable older people - an intuitively attractive idea.
But what should we to make of all this? It would be churlish to deny that there are some useful suggestions being floated. Two of these stand out: plans to reform the NHS payment system so that those who provide integrated care will be financially rewarded (rather than, as currently, health and social care providers are paid by the amount of “activity” they have). And the proposal to measure the success of integrated care by looking at service user/patient outcomes rather than measures such as how many emergency re-admissions or delays there are in transferring people’s care.
Not so fast - we still need more money
Despite all this talk it would be naive to imagine that a problem that has dogged policy makers since the birth of the NHS in 1948 will be so quickly and easily addressed. There are three main problems: unrealistic expectations, inadequate funding, and the dominance of the government’s obsession with competition.
Health Minister Norman Lamb has warned that the NHS is “at risk of collapse” in the absence of a major shift towards integration and says the selection criteria for his integration pioneers demands levels of achievement and evidence that we haven’t achieved anywhere in England before. Ed Miliband has even claimed that without integrated care there will be a £29 billion funding gap by 2020.
This sort of talk badly underestimates that we still need investment to make any of this integration a reality. The research evidence is not encouraging. The findings of the recent national evaluation of the Department of Health’s Integrated Care Pilots were, at best, equivocal. And while it is certainly possible that future savings will accrue, this isn’t guaranteed nor would it happen quickly.
There also doesn’t appear to be an additional penny anywhere in the system to fund this strategy. The Department of Health is merely “encouraging” all hard-pressed Clinical Commissioning Groups (the doctors who now hold some £70 billion of the NHS’s purse strings) to consider setting aside 2% of their funds for “non-recurrent expenditure” for integrating services in local authorities.
This constitutes a woefully weak funding base for such an ambitious programme of change, and is surely destined for disappointment.
Competition and collaboration are chalk and cheese
But there is one final factor that could fatally undermine the penchant for integrated care - the government’s even greater fondness for competition in health and social care.
Section 75 regulations, which recently passed after much protest), impose competition in the NHS.
Section 75 requires that all NHS services are put out for tender unless the commissioners can prove there is only one provider capable of delivering them - and potential opens the way for costly legal challenges. Such decisions could be exposed to costly legal challenges. It puts the NHS on a par with social care, which has been effectively privatised over the past 25 years.
As providers proliferate and competitive tendering becomes the norm, integration will become more difficult. Partnership working is a complex task based on a shared vision and relationships that are high in trust. It’s difficult to see large private companies, focused on short-term profit, cosily working in productive long-term relationships with the NHS and other public sector organisations.
The key argument at stake here is the relationship between competition and collaboration. At the Department of Health and within enforcement bodies such as Monitor, the line is that choice, competition and integrated care are not mutually exclusive.
This is a tenuous argument that is failing to convince most people trying to make this system work locally, although a few are trying to pave some way through. The only way it can work is for local commissioners (buying services) to put an entire contract for an integrated service out to tender - a mammoth task that is likely to create expensive transaction costs and to favour large private companies over public sector agencies and small charities.
What do we want our NHS to be?
Underlying all of these practical issues is an even more fundamental question – what sort of a society do we want to live in?
The NHS is one of the last bastions of social solidarity – a way of organising crucial resources as an expression of the moral obligations that most citizens feel for each other. This is more than a contract between citizens; it is an expression of a sense of collective identity, of civil association. By contrast, the moral assumption behind the NHS reforms and the way social care is delivered is that we are defined by our individual choices rather than our sense of collective mutuality.
What seems to be missing here is the central argument made by popular philosopher Michael Sandel in his book, What Money Can’t Buy: the Moral Limits of Markets. Sandel argues that the financial crisis has done more than cast doubt on the ability of markets to allocate risk efficiently. It has also prompted a widespread sense that markets have become detached from morals. This is as true of healthcare as other sectors and was seen, for example, with the Southern Cross nursing home collapse and the PIP breast implant scandal, both of which sent government into a policy tailspin.
Sandel’s concern is that we have, without any real debate, drifted from having a market economy to being a market society. Markets and market values have penetrated into spheres in which they do not belong, and we need a public debate about the moral limits of markets.
The way we organise our healthcare and our social care is surely a litmus test of the moral limits of markets. The debate we need to be having is not simply about the technicalities of restructuring and the pursuit of integrated care. It’s really a question about how we want to live together.