Health and social care: How serious is Theresa May's agenda?
Theresa May has unveiled her vision for a "shared society" and plans to tackle the "hidden injustice" that affects people with mental health problems. But Paul Dossett, head of local government at Grant Thornton, says the problems with mental health care, while significant, are only a small part of the issues facing health and social care.
Theresa May yesterday used a major speech to temporarily shift the focus away from Brexit and set out her commitment to provide a long-overdue overhaul of mental health services in the UK. This is welcome news, but optimism must be tempered with caution. No new funding has been announced to support these plans, the NHS is in a humanitarian crisis according to one prominent charity, and fixing mental health is just a small part of a much wider web of complex issues currently facing the health and social care sectors.
Let's start with the facts, and they make for sobering reading. Looking beyond the financial shortfall, the UK has an ageing population - and a highly unhealthy one, with Public Health England claiming that eight out of 10 middle-aged Britons are now overweight, drink too much and don't exercise enough. People born with physical disabilities are also living longer and require ongoing support throughout their lives.
A large part of the problem lies with the centralisation of NHS management. None of this context was in play when the NHS was founded in 1948. Nye Bevan's quote that the dropping of bedpans in Tredegar should be heard in Whitehall made sense in the historic context of the era, but the fact that the management style in the NHS hasn't moved on in 70 years is depressingly true.
Social care has followed a very different political path. It is currently delivered by 150 sovereign political bodies in England and is subject to rigorous inspection from the Government by the Care Quality Commission and Ofsted. Since 2010, Government funding has been severely reduced in real cash terms. The overall government grant has been reduced by well over 30 per cent, while NHS funding has increased in real terms. The reduction in Government funding while demand goes up inexorably led to the famous Barnet "graph of doom" which predicted that the combination of increased demand for social care and reduced funding would squeeze out all other local government services.
The Government have responded, not by extra funding, but by allowing councils to increase council tax by two per cent in 2016-17 and by a further three per cent in 2017-18, the so-called social care precept. The Better Care Fund is supposed to facilitate integrated care but, to date, it has largely represented a chimera, some good examples in parts of the country but in others the subject of acrimonious dispute. Local government does not hold the same place in the nation's affections as the NHS, not helped by an unsupportive national media and sometimes by the vagaries of Government support at different points in the political cycle.
Why does any of this matter? It means that two services, which are inextricably linked, are funded and politically led in two completely different ways. This has led to organisational stasis where public services are delivered the way they always have been and the NHS is perversely incentivised to fill up acute sector beds rather than preventing people getting anywhere near a hospital. With both the NHS and local government facing an acute funding crisis, it seems extraordinary to cut funding to social care. The only outcome of doing so will be the shifting of costs from one public service to another and then adding to it, as the cost of a hospital bed (circa £600 per day) far outstrips any daily cost of providing social care we have ever known.
What is to be done? First and foremost, it is critical that the Government and parliament are able to forge a national consensus on how we fund health and social care for the long term. It will mean awkward questions for the Prime Minister, including potentially increasing taxation or radically redirecting other Government spending towards health and social care. It might also mean a fundamental reorganisation of the way funding is allocated, which will be a monumental endeavour.
There are no easy choices for a Prime Minister hell-bent on reforming the UK so it works for ordinary people. This is the biggest public service challenge of our generation and politicians from all sides will need to step up to the challenge.
Brexit further complicates the situation given the huge contribution that the NHS and councils have acknowledged comes from the role of EU workers.
The proposed business rate reforms to make it the major source of funding for local government created further challenges. Based on current funding streams, businesses will then become the prime funder of social care - surely a difficult sell to business and somewhat counterintuitive. These are our services caring for us and our relatives. We need to get this right now, and for the generations that follow.
Paul Dossett is head of local government at Grant Thornton