Pathways to progress


Norman Warner outlines his vision for a new approach to health and social care 

With central government grant to local authorities already severely cut back, adult social care is taking over an even higher proportion of discretionary expenditure. All too soon, some councils will be able to fund little else but adult social care and child protection. Libraries, leisure services, arts and many other parts of civilising local government will continue to disappear. 

These sacrifices will not be enough to preserve good quality publicly-funded care services. Eligibility criteria will be tightened even further, limiting it to those in the severest need. Service providers will continue to see their income dropping below their costs as local authorities cut their payments, and quality of care will deteriorate as the training of staff is sacrificed. As a result, independent providers – who are in the majority in social care – will start to pull out. Private payers will get services; those who cannot pay will see access diminish or disappear. 

Nothing can stop the arithmetic of demography. The ageing and longevity of the population base of adult social care inexorably increases demand. With over a third of adults with long-term conditions (often with multiple morbidities), the demands on health and social care services will rise year on year for at least the next two decades. We pretend the NHS’s core business is acute hospital treatment when it is clearly now community-based. Yet our funding of health and social care is in separate silos with strong incentives to cost shunt and protect budgets.

We have to begin treating the Health Department expenditure limit as a single budget to be spent in the most cost-effective way for the people with care needs. It is my view that we need to re-imagine the whole system as a care system with a medical treatment adjunct rather than as a hospital treatment system with a care adjunct. And it needs money flows and payment systems that reinforce that approach.

This means radically changing political and public attitudes to acute hospitals. I think we need to reduce substantially the excessive number of 24/7 acute hospitals trying to provide a full range of medical specialties and concentrate those specialist services on fewer sites. The money saved could then be used to boost primary care and community health and social care services. 

We now need an agreed cross-party mechanism to bring this about. 

My brief sketch of this - which I will develop further over coming months – is an independent medical specialty led review of 24/7 acute services, under the aegis of the Academy of Medical Royal Colleges. I would ask them to see how these services could be reconfigured on fewer sites with the objective of safer specialist services that released £10bn over 5 years to create a new time-limited Care Development Fund. This fund would have independent “trustees” whose mission would be the development of more community-based services jointly by local authorities, CCGs and Health and Wellbeing Boards. It would not be a new reorganisation, just making better use of the new bodies.

Even with changes of this kind we still need major reform of social care funding to make it sustainable over the long-term. This is because people have to save more for their old age and use more of their own assets to pay for their care, especially by equity release from housing assets. 

To do this we have to find a way of implementing a version of the Dilnot recommendations, instead of sheltering behind the current fiscal difficulties of doing this. If we were to set the Dilnot cap at £50K or £60K and implement the Commission’s other recommendations, it would cost no more than a £1bn a year to make a start. I believe we could do this for three years by using underspends on NHS capital rather than repatriating them to the Treasury and then if necessary find other funding sources, including subsidies from the development fund I propose. And alongside this we need to explain to the public why they need to make a greater contribution to their own care.

Lord Norman Warner is a backbench Labour Peer in the Lords and a former Health Minister 

Published 29th November 2012 


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