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Is this the time to rewrite Bevan’s settlement?

May 3, 2014



The boundary between health and social care created as part of the 1948 settlement is dysfunctional.  There is nothing new in that conclusion but there may be a growing argument that now is the time to do something more radical to address it in a way which unifies the resources committed by the state to care on an equitable basis.

That was the conclusion of the Kings Fund’s Barker Commission whose, well-argued and eminently readable interim report was published before Easter.  For many years I have thought this issue undoubtedly worthy but in the too difficult pile.  I am starting to think that it is worth grasping the political and financial nettle of such a bold step.  The reasons for doing so are not the traditional ones relating to the injustice of people losing their homes to meet a care need which is deemed to be “social care” which would be free at the point of delivery if it was categorized as “health care”, distressing though this is for many individuals.  The measures identified by the Dilnot review and, which somewhat slowly and reluctantly, the Government are implementing, are probably sufficient to address this.  Instead I would argue that the rationale for the change sits with a deeper challenge that if we not take an integrated approach to health and social care the NHS itself will become both unsustainable.

I have some personal history on this subject.  In the 1990s I worked on developing the guidance to define NHS Continuing Care which came out in response to a very critical report from the Health Ombudsman – an interesting if ultimately thankless task. While at that time the dominating question was that of financial equity the exercise gave me an insight into how the health and social care systems could work against each other with service users and carers the inevitable losers on all fronts.

During the years of plenty at the start of the century the issue didn’t go away but was undoubtedly softened by the development of a positive strand of joint commissioning activity between the NHS and Local Authorities.  Mental Health had a particularly good track record which was furthered boosted by the money which came into the system through Supporting People.   However, since the start of austerity things have got worse as organisations have been forced to look inwards to balance their own books.  The disproportionate pressure on local authority budgets has exacerbated a growing divergence between health and social care.   

The issue is brought into focus by the changing nature of demand within the NHS.  40% of the NHS costs relate to 10% of patients, often but not exclusively the frail elderly, with complex medical and social care needs.  As work around integrated care highlights the needs of this group cannot be met effectively without a joined approach across health and social care.   The Better Care Fund  is trying to recognise this fact but there is a danger that, as the Barker Commission suggests, it is a sticking plaster when a more fundamental alignment of health and social care is required.

There is a political dimension to this.  Over the years sadly social care has, in general, failed to harness anything like the same political capital as the NHS.  It staggered me in the midst of the debate about the Dilnot reforms how difficult it was to secure media and public interest in the issues – VAT on pasties and caravans fared much better!   For reasons I am not sure I fully understand, given the numbers of individuals and families affected, the public do not seem to understand or engage with social care.  However when the public do engage they can see no sense in the artificial boundary between the two systems.  Needs are needs and care is care.  Bringing the systems together simplifies the political debate about how we look after the most vulnerable members of society and how much we are prepared to pay collectively to do so.  It would give social care the welcome protective shield of the public’s support for the NHS and create a better chance that people who need support will have their needs met in a more effective manner.

So what of the cost of such a change?  The Barker Commission’s interim report sets out the options clearly.  There are two choices. We have to be prepared to pay more tax which the Commission also does a good job in explaining is more affordable in the long term than many doomsday commentators would argue.    If we are not prepared to pay more tax we have to be prepared to accept a greater level of charges which might apply equally to areas which we currently class as health care. A mixture of the two may be required although the impact on health behaviour should be thought carefully about before imposing further charges at the point of use.

We also have to consider the political implications of such a change.  We have had for 65 years a national administered health care system which, at least in theory, is meant to deliver common standards of access and care while social care spending is, in general, subject to local political decision making.  If a single budget and system of entitlement was created there would have to be a clear view on who made the decisions about how it was spent.  Perhaps that could be done within existing structures such as Health and Wellbeing Boards but this issue would need careful thought.  Even if there were no major changes in organisations or decision making structures the unification of health and social care would have major implications, in particular for local government.

But as the Barker Commission highlights, hard choices are not always a good reason to put off difficult decisions.  I am beginning to feel that Bevan’s decision to run and fund social care on a separate basis might put his great legacy, the NHS at serious risk in the future.  That is probably a reason to act.   

 Read the Barker Commission’s interim report available at the link below:



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