'Show me the money' — a new solution to the social care challenge?

This week the government announced its long-awaited plan to address the challenge of providing social care. This is the latest in a number of aborted plans, policies and proposals which have sought to resolve the seemingly intractable social care dilemma facing successive governments — how to provide affordable high-quality care to an increasingly ageing population. Will this plan succeed where so many others have failed or not even been implemented?

The new plan involves raising money through an increase in national insurance and taxes on share dividends of 1.25%. The government says the money raised will be ring-fenced for spending on health and social care. No one will pay more than £86,000 towards their care and if a person’s assets are below £20,000, they will pay nothing. A person with assets between £20,000 and £100,000 will pay a contribution.

This is proposed alongside the creation of statutory integrated care partnerships which will be responsible for delivering integrated health and care services at a local level. These will involve representations from hospitals, primary care providers and local authorities and should be in place in shadow form from November 2021. After the headline announcement yesterday, the government said a further White Paper focussing on integration will be published later this year. An accompanying document, Building Back Better, stated:

“The government will work with citizens, the NHS, local governments and other key stakeholders to co-produce a comprehensive national plan for supporting and enabling integration between health and social care. This will involve creating the right local incentives for integration and prevention, as well as working with the NHS, social care providers and other partners to ensure that they are working to deliver more effective care in people’s own homes and their communities, breaking down the barriers between services. The development of the strategy will include a renewed focus on outcomes, empowering local leaders and wider system reforms.”

So far, so generic. What is different in the government’s proposals this time around, though? The financial proposals are not dissimilar to those which were proposed in the Dilnot report in 2011, though the financial thresholds proposed then were lower. The coalition government included in the Care Act proposals for a care cap to be introduced in April 2016. The cap was indicated to be £72,000 and in order to manage the cap, local authorities were to be asked to maintain care accounts for adults detailing care received and eligibility. The deadline for implementation of the cap was first extended and then abandoned altogether. At the time, it was stated that more time was needed because of the administrative burden of creating care accounts. Whilst this was undoubtedly a significant task, it was suspected that it was more about political expediency and the proposals were shelved altogether.

There was then the short-lived Conservative manifesto pledge in 2017 to introduce a cap on care costs, which Theresa May u-turned on in a matter of days. So, will this new plan fare any better?

It is undoubtedly a step forward that a government is willing to accept that public money needs to be invested in social care and that requires an increase in taxation. The long-standing unfairness that if you have cancer, the state will fund all of your treatment, but if you have dementia, it will not, is partially addressed by the proposals. However, there are many questions to be addressed before we can assess whether it is likely to succeed where previous plans have stalled, not least because there is no published plan as such, at this point.

One immediate concern is that initially the extra funds raised will be used not to fund social care at all but to fund the NHS to support the backlog of work created by the pandemic. One of the concerns of local authorities has long been that, politically, social care is a Cinderella service compared to health and that when funding options are assessed, all political parties will always prioritise funding to the NHS. Once the NHS becomes used to those additional funds, how easy will it be to change funding streams to social care? Not easy at all, given that last week NHS Providers and NHS Confederation jointly said that a £10 billion annual rise was needed by 2022-23, to avoid cuts to services affecting patients. In a joint statement responding to the announcement yesterday they said:

“No one should be in any doubt that this extra funding is welcome. But the government promised to give the NHS whatever it needed to deal with the pandemic, and, while it makes a start on tackling backlogs, this announcement unfortunately hasn’t gone nearly far enough. Health and care leaders are now faced with an impossible set of choices about where and how to prioritise care for patients.”

Even if you ignore the financial concerns, there are no details yet about how the new system will be operated. Who will operate the care services and how will the funding be managed? What will the respective roles of local authorities, NHS bodies and integrated care partnerships be?

The onerous administrative burdens identified as part of the Care Act proposals are a real problem for which there is no clear solution. If local authorities are to be expected to maintain a care account for every adult in the country, how will this be set up and maintained? That problem is no easier to resolve now than it was in 2016/7.

The Prime Minister in announcing the proposals stated that the government would also be “integrating health and care in England so older people and disabled people are cared for better, with dignity, and in the right setting.” The placing of health and care partnerships onto a statutory footing should be a catalyst for further integration but much of the detail on how these will operate in practice is still being developed and much is likely to be left to local partnerships to design.

The announcement is undoubtedly a major step forward but there have been false dawns before, and much detail needs to be developed in coming months. All local authorities and the various healthcare stakeholders need to be fully involved in the debate to ensure that they can influence the way in which the government develops these proposals. If they are not, or if the government focuses on the headlines and does not get to grips with the detail, the best chance of delivering effective change in the health and social care system for a generation may be lost.