Season of bewilderment: Delivering health and social care in an environment of uncertainty
31 July 2017
It seems hard to grasp that the general election was only 2 months ago: the political world seems to spin much faster than conventional time. A general election campaign dominated by public concern about the NHS has given way to a becalmed policy environment, at least as far as health is concerned, obscured by much greater anxieties about Brexit, the economy and political infighting on all sides of the house.
From the public’s point of view, there are a few certainties in relation to health and care. They can expect some sort of consultation at some point on social care. The Queen’s speech promised that the government would work to improve social care and ‘bring forward proposals for consultation’. The proposed reforms to social care funding for older adults put forward in the Conservative manifesto were very quickly withdrawn, and elsewhere in the manifesto, the Conservative party signalled that it also wanted to look at the quality of social care and ‘reduce variation in practice’. As my colleague Adam Roberts explains, it is somewhat easier to understand the scale of the current shortfalls in funding than it is to grasp the state of quality in social care.
Some alternatives on funding are likely to be developed by a team at the Cabinet Office and Department of Health. Alongside this, we will also be contributing to the debate. Over the summer and autumn, the Health Foundation will be working with The King’s Fund to develop some alternative funding models. The first step will be to come up with some funding options (in conjunction with academics, policy experts and those who represent the providers and users of social care services) accompanied by a thorough examination of the implications of any models in relation to local and national taxes, and benefits.
This will also be informed by a parallel stream of work, already underway, being led by RAND Europe. The first part of this has been a review of what sort of funding mechanisms are used in comparable wealthy countries for both health and social care, what sort of reforms have been considered by policymakers or tried (particularly in relation to social care), and how they have fared. A working paper will be published soon and will be available on our website.
Anyone familiar with funding models used in other countries will know that there are no ‘ideal’ systems, and there is very limited room for manoeuvre for change, as policymakers are hedged in by political institutions and norms, as well as what might be acceptable to the values and expectations of their respective societies. In the case of social care for older (and younger) adults in England, one of the biggest problems that policymakers face is very limited understanding of what social care is among the general public. For those who do use social care, experiences are heavily shaped by local circumstances that may not always be representative of a national picture.
One of the components of our joint work with The King’s Fund will be some in-depth work with samples of the public, to explore their knowledge of social care and expectations in relation to how it could be funded. As Dan Wellings of the King’s Fund explains, this is tricky territory, as it reaches deep into the realm of the private. It involves navigating attitudes towards passing on (or not) wealth and housing to younger generations, the attitudes towards the role of younger family members in caring for their relatives, and assumptions about the role and reach of the state.
The public in the UK are, of course, much more familiar with the NHS, but the general election aftermath will have done little to quell the anxiety about how well the NHS will hold up under the financial and staffing pressures that are regularly reported in the media. It would be reasonable to feel bewildered in the face of this. For example, on the one hand, the government can announce £325 million capital investment in new facilities across England, but our analysis of the Department of Health’s annual accounts for 2016/17 shows that £1.2 billion’s worth of capital budget has been transferred to meet day-to-day running costs, representing a fall in capital spending of 20% over the last two years.
In England, there is an increasing amount of information available about the performance of local bodies, including Sustainability and Transformation Partnerships (STPs) and clinical commissioning groups and how well health and social care are working together locally. However, the big plans for transforming care through new models and STPs are still very remote for most people. People’s experience of care as patients is still shaped by their contact with individual services.
What is remarkable about the NHS, is how resilient many people working in the NHS have been in the face of these known pressures, both to make savings and improve at the same time. Even though the prognoses for funding and workforce pressures are gloomy in the future, there are still organisations embarking on ambitious programmes to improve all aspects of their care. An example is Sussex Community NHS Foundation Trust, whose chief executive Siobhan Melia told us this month why her enthusiasm and optimism about the potential of her staff was undaunted by the pressures ahead.
What is striking about her observations is that making improvement in care happen doesn’t always require large sums of money, but that some explicit support and encouragement from the centre on quality improvement, in addition to the messages of achieving efficiencies and meeting targets, would not go amiss.
Ruth Thorlby (@RThorlby) is Assistant Director of Policy at the Health Foundation