Will a Burnham premiership have an impact on health and care?

Andy Burnham’s public position on social care reform has been consistent over the years: create a care system with the same moral status as the NHS. As health secretary between June 2009 and May 2010, he led development of a white paper, Building the national care service, published weeks before the 2010 general election.  

The plans framed social care reform around a new national care service with familiar themes of universal entitlement based on need; national quality standards; prevention and early intervention; greater personalisation of care; and closer integration with the NHS. The intention was to move towards the end goal in stages, starting with free personal care at home for those with the highest needs. 

Decisions about funding were deferred until after the election, not least following leaked plans about what was dubbed a ‘death tax’ created a storm. Needless to say, the incoming coalition government didn’t proceed with the plans, instead embarking on mammoth NHS reorganisation, but did establish the Dilnot Commission, which shaped the 2014 Care Act. This created, among other things, national eligibility criteria for social care and proposed a cap on the maximum amount individuals would have to pay for care. As we know, the latter has never been enacted despite various commitments to do so.

Since leaving government, Burnham’s language has shifted from institutional reform to the broader idea of ‘whole person care’: integrating physical health, mental health, social care, housing and community support around individuals rather than administrative or sector boundaries. In short, helping people remain at home to live as independently as possible.

As Mayor of Greater Manchester, Burnham translated these themes into his devolution narrative, arguing that prevention, early help and neighbourhood support require local leadership, integrated budgets and place-based decision making. Greater Manchester’s Live Well programme and wider devolution arrangements exemplify this approach: the aims include reducing inequalities, strengthening coordinated support in the community and shifting away from late crisis intervention.

Burnham’s more recent comments on social care have emphasised urgency and linked the need for reform to the future of the NHS. This points to the Casey Commission’s timetable being accelerated and an early announcement to establish momentum – perhaps to launch the ‘national conversation’ signalled in Casey’s recent speech to the Local Government Association. 

Tensions to negotiate

If anything, Burnham’s distinctive contribution has been his insistence on integration with wider devolution and the NHS operating model. Obvious and fundamental questions, however, remain. For example, whether the vision for the social care system is to be a better organised local authority system, a new national entitlement with stronger enforcement or a more radical merger between the NHS and social care at local or national level?

There are other tensions to negotiate. Given the fiscal arithmetic, what will prove to be the balance of public and private funding over the next two decades, related to the projected increase in costs and relative to other priorities? Consider also the related balance between the role of the state alongside private responsibility and agency, as well as the extent to which private provision in social care is desirable. The first two issues were at the heart of the faultlines that undermined the Sutherland Commission’s report in 1999. All three are likely also to strike at the heart of the Labour party and test the unity of Burnham’s government. 

Some of this may play out in welfare reform and in the response to the final recommendations of Alan Milburn’s review of young people and work, due in September. This will sorely test Burnham’s leadership skills and obvious commitment to a more collaborative approach to party management.

At a more practical level, given recent examples, could a care service – national or local – actually be delivered and managed competently? The infrastructure for oversight regulation and accountability of local government, for example, is weaker now than in 2010. Despite Burnham’s instincts and preferences, local authority funded social care is almost all provided by private providers. If it’s part of the plan, significantly changing that would take years: the ‘end of neo-liberalism’ may not be in sight.

Current and future priorities

On the NHS, the current government’s commitments to reduce waiting times will surely remain the top priority to 2029. Some aspects of the 10-Year Health Plan and the Health Bill currently before parliament align with Burnham’s thinking, for example, the push to more joined-up local neighbourhood care. But others do not, such as the centralisation of powers in the hands of the secretary of state; and weakened links between NHS integrated care boards and local authorities responsible for social care and public health services. At the very least, expect some revisions to the bill to address the latter, moderate the centralisation of power and possibly to restore Healthwatch as an independent voice for patients.

More broadly, it is worth noting that the impact of devolution on health and NHS performance in Greater Manchester was mixed. Health Foundation-funded analysis pointed to improvements in healthy life expectancy and cancer screening coverage, but increases in adult obesity and longer waiting times for A&E treatment. Spending energy rearranging the NHS to fit a desired devolution plan may well have adverse impacts. Energy could be well spent rebooting the health mission, which currently remains missing in action.

Finally, there is also limited time until the next election to demonstrate change. While social care has never been a big priority in MPs’ mailbags, NHS care usually is. The most feasible route for a Burnham government is incremental change with well-communicated directional purpose: possibly national entitlements and standards for social care; local delivery partnerships; perhaps pooled budgets for defined high-risk populations; workforce reform to improve the lot of social care workers (which is demonstrably needed); and some staged funding reforms. Least feasible is a major institutional merger of health and social care, with or without a funding settlement. 

As for Burnham himself, perhaps his main contribution should be constancy of strategic purpose and communication with the electorate. That constancy may wane in close contact with economic reality, political priorities and voter preferences. Time will tell.