Despite the prime minister assuring the nation that he had a “clear plan” for resolving the crisis in social care the subsequent delay is now the subject of multiple proposals. While most concentrate on finding a solution to funding long-term care, there are also some fundamental suggestions around service structure and delivery. The most notable of these is that responsibility for social care could be transferred from local government to the NHS. It is a deeply flawed proposal.
The NHS and social care went their separate ways after the passing of the 1946 NHS Act and 1948 National Assistance Act respectively – the NHS centralised, free at the point of use and funded from general taxation; social care localised and means-tested. The privatisation of care provision added a further complication.
Pick and choose strategy of NHS
The sectors are complementary to each other in many ways and there has been no shortage of attempts to join them up. However, social care and the people who work within it following CQC policies and procedures or often viewed by the NHS as the poor relation.
Over the years, the NHS has been able to pick and choose, shifting many of its responsibilities for long-term care for older people to local councils (usually without transferring accompanying resources) while wrongly trying to retain control of long-stay provision for adults with learning disabilities, mental health issues and other complex conditions. One only has to look at how long it has taken to move people form long stay hospital facilities to community settings.
Social care needs a vision
The problems facing social care are well documented. There is little disagreement that social care is on the cusp of collapse – it is failing to meet the needs and requirements of commissioners, providers, the workforce, users and carers. Proper funding is most certainly needed to resolve this predicament, but it is also clear that social care itself needs a new vision.
The Local Government Association and the Association of Directors of Adult Social Services have recently articulated the principles on which a new vision may be realised. They both emphasise the need for locally determined integrated care that achieves person-centred support, alongside a review of how the care market operates and the way the workforce is treated.
There is no reason to think that handing over the social care budget to the NHS will help to deliver on these principles. The response to Covid-19 has exposed a healthcare establishment with little or no understanding of social care, a shortcoming fatally exposed by the discharge of untested patients from hospital to care homes.
Hospital care will always be the prime focus of the NHS, and the absorption of social care into the NHS would not lead to a reappraisal of priorities. There may well be some greater service coordination, but this would be geared to solving the problems of the acute sector, not social care.
Integrated Care Systems
According to Bob Hudson (Visiting Professor University of Kent) ‘the specific proposal that social care could become the responsibility of the nascent integrated care systems is notably inept’. The NHS has been subjected to a bewildering array of unproven initiatives in the last few years: new care models, the vanguard programme, sustainability and transformation partnerships and now integrated care systems (ICSs).
ICSs are informal regional arrangements pursuing greater coordination within the NHS family; they are remote, unknown, unelected and unaccountable, with few links to local councils and even fewer to the voluntary sector and local communities. Incorporating social care into these bodies would not only fail to deliver on a new vision of support but would weaken local democracy to the point of collapse.
We have then a dichotomy, between a centralist NHS funding model, and locally funded person-centred care. If funding was entrusted to the NHS it may be that social care is no better off. There is no way of knowing if funding for social care would be ringfenced or dispersed by the whim of NHS management as part of a larger pot whose main focus will always be on acute services.
We all know that there is a desperate need to find a solution to the social care crisis, but we should think carefully about transferring responsibility for allocating funding through the NHS. I believe the sector would be best served by specific ring-fenced funding administered by local authorities.
Albert Cook BA, MA & Fellow Charted Quality Institute Managing Director Bettal Quality Consultancy