interviews

‘I don’t think we should be deterred in any way by worrying about the political reaction’

The Barker Commission seems set to make radical recommendations in its final report on health and social care integration later this year. NHE spoke to commission member Julian Le Grand, professor of social policy at LSE and former senior policy adviser to Tony Blair.

On 24 April, the Barker Commission – more formally, the King’s Fund’s ‘Commission on the Future of Health and Social Care in England’ – unveiled its interim report, ahead of a final report by September 2014.

Commission chair Kate Barker, an economist, is blunt about the problems with the current health and care systems, which she says “rub up against each other like bones in an open fracture”. In their interim report, ‘A new settlement for health and social care’, the commissioners found evidence of fragmentation, inefficiency, unfairness, a lack of transparency, public misunderstanding and confusion, a lack of alignment in entitlements, funding and organisation, and said “key aspects defy notions of equity”.

The cost of care

Social care support is means-tested and needs-based, but “probably the least understood part of Britain’s welfare state”, it says, and vast numbers of people assume conditions like dementia and Parkinson’s are ‘covered’ by the NHS in the same way that, say, cancer is.

The report makes the true situation clear: “People with conditions that can involve very similar burdens, both for themselves and their families – cancer and dementia, for example – end up making very different contributions to the cost of their care. The battles over whether people qualify for NHS continuing care are the sharpest illustration of this. But they are far from the only ones.”

It quotes evidence gathered by the Dilnot commission: “…less than half the population understood that social care is means-tested…One reputable survey found that more than half the public think social care will be free at the point of use when they need it”.

It went on: “Indeed, such is the misunderstanding of how social care works that some of the opposition to the Dilnot reforms came from people who believe they will be required for the first time to pay up to £72,000 for their care rather than the £72,000 being a cap.”

Professor Julian Le Grand, Richard Titmuss Professor of Social Policy at the London School of Economics (LSE) and a former senior policy advisor to prime minister Tony Blair, is one of five members of the commission. Interviewed by NHE after the report launch, he said that this endemic lack of information about social care about the public has a direct and malign impact on the policy debate.

He said: “It is very important that people should understand it. Any ideas of trying to improve things, even by making social care free, or reducing charges, runs up against this insuperable problem that people think it’s already free at the point of use. It’s very important to convince the public what the situation is. We often accuse politicians of being cowardly and refusing to face up to hard choices, but actually to be fair, they’re often just being democratic, and responding to what they see to be the fears of the public.

“Many politicians are in fact very well aware of the kinds of dilemmas that we draw attention to in the report. But the key really is to educate the public. “

A single budget, singly commissioned

Even at the interim stage, the commissioners are clear on the basic answer: a single, ring-fenced budget for health and social care in England that is singly commissioned as one service.

The report says: “Existing divides – artificial and historical – between health and social care would largely be done away with, and entitlements would be more closely aligned. Through this, we would get closer to equal support for equal need, or similar support for similar need, regardless of whether what is needed is currently defined as health or social care.”

Simply making all social care free is not viable economically, the commission says, having taken account of all the figures on total spending. Health spending in 2013/14 was £111bn (prescriptions, dental charges and income from private patients brought in just under £1.6bn), of which £2.5bn went on social care. Social care expenditure by local authorities in England for 2012-13 was £17.1bn, including client charges and the cash transferred from health. Another £11bn is spent privately on care homes, £820m on hourly-purchased care, and £300m is spent on sessional/live-in care.

Totting up all aspects of health and care spending, you get £150bn, of which about £122bn was public expenditure

This does not include the undoubtedly vast contributions of voluntary carers. If their time was to be valued at £18 an hour (a contentious idea), the ‘value’ of informal care in 2011 was £119bn, according to a University of Leeds study for Carers UK.

Paying for a single system

The report examines virtually every option for raising money to pay for a combined health and social care system (see box out). You can get a flavour of the likely recommendations in the final report from the comments in the interim report – some radical solutions are essentially ruled out (patient passports; a new social insurance model; rationing of treatments). But other – also radical – solutions are presented neutrally. These include, controversially, the idea of charging for NHS services to help fund free or cheaper social care.

Naturally, it was this element of the 74-page report that grabbed the attention of newspaper headline writers.

‘It’s unlikely we would recommend full-scale charging’

Care minister Norman Lamb MP was notably cool in his response to the interim report, saying the reforms already in the pipeline will make social care fairer and protect people from catastrophic care costs, and adding: “The founding principle of the NHS is that it is free at the point of use. We are clear that it will continue to be so — this government doesn’t support the introduction of charges for treatment or hospital stays.”

We suggested to Prof Le Grand that if the Barker Commission gets too associated with charging, it will make its ideas a harder sell at Westminster.

He acknowledged: “I do think that is a problem, especially in the run-up to an election. By the time the final report comes out, it will be only about nine months before the election. I don’t see many politicians endorsing a report that recommended full-scale charging for the NHS at that point in the electoral cycle.

“I think it’s unlikely that we would recommend full-scale charging. The point we wanted to make was that people do accept very heavy charging and means-testing for social care, but it really isn’t clear as to why social care is different to healthcare in that respect.

“It may be that if the only way in which we can significantly reduce the costs of social care is to slightly increase the cost of healthcare, then that may be, in the end, the best way to go.

“I don’t think we should be deterred in any way by worrying about the political reaction. Even if politicians do reject it in the run-up to the general election, then there will be a new five-year government in place in May 2015. They will have a five-year mandate and be better placed to do more radical things. Really, in some ways, that’s the audience we’re aiming for.”

No nationalisation

We asked Prof Le Grand whether – if he was prepared to be radical – a single deliverer of health and social care would be worth at least considering. 

But – as befits his reputation for favouring market reforms in public services – he told us: “I think that would be daft. My nutritional needs are fairly complex, but that doesn’t mean I’ve got to go to a single supermarket or a nationalised industry to provide me with my food.

“Provided that I’m in a position to make appropriate, well-informed choices, I think the idea of having a diversity of suppliers and providers is the right way to go.

“Of course, that’s a rather big condition – being well-informed, or at least having an agent to work with, whether a GP in the case of healthcare or social worker in the case of social care. It’s important to get that bit right, but given that, I’m a great supporter of having a diversity of providers.”

Dilnot

The final report will, of course, take into account the Dilnot recommendations, though Prof Le Grand made the point that it was outside Dilnot’s scope to consider some of the issues that the Barker Commission has been able to – for example, why the cost burden for a cancer sufferer versus someone with Parkinson’s should be essentially zero versus potentially unmanageable.

“Although both are a step in the right direction, neither the Dilnot commission’s proposals nor the Better Care Fund offer a sustainable basis for funding health and care in future,” the report says. “The Dilnot reforms do not address a key test of equity – one that might be described as equal support for equal needs, or at least as more equal support for similar needs.”

Funding, not structure

The report shies away from the shape of future commissioning if its proposals were adopted, arguing – as so many others have – that the last thing we need is more structural reorganisation.

But it hints that health and wellbeing boards, if early signs stay promising, could be good vehicles to take on joint health and social commissioning, beyond their current strategy and oversight role.

Prof Le Grand told us that other reports, such as that by Sir John Oldham, have examined commissioning in a useful way already.

“We think the funding issue is much more important than yet another organisational change to the structure,” he said. “But I do think there’s a case for local government being more involved in commissioning. One of the problems with the PCTs and now CCGs is that they really don’t have any electoral legitimacy.

Local government, with all its imperfections, does at least have that element of legitimacy. So the idea of involving them more in commissioning is a good one: though it’s early yet to say whether health and wellbeing boards will be a good vehicle for that. But the very early signs are not too bad. It’s worth exploring further.”

Funding the future

These are the basic options investigated in the interim report to fund the proposals:

Option 1 (more efficient use of existing resources) via:

- Productivity (moving poorer performers closer to the best; improving end-of-life care, integration, and ensuring NHS money is spent cost-effectively – but this is considered insufficient to meet all the costs)

- Shifting resources within health and social care to improve integration (though most evidence suggests integrated care improves outcomes and the patient experience without necessarily saving much money)

- End-of-life care (optimised services outside hospital)

- ‘Rationing’ (reducing or eliminating access to certain procedures and treatments – the commissioners reject this option for a range of reasons)

Option 2 (raising more private funding) via:

- New or extended NHS charges, as one element of a new settlement that better aligns entitlements in health and social care (e.g. remove or change blanket exemptions on prescription charges, charges to visit a GP, a charge for outpatient attendance, a charge for hospital stays or hospital treatment)

- Develop an insurance market and other financial products 

- Provide tax relief on private medical insurance (‘lifting a burden’ from taxpayers as more people go private – the commissioners dislike this option)

- A ‘patient passport’ (also dismissed)

- Remove tax disincentives on health and wellbeing programmes (making more wellbeing programmes available in workplaces, for example)

Option 3 (more public finance) via:

- Introducing a hypothecated tax for health and social care (National Insurance plus alcohol and tobacco taxes raise nearly the same amount as public spending on health plus social care, for example – but the tax take would not move in line with spending need year to year)

- A wholesale switch to classic social insurance (this, the most radical option in the whole report, is basically rejected)

- Diverting existing benefits, such as Attendance Allowance, winter fuel allowance, free bus passes and concessionary travel, or free TV licences

- Changes to the tax regime for pensions

- Apply National Insurance to those working on past state pension age

- Forgiveness of capital gains tax at death

- Increase inheritance tax

- Levies on death

- Impose VAT on private health care

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