Health and social care service funding

1. Through the Local Authority, together.
2. Capital projects should be funded through municipal bonds, rather than PFI
3. As in the past, with a mixed economy of public sector, public domain, charities and commercial organisations. The NHS has shown how effective franchising can be, with thriving networks of general practitioners, dentists, pharmacists and opticians; this government seems likely to add hearing centres to this list, and possibly physiotherapy. A future government might extend the franchise approach to care homes, which are struggling to provide adequate services for frail older people within an obsolete business model.
4. Charities have added hospice care, community-based services for people with dementia, sexual health and abortion services to the NHS, and act as sources of innovation. The commercial sector can supplement the NHS and and also stimulate change, as with day-case surgery, but it is economically vulnerable and can easily loose out in competition with the NHS.
5. A mixed economy of the kind we have had in the NHS since 1948 requires some form of provider-purchaser split.
6. The policy problem that remains is Wanless’ “full engagement” scenario, in which the NHS remains economically viable only if the population is fully engaged in staying healthy. This is a utopian expectation in one sense, because it emphasises a rational approach to an emotive problem, but it is important because it focuses attention on both lifestyle and environment, and the actions that government can take to make both healthy.
7. The Labour Party needs to bite this bullet – only by basing these essential services on progressive direct taxation (of both corporations and individuals) will coverage and fairness be achieved. This is the principle of risk pooling which is understood (just about) in relation to health care. Why should social care be any different? To fund the system properly will mean higher taxes – let’s go for it and make them fall fairly in relation to wealth and income thus reversing 30 years of disastrous neoliberal policies under Tory and New Labour governments.

How should we best integrate physical, mental and public health services and social care?

1. Focus on:
   1. Strengthening communities through community development.
   2. Involve Local Authorities who play a bigger part here than the NHS.
   3. Use time banks.
   4. Supporting mental health in work – kite marks.
   5. Keep Health and Wellbeing Boards and ensure they work on this.
   6. More stress on appropriate housing for vulnerable people
2. By developing vertically integrated structures serving communities, stretching from the GP surgery, social services and the care home to the hospital. There are few reasons for keeping social work within local government, and this discipline should be relocated in the NHS. Hospitals can embed themselves in communities by incorporating community-based services into their organisations, on the US model. Integrated services can compete around their geographical margins, but essentially act as ‘industrial markets’ in which resources are balanced to keep all components of the service in good order.
3. In the past this approach to integration has been risky for community services because specialist services use up all the resources they can access; the saying that “nothing grows in the shadow of a teaching hospital” reflects this. This risk may now be less because hospitals are franchisees of the NHS, and therefore obliged to work to contracts determined by commissioners. The problem that remains is that commissioners need to be independent of providers, which they will not be under the Health & Social Care Act.
4. Recognise that the Dobson model of PCTs got this partly right- combining public health, primary care and community health services – the opportunities of this innovation were squandered by the neoliberal turn in Labour health policy under Hewitt and Milburn.  However the innovation only went so far – failing to integrate social care and mental health. This means revisiting Herbert Morrison’s vision of health services coming under local authority leadership (also the Scandinavian model, where it works pretty well) – but this can’t be achieved in one step. First Local Authorities need their budgets restoring, then they need renovating to combine representative and direct democratic processes. The move of public health to Local Authorities s is one step in the right direction. A bigger challenge is primary care which needs effective strategic management, something the commissioning fixation of recent policy singularly fails to provide.
5. To some extent the answer lies in thinking not so much about ‘services’ as in the construction of a different kind of society, one that focuses on human development as its primary end – a socialist society that, inter alia, has effective services. So, for example we could learn from some of the Brazilian experience of community mental health social movements that work to re-integrate people suffering mental distress in not just social groups but in social action t construct a new social reality. The locality focus mentioned above in relation to hard t reach groups is also relevant here.

 What can we learn from the Dilnot Commission about to how we fund social care?

1. Not a lot – the only sensible answer is a system based on progressive direct taxation as discussed above. Progressive direct taxation includes a means test of course.
2. It is very difficult to see why anyone who owned a house would take out insurance against the possibility of having to pay £30,000 in care charges – a very modest sum in relation to the value of houses. People who don’t own their own home don’t need to worry about charges because they are not asked to pay them.
3. The aspiration of most people is to have a long active life, followed by a brief final illness concluded by a dignified death at home.  No one wants to become dependent and yet we seem to have created a system which fosters passive dependency and often ends with a lonely and undignified death in hospital.  Nursing homes are an illustrative example.  The best available evidence suggests that around 30% of people die within 3 months of admission to a nursing home[i].  There is also evidence that nearly half of care home transfers to acute hospitals are inappropriate and that of those admitted 34% die, most within 5 days of admission.  Given the expected increase in old people over 85 who are the group most likely to end up in a nursing home, perhaps we need to re-think the nursing home model.

The current model seems to be based on their use as a staging post between occupying an expensive hospital bed for too long, and then being shunted back to hospital for a short period to die.  Rather than being an undervalued passive repository we need to explore a model in which nursing homes become the community hub for end of life care for older people as part of the Gold Standards Framework in Care Homes[ii].  This would require an integrated approach between Clinical Commissioning Groups and their component practices, care of the elderly and palliative care specialists and social care.  All patients identified as nearing the end of life would have an advanced care plan that was agreed with the patient and their carers or relatives that was focused on palliation rather than active and often futile intervention.  This would be for patients living in the community as well as those in nursing homes, and for patients in the community might include transfer to the local nursing home if and when appropriate rather than admission to an acute hospital.  It could also include enhanced home care support, provided as part of an outreach package from the nursing home, which would ensure continuity of organisational care if a nursing home bed was required.

This would mean nursing homes becoming more like hospices.  Hospices are highly valued by their local communities who raise significant sums of money to support them as local “not for profit” charities.  They also work with local volunteers for all sorts of activities and they have staff who feel valued and committed with high levels of job satisfaction.  This is very different from the current commercial “for profit” nursing home model.  The withdrawal of Southern Cross from the nursing home market is one example.  Another, is the  link between high turnover of poorly paid staff, often from non-English speaking countries, and recurrent scandals about quality of care.  Perhaps the time has come for a completely different model.  This would require a real commitment both nationally from the Department of Health and the National Commissioning Board and locally from Health and Wellbeing Boards and health and social care commissioners who would have to think very differently about their responsibility for provider development and the provider models that they wish to commission.

 What can we learn from the Scottish example of providing free personal care?

1)   that it can be done.
2) we can learn about the limits of this exercise too in order to do better when we implement free personal care based on taxation funded risk pooling in the UK.

2)      voters are prepared to pay extra from taxes for improved healthcare and we believe social care is the same