The Long-term Sustainability of the NHS and Adult Social Care

Baroness Greengross Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Greengross (CB)]

My Lords, I welcome the Government’s commitment in their response to the committee’s valuable report to making sure that the NHS meets the needs of everyone, no matter who they are or where they live. I shall look mainly at the needs of older people, but also at the fact that intergenerational fairness is becoming more important and we must consider that.

I share the view of the British Geriatric Society. It is not as confident that the Government’s response represents a genuinely strategic approach to ensuring sustainability. I am concerned that the range of positive initiatives either under way or being planned are less joined up and integrated than they could be. I endorse the British Geriatric Society’s call for a new strategy for people living with frailty, dementia, complex needs and multiple long-term conditions, ensuring access to comprehensive assessment, personalised care plans for treatment and long-term follow-up for all older people with frailty, dementia and complex multiple long-term conditions.

Sadly, disability-free life expectancy is rising more slowly than life expectancy itself. Most people aged 75 and over have one or more health conditions and one in four people aged 85 and over is frail. Significant changes are needed in the workforce, flexibility in the place of care, and a more strategic and integrated approach for people living with those conditions. If we do not do that, the long-term sustainability of the NHS will not be achieved.

I agree with Care England that a well-funded, sustainable social care system underpins a sustainable NHS. Delayed discharges are a good example of this. Older people are unable to be safely discharged because adequate social care plans are not in place. This is even more important than it used to be and it must be properly addressed.

I am indebted to Age UK’s report Why Call it Care, When Nobody Cares?, which looks at some key questions which remain to be resolved. For example, when the Green Paper is published, how will it ensure that older people in care are consulted, especially about their unmet care needs? In the interim, will the Government consider additional funding to support the system until the outcomes of the Green Paper can be implemented?

We know about the ignorance of the whole system. Many people are shocked by the cost of social care. There are huge misconceptions about how it is funded and how to access support and deal with the complexity of the system. Earlier this week, Sir Andrew Dilnot spoke at a parliamentary forum that I chair on intergenerational fairness. He reminded us that the increasing number of older people is not at all a surprise. Of the £150 billion spent on older people per year, only £7 billion is on social care. His proposed care cost cap, which would have ensured that people did not face catastrophic care costs, would have cost £2 billion, the same as the cost of the winter fuel allowance. It needs to be reconsidered.

We know that the main difficulty facing this and previous Governments is how to pay for all these things. On fairness grounds, the cost must be spread across all age cohorts, but especially this must now include older people themselves. It could be through an increase in national insurance, whereby older people would no longer be exempt from national insurance payments if they worked beyond retirement age. This would be fair: everybody in paid employment pays national insurance and you do not pay it if you are not in employment.

We know that self-funders of social care are subsidising people who are funded by local authorities. This is a hidden tax which is unfair. The extra funding that the Government have made available to adult social care to date is welcome, but the LGA, of which I am a vice-president, tells me that adult social care faces a funding gap of £2.2 billion by 2020. This must be addressed as an urgent priority. It should ensure that local partnerships with the NHS recognise the vital contribution of adult social care, public health and other key council functions, as well as suitable housing, to achieving improved health outcomes and sustainable services.

Good local public services are the bedrock of good mental and physical health, well-being and resilience. Despite the potential benefits of public health services, we know that local authorities face a £331 million reduction to their public health budget, on top of a £200 million reduction announced in 2015. Almost every service provided by councils has an impact on public health. Reducing health inequalities makes sense at a pragmatic as well as at a moral level, because it can prevent people becoming and remaining ill and reduce the associated costs to local government, the NHS and the rest of government.

Recent research modelling from the International Longevity Centre-UK, of which I am chief executive, explained that, between 2000 and 2015 across the OECD, even after controlling for other factors, health spending positively correlated with life expectancy. Therefore it is safe to assume that the increases in life expectancy seen in the UK in the past 40 years are similarly due to increased health spending. Indeed, between 1971 and 2012, average health spending per person increased by 3.7%, while GDP per person increased by just under 2%. Health spending is also increasing in terms of the total proportion of public spending, increasing its share of overall government expenditure by more than six percentage points over the same period

Last year, the ILC-UK published Towards Affordable Healthcare: Why Effective Innovation is Key, a report that concluded that while the UK is well placed to innovate to improve health outcomes and reduce costs, we are often not doing enough with the tools at our disposal. As it is impossible to control the rate of growth in the economy, or the rate of population ageing, policymakers must concentrate on the residual costs that can be accounted for by policies and institutions, relative prices and technological change.

The ILC-UK report identified that targeted investment to implement and upscale seven systems already in operation in the UK or abroad could save the NHS £18.5 billion between 2015 and 2030. But funding mechanisms within the health system can often discourage targeted investment in innovations and there continues to be a slow uptake in the UK of new drugs and treatment. Speaking of costs, the Select Committee report raised a fundamental question: is it not time to stop increasing spending ad infinitum?

We must also learn from other systems and take them on. No social insurance system is wanted here, but we can learn from such systems because, through them, people know the value of what they get and what they pay for. We can borrow from those systems and learn.

I mentioned those who work paying national insurance, and everyone who puts in an annual tax return of earnings should declare all benefits, including free travel locally, TV benefits, fuel benefits and so on. Perhaps if we pushed that up a notch it would be fair; it would not bring in a lot of money, but it would be brilliant PR for the Government who introduced it and would contribute to free services for all.

Our health system is one of our most-valued services. Let us protect it at all costs and do something about the uncrossable divide between health and social care. These are services for everyone in times of need. Let us value them accordingly.