NHS and Social Care: Winter Service Delivery

Lord Kerslake Excerpts

Thursday 25th January 2018 Lords Chamber

[Lord Kerslake (CB)]

My Lords, I declare my interest as president of the Local Government Association.

“Our NHS … is in crisis and the adult social care system is on the brink of collapse”.


These are not my words but the opening line of the report of the ad hoc committee The Long-term Sustainability of the NHS and Adult Social Care. Chaired by the noble Lord, Lord Patel, it was published in April of last year, and as we heard earlier, we have still to see a response from the Government. It would be good to hear from the Minister when that response will be received. The recent headlines have focused on the intense pressure on the NHS. Today’s debate provides a welcome focus on the less visible but no less important issue of social care, and I am very grateful to the noble Baroness, Lady Wheeler, for organising it.

My first and most important point is that we do not simply have a winter crisis. We have a crisis of funding in the NHS and social care, which has been brought into sharp relief by the additional pressures of winter. I have no doubt that every effort has been made nationally and locally to prepare for winter. There are certainly some excellent individual examples of local services taking action to minimise hospital admissions and delayed discharges. But the issue here is systemic and not seasonal. Without action to address the fundamental issue of funding, no amount of work locally, excellent though it is, will stop the problem from getting worse. In the meantime—this is a crucial point—we are putting intolerable pressure on the system and the people who work in it.

A lot has been said recently about the shortfall in NHS funding. I will simply quote what the very well-respected chief executive of the King’s Fund, Chris Ham, said in a blog he shared with me at the time of the Budget last year:

“In the 40 or more years I have worked with and for the NHS, I can’t remember a time when the government of the day has been so unwilling to act on credible evidence of service and funding pressures”.


Put simply, the Government are in denial of the scale of the problems. But, as the LGA put it so well in its brief for today’s debate, there cannot be a sustainable NHS without a sustainable adult social care system, and, in my view, the current position is not sustainable. Give or take a bit, social care—adults and children—takes up about half of local government funding. Since 2010, local government spending power has been reduced by around a third. The brunt of this reduction has been borne by staffing reductions and cuts in universal services such as highways maintenance and libraries. Children’s care pressures have, if anything, increased in that period. So it does not take a great mathematician to see that however hard local government tries to avoid reductions in adult social care—and I know from personal experience that it does—cuts will be inevitable. The extra money and the increased flexibility on council tax are welcome but, as others have said, they are nowhere near enough. Crucially, the LGA has said that by 2020 there will be a £5.8 billion funding gap in local government as a whole, of which, as we heard, £1 billion is to do with social care, and we have another £1.3 billion of pressure on the provider sector.

Many people have said that this problem can be solved by simply bringing the funding streams together. By giving control to one Minister, the newly named Secretary of State for Health and Social Care, local government can somehow be “brought into line” on delivery. I urge extreme caution on this. First, the squeeze on local government is across all aspects of its funding. People want to see clean streets and maintained roads too. You cannot simply deal with social care in isolation from the rest of local government finance. Secondly, because of the increased retention of business rates, most if not all local authority income will come from locally generated and retained income sources. It will not be in the gift of any government department to give control over that. So bringing together health and care is a good thing, which results in better and more joined-up services. But it will not solve the funding gap.

Money is not always the answer. But in this case it is inevitable and essential that it is provided. We need an immediate cash injection to stabilise the system, but we also need a royal or cross-party commission to look at the longer term. We must engage in a debate with the public on what kind of health and care system they want, how much it will cost, and how we should pay for it. Like the noble Lord, Lord Macpherson, my view is that it should be a hypothecated tax on both income and wealth. But let the commission decide on the options. We might then, with that commission, be able to address the urgent questions set out in the Select Committee’s excellent report.