Social Care

Lord Warner Excerpts

Thursday 29th November 2012 Lords Chamber

[Lord Warner]

My Lords, I congratulate my noble friend on securing this debate and opening it in her customarily clear, knowledgeable and wise way. I shall not repeat her analysis. I want to talk about the funding crisis. It is pretty clear from the contributions so far that there is a funding crisis in social care in a wider context. I shall touch on Dilnot—here, I declare my interest as a member of the Dilnot commission—but we cannot solve the problems of stabilising social care funding by Dilnot alone.

We are seeing local government in many areas having to concentrate virtually all its discretionary spending on adult social care and child protection, a situation to which the right reverend Prelate drew our attention. This will mean that big cities in particular lose those civic services around arts, leisure and other things which make for a civilised society as their authorities concentrate on social care and child protection. Yet these sacrifices may be insufficient to preserve good-quality, publicly funded social care services. Eligibility criteria will be tightened even further. Quality of care will deteriorate in a labour-intensive sector where the people providing the services have less money to ensure the quality and training of staff. These things are happening now on a considerable scale and the situation will only get worse. Local authorities will continue to chop their payments for publicly funded care.

We will see, and it has already started, private payers taking more of the services because the providers of those services, which are largely no longer public bodies, will have to concentrate their investment and activities on people who pay the true cost of care. Increasingly, that is not those who are in receipt of publicly funded social care.

Nothing stops the remorseless arithmetic of demography. The ageing and longevity of the population base of adult social care inexorably increase demand for care. With more than a third of the adult population having long-term conditions, and often with multiple morbidities, the demands on health and social care services will rise year by year for at least the next two decades. Yet we still pretend that the core business of the NHS is acute hospital treatment, when it is now community-based care involving care pathways that embrace health and social care and often housing and financial support. Yet our funding is in separate silos, with strong incentives to cost-shunt and to protect hospital budgets.

We have to begin treating the Department of Health budget as a single budget to be spent in the most cost-effective way for people’s care needs. We need to reimagine the whole system as a care system with a medical treatment adjunct rather than as a hospital treatment system with a care adjunct. We need money flows and payment systems that reinforce that new approach, rather than one that incentivises and reinforces episodes of care in acute hospitals and diverts money from overstretched community-based care. This means radically changing political and public attitudes to hospitals so that we can reduce the excessive number of 24/7 acute hospitals trying to provide a full range of medical specialties and concentrate specialist services on fewer sites. Not only would that be more cost-effective but it would be safer in many areas, such as maternity, for the public who receive those services. Money is now locked up and being spent in inappropriate ways in acute hospitals. That money should be extracted and used to boost community health and social care services.

We cannot expect local commissioners to produce these changes without national leadership. I am all in favour of localism, but to expect local commissioners to engineer these big-scale changes is frankly fantasy politics. I would like to see set up an independent, medical-specialty review of 24/7 acute services, led by specialist doctors and possibly under the aegis of the Academy of Medical Royal Colleges. I would ask them to see how these specialist services could be reconfigured on fewer sites, with the objective of safer specialist services that released—let us say—£l0 billion over five years to create a new time-limited care development fund. The fund’s mission would be the joint development by local authorities, clinical commissioning groups and health and well-being boards of more community-based care services. It is not a fantasy idea. In the US, Medicare is setting up a $10 billion fund to develop these kinds of community-based services.

Even with such changes, we still need major reform of the funding of social care to make it sustainable in the long term. This is because people have to save more for their old age and use more of their own assets to pay for their care, especially by equity release from housing assets. To do this we have to find a way of implementing some version of the Dilnot recommendations instead of sheltering behind the current fiscal difficulties to not do so.

As my noble friend said, there are ways of funding the relatively modest cost of starting on Dilnot. If we set the Dilnot cap at £50,000 or £60,000 and implemented the commission’s other recommendations, it would cost barely £1 billion a year or less to make that start. We could do this for three years by using underspends on NHS capital rather than repatriating them to the Treasury, and then if necessary find other funding sources including subsidies from the care development fund that I am proposing. There is a lot of money knocking around in government that could actually get Dilnot going in a reasonable way.

We cannot ask the social care world to adapt and find new ways of working without demanding much more from its wealthy relative, the NHS. Without more radical funding reform involving more use of NHS resources for social care, the good intentions of the draft Care and Support Bill will simply remain a wish list with no Santa Claus to deliver it. I hope the Minister—and my own Front Bench both here and in another place—will see these as constructive suggestions for further consideration.