John Kell, Head of Policy

In my last post, I observed that at a political level we have struggled to reach an agreement to provide the resources that we need for health and social care. This post explores the issue at greater length, and argues that the key barrier is indeed a political one, rather than a matter of policy.

In a previous role, I heard Andrew Dilnot (Sir Andrew Dilnot as he now is) describe the political parties as being in a ‘game theory situation’ where social care funding was concerned: none of them dared move first to commit to a solution for funding social care, because they suspected they would immediately suffer a political attack from their opponents on the issue. The then recent experience of the partial collapse of Andy Burnham’s effort at cross-party talks and the subsequent ‘death tax’ political campaign provided ample evidence for this concern. Today, the situation appears to remain the same, and indeed to have extended to NHS funding as well.

Even before the Dilnot Commission was established, social care funding was widely held among policy analysts to be troublingly low: in 2009 I attended the first meeting of the Care and Support Alliance, which was founded – well before an austerity programme hit government spending – to secure improvement to a settlement already viewed as inadequate. Since then there has been repeated national failure to grasp the funding nettle: providers have begun exiting the social care market at scale; the sector is struggling to function; and the amount of need going unmet has increased hugely. In discussion among charities and other commentators, there has long been a sense that things surely can’t go on like this. But they have done just that, and increasing numbers of people who need social care have been left to go without, to an extent that seemed unimaginable five or so years ago. All of this has been despite there being no lack of serious policy work, not least by the Dilnot and Barker commissions, to identify plausible and workable solutions for funding social care.

The terrifying thing is that the NHS is exhibiting the same symptoms, at a delay of five or six years. It is now unambiguously underfunded, even in terms of maintaining services at current levels, never mind improving its offer as medical capabilities advance. Initiatives are being pursued to oblige people to fall back on their own resources, currently for relatively minor interventions such as over-the-counter medicines. Spurious bars on treatment are being imposed, and waiting times are escalating. The system is effectively unable to function fully in the winter months, with hospital wards overwhelmed and elective surgery cancelled wholesale; the safety and dignity of patients is being compromised, in some cases fatally (and that is not necessarily a metaphor). The private sector evidently has limited and diminishing appetite for NHS work, given the tightness of the money on offer (I will return to the issue of ‘privatisation’ next week). And the overwhelming consensus is that things can’t go on like this. But, as with social care, the truth is that they can and they might.

So, the problem is real and a political one. No mainstream party went into the last general election promising Barker levels of extra funding for the NHS and social care, which is what they need. With fiscal ‘responsibility’ still held to be a political positive, each party seemed to fear a successful attack by its opponents too much to commit to spending increases on the necessary scale. So, what is the solution? It certainly isn’t a royal commission, which would be far too cumbersome and time-consuming, would waste years identifying levels of funding need that we already know about, and would carry no guarantee of the necessary political will to implement its recommendations. Some form of less formal cross-party talks to identify a consensus solution would be much more promising, although finding the trust to embark on them will be hard after the social care talks failed amid so much ill will in 2010. Nonetheless, it would be highly desirable to see them tried – somehow our politicians needs to break out of the ‘game theory situation’.

Recent talk about (cross-party) talks, however, has been understood in a worrying variety of ways. The letter signed by numerous dozens of MPs to the Prime Minister suggesting an ‘NHS and Care Convention’ framed it in terms of delivering a ‘sustainable, long-term settlement’, which appears to be primarily a reference to funding. Some signatories, however, appear to construe the call far more in terms of redesigning and restructuring the NHS. Another round of initiatives on that front, particularly directed by politicians, is surely the very last thing we need. NHS England is already embarking on such a programme, kicked off by the Five Year Forward View in 2014. Whatever the shortcomings of that process (for which see next week’s post), it is and surely must remain the only game in town where large-scale service redesign is concerned.

If there is some sort of exercise soon on funding for health and social care, it will of course not be without risks. Jeremy Hunt has spoken in terms of a ten-year settlement being desirable – which sounds eminently sensible, provided it does not lock us into a plainly unsustainable funding scenario in the same way as the last five-year spending review did. Another risk would be the entrenchment of an ungenerous boundary for what the NHS will and won’t offer – at present, the line is not clearly drawn, but initiatives such as restricting prescriptions for over-the-counter medicines would sharpen it up considerably, and almost certainly to the detriment of patients.

Ultimately we need political leadership, above all on the question of the funding and sustainability of health and social care. We do not need to spend years groping for answers – they are pretty well understood already, but happen to be challenging politically. None of which is to say that questions about the structure and operation of the system do not need to be addressed, however – and I will return to that issue in the final post in this series next week.