Cowper's Cut 178: Special issue on the health but social care announcements
“My job is to make sure you don’t have to wait 3 weeks to see your GP, and we start work this week with 20 new hospital upgrades, and ensuring that money for the NHS really does get to the front line.
“My job is to protect you or your parents or grandparents from the fear of having to sell your home to pay for the costs of care, and so I am announcing now – on the steps of Downing Street – that we will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve.”
Boris Johnson’s first speech as PM, 24 July 2019
EDITOR'S NOTE: I won't typically do 'extra' issues of 'Cut' as it's a lot of work, but I'm sending this because of the importance of today's announcements. Please forgive any slight roughnesses in the below as a result.
The health policy universe started the week on tenterhooks about what crap, fallacy-ridden arguments Team Johnson and Team Sunak (well-described in this Politico article) would deploy in the next salvo of their War Of The Briefings, as chronicled in last week’s ‘Cut’.
Actually, scratch that. We were on eleventerhooks, at least. Possibly even twelveterhooks.
There’s nothing like a Government with sophisticated strategies for developing public policy, and this is nothing like a Government with sophisticated strategies for developing public policy.
Back in the real world, the REAL Centre of the Health Foundation issued a report assessing the actual NHS financial support required. It’ll have made our dear chums the Treasury Munchkins stumble on their Yellow Brick Road to see the figure of £17 billion over the remainder of this Parliament.
The report says this sum will be required “to clear the backlog of people waiting for routine elective care, return to 18 weeks, and treat millions of ‘missing’ patients who were expected to receive care during the pandemic but did not. In all, this would allow an additional 2.2million extra patients to be seen a year.
“The overall funding the NHS may need could yet be significantly higher than this as the REAL Centre’s modelling does not include the ongoing impact of COVID-19 on NHS productivity, and the additional investment that may be needed in primary and community services to support the recovery”.
Towards funding the NHS backlog
So, what is the sector getting?
On Monday, an additional £5.4 billion for the NHS was announced for the remainder of the current financial year. This breaks down into
· £2.8 billion for COVID-19 costs including infection control measures;
· £600 million for day-to-day costs;
· £478 million for enhanced hospital discharge; and
· £1.5 billion for elective recovery, including £500 million capital funding.
Towards a Health But Social Care Levy
On Tuesday, the Prime Minister announced a 1.25% increase in employers’ and employees’ National Insurance contributions and on share income dividends – branded a ‘Health But Social Care Levy’.
The ‘floor’ of an individual’s assets is to be set at £100,000, while the ‘cap’ on lifetime social care contributions will be set at £86,000 – more than double the £35,000 Dilnot proposed in 2011 (as a mid-point figure across his suggested range of £25,000-£50,000).
Comically, assertions have been made that the HBSC Levy will be “legally ringfenced” to prevent it being siphoned off by future governments. Lawyer and writer David Allan Green is very good on why this is utter nonsense.
How will this land?
NHS England boss Amanda Pritchard welcomed the extra NHS funding for 2021-22 as follows: “this funding provides welcome certainty for the NHS, which has pulled out all the stops to restore services, while caring for thousands of seriously ill Covid patients requiring hospital treatment during the toughest summer on record.
“This additional investment will enable the NHS to deliver more checks, scans and procedures as well as helping to deal with the ongoing costs and pressures of the pandemic as the NHS heads in to winter”.
What does it mean?
Crucially, the social care reform is only a reform of funding. And delivering it via the often poorly-understood National Insurance limits and minimises its progressive nature towards income. There seems to be some legacy public belief that it is 'paying your stamp' and has some magical link to health/care funding. It doesn't.
To get a sense of the scale of missed opportunity, it’s worth re-reading 2019’s Health Foundation report on ‘What should be done to fix the crisis in social care?’ The authors point out that restoring the access to services caused by cuts to the central Government grants to local authorities since 2010-11 in the now-banished name of ‘austerity’ would (then) have cost £12.5 billion.
More to the point, the proposal for the HBSC Levy to largely fund clearing the NHS backlog for the coming three financial years, thereafter reverting 100% to social care, is at best unproven and improbable. It both delays the arrival of extra funding for social care and obscures the question of a durable and post-Covid financial settlement for the NHS.
It seems that of the £36 billion raised in the first three years, only £5.4 billion is for social care. Of that £5.4 billion, £2.5 billion funds the new care cap, leaving just £2.9 billion over 3 years for reform.
There is not a word on how current social care provision (slightly over half of which is not on the pensions-age population) or pay and conditions for staff will be improved. That's just strange.
Nor does there appear to be any kind of an actual plan for how to clear the NHS backlog. That's even stranger.
One of the biggest impediments to getting NHS staff working extra shifts in evenings and weekends (what worked in the 2000s version of this) is that they are knackered post-Covid19. Nor is it clear that the extra NHS funding on offer will incentivise NHS staff to work those extra shifts.
There's another huge impediment, also linked to residential property inheritance: the pensions taper tax, which Gideon George Osborne introduced in 2015 to offset losses by putting residential property up to £1 million in value for two-child-inheritor estates outside inheritance tax.
The discussion of the pensions taper tax, about which I’ve been banging on for ages and ages, has gone very, very quiet. There is no reality-based version of clearing the NHS backlog that does not involve sorting out the pensions taper tax incentive dilemma.
Well, we got a document, but very much not a plan. Despite being called ‘Building Back Better: Our Plan For Health And Social Care’.
So what does it say on the NHS backlog?
“The Government will tackle this elective backlog in the biggest catchup programme in the NHS’s history. We will spend £2 billion this year, double our previous commitment, to start to tackle the backlog. In addition, the Government plans to spend more than £8 billion in the following three years from 2022-23 to 2024-25. The £9 billion that we are putting in now, on top of the £1 billion that was included in the 2020 Spending Review, could deliver the equivalent of around nine million more checks, scans and procedures. It will also mean the NHS in England can aim to deliver around 30 per cent more elective activity by 2024-25 than it was before the pandemic, after accounting for the impact of an improved care offer through system transformation, and advice and guidance. Further, once the NHS has recovered from the pandemic, activity should be the equivalent of ten per cent higher than under the NHS Long Term Plan”.
Mmmm. If not mmmmmmmmm.
Look at the verbs: "could"; "can"; "should". Not one of which means “will”, “shall” or “must”. That's one carefully-drafted document: I’d say the NHS asked for more money, and possibly a commitment on workforce training and capital, and didn't get them. So the Treasury Munchkins didn't get guarantees.
That’s how this shit works.
"NHS England and Improvement will also publicly set out how it will embrace efficiency and reform to seek to maximise funding for elective activity within the funding envelope". Here comes the 15-Year Forward View!
“The Government will also establish a new £250 million Elective Recovery Technology Fund to enable cutting edge technologies and provide £250 million in funding to increase operating theatre capacity and improve productivity in hospitals, which together will increase elective capacity”.
Ahem. There are more than 250 acute hospitals in the NHS, even discounting the Tories’ ‘fictional forty’. A million pounds each will not go far.
“The Government will ensure Local Authorities have access to sustainable funding for core budgets at the Spending Review. We expect demographic and unit cost pressures will be met through Council Tax, social care precept, and long-term efficiencies; the overall level of Local Government funding, including Council Tax and social care precept, will be determined in the round at the Spending Review in the normal way. We will invest £5.4 billion in adult social care over the next three years to deliver the funding and system reform commitments set out in this document.”
The notion that “demographic and unit cost pressures will be met through Council Tax, social care precept, and long-term efficiencies” is laughable.
“To begin this transformation in adult social care, the Government will:
1. introduce a cap on personal care costs;
2. provide financial assistance to those without substantial assets;
3. deliver wider support for the social care system, particularly our brilliant social care staff; and
4. improve the integration of health and social care systems.”
Connecting For Health But Social Care, here we come
The PM also promised a “single digital health and social care record across primary care, NHS trusts and social care providers”. (1 Sept 2021 was supposed to be the date for the shared care record according to Matt Hancock.) Is this in any way costed? How will it be delivered?
Thank goodness that’s proved so straightforward in the NHS thus far. Connecting For Health But Social Care will be high-quality entertainment.
Parliamentary presentation 12.30
PM Boris Johnson: “Too often, people were in hospital beds because they or their relatives were worried about the cost of care in a residential home, and that same fear kept many others at home without any care at all. This anxiety affects millions of people up and down the country: the fear that a condition such as dementia, one of nature’s bolts from the blue, could lead to the total liquidation of their assets, their lifetime savings and their home—the loss of everything, however great or small, they might otherwise pass on to their children—while sufferers from other diseases, who have to be in hospital for the majority of their treatment, have their care paid for in full by the NHS”.
There was some utter bollocks from the PM about people staying in hospital beds because they were scared of paying for residential care. In reality, the residential care beds that would accept high-acuity patients were not there. It’s not “an indictment of failure”, in the PM’s words. It’s a straightforward fucking lie.
Hospitals are not legally allowed to discharge patients into unsafe environments, and care homes could not be forced to take them if not staffed/equipped appropriately. Hospitals are legally obliged to make sure that suitable care arrangements are in place for patients to be discharged.
The PM saying that NHS backlogs were due to people “not coming forward” & bed-blocking because they don’t want to pay for social care is … an interesting look.
Spending Review announcement https://www.gov.uk/government/news/chancellor-launches-vision-for-future-public-spending
Press conference 16.30
PM goes with his standard health guff: “48 new hospitals, 50 million new GP appointments … by 2024-5 this should allow NHS to aim to treat 30% more”.
It’s interesting that he's careful on the language of the 'target' there: "By 2024-5 this should allow NHS to aim to treat 30% more". And he ain't a careful man on language. I'm right about this indicating there wasn't a mutually satisfactory Treasury/NHSE deal on funding/targets, I think.
500 million going to hundreds of thousands of new care training places? That is not very much £ apiece.
Sunak is an assured, smooth performer. Oh … I type that, and then he does the “legally ringfenced” shit. "No government wants to have to raise taxes". Mmm. No Conservative government, maybe.
In (some reasonably good) press questions, the PM wouldn't rule out more tax rises, nor would he be drawn on whether or not he'll reshuffle the Cabinet this week.
Neither would Sajid Javid say when he expects NHS backlogs to be cleared, or guarantee future split of levy between social care and the NHS.
Covid19 update
The creaking system
Cronyvirus and Coronamillions update
Getting the Bill (Health and Social Care)
Very good questions from Labour’s Bristol South MP Karin Smyth at Tuesday's Bill Committee. Effectively exposes the under-cooked nature of accountability and capital funding plans in the new legislation
Other important things
Would appear here.
Recommended and required reading
Stuart McDonald on the new ONS deaths data, showing increasing mortality rates over the long-term average. It’s very unusual to see such increases in the summer months.