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Editorial Tuesday 29 May 2012: Nuffield Trust on social care, Kings Fund on listening

Two useful documents today: from the Nuffield Trust on reforming the funding of social care, and the King's Fund listrening to patients' preferences about treatment.


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The Nuffield Trust document demonstrates some political courage, since its thesis is that 'Labour's Death Tax', in the charming formulation of Andrew Lansley (saviour, liberator) is an idea whose time has come.

The Nuffield document, by former Treasury economist Anita Charlsworth and Ruth Thorlby, observes that "in the short term, more funds could be made available from the NHS: primary care trusts (PCTs) are currently projecting an underspend of £1.5 billion in 2011/12. The Department of Health should consider using part of this for further transfers to social care (yet ... redirecting some of the 2011/12 NHS surplus will not be enough on its own".

It continues, "it is not clear that the current mix of spending on social care, health and welfare payments for older people is optimal. The Government should consider shifting resources from the welfare payments currently received by better-off older people, to fund long-term reform of social care. It should also explore whether some of the health budget could be more efficiently spent on preventative social care.

"If the costs of social care cannot be met within the overall sum of state support to older people, some form of higher taxation may also need to be considered. This should be guided by principles of equity – between generations as well as between people with differing levels of income and wealth. In particular, the Government should explore options to direct the burden of any tax increases onto wealthier older people".

This suggestion of progressive taxation of the wealthiest is not likely to win the Nuffield Trust many friends in Conservative policymaking circles. The document goes on to note that the case for funding rises, be they public of private, will be un-makeable if the quality of social care provision "is seen as being of poor quality and unable to treat people with dignity".

More than a fair point. I remember well chatting with a very good residential home manager, who told me if I were ever having to choose a home for a relative, there were two useful quality markers she would suggest. The first is simple: does it smell of urine? The second was, go and check the bins to see what amount of food is thrown out prepared but uneaten (we agreed that weighing the food delivered and food binned would be ideal, but impractical). Both are good indices of the diligence and care of the staff.

Pages 4-8 analyse the practical nature of the problem. 9-10 examine the impact on the NHS and assess the future funding gap.

The document looks at the Dilnot Commissioni funding proposals, and finds that "although the Dilnot Commission attempts to strike a balance between people with differing levels of income and wealth, the cap in particular delivers greater benefit to the better-off, as public funds are used to protect more of their wealth than under current arrangements".

It also looks at Dilton's ideas regarding eligibility for state support: "the Commission’s recommendations are based on standardising the assessment threshold at the current ‘substantial’ FACS category. It will be important that this threshold for eligibility should not be too high. Increasing the scope of means-tested support would be undermined if only a very small percentage of those needing social care are able to qualify".

The document goes on to consider three options to tweak Dilnot:
• reducing the costs of implementing the Dilnot proposals
• redistributing funds from health to social care
• redistributing older people’s income or wealth through reform of current welfare payments and/or taxation.

It explores the option of raising the lifetime cap to £50,000 and setting the annual contribution towards living costs at £10,000 rather than the proposed £7,000. It suggests that a £50,000 cap "should still deliver most of the Dilnot Commission’s objectives and most importantly the ‘savings’ could be used to reduce the threshold for publicly funded adult social care, ensuring that more people receive the care that they need, which would bring potential benefits for themselves, their carers and other services such as the NHS".

Coming for the NHS's cash?
Inevitably, it considers the possibility of looking at the NHS revenue budget: "One option for reprioritised spending on public services would be to shift resources from health into social care. Funding for health care has grown at twice the rate of social care funding over recent years, but it is not clear that this differential rate of growth has delivered the most cost-effective mix of health and social care, particularly for very elderly people with complex health and care needs who receive support from both the NHS and social care providers. But the evidence is not clear-cut: attempts to invest in enhanced, preventative social services at the patient or community level have often not delivered the anticipated level of savings (Steventon and others, 2011).".

It concludes that the DH should "consider a review of the optimal balance between health and social care funding before the next spending review.".

Nor are the authors deterred by the recent budget's 'granny tax' PR problems, suggesting "restricting some of the universal benefit payments to older people with higher incomes and wealth. This could include, for example, the winter fuel payment, free TV licenses and travel concessions (the free bus pass)".

More is needed - and the document considers the possibility of an estimated £3 billion annual yield from a five per cent tax on estates above £25,000, citing analysis by the The Strategic Society Centre.

Charlsworth and Thorlby suggest that "if revenue-raising were to focus on older people, there is a case for any additional contribution to the cost of protecting individuals from the risk of very high care costs to be targeted at the better-off elderly. This is the group that would receive the greatest benefit from the Dilnot Commission proposals, as a cap on lifetime costs has the effect of protecting individuals’ accumulated assets".

The paper says, "it would be reasonable to consider reform of taxes on wealth as a source of funding for social care. The Government should undertake further work to explore options that could command public support and would have limited scope for tax avoidance. The objective of reforming the tax system in order to fund a cap on lifetime social care costs would be to levy a low rate of tax across as many of those with assets above the means-tested threshold as possible".

The document is thorough and thoughtful. Social care will create more and more problems for the NHS over coming years. It is a useful and readable contribution to advancing the debate.

Does the patient take sugar?
So too is the paper by Al Mulley, Chris Trimble and Glyn Elwyn for the Kings Fund. 'Patients' Preferences Matter' argues the apparently uncontentious point that patients' preferences for how they are treated are often ignored, with the provocative sub-heading 'Stop The Silent Misdiagnosis'.

It lists the following five "erroneous assumptions:
Stop believing that science alone determines need
Stop believing that variation is the problem
Stop believing that patient choice is about time and location
Stop believing that ‘the market’ can sort out healthcare
Stop believing that commissioners can calculate need

Mulley, Trimble and Elwyn "present an accumulation of evidence which shows that preference misdiagnoses are commonplace. In part, this is because doctors are rarely made
aware that they have made a preference misdiagnosis. It is the silent misdiagnosis".

They conclude that "the most important step the NHS must take in order to stop the silent misdiagnosis is conceptually straightforward: it must measure and report the incidence of preference misdiagnoses".

It is at once a simple and deeply subversive recommendation. It will involve educated, expensive and highly-trained professionals admitting on what the authors claim to be a pretty regular basis that they are getting a key part of their jobs wrong.

Equally, it will involve patients becoming much more risk-and-reward-literate about their health and healthcare. That could well feel like rationing to some.

This agenda will be, to put it mildly, a big challenge.

The authors conclude that to bring about this significant change, the system must start "providing doctors with more and better information about what patients want, and by providing patients with more and better information about options, outcomes, and evidence. To assess progress, the NHS should implement measures that indicate how much doctors
and patients have learned.

"To fully realise the agenda that we propose here, the NHS must recognise the need for new, dedicated teams focused on gathering and disseminating information. It must also aid commissioners in shifting their focus, from trying to calculate need to trying to eliminate preference misdiagnoses, so that patients receive the care they need (and no less), and the care they want (and no more)".

This does sound as if it might have quite an opportunity cost in the short term - though the authors would doubtless argue that the opportunity cost of silent misdiagnosis is far higher.

It would be fascinating to see this approach piloted somewhere. A challenge might be that in an NHS focusing on outcome metrics, unless these change bring short-term savings to match the set-up costs, this might look cost-ineffective.

But the ideas look good, and the move towards patient-centricity seems appropriate.

So who will trial it across a health economy or two?