What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West.

Describing the government’s current answer to the dilemma of social care funding as a sticking plaster risks a successful defamation action by Elastoplast, as plenty as others have noted.

There’s no question, the problem has been left far too long. Again this winter we see hospitals very clogged up; there aren’t the alternatives elsewhere to allow the NHS to continue its decades old strategy of closing acute beds.

Years of policy back-and-forth have made many reticent to even entertain the idea that the government might actually act on social care.

Yet the prime minister has now unavoidably set herself the task of returning to the unfinished business of care funding and integration with the NHS. “The issue of social care has been ducked by governments for too long,” Theresa May told the Commons last month. “That is why this government will provide a long-term sustainable system for social care that gives people reassurance.”

Government policy on the health/care connection has been subject to an uneasy settlement since 2014. Simon Stevens arrived and, taking back his own leaky bucket, put a strict limit on the NHS’s participation in the better care fund. 

The Forward View said little about social care and ignored the BCF’s push towards melding clinical commissioning group and council budgets, in favour trying out different routes - new provider-led care models, and personal commissioning. While on paper the government’s policy is to bring health and care together by 2020, it’s entirely unclear how, or what this means. Meanwhile, ministers kicked care funding down the road with the delay of the Dilnot cost cap to 2020.

The government is now scoping what appears to be a very wide-ranging set of issues. These include long-term funding, standards of delivery and commissioning, and - closer to home for this newsletter - the connection with health. Those calling for cross-party talks on funding can presumably hope that might be the next stage after an initial scoping review.

If the project ventures towards the radical end of potential changes, there would be big implications for health and care commissioning.

Of course it is entirely possible the government’s new review will come to no more than further delay and the centre barking at councils to try harder and do better. Theresa May Not Act after all.

Even if she doesn’t move now, however, there are forces making the current stasis very difficult to sustain, whether that be the glaring knock-on effects on performance, variability and sluggishness in bottom-up reform, or the issue’s growing political salience.

An intriguing twist will come if, as is very likely, Andy Burnham, the most prominent political advocate of full structural integration of recent years, becomes elected Mayor in Greater Manchester in May. He could use that platform in what is seen as the crucible of integration to move it even further up the agenda - or damage the cause by playing politics.

For the NHS, given the forces and pressures described above, it can’t be a bad thing if the government is waking up to the issue, but there are pitfalls too.

The prime minister and chancellor are, it seems, unconvinced about whether the NHS deserves its special status as a (theoretically) protected budget. We could find them leaning more heavily on the health service to pay for care - a return to the “two financially leaky buckets” threat, leaving both sectors in an even worse place.

The government could also shift to a harder line on structural reform, perhaps favouring a specific model like the provider-led integration being taken forward in Salford, Northumbria and elsewhere.

The case for this is a bit more difficult to reject, because arguably the current approach of having a handful of large-scale experiments, moving relatively slowly, isn’t good enough.

Much of the health service recognises major change is needed, but there is no consensus on the next steps, meaning any decisive shift would be controversial and risky.

Most places would like to operate like Greater Manchester, or at least the idealised descriptions of Greater Manchester, if they could - but that’s a large if, until somewhere proves it can be replicated.

Accelerating organisational change without first reforming funding could easily just exacerbate the crisis, and most mainstream advice will probably back continued experimentation and diversity, unless and until a financial solution is found.

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