Put social care funding on par with health, King's Fund proposes

This is the core message at the heart of an integrated approach to the health and social care system set out this week by Kate Barker, the economist and former member of the Bank of England’s monetary policy committee.

The ultimate vision, outlined by the King’s Fund commission on the future of health and social care which Ms Barker chairs, is not contentious. But the means of realising its ambition could prove controversial.

Ms Barker’s report could see councils handed a much greater role in the NHS.

Under its proposals, all non-acute health spending would be pooled with councils’ care budgets into a ringfenced pot and jointly commissioned by councils and the NHS.

“I think it will mean a bigger role for local authorities,” she said, adding that the pooled budget “would be worth a considerable amount of NHS expenditure”.

Ms Barker said she finds it “interesting” that “the health system may not like this because they like to ringfence healthcare and don’t want to see that [money] going into social care, and councils don’t want to ringfence this money because they want to have flexibility to move it around”.

“This all tells me people see social care as a kind of poor relation that they can economise on,” she said.

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In the process of putting together the report she said she noticed an “incredible, perpetual kind of tension about whether commissioning should be done by local authorities or [clinical commissioning groups].”

Ms Barker said: “I don’t think that’s particularly helpful. I think that’s partly what makes life so difficult for some patients who get caught in this wrangle between the two.”

While the commission’s report stopped short of saying which organisation should be in charge of commissioning services from the pooled budget, it suggested health and wellbeing boards could take on the role.

“I think commissioning all this nationally clearly isn’t going to work so you’re going to have to move it down, and my sense is that the health and wellbeing boards are going to have to grow into the sort of body that can do it,” she said.

“We don’t think health and wellbeing boards as they’re structured today would be right for doing the commissioning because of the need for greater clinical expertise.”  

However, reshaped HWBs with more clinicians on them could become the new commissioners, she added.

Ms Barker’s report said everyone with “critical” care needs should be given free social care immediately and this should be extended to those with “substantial” needs “as the economy improves”.

She said she was “slightly reluctant” to use economic growth as a determinant of care spending. However, she added: “It’s kind of clear that today with the issues around the deficit it’s very difficult to… lurch towards a system like that.

“I think it’s regrettable that we can’t do it more quickly because it puts a lot of pressure on individuals and carers, but I also think we have to be realistic.”

Asked what would indicate that the economy had improved enough to extend free care, she said: “It’s when the public finances are in an overall slightly better state and… we could keep paying down the debt without having to introduce further cuts in expenditure or rises in taxation.”

This, she acknowledged, could be “some considerable time off”.

The commission’s proposals for funding the reforms include three increases in National Insurance contributions for those on high incomes, those over 40-years-old and those working past the state pension age.

Asked if any political party would accept these rises, she said: “We did it in the 1990s for the health service and that was accepted and the health service did get better funding.

“There’s clear evidence that, as people get richer, they want better health systems.

“You have got to ask yourself why in a relatively well off country we would be unprepared to fund this system better.”

Ms Barker said many of the commission’s plans for funding an expansion of social care are designed to place the cost burden on people in the age range that will benefit from the plans.

However, she said: “It’s not clear to me that in future it would carry on being such a fair way [to fund the system] because we have a particularly well off set of retired people [at the moment].

“But I’m trying to produce a report that will guide us through the next decade.”