The funding of care in England and Wales is a Byzantine structure of mysterious entitlements and clawbacks. The new government has wasted little time (rather like its predecessor in 1997) in announcing an investigation into this morass – and, with its Commission on the Funding of Care and Support due to report next summer, it’s expected that campaigning organisations and think tanks and interested parties will be lobbing in their two penn’orth over the next few months.
The right-leaning think-tank Policy Exchange has been the first off the mark, with a report, Careless, whose headline recommendation is that the National Health Service and social care aren’t actually separate entities and should be amalgamated. The report’s authors, Henry Featherstone and Lilly Whitham, point out that the NHS already devotes 4% of its budget to care and is often the provider of last resort.
Social care consumes 40% of the money that local authorities have at their disposal and cuts are widely seen as inevitable. Featherstone and Whitham object that willy nilly, more care costs will creep into the NHS, where funding is ring-fenced. Their proposal to amalgamate the two services is highly political, because either everything would have to be free at the point of use, or there would be some charging. Predictably enough, they are against free social care funded by general taxation and warn the Commission against considering it, although most experts in the field seem to think that’s effectively been ruled out anyway. Policy Exchange argues that charging for aspects of the combined service would merely extend a principle that already exists in the NHS, where some people pay for prescriptions and cancer drugs.
If you could take out the politics, looking at the scope for amalgamation might be a bright idea. But you can’t. The opposition would rightly deride the idea as a Trojan horse for the dismantling of the NHS. And the coalition has staked its morality on defending a talismanic NHS, exempting it from the general slash and burn; to go back on that would be to lose all credibility.
Featherstone and Whitham’s second controversial proposition is that the anticipated hike in social care budgets may not actually arise. The Department of Health and the Office of National Statistics have taken the view that an ageing population will be an infirm population; that healthy life expectancy – the number of years we spend being fit and well – is decreasing as a proportion of total life expectancy. But the figures are far from clear. Most serious researchers are cautious about the reliability of the evidence and caution that results vary across population groups.
There is highly respectable research suggesting that the length of time spent unwell is not growing, and some equally serious studies showing it is. Policy Exchange’s scepticism is particularly interesting in the light of reports this week of a new superbug, leading to press speculation that we could be heading towards an era without antibiotics when pneumonia may once again become ‘the old man’s friend.’
Policy Exchange claims this lack of clarity means there’s less urgency to reform social care than everyone has assumed, but this is a bit feeble because there are anomalies and inequalities now that would hardly be tolerated in other aspects of government. Besides, as a general principle, there is nothing wrong with planning for the worst.
The care system only gets away with its discrepancies and injustices because it’s something we don’t want to think about. The third really interesting point in the Policy Exchange report (which isn’t new, but bears repeating) is how much ignorance there is about the care system. Many people (48% responding to government research) think care is free, and don’t bother to inquire too closely because no one wants to think about it, in the same way we don’t want to think about death.
Despite a 1997 Royal Commission, two reports from House of Commons Select Committee inquiries, three major reports from the last government and the coalition’s speed in setting up its commission, care doesn’t appear on lists of voters’ concerns.
Unless you happen to be a carer, of course. Carers provide services estimated to be worth £87bn a year. This is not paid work and it’s not exactly volunteering; it’s something much more precious and intangible – you might call it love, or friendship. Over a very long time, governments have exploited the fact that caring comes from somewhere quite different from the technocratic workings of government with its tick-box targets and effectiveness measures. The real conundrum in this debate is how to reward carers.
Successive governments have resisted moves in that direction, for fear that it’s a slippery slope: you could never satisfy their needs. The alternative has been, and remains, to do nothing, which is simply not fair. Amalgamating the NHS and the care service is a slick idea, but it’s a technocratic solution, of appeal mainly to people who are interested in systems. A much bigger and more radical challenge is to find a way of integrating the precious gift economy of caring more closely into society, rather than, as so often, isolating and excluding it.