A week ago, the Prime Minister delivered a long-anticipated plan for social care and health. The headline announcements were a multi-year, multi-billion-pound funding settlement for the NHS and a new ‘cap and floor’ system in social care.
The reaction has been tepid at best. The cap and floor will be an incremental improvement on the current system. But critics have rightly asked where the plan is to improve the actual quality of social care, why the NHS was given such a plainly insufficient amount of money, and why such a regressive tax rise—National Insurance—was necessary to pay for it.
Any hope the Prime Minister and Chancellor had that this would lessen the focus on their health and care record looks misplaced. Indeed, the clear limitations of their policy will guarantee three questions feature prominently in the public debate between now and the next general election: first, what we want from social care; second, how we define recovery in the NHS; third, how we fund world class public services. It’s on these questions that progressives need develop a compelling, consensus vision for the future.
Question 1: What Do We Want From Social Care?
How we fund social care is important. But the starting point should have been: what kind of lives do we want social care to help people lead?
Currently, our system of care suffers from a chronic lack of ambition: what Social Care Future have called ‘the soft bigotry of low expectations’. Care at home is often reduced to ‘life and limb’ services, reducing people to a ‘checklist’ of mechanical jobs like washing up, laundry, and shopping. At worst, people are left with nothing more than ‘flying’ 15-minute visits.
There are horror stories in the residential sector, too. At worst, some large providers have become little more than care warehouses. They provide people shelter and food—at a price—but do little to empower them to maintain relationships, participate in their community, and lead flourishing lives.
We need to start again. The paradigm shift we need is away from a social care system which ‘manages’ need, and towards one which enables brilliant lives.
That means a fundamental change in the threshold for publicly funded social care support. Severe funding pressures on local authorities have often led them to gatekeep care – reserving publicly funded support only for those with the most severe needs. That’s why 1.5 million are living with unmet care needs today, a figure Age UK estimates will reach 2.1 million by 2030. It’s also why 35 percent of care requests by 18-64-year-olds are rejected. We should be providing care at the earliest possible point someone wants and needs it – and that means properly funding local authorities.
It also means doing care in people’s homes and communities. Deliberative research is clear: people want care that works around them, in places they call home, and in support of their passions, work, and relationships. But the UK system pushes people into institutions and care homes far too readily – with recent IPPR research exposing a huge and expensive postcode lottery in access to care at home. There are brilliant models of care at home, like the Shared Lives schemes being piloted in locations in the UK or the Buurtzorg scheme in the Netherlands. The UK should be harnessing these ideas and funding their roll-out at scale – like in America, where Joe Biden is investing $400 billion in community care services and innovations as part of his Covid-19 stimulus.
When people do then need residential care, they should receive it in places they can genuinely call home. Models like dementia villages, found in the Netherlands and America, provide people with care in places that replicate their homes and communities. It costs no more than other, less ambitious forms of care, and delivers much better outcomes.
Then we need to make sure there is a fit for purpose delivery mechanism. The obvious candidate is the one used by the NHS: free at the point of delivery, based on need. Importantly, combining a concept like free personal care with bold reform makes sure the policy increases access to genuinely good services – not just a broken status quo.
Question 2: What Do We Want From Health Care?
It surprised many that the government’s plan for social care allocated half the available funds to the NHS, and just a sixth to social care. But we should be clear: the NHS funding will be nothing like enough to deliver on the Prime Minister’s aspiration that it be ‘the pride of Britain’ and ‘the envy of the world’.
The extra funding amounts to about £5 billion per year for the NHS. That is just half of the amount needed to deal with the continued impact of Covid-19. Earlier this month, the NHS Confederation and NHS Providers jointly costed recovery at £10 billion.
Even then, we should have more ambition. Simply undoing the impact of Covid—and returning to the status quo of 31 December 2019—is nothing like enough.
The 2019 health service was already at breaking point. Workforce shortages were rife in every profession. More than four in five hospitals had more patients than is considered the safe limit. Funding was well below the G7 average, even if we exclude America. And UK patients were not able to access the excellent equipment, medicines, and technologies available through other, similar health systems.
The strain was already undermining patient care. Performance on cancer and A&E waiting times were at record lows. Corridor care was increasingly common. And the historic trend of steady improvements in heart disease, cancer mortality, and overall life expectancy had become stagnant.
The right aspiration is not ‘recovery’ from Covid. We need a health service run at the top of its game, not the top of its capacity. And that means funding, innovation, and reform to support the NHS to leapfrog well beyond its 2019 state.
Question 3: How Do We Fund It?
The government’s health and care reforms will be funded by a new Health and Social Care Levy, predominantly raised through National Insurance contributions. As a funding option, it’s evidently unfair. It asks those who earn their money from work to contribute far more than those who earn their money from wealth.
The debate on National Insurance opens up a more fundamental conversation: specifically, what kind of taxation system can provide a progressive source of revenue for world class public services?
The real problem is the fundamental unfairness in our current system of taxation. It is designed in favour of wealthy asset owners. Currently, someone who earns £23,400 from work will pay about £4,000 in tax; but someone who earns £45,000 from stocks, shares, and investments will pay about £2,500. This needs to change.
Fortunately, there are immediate reform options. National Insurance itself could be adjusted – to include older people in work; to align thresholds with income tax; and to remove caps limiting how much the highest earners pay. More fundamentally, we could ensure the tax system treats income from wealth and work equally – including through reforming capital gains tax. IPPR analysis estimates this alignment could raise £90 billion over five years.
The Need for Hope
The next few years will be a crossroads for public services. On the one hand, the pandemic has made clear their value – in ensuring our collective wellbeing, prosperity, and resilience when crises do happen.
But there is also a risk. If outcomes remain poor, there is every chance people could get exasperated and give up on the system altogether. They might directly fund their care, or take out private health insurance, or otherwise buy out the system. Eventually, this trend would erode support for ambitious, well-funded health and care services.
That means easy criticism of the government’s proposals is not enough. The onus is on us to come up with compelling alternatives. On health, we need a vision for a sustainable, resilient, and world class NHS. On care, we need to describe a system that supports genuinely brilliant lives. Across the board, we need a vision for public services that gives people genuine hope – and creates trust they can be the vehicle for better, fairer lives.