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Health and social care should be redesigned to focus on individual needs regardless of diagnosis, with a graduated increase in support as needs rise, an independent commission has concluded.
This is required because the way that health and social care are currently organised and funded creates confusion, perverse incentives and distress for individuals and families, according to the commission, established by health and social care charity The King’s Fund and chaired by Dame Kate Barker.
One of the key recommendations of the report is moving to a single, ring-fenced budget for the NHS and social care, with a single commissioner for local services.
It also recommends that social care for those whose needs are currently defined as ‘critical’ should become free at the point of use. This, the report said, would end the confusing distinction between social care provided in residential care homes and NHS Continuing Healthcare, which is provided free of charge in nursing homes.
As the economy improves, free social care should be extended to those whose needs are currently defined as ‘substantial’, the report adds. Also, by 2025, some support should be provided to those whose needs are currently defined as ‘moderate’ but this should continue to be on a means-tested basis.
Additionally, the commission recommends integrating Attendance Allowance, the benefit paid to older people with care and support needs (which would be renamed Care and Support Allowance) within the single budget for health and social care.
Looking beyond the deficit
The commission challenged politicians to look beyond the deficit and engage the public in a debate about how care will be funded in the future. It calls on the government to plan ahead on the assumption that public spending on health and social care combined will rise to between 11 and 12% of GDP by 2025. These levels will be broadly comparable to current expenditure on health alone in many other countries.
It advocates phasing in a partnership model, in which the costs of social care will be shared between individual and the state, to provide fairer, more consistent entitlements to social care.
To pay for the changes, rather than extending charges for NHS services – except for prescriptions – the report argues that the bulk of the additional funding should come from the public purse, with wealthier people and older generations – the main beneficiaries of the changes – contributing more.
To fund the initial roll-out of the new settlement, the report recommends reducing prescription charges to as low as £2.50 but significantly reducing the number of prescriptions exempt from charges. It also advocates limiting free TV licences and the winter fuel payment for older people to those on pension credit and requiring people working past state pension age to pay National Insurance at a rate of 6%.
It also recommends that new recipients of NHS Continuing Healthcare should pay the costs of their accommodation, as those receiving residential social care do now.
As the more generous elements of the new settlement are phased in, the report recommends further measures to raise revenue, including a 1% increase in National Insurance contributions paid by those over the age of 40 and by those earning more than £42,000 a year.
The report also recommends that a review of wealth and property taxation should be undertaken to raise additional funds.
Radical change needed
“We have concluded, as others have before us, that our system is not fit to provide the kind of care we need and want,” Barker said. “We propose radical change, greater than any since 1948, that would bring immense benefit to people who fall between the cracks between means-tested social care and a free NHS. This includes people at the end of life and those with dementia or other conditions where too often there is a conflict about who pays at the expense of what people need.
“Our proposals would continue a system where costs are shared between the private individual and the state but with the taxpayer carrying a heavier load of that cost than at present. The cost of a more generous settlement, though large, can be afforded if phased in over time.”
Professor Chris Ham, chief executive of The King’s Fund, added: “The proposals as set out by the commission may not appeal to politicians, fearful of commitments of greater public expenditure, but these issues cannot simply be ignored. The commission is clear – there is no “do nothing” option. As the costs of what we now classify as social care grow, these will increasingly fall to individuals and families, creating fear, uncertainty and inequity on a scale that the public would find completely unacceptable if applied to health care. The recommendations are therefore radical – tinkering around the edge of our systems of care is not enough to deal with the challenges we face.
“The issue is not whether health and social care are affordable in future –they have to be paid for one way or another. The issue is how far they are publicly or privately funded and at what level of quality and decency. This report lays down a challenge to politicians of all parties to acknowledge the unsustainability of current funding for health and social care and to set out, ahead of the election, some of the difficult choices that need to be made.”