A new settlement for health and social care?

Demolition derby

The report demolishes three myths and misconceptions that are repeated in many debates about the fragmentation of care for older people, such as those triggered by the stories from the Mid Staffordshire inquiry6 or by television exposés of care home malpractice.7

The first myth to be demolished is that population ageing causes unsustainable inflation of health and social care budgets. This correction is not new. The drivers of rising healthcare costs were clearly identified as technology and professional practice, not ageing, in the landmark paper “Apocalypse No,”8 but this King’s Fund report supports this argument with evidence and gives it authority. More than half of all NHS expenditure in England goes on those under 65, as does virtually half of social care expenditure.

The second myth is that spending on health and social care cannot continue to rise in the long run without damaging the economy. The Barker report shows that this argument is not just unsound but a misconception with political undertones. Tightening eligibility rules (in response to budget cuts) has reduced access to publicly funded social care, so much so that there can seem little left to integrate. As Fernandez and colleagues have shown, the number of older people receiving state supported community based social care in England has fallen substantially, by at least 31% between 2005-6 and 2012-13.9 This has been achieved without much public debate, just as the transfer of care homes from the public sector to the commercial occurred quietly in the 1990s.

The third myth is that a heroic restructuring of health and social care is needed. The report dismisses this but does not deny that a short term problem needs solving. One part of this problem is that the baby boomer generation wants to keep and pass on its wealth while having its care paid for by a third party. Another part is that underinvestment in social care means that social services cannot keep up with hospital discharge, causing bed blocking. Spreading responsibilities and budgets between health and social care, as occurs with continuing healthcare funding in England, leads to cost shunting as each sector tries to protect its budget. The consequences are disputes, complaints, and inconsistencies in provision.

Solving the short term problem requires additional funding to be mobilised, especially for social care. The Barker report outlines the options available, from restricting the healthcare offer (no more tattoo removal), through increased copayments (charges for general practitioner consultations and the like), to tax changes that reflect the unprecedented affluence of the older population.

The Barker report invites responses to the options it outlines. Restricting the healthcare offer and extending copayments look to us like solutions that will raise more indignation than money. Tax changes seem more realistic as sources of investment but are outside the remit of the health service or local government. These are the “hard choices” for politicians that will probably need cross-government, all party agreements to make—the Barker report’s new settlement.