Vicky looks at the impact of a curious and controversial Spring Budget.
During the Spring Budget, Chancellor of the Exchequer Philip Hammond announced an extra £2bn of funding for social care over the next three years, with the first £1bn ‘front-loaded’ between 2017/18.
In his speech Hammond declared that “the social care funding package will deliver immediate benefit to the NHS, allowing it to re-focus on delivering the NHS England Forward View Plan”.
Social care and healthcare are so inextricably linked that this isn’t exactly a controversial statement, but on one level the additional £2bn does seem to miss the point. The announcement acknowledges that the NHS is dependent on a functioning social care system, but doesn’t address the deeper problem; that health and social care are still deeply fragmented.
Not much fund
To explain this better, let’s start by considering what the impact of the £2bn is likely to be. Research suggests that improving social care can help the NHS in two key ways.
Firstly, it affects the ‘front door’ of hospitals. Carers UK reported last year that the reduced provision of local care and support services had contributed to a rise in A&E visits and hospital admissions. In fact – according to the Health and Social Care Information Centre – in the past five years, emergency hospital admissions of older people have risen by 18%.
Secondly, and most demonstrably, it affects the ‘back door’ too. Hospitals have found themselves unable to discharge elderly patients – the biggest users of hospital care – due to a lack of social care places. In 2015, the National Audit Office found that 1.5 million bed days had been lost to delayed transfers of care. Quite simply there is nowhere to send elderly patients.
That’s not to mention the long-term health impact, and the resultant costs to the NHS, of a delayed discharge. Monitor – the body that monitors NHS trusts – has highlighted that 10 days in a hospital bed for a healthy adult can have the equivalent impact of 10 years’ ageing on their fitness and mobility.
So it is clear then that improving the funding for social care can vastly improve the situation for the wider NHS. The biggest problem may not actually be the amount pledged, however, but the way the Treasury and Chancellor are continuing to view the funding in budgetary silos.
Pounds and fence
The ring-fenced NHS budget is a familiar pledge. It represents the commitment of multiple governments to avoid returning to the crisis state of the ‘90s when Tony Blair memorably declared, “we have 14 days to save the NHS”, on his election run.
But the promise has become a bit of ‘bait and switch’ – the ring-fence has masked the deep cuts to social care and public health. Social care funding has been falling in real terms since 2009, and the public health budget became a target after it was separated from the overall health budget in 2015. Nigel Edwards – Chief Executive of the Nuffield Trust – has said that the £1bn extra for social care funding next year was “only the sum that’s already been cut over the last five years”.
The danger of this division between what is ring-fenced and what is not has been expertly made before, by David Hunter – Professor of Health and Policy Management at Durham University – who wrote in the BMJ that “if partnership is critical to improving health and wellbeing, and tackling health inequalities, then ring-fencing the budget of one of the partners makes no sense” as it will “almost certainly trigger greater fragmentation”.
National policy, like the Five Year Forward View (5YFV), acknowledges the need to integrate social care, community and healthcare, but the national budget itself, mandates division.
The other problem is that the ring-fenced NHS budget encourages a focus on acute services and treating disease, rather than on public health, social care and preventing hospital admissions in the first place. Again, this is something the 5YFV has made a priority.
While the £2bn of extra social care funding is to be broadly welcomed – even if it’s not quite as much as desired – we also need to consider if this approach of investing a little here and a little there is really sustainable.
If the healthcare, social care and public health budget are approached as a whole, the Chancellor can only ensure resources are directed to where the ‘pay off’ will be highest.
The 5YFV has urged integration, vanguard sites are test-driving combined budgets and last year Scotland brought together their health and social care services under one partnership arrangement for each area. Surely, it’s time the Chancellor did the same.