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Chris Perry is former Director of Social Services at South Glamorgan County Council.
One of the biggest challenges facing the Labour in government is fixing the crisis in the NHS and social care. The problems are deep rooted. They cannot be solved at a component level or simply by putting in more money.
The NHS and social care need radical reform, restructuring, and cultural change based upon a whole systems approach to liberate the dedicated, conscientious staff who struggle to do a good job despite the system, rather than the system supporting them in their work. And unless Government does something to reverse the widening income inequality and increasing poverty in our society, the NHS will not keep pace with demand.
Successive Governments have tried to get health, social services, police, education, and housing to work together. None has grasped the nettle of different geographical areas, different funding streams, and different lines of accountability, which have been the main impediments.
There are now 24 County Councils, 181 District Councils, 58 Unitary Authorities, 36 Metropolitan Boroughs, and 32 London Boroughs in England 22 County Councils in Wales, 223 NHS Trusts, and 43 Police Authorities. All serve different geographical areas, with different funding streams and different lines of accountability.
These 619 organisations could be merged into around 120 Unitary Authorities – based on the 1974 County Council, or Police Authority, areas – returning the NHS and police to local democratic scrutiny within central government direction and, in many cases, taking out a tier of local government. This would save millions on the cost of democracy, and management, whilst making services more democratically accountable.
The controlling contract culture needs to be replaced with an enabling leadership culture in which management recognises staff want to do a good job and see their role primarily to train, enable, and monitor.
Functional divisions need to be removed from patient/client pathways by creating multi-disciplinary, inter-agency, whole task, right-sized teams aligned behind outcome with access to all the resources required to achieve their goals. These teams need to operate out of a shared base and be able to “plan, do and evaluate” their work which completes the “learning cycle” of “constant improvement” and enables them to gain the satisfaction derived from seeing the outcome of their interventions.
Social workers need to be freed up to practice their skills in using relationships and various therapeutic techniques to resolve problems and where possible avoid the need for long-term care.
There is a wealth of empirical evidence on the “social determinates of health” demonstrating the correlation between income and demand upon the NHS.
Britain has one of the lowest state pensions in the developed world with two million older people living in poverty – many of whom, before the abolition of the “default retirement age” by David Cameron in 2012, were forced into retirement and condemned to spend the rest of their lives in poverty. In 2019, before the pandemic claimed 150,000 older lives, 4/5ths of the expenditure of the NHS was on older people. £19.6 billion was spent on treating malnutrition.
To increase the state pension to 60 per cent of average earnings and lift older people out of poverty which would still be less than much of Europe and slightly less than the “living wage”. It would cost £102 billion less than some means-tested benefits. And £19 billion would be clawed back through income tax from people with occupational pensions.
It would enhance the lives of older people and reduce the demand on the NHS. And if they did need long-term care, applying the same financial assessment, they would be able to pay more and therefore not take capital, or their house, into account would cost £1.5 billion, considerably less than the Government’s proposed cap. It would be necessary to retain means-tested housing benefits due to the wide variation in rents between the North-East and London.
The Government committed £57.5 billion to the failed Health and Social Care Act 2021 which might have been better spent on pensions. If people went on paying national insurance whilst-ever they were working and did not draw their state pension until they retired with phased arrangements – such as two days work with three days pension – that would bring in another £8.2 billion.
The Government estimated its cap at £86,000 on care home fees, which would have benefited the rich as those without sufficient savings would still have to sell their house, would cost £5.4 billion. To reduce malnutrition by 90 per cent would save the NHS £17.85billion.
The estimated total savings to the NHS and social care from reduced demand and the organisational and cultural changes outlined above would more than recover the cost of increased pensions and provide a better service at less cost. Older retired people did not benefit from the cuts in national insurance, lost their free TV licences, and have been hit particularly hard by the cost of living crisis and the freezing of the tax free personal allowance. The “Triple Lock PLUS” could have been a life saver.
In contrast, the first thing the new Labour Government has done for the majority of retired people is to reduce their income by £200 – adding to their hardship and increasing the pressure on the NHS.
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