Hidden amidst the aspirations on social care are some nasty precedents which could undermine the whole principle of free NHS care.
The NHS should charge some critically ill patients for their NHS bed, suggests a report published today by Kate Barker for influential health policy lobbyists, the Kings Fund.
The report also recommends considering ending free prescriptions for most pensioners and for people with long term conditions.
“new recipients of what is currently defined as NHS Continuing Healthcare should meet their accommodation costs” says the report. NHS Continuing Healthcare is NHS care provided to people who are severely ill and either deteriorating or dying.
And on prescriptions the Barker Commission suggests “medical exemptions and the low-income scheme would be abolished for all, including pensioners”.
The controversial proposals are included in much-anticipated set of recommendations to radically transform health and social care provision and funding. The report will be being promoted heavily around the party conferences over the next month by the Kings Fund,who commissioned it.
Whilst it’s hard to imagine these suggestions ending up explicitly in a party manifesto, their advocacy by a key 'think tank' will raise fears that they could be implemented post-election under the guise of ‘integration of health and social care’ which all three big parties are publicly supporting. Shadow Health Secretary Andy Burnham has already says Labour ‘welcome this bold and timely report'.
Barker backed away from other user charges (such as charges to see your GP) which have been advocated by other groups such as Reform. She calls instead for National Insurance increases (and scrapping most of the Winter Fuel Allowance) to provide social care for the most ‘critical’ needs, free of charge. Currently such care is means-tested. The report suggests that less severe needs could possibly be met from higher taxes in future, too.
Many who are battling with social care problems - from charities to hospital managers keen to free up ever-scarcer hospital beds by discharging patients ‘into the community’, have welcomed these proposals.
But the trade-off is hidden. If all these proposals are implemented, whilst more care at home might become free, care in NHS beds for some of the very sickest patients will no longer be free.
Compulsory charging for NHS beds - even if only for a minority of patients, outside of acute hospitals - is line the NHS has not previously crossed. The proposals will - Barker admits - raise little, so why cross this Rubicon?
Separating out NHS ‘accommodation’ costs from NHS ‘care’ costs, and redefining NHS accomodation as an 'extra' to be paid for, will be familiar to those who study health privatisation strategies. It has long been a favoured tactic of those who seek to gradually chip away at our entitlement to free health care.
The justification the Barker Commission gives is that separating - and charging for - the ‘accommodation’ element of some NHS services, will better ‘align’ health with social care practices. But since when did that become and end in itself, more important than protecting the precious principle of an NHS free at the point of use?
Will politicians of all hues, when they have time to read the detail of the Barker report, reject these particular suggestions roundly?
They’re certainly a long way from the promises we were given during the course of the Health & Social Care Act 2012, which was also spun as ‘integrating’ health and social care.
Critics argued that the privatising Act would saddle the NHS with huge extra costs, which would inevitably end up being passed on to the public, in charges or raised taxes.
“Absolute nonsense” responded the Department of Health. “The Bill reaffirms that healthcare will always be there for everyone who needs it, funded from general taxation, and based on need not ability to pay.
“Ludicrous scaremongering” piped up then Health Minister Andrew Lansley. In fact the Act meant “cutting bureaucracy so more cash got to the front line”.
“I’m fed up with these lies” Shirley Williams told fellow Lib Dems. “The National Health Service should continue to be primarily a public service, available free of charge…”
But - at the very moment the final key regulations of the Act slid through parliament last April - the ‘health establishment’ - the outsourced world of health policy making - changed its tune.
The patrician new Chair of the NHS Sir Malcolm Grant dropped a bombshell, announcing that “NHS patients face more charges” in future.
Health policy ‘experts’, who til then had been so reassuring about the fears around the Act, rushed to follow suit. The NHS was unsustainable, just like social care, they thundered. No-one’s been talking about it, they started telling us endlessly, but we cannot afford the current system. The only solution is to either tax the elderly more, charge for NHS services, or cut it so it is no longer universal and comprehensive, merely some ‘core entitlements’ - just like social care.
The groundwork has been well laid. When faced with a report suggesting only a fairly limited extension of NHS charges (for now), we are all supposed to sigh in relief, even if a fundamental principle of charging for NHS beds has been breached.
We should be wary of what is masquerading under the rubric of ‘health and social care integration’. Particularly when so much of the rubric - like Barker - ignores the largely privatised provision of both home-based and care-home social care, which siphons large sums out into private profits and private equity companies (like Bridgepoint, the owners of Care UK). Her report says nothing about the notoriously poor quality of even ‘critical’ care, often reliant on 15 minute appointment slots provided by staff on zero hours contracts. Indeed many feel the separation of health and social care in the first place was artificial and designed to promote private involvement - but we can't re-integrate properly unless we're honest about these problems.
If NHS acute hospitals need to relieve pressure on beds (and sometimes aren’t the best place for old or very sick people) then why not give the NHS funding to provide both properly skilled, publicly provided, home care and cottage hospitals, as appropriate?
This is not what Barker proposes. Instead, her report strongly argues for an extension of personal health budgets - hard to distinguish from Thatcher-era voucher schemes which fundamentally undermine properly funded public services. Personal budgets in social care have turned out to be a useful way of imposing cuts on the quiet - and their trials in health have been shown to be expensive and ineffective. Their use has led to services being withdrawn, and isolation for their users. Simon Stevens, the new NHSboss (freshly returned from US healthcare giant United Health) is a big fan, however, and has announced today a further roll-out of their use.
And pro-market think tank Demos has another idea - this week it joined forces with Paul Burstow MP to call on hospitals to sell off their land cheaply to private care homes.
Is all this the ‘health and social care integration’ we want?
Rather than tying themselves up in knots over higher taxes and charges, there is another, far better, option for freeing up health and social care funding that politicians could consider. The National Health Action Party estimates that scrapping the NHSmarket could free up at least £10billion a year, and rebel Lib Dems have put the figure at considerably more. Such sums could pay for free critical and severe social care needs for all, according to Barker's calculations. Oddly, the Barker report failed to look at this potential cost saving at all. Some in the health policy community think it can't be done - but the new Bill by Allyson Pollock proposed this week shows just how it could. Will politicians have the courage to study that Bill, as seriously and closely as the Kings Fund is urging them to study the Barker report?