Rt Hon Norman Lamb MP who made a brilliant speech as part of a series of debates initiated by Mr Speaker Bercow
Regular readers of my blog will note that this blog is both longer and cleverer than my normal ones. That’s because its not mine. It’s a speech made my Rt Hon Norman Lamb MP at a ‘Speaker’s Lecture’ last Monday 27th November. It’s a very good speech which was very well received by members of all Parties and none who heard it. I have reproduced it in full with Norman’s permission.
I suspect that many people have only a vague idea of what social care is – seems a rather old-fashioned term. Part of the problem in terms of the attention it gets from Governments of all persuasions is that is usually compared to the NHS which is ‘the nearest thing the English have to a religion’ as Nigel Lawson famously said.
Go to Wikipedia and you will find that social care is defined as “the provision of social work, personal care, protection or social support services to children or adults in need or at risk, or adults with care needs arising from illness, disability, old age or poverty.”
This comes across very much as the provision of a service to people. My preference is to think about what we are seeking to achieve. What should our objective be for people?
For me, this must surely be about how we enable people to lead a good life, a happy, fulfilling life – a life they want to lead – as far as that is achievable. That involves people having power and control – rather than having things done to them.
And then, at the end of life, the really important priority is how people can have a dignified death. This is denied to many people. As we have achieved enormous advances in keeping people alive with medical technologies and therapeutics, that has become the purpose – to keep you alive -sometimes completely irrespective of the dismal quality of that life. But just keeping you alive is not what I want and, I suspect, it’s not what most of us want.
For those who haven’t read it, I would encourage anyone to read Atul Gawande’s Being Mortal. Gawande is a surgeon living and working in the U.S. but his book has universal relevance. It’s full of humanity.
It presents a stark critique of where we have gone wrong, too often focused on minimising risk, restricting the lives of vulnerable people, often institutionalising them. He makes the point that we permit children to take more risks than we do a person approaching the end of their life and receiving care. Their choices, even when it might shorten life, should surely be the most cherished and respected. ‘We have exalted longevity over what makes life worth living’, says Gavin Francis, a GP and writer, in a review of Gawande’s book.
So that is the context to how, I believe, we should consider the future of social care. I will set out some thoughts on the way forward. But we first need to understand how Governments of all complexions have addressed this area of policy and what we can learn from it. We also need to understand the scale of the problem.
The history of the last 20 years suggests a very clear public policy failure.
It started well. Coming into office in 1997, the first Blair Government delivered on a key manifesto commitment by establishing a Royal Commission on the funding of long-term care.
What’s remarkable is that the range of failings the Commission identified in its report hold just as true today as they did almost twenty years ago. I quote directly:
“It is too complex and provides no clarity as to what people can expect. It too often causes people to move into residential care when this might not be the best outcome. Help is available to the poorest but the system leads to the impoverishment of people with moderate assets before they get any help.”
These words could have been written yesterday.
For all its merits, the process of a Royal Commission ultimately failed to resolve these fundamental issues. Its chief recommendation of free personal care on the basis of need divided the Commission, and was rejected by the Labour Government on the grounds that it would carry “a very substantial cost” and “would not necessarily improve services”.
Six years later, a government green paper once again declared that “it is not acceptable to continue to deliver social care in the way we do today”. Further consultations were published during the Labour years – more generous means-testing, a ‘National Care Service’, a two-year cap on paying for social care from 2014, and care free-at-the-point-of-use at some point after 2015.
Whilst Labour had made no progress on reforming the funding of social care, other changes had started to happen. They started the roll-out of personal budgets, a concept which had its origins in the United States with disabled people demanding more control over their care. The right to a personal budget was later enshrined in legislation by the Care Act, 2014.
With the arrival of the Coalition came a new initiative. The Dilnot Commission was established to consider a partnership model for funding social care – between individuals and the state.
The Dilnot report concluded that “the current system is confusing, unfair and unsustainable”. It highlighted that it leaves people “unable to plan ahead to meet their future care needs”. Echoing one of the conclusions of the Royal Commission, it said that “a major problem is that people are unable to protect themselves against very high care costs” in old age.
Dilnot central recommendations: a £35,000 lifetime cap for over 65s and lower caps for those in younger age groups, along with a more generous means-test.
The Care Act, which I took through Parliament, enshrined the three principles of choice, independence and prevention. Promoting the individual’s wellbeing must be at the heart of all decision making by the local authority. And that, for the first time, includes the wellbeing of the carer.
The cap on care costs proposed by Dilnot led to long negotiations within the Coalition. Eventually, the Liberal Democrats negotiated to include a cap within the Care Act. It was initially set as a lifetime cap of £72,000 for everyone over the age of 25 with a more generous means test for support for those who hadn’t reached the cap – set at £118,000. This meant that more people could get a contribution towards the cost of care. All this was due to be implemented in April, 2016.
Within weeks of the election of a Conservative Government in May, 2015, it was announced that the cap would be postponed until 2020 – which left me really furious. So, you can imagine my feelings when we learned last week that the 2020 date has also been abandoned.
Then we had the Conservative General Election Manifesto. The cap had been abandoned and, instead, they proposed to protect just the last £100,000 of assets. Anyone with assets above this level would pay the full cost of care whether in a care home or care at home. There was to be no pooling of risk. This was immediately dubbed a ‘dementia tax’. It led to an embarrassing retreat just a few days later.
The Budget last week failed to even mention social care. Now, the process will start all over again with a Green Paper next summer.
So how bad are things? And how significant is the challenge which lies ahead?
First, it’s worth reflecting on the extraordinary demographic change which has been happening since the late 18th century but which is gathering pace.
In 1982, there were about 600,000 people over the age of 85. By 2007 it had more than doubled to 1.3 million and by 2032 it will be 3.1 million.
In just a 10-year period, the number of people living with 3 or more chronic conditions, will increase by 50%.
And over half of people over the age of 75 live alone. We know that social isolation damages your health and your wellbeing. Loneliness is said to be more damaging to your health than smoking 15 cigarettes a day.
And, whereas in the past, your family would all live on the same street or nearby, now, inadvertently, we have left people stranded as extended families have been dispersed far and wide.
It’s also worth noting that healthy life expectancy at the age of 65 varies enormously depending on where you live and on levels of deprivation. In Tower Hamlets, it is only 6 1/2 years of healthy life to look forward to at the age of 65. Yet just 16 miles away in Richmond it is about 14 1/2 years. Reducing these inequalities must be a clear objective of public policy.
And it’s not just that the numbers of people who need care and support is growing so rapidly. Our ability to fund services to support them also gets more and more difficult, irrespective of where you are on the political spectrum. This is because the ratio of people of working age – who work and pay taxes – compared to people in retirement, is changing. For every 1,000 people of working age, the number in retirement is projected to rise from 305 in mid-2016 to 370 by mid-2041.
By 2065, 26% of the population will be over the age of 65 years old, compared to 18% today. That’s a dramatic shift.
There’s also another significant and growing pressure. Around 300,000 working-age adults rely on the social care system. And for the first time, financial pressures due to the increasing care needs of younger adults with disabilities or mental health problems are greater than those due to supporting older people. Quality of life, control and wellbeing is just as important for all these people. There should be no second-class citizens.
As these trends have been growing, the failure to reform the funding system has been exacerbated by reductions in funding. Social care has always lost out to the NHS even when the money was flowing in the last decade. It rose quite steeply from 2000 to 2005 but then grew at a much slower rate than the NHS.
Since 2010, first under the Coalition, and then under the Conservatives from 2015, cuts to local authority funding has resulted in social care being cut by 8% from a peak in 2009/10 despite demand rising rapidly. Councils are looking to make additional savings of £824 million this year alone. Cutting the preventive end of the spectrum so much hardly seems rational.
This has put the sector under immense pressure – and the impact on those in need of care, some of the most vulnerable in our society, is stark and distressing.
Analysis by Age UK suggests that there are now 1.2 million older people in England, over the age of 65, who do not get the social care they need – no help with eating, dressing and bathing – and the figure is rising.
Then there are the 2.25 million bed days that were lost in the NHS last year due to delayed transfers of care – patients marooned in hospital, with the number of delays attributable to local authority social care rising by 85% over the past two years.
It is one of the clearest examples of how “the complex patchwork of health and social care strains at the seams”, as the CQC recently warned.
Mr and Mrs Goleby in North Norfolk have been waiting almost 5 months now for a care package for Mrs Goleby, who remains in a care home despite being desperate to get back home – a couple who have been married for a very long time, forcibly separated and left in enormous distress. Should they really be faced with this at their time of life?
And as the financial pressure mounts, more and more care providers will go out of business – or will focus on the private care market. Domiciliary care contracts were handed back to 43 councils last year because of insufficient funding to meet care needs, which ADASS estimates has affected more than 3,000 people. More will leave the market as the finances for many simply do not stack up. The risk is greatest in parts of the country where there are fewer people paying privately.
These pressures show no signs of abating, and The King’s Fund, The Nuffield Trust and the Health have warned of a looming £2.5bn annual funding gap in adult social care by the end of the decade.
The way forward
Faced with this dismal landscape, it’s easy to conclude that this is an intractable problem. That would be the wrong conclusion. I will offer 7 proposals.
1) We will not solve this through the normal process of partisan politics. The record is one of total failure. And we need to recognise that the big challenges of today, people living with multiple long term chronic conditions – often a mix of physical and mental health issues – necessarily involves health and care services working closely together.
So, we need to establish a cross party process to develop a sustainable, long term settlement for the NHS and social care. Critically, this has to engage with the public and with staff.
I’ve been making this case since 2010 when I attempted to bring Andy Burnham and Andrew Lansley together.
And just over a week ago I coordinated a letter – together with Sarah Wollaston and Liz Kendall – from 90 MPs from across Parliament calling on the Prime Minister and the Chancellor to embrace a cross party process – an NHS and Care Convention. The discussion should not just be about money. We need to focus on those profound questions I highlighted at the start: how we help people have a fulfilling life and a good death; what responsibility we have to each other; the role of family and the wider community.
2) How we raise the additional resources necessary has to be done in a progressive way, based on ability to pay, but it must also be fair between the generations. Serious consideration should be given to a hypothecated Health and Care Tax perhaps based on a reformed National Insurance system. This could be a top up to other spending or could meet the full cost of the NHS and care.
But reform of NI would be necessary to ensure that people on high earnings above retirement age make a fair contribution. We cannot expect those overstretched in younger adult life starting a family, trying to buy their first home or renting to meet the full burden. And I have just turned 60. Does it really make sense that I get free prescriptions? Kate Barker’s Commission for the King’s Fund suggested a range of ways of raising extra resources. Many of these have merit.
Critically, additional resources for health and care must be used effectively to make the system more efficient and more effective and to shift emphasis to prevention of ill health which would potentially reduce the scale of increase in demand on health services.
3) We need to tackle the irrational and highly damaging divide between health and social care budgets. Too many people fall through the gaps, caught in the crossfire between the NHS and local government. The drive for a pooled budget in Greater Manchester has massive potential to deliver better outcomes for people, making sure that the needs of individuals are not trumped by commissioning silos and organisations passing the buck. So, I favour the introduction of pooled budgets for localities with a single commissioner for local services with some democratic legitimacy – accountable to the community rather than to Whitehall.
We also need to see greater local experimentation, giving regions the freedom to innovate and shape a health and care system that works for local populations. As a liberal, I believe in giving greater autonomy to communities, and I think we should be open to the idea of devolving tax-raising powers to the regions to allow them greater flexibility to innovate and try new things.
4) The Dilnot cap should be implemented. Pooling of risk makes sense and, for it to be sustainable, the partnership model – shared responsibility between the individual and the state – makes sense. It reduces the divide between the free NHS and means-tested social care, which causes such a sense of unfairness.
5) A recent report from Stanford University School of Medicine says that ‘a focus on data in the coming years has the potential to make health care more preventive, predictive and personalised, meaningfully reduce health costs and lead to better patient outcomes.’ The power of data has the potential to transform the future of health and social care. Some estimates suggest a growth in the amount of medical data of 48% every year. Information is becoming easier to collect, analyse and understand, opening the door for major advances in preventive care, quality of care and cost of care. At both the individual and population level, data is helping to prevent ill health, diagnose earlier and treat patients.
One example is the dramatic increase in use of wearable devices which are collecting healthcare data. Globally, there were an estimated 274 million devices sold last year. Fitness bands are the most popular. Data produced can be linked directly to health professionals. We have the ability to track temperature, pain and stress through thermoelectric pulses. The promise of wearables is that they will help us to detect and treat illness at an earlier stage. At present the market is dominated by recreational technology and fitness companies but health and care organisations see the potential to make use of medically robust and relevant data.
We are at a very early stage but remote home monitoring is emerging, although the adoption of technologies in the UK is very slow. Some other European countries are ahead of the game – Norway has developed a national programme to drive the use of technology. In Spain, they are exploring how they can change the incentives to make it worthwhile for providers to invest in technology. They are moving to procurement of a service over a four year period with risk sharing. We need to learn that lesson. At a seminar last week we heard from a tech industry representative who was gloomy about the willingness of the NHS and care services to invest in technology solutions. The point was made that when the Government gets behind a technology, such as electric cars, it makes things happen. The argument was made that we could see dramatic advances in health and care and in the efficient use of resources if the Government similarly got behind assistive technologies in health and care.
The potential here is that we can empower people to take control of their lives, maintain independence for longer and stave off dependency which is so sapping of morale and of purpose.
6) But technology alone is not the answer. Ultimately, human contact, kindness and attention are essential for making life meaningful. As I’ve already mentioned, half of over 75-year old’s live alone. But couples can be lonely too – particularly where someone is caring for a loved one perhaps with dementia. And we can’t simply recreate the extended family all living on the same street. Adult children have careers often hundreds of miles away.
So, it seems to me that we all have to step up to the crease. We surely have a responsibility to each other. On every street, there are people living alone. In Potter Heigham in the Norfolk Broads a group of local people make sure that no one in the village need be lonely. They take people to the doctor or to hospital. They get people out of their homes. They do the shopping. The Community Circles initiative is another brilliant way of bringing people together to make a positive difference to the lives of others.
In Cornwall, one of the integrated care pioneers I identified, as minister, brings together volunteers with GPs and other health workers. Voluntary, public and private sector working together. It was a collaboration between councils, the NHS, Age UK, community services and Volunteer Cornwall. The aim, in part, was to help people have a good life.
One of my great frustrations is that the Pioneer programme was superseded by the Vanguard programme and the national support and promotion moved on. So often, exciting initiatives have their funding cut as crisis management takes over. And, when budgets are tight, it’s always community organisations which lose out first.
Another brilliant example of an approach which uses the power of communities is Shared Lives Plus. Families take people with learning disability or mental ill health into their homes instead of that person ending up in institutional care. They are paid for the care they provide but the cost is a fraction of the cost of institutional care. Within the membership of Shared Lives there are also small community based services which share the values and ethos of Shared Lives. There are 3,500 shared lives carer members and the numbers continue to grow. This is a very different approach which helps put people in control and helps them lead ordinary lives.
7) Finally, we must re-commit to the importance of people being in control of their care and their lives. Although the Care Act enshrined the right to a personal budget in law – and put the wellbeing of the individual at the heart of decision-making, the financial tsunami facing local authorities has undermined this shift of power. Increasingly, people are told that if care would be a bit cheaper in a care home than at home, that’s what the council will pay for. Budgets are constantly trimmed down to the bare basics. Funding for transport is lost, so people are more likely to be stuck at home. I would like to see innovation enabling people to pool their budgets to employ local social enterprises of carers working in their locality. Too many councils still pay lip service to transferring power to citizens. This has to be challenged.
And then at the end of life, we must enable people to die where they want to and for their priorities to be respected. Too many are still trapped in an alien environment of the busy acute hospital. This will necessitate a shift in the financial incentives. We have the ludicrous situation that care is free in the place the person generally least wants to be but not free at home.
To conclude, as chair of the Science and Technology Select Committee, I can definitively confirm that this is not rocket science. It is solvable. At present we let people down horrifically. We waste money. We deny people dignity. Even if we are now only the sixth biggest economy in the world – as the Chancellor admitted last week – we are capable of doing better than this.