In setting up an independent commission to consider the integration of health and social care, the Labour leader, Ed Miliband, is daring to broach a problem that is overdue for a solution. He is at once stealing a political march on the Coalition – it is hard to imagine David Cameron proposing any new reorganisation of health provision, having just completed a controversial restructuring of the NHS – but also entering a practical minefield he may come to regret. He should not be deterred.
The line of demarcation between health and social care as it exists in most parts of the UK is as complicated and baffling to ordinary citizens as the most intricate national border, and almost as heavily policed. Yet it is a line that many, many people must negotiate almost daily, as they or their relatives need help if they are to continue living in their own homes. Not all those who require such assistance are elderly – they include children and younger people with special needs and chronic conditions. But the majority are, and their numbers are only going to rise, as life expectancy increases.
The institutional separation of health care, which is provided and funded by the NHS, and social care, which is provided and funded for the most part by local authorities, is inefficient and wasteful in almost every way. Functions are duplicated, communication is poor, and there are yawning bureaucratic gaps that those who need help all too easily fall into.
Anyone with multiple needs finds themselves having to deal with half a dozen different agencies. The difficulties often start with a hospital admission. The patient may be ready to be discharged, but will not be able to manage at home without help. At which point a series of tussles ensues – first at the hospital, where the financial pressure is for an early discharge, as hospital care is expensive, but the doctors will not authorise it unless home care is available, and second, between the hospital and the local authority – because neither wants to pay.
The consequence is that people are in hospital for longer than they need to be, or are sent home without the care they need, which all too often turns out to be a false economy because they soon find themselves back in hospital after another emergency. Even where home care is provided, however, the conflicts are not over. Many local authorities have outsourced their home care services to agencies, which do not necessarily talk to each other, and different local authorities set different payment requirements. For while NHS care is free, so-called social care in England and Wales is heavily means-tested – increasingly so, as local authorities try to cut costs. Even those who are not at all well-off find themselves billed for care that is, on the one hand, inadequate, but on the other, essential to their survival.
Given the difficulties that currently attend the transfer from hospital to home care, and the popular dissatisfaction with provision of social care, Mr Miliband might be thought to be knocking at an open door in considering the integration of the two. That he has set up an independent commission, rather than simply announcing integration as Labour policy, however, suggests that he is well aware of the complications. And the biggest – and most threatening – of these is institutional protectionism.
Here are two huge public spending streams and two huge bureaucracies that will fight tooth and nail to defend their interests. Mr Miliband is to be commended for wanting to tackle the issue, and he is right to be soliciting advice on how to do it. If he is to succeed, however, he will need to appeal over the heads of the vested interests to those who rely on the services, and gird himself for an exceptionally tough fight.