A whole systems approach to solving the health and social care crisis

The Health and Social Care Bill currently in the House of Lords is intended to:

  1. sort out the under-funding of social care;
  2. remove the need for people to sell their houses to pay for their care;
  3. promote joined-up service delivery;
  4. replace the competitive model with a collaborative one.

Sadly, as I wrote here, it appears to be a quick fix component level response to a whole systems problem which will simply “kick the problem on for a few more years”. There is little point putting more and more money into the first aid camp at the bottom of the cliff without building a fence at the top.

The cap on the amount which can be spent on care home fees will favour the rich in that people who do not have sufficient savings will still have to sell their house to pay for their care.

The “Integrated Care Systems” and “Integrated Care Partnerships” will be very costly and appear more concerned with preserving:

  • the current configuration of local authorities and NHS Trusts, and;
  • the purchaser / provider split and commissioning;

than they do the provision of integrated care.

Successive Governments have tried to get health, social services, police, education and housing to work together, but none has grasped the nettle of different geographical areas, different funding streams and different lines of accountability, which have been the main impediments.

Since the 1990 National Health Service and Community Care Act the “contract culture” has led to:

  1. a “minding” rather than a “mending” service with social workers increasingly used to assess the eligibility to specific services rather than using relationship and therapeutic counselling to resolve problems;
  2. further fragmentation with different components of a “package of care” bought from different providers, and;
  3. “self-funders” (a dreadful term) being waived away denying them an “independent verification of their wishes” and their families the help and support they need.

There is a wealth of empirical evidence on the “social determinates of health” which have demonstrated the correlation between income and demand upon the NHS.

At just £7,430 (£9,698 with pension credit) Britain has one of the lowest State Pensions in the western world. The national living wage is £18,278 and average earnings £30,212. The definition of poverty is less than 60% of median household income.

There are two million older people living in poverty in Britain – many of whom, prior to the abolition of the “default” retirement age in 2012, were forced into retirement and condemned to spending the rest of their lives in poverty. As they retired before 2016 they are not entitled to the new State Pension. Rising food and fuel prices, being essential items, will hit the poor disproportionately.

Occupational pensions have been eroded and savings not kept pace with inflation.

80% of the expenditure of the NHS is on older people. The Netherlands with the highest state pension in Europe spends 60% of its health budget on older people.

An estimated 1.3million older people suffer from malnutrition costing the NHS £19.6billion per year. There are five main causes of malnutrition: lack of money; lack of motivation; incapacity; lack of support and social isolation. Therefore, if by increasing the state pension to lift older people out of poverty, together with the other changes, were to reduce malnutrition by 90% it would save £17.85billion. Given the correlation between income and demand upon the NHS there could be a further reduction in demand of between 10% and 15%.

What might the outcome have been had the Government used the £57.5b, it has already committed to health and social care, differently to pump prime radical reform based upon a “whole systems review” by:

  1. raising the State Pension to 60% of average earnings (3.8m older people live alone) or £18,127, which would still be lower than much of Europe and slightly less than the “living wage” to lift all older people out of poverty. There would be savings on pension credit (which only had a 60% take up), housing benefit (there would need to be some provision for the higher rents of London and the South-East – possibly with the addition of regional housing allowances), and the winter fuel allowance. And a minimum of 20% of this increased pension would be clawed back from people with other income through taxation.
  2. bringing all services together, on the old County Council areas, in-order to achieve shared geographical areas, funding streams and lines of accountability – returning health and police to local democratic scrutiny within central government direction and taking out a tier of local government, making collaboration easier and saving millions on management with greater public accountability.
  3. removing the purchaser / provider split and discontinuing specialist commissioning and replacing them with a statutory, voluntary, private sector partnership.
  4. Freeing up social workers to practice their skills in using relationship and various therapeutic techniques to resolve problems.
  5. making other requisite organisational, leadership and cultural change to:
    1. liberate professionals and organisations working directly with people from the “straight jacket” of the “contract culture” enabling them to respond in situ to changing need, innovate and develop;
    2. remove functional divisions along patient / client pathways by the creation of “whole task, right sized multidisciplinary teams” able to “plan, do and evaluate” their own work which completes the learning cycle of constant improvement;
    3. change from a “constraining management culture” to an “enabling leadership culture”, and;
    4. agree a strategy with the Trades Unions to end the use of agency staff to save money and ensure greater continuity of care.
  1. work with Housing Associations and the Private Sector to develop extra-care sheltered housing with nomination rights and a base for the “multi-disciplinary teams”
  2. ensure that all older people have a “verification of wishes” before being admitted to a care home;
  3. extend NI to all working people (as Government intend) with the State Pension only paid on retirement with phased arrangements – ie one day’s work – 4/5th
  4. the higher state pension would mean that people who do need long term care could pay more by handing over their income, less their personal allowance, up to the cost of the home as they do now and remove the need to take capital (savings or house) into account;

A more detailed costed article was published in the Municipal Journal on the 21st December which confirms that after initial up front pump priming this would be achievable at less cost than Government has already committed to health and social care. A win win.


* Chris Perry is a former Director of Social Services of South Glamorgan County Council, a former Non-Executive Director of Winchester & Eastleigh Healthcare NHS Trust and a former Director of Age Concern Hampshire.