Sajid Javid called the Health and Care Act the most significant change to the system in a decade. How significant do you feel the Health and Care Act really is?
I certainly agree it is the most significant change in the last decade. It could be hugely important as it ends the era of competition, makes it much easier for areas to collaborate – across local government, the NHS and social care – but it is more ‘enabling’. You can’t force people to collaborate. You can’t legislate for people to work well together. So the Act creates a legislative statutory structure that should make it easier to get better integrated care, to get better health and social care together but the devil is going to be in the implementation. How is this done? It is unfortunately possible in two years’ time we will look back and think “Oh well it turned out that it was old wine in your bottles”. It is still all to play for.
So do you agree with Sajid Javid that it will put the health and social care system in the strongest possible position to recover and rebuild from the pandemic?
Yes but in a very limited way, and that’s because I’m not sure there is that much legislation can do to help with recovery from the pandemic. We are in it now. Legislation by its nature is slow and processed, and the bill isn’t enacted in the most important way until July.
As far as legislation can do anything, it is creating that structure. But you have to remember it is also disruptive, so if you want to focus on recovery there is a credible view we should just let people focus on that, and not start moving the deckchairs about. That’s true, there’s never a good time for a change. But I think we have to recognise that it will always cause a degree of disruption.
But really thinking about recovery we need to ask is there enough money and is there the workforce? That is not a zone for legislation. So while I agree to a certain extent with Sajid, the real action on recovery is not on the floor at the House of Commons. It is in budget setting, staffing and, critically, asking ‘has social care got the money and the staff that it needs?’
Are there any measures in the final act that you feel should have been there? For example, the workforce planning amendment the Lords wanted introduced?
The workforce one is one of the big ones. Workforce planning both in health and social care, to be honest for the last decade, has been either non-existent or done behind closed doors and never sees the light of day. We strongly agreed with the Lords and with Jeremy Hunt, and indeed we worked with other organisations to brief parliamentarians and help shape the proposed amendment.
Workforce planning isn’t a magic bullet, but at least it might force the government into confronting what is the big issue facing recovery, and indeed facing any ambitions for health and social care. I think the dark hand of the Treasury, mistakenly, led the government to reject that amendment, feeling that it binds their hands on future spending, even though future spending forecasts are already in the OBR numbers. The workforce crisis is the Achilles heel of the sector, so that was very unfortunate.
We also wanted the care cap amendment to be withdrawn. The government is very clear about its levelling up ambitions and fairness, and their amendment on the care cap means it is much less fair. More of the burden falls on people with small to moderate assets. That just felt to be inconsistent with their stated objectives.
Therefore the care cap amendment should have been taken out and council funding and local government funding should have been included, even though the government claims the amendment will save £900m?
Yes. It seems to have been something that was negotiated at a fairly late stage. It surprised many of the people that worked on the care cap, I suspect. It was a piece of arm wrestling on making a few more savings rather late at night between the Department of Health and the Treasury. They said it saves £900 million, which sounds like a lot of money but £900 million in a few years’ time won’t break the bank.
£900 million could have been found in other ways. But £900 million off of people with low to moderate assets is a lot of money. To them it really will sting. It just felt to be something of an own goal. If you did need to save the money, save it in some other way, not off people that you really wanted to help. So we did support the Lords and for a while, there was a hope that the government might move but that wasn’t the case in the end.
In the King’s Fund’s recent discussion looking at what's in store for health and care in 2022, Sally Warren outlined her optimism for the role of local government in the ICSs and local level decision making in general. Do you share her optimism?
I am optimistic, but it might take longer to show up in terms of real action on the ground. The biggest complication is that it relies on developing relationships and governance agreements.
This won’t happen overnight, and it won’t solve the immediate recruitment crisis in domiciliary care. In two or three years’ time if health and social care work closer together they might be able to find common ways that might improve workforce retention and recruitment but that is going to take a while to develop.
In some parts of the country older conflicts and older styles of more distant working will remain, because you can’t legislate people to work together. But in others the relationship is already better and this will really help make life easier.
Coming out of COVID some of the cooperation between the NHS, local government and social care in some parts of the country went forward leaps and bounds. What you hope is this can now be cemented in so it becomes something that becomes routine.
At the start of his premiership Boris Johnson spoke of fixing the social care crisis. Do you think these recent policy efforts indicate a willingness to fix this crisis in social care once and for all, or is it all a bit of a smoke screen?
Successive administrations - Conservative, Coalition, and Labour - in England have failed to grasp the long term offer on social care. The care cap, whether you like it or not, is a genuine attempt to implement this offer, and they have done it when all before it have failed.
These long term structural changes… are just not targeting those issues
Where they slip is if you ask local government and social care at the moment what really matters, they will say vacancies and workforce shortages, and these long-term structural changes that the government is implementing are just not targeting those issues. For those you need to ask, ‘what is the funding offer now and how are you going to help social care providers, local government and the NHS overcome the workforce crisis?’
Without answering that question, you have an answer to the longer term challenges facing health and social care, but very little about what is going to happen now.
For a government facing an election in a couple of years it is a slightly odd thing to have done. Governments have tended to do short term patches of social care; this government tried to provide the long term solution but hasn’t got much of an answer for the short term.