The future funding of health and social care in England

Abstract

These are embarrassing times for baby boomers. As beneficiaries of the Attlee settlement, we have enjoyed affordable health care, decent housing, free higher education and a generous welfare state. Notoriously, these are blessings that could be denied the next generation. The NHS is facing yet another funding crisis and social care is under increasing strain. The confusing border between the two has long been a source of administrative waste and frustration for users. Patterns of ill health, life expectancy, family structures, and medical technologies have changed considerably since 1948 when Beveridge and Bevan established the current system. A King's Fund commission, chaired by the economist Kate Barker, proposes a new settlement fit for today's circumstances. 2 An interim report used five criteria to assess future options: equity, transparency, efficiency, the split between collective and individual responsibility, and affordability. 3 The evidence suggests that the present arrangements fail on all of these criteria. systeMic failingsThe contrast between a health service free at the point of use and a social care service that is means tested and publicly funded only for those with heavy needs, means that the type of ailment you have determines the financial support you receive. Compare the personal cost consequences to our patients of developing cancer or dementia. The outcome of this 'lottery' is inequitable; similar needs do not receive equal treatment.The current lack of funding for social care is little understood by the public; greater transparency is badly needed. Sir Andrew Dilnot's proposed reforms to the funding of social care, due to be implemented in 2017, are a step forward. 4 The higher threshold for the means test will allow people to keep £118 000 of assets, rather than the current £23 250, and still receive local authority funding. Above that, however, those who can will still have to meet the first £72 000 of the cost of their social care. Efficiency is hampered by a lack of organisational integration, health is run by the NHS and social care by local authorities, with the two commissioned separately. While the NHS is often perceived as monolithic and unchanging, there have been a number of shifts in the boundary between public and private funding in the post-war period. In general, these have restricted free access to social care and increased private payment for health care. Large amounts of Continuing Healthcare have been moved out of the NHS. More social care is now provided by unpaid carers. unification is PossiBleThe commission proposes moving towards one ring-fenced budget for health and social care, with a single commissioner and within which entitlements are much more closely aligned. Bringing the Attendance Allowance into this budget would create a more graduated pathway of support. The key issue is that of affordability.Many believe that the health costs of the rising number of older people are simply unaffordable. In fact, it is largely advances in medical knowledge and technology...

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