LSE-Lancet inquiry is the first major inquiry of its kind to embrace social care and public health too, David Brindle explains why this is significant.
The day after the momentous May elections was probably not the best time to launch the findings of a three-year commission of inquiry into the future of the NHS. But before everyone’s attention was diverted by the results, analysis and fallout, the LSE-Lancet commission did manage to grab the odd headline.
To be sure, the findings warranted it. Over the next 10 years, the commission’s report concluded, health spending should rise by 4% a year every year at a cost of an eye-watering £102bn. The cash should come from an initial 1p increase in all three of income tax, national insurance and VAT, doubling to 2p by 2030. Bold it most certainly was.
But the commission, set up and run jointly by the London School of Economics and The Lancet medical journal, was noteworthy for another reason too. While there has been no shortage of reviews and inquiries into the viability and future of the NHS during its 73-year history – the first set up by the then government in 1953, within just five years of the health service opening its doors – none has previously embraced both public health and social care as this one did.
Pretty much everyone agrees that the only way properly to plan health and care for the nation is to consider the whole system. This has become increasingly evident over the years as we have learned more about the importance of preventative measures, stopping people becoming ill in the first place, and as we all live longer and live often with long-term conditions. Average life expectancy for a man in 1945 was 66 years, just one year above pension age. Today it is almost 80.
Putting this principle into practice has proved quite another thing, however. One reason is the sheer power of the NHS brand and the influence of those who work and lobby for it, especially the hospital sector. Sir Simon Stevens, the outgoing chief executive of NHS England, has to his credit consistently spoken up for public health and social care, but his two great achievements – the NHS Five Year Forward View in 2014 and the NHS Long Term Plan for 10 years from 2019 – tell their own story.
The semi-detached status of both public health and social care is the other reason why they feature only marginally or not at all when the planning push comes to shove. Opinion remains divided on the wisdom of moving public health commissioning in 2013 from the NHS to the arms-length Public Health England and to local government, where it suffered a £531m budget cut over the next seven years. The public inquiry into the handling of the coronavirus pandemic will no doubt hear passionate arguments on both sides.
Social care, meanwhile, continues to struggle to win the reforms and funding it so desperately needs. Undoubtedly that is in part because of its structure – commissioned by councils, delivered largely by independent for-profit and charitable providers – and some say it would fare better within the NHS, or at least constituted as a national care service led from the centre as is proposed in Scotland. Others fear that would lead to it being subsumed into the medical model of care.
It would be an overstatement to say that the LSE-Lancet commission approaches public health and social care with the same detail and rigour it applies to the NHS. In some respects, they appear as supporting cast: as Martin Knapp, LSE professor of health and social care, said at the report launch, while social care’s primary purpose was not to prop up the NHS, ‘improving the way we identify and respond to social care needs has enormous potential to reduce pressure on it’.
But it is nevertheless striking and significant that a report of this stature has at last captured the big picture. Not only that, but it calls for funding increases for both public health and social care on a par with those it wants for the NHS: 4% annually for 10 years for public health including an immediate £3.2bn boost to help make good recent cuts, expand the workforce and prioritise poorer communities; and 4% annually for 10 years for social care including, again, an immediate £3.2bn to improve protection of the most vulnerable people, make the current means test for state support more generous and introduce a cap on personal liability for costs.
Chances of the Johnson government agreeing to such an ambitious menu, and the tax rises suggested to fund it, are poor to non-existent. But public health and social care have for once got on to the same playing field as the NHS – even if it’s not yet a level one.
David Brindle is a care sector commentator and former public services editor of the Guardian. He is chair of Ambient Support.
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