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Do YOU think the NHS should take over social care?

Do YOU think the NHS should take over social care?

🕔29.Oct 2018

It’s maybe not up there with the flat-earthers, John Lennon’s “We’re bigger than Jesus”, or even “I was watching Roger Federer on the box, and I reckon his backhand’s going”. But heresy it was and, in the world of English local government, a biggie, writes Chris Game. 

The setting was the recent annual SOLACE conference (Society of Local Authority Chief Executives and Senior Managers) in Brighton, and, speaking at a fringe session, Birmingham City Council Chief Executive, Dawn Baxendale, addressed the inbuilt difficulty of trying to integrate NHS-run health services with council-run social care services.

The manifest tension in the relationship has frequently been touched on in these columns over the years – recently as bubbling away on the fringes of the Conservatives’ Birmingham Conference, last winter in the context of bed-blocking fines and DToCs – Delayed Transfers of Care.

Ms Baxendale naturally drew on her own extensive senior management experience, but spoke also as a daughter who had experienced the shortfalls of integration in caring for her recently deceased mother.

I’m just coming to the conclusion we have a David and Goliath situation between health services and social care. I don’t think David is going to win in this situation. Because of where the NHS sits in the national psyche, should it be one system? Should we be running social care at all?

(my emphasis)

Without highlighting directly the chasm between Theresa May’s £20 billion a year ‘70th birthday present’ to the NHS, however fanciful, and the £240 million winter ‘sticking plaster’ funding for social care, Ms Baxendale called for a debate about the sector’s status because there is simply “not enough money” in the system.

But it was a debate in which she’d already revealed her own hand and, hardly surprisingly, there were plenty in the audience both surprised and instinctively opposed to the very idea of elected and accountable local government handing over such a core and cherished service to the notoriously unaccountable NHS.

Personally, when I first saw the Local Government Chronicle’s headline, I thought immediately of Jim Hacker in ‘Yes, Prime Minister’ and his own brilliant idea for a carbon tax. As Sir Humphrey had to explain, the media would praise it as a really courageous decision – a “controversial” decision being one that will merely cost you votes, while a The debate’s on: Do YOU think the NHS should take over social care?“courageous” one will lose you the election. But then chief executives don’t fight elections, do they.

Still, Ms Baxendale’s contribution was courageous, not least because it virtually coincided with a key full-conference speech by Melanie Dawes, Permanent Secretary of the Ministry of Housing, Communities & Local Government, that touched on the same topic.

Ms Dawes obviously wasn’t going to thrill to the idea of losing a significant slice of her MHCLG empire to a Whitehall rival, but she didn’t have much hard cash to offer either.

She referred to the PM’s birthday gift – with a prediction so widely anticipated that it couldn’t conceivably qualify as a Budget leak:

In relation to the extra £20 billion for the NHS, I don’t think we can expect money from that to be given to social care. We need money for social care separately.

As to where that money might come from, just cross your fingers for next year’s comprehensive spending review.

Meanwhile, her audience could help by providing her with evidence of “really serious short-term pressures on the local government system” [over and above, presumably, all the evidence shown on a daily basis over the past few years], so that she can better make the case to other departments that they should ensure councils are placed on a sustainable footing.

It sounded like a real admission of just how weak a player the MHCLG is – and is seen as being – in Whitehall politics. Ms Dawes reiterated the Government’s plan to fund councils through a greater share of business rates retention – a plan with formidable implementation difficulties – and then was asked about lifting council tax increase limits.

Resorting to the formula of any cornered podium speaker, Ms Dawes reckoned that, while it’s “difficult” to ask residents to pay more tax [than the current 4.4% that doesn’t go straight to central government – see pie chart], “we are very much up for that conversation”, but it was sufficient to give the Local Government Chronicle its headline, and apparently encourage some of the audience.

I could stop there (as the Ed. would probably prefer), were it not for the light shone on some of the issues underpinning this central-local debate by the almost simultaneous appearance of an important and insightful publication that merits our attention in its own right.

Not a government publication; in fact, the very reverse. One launched to attempt to do some of central government’s job that it was demonstrably not doing itself – namely, monitoring systematically its own policy performance. I refer to the third, and biggest yet, edition of the Institute for Government’s Performance Tracker.

The IfG is an independent think tank, founded ten years ago specifically to improve government effectiveness. It quite quickly discovered, or confirmed, that what hugely dominates ministers’ attention – and to an extent, therefore, that of civil servants – is the taking of decisions, while the monitoring of those decisions’ financial impacts and policy outcomes becomes a secondary, even incidental, concern.

The Performance Tracker, therefore, attempts to do “something government should do – but does not: to look at the money that goes into public services and their performance”. What’s more, it almost certainly does it better than civil servants would, turning in this edition 150+ data sets into clear and compellingly readable graphs, tables and commentary.

This month’s report focuses on nine major service areas, and for each seeks to answer three big questions about both the past and future – as shown in the striking traffic-light table of green, yellow and red boxes.

Potentially 54 answers, though in ten cases the researchers couldn’t find sufficient national-level data even to attempt one. Of the remaining 44, nearly a quarter (10) are green, which could sound encouraging, until you see that seven of the ten green boxes are in the efficiencies row.

To which the response must surely be: set aside quality, how is it even possible NOT to deliver lower cost services in real terms after eight years of taking literally billions of pounds out in staffing pay caps and freezes?

The IfG’s conclusion here, therefore, is that, public sector productivity has risen since 2010 – though sometimes with reduced quality and mainly by doing ‘more of the same’, rather than through significant reforms.

Genuine productivity reforms – telephone consultations with GPs, digitizing criminal court procedures – are acknowledged, but as exceptions.  Nor, the IfS suggests, is the recent modest easing of the pay cap likely to end the critical staff workload, recruitment and retention problems in schools, hospitals, prisons, adult and children’s social care.

And that qualified productivity assessment is about the best bit of the IfG’s tracking verdict. Three services are identified as causing exceptional concerns: prisons – far too dire even to condense here – and adult social care, each with six red boxes, plus ‘neighbourhood services’, which here unhelpfully lumps together transport, housing, cultural, regulatory and planning services.

As local responsibilities, and with adult and children’s care somewhat protected, it is these services that have suffered the severest real-terms spending cuts of all – from waste collection (20%), through food safety (25%), road maintenance (29%) to libraries (nearly 40%).  With more national-level data, there would surely have been more red boxes covering both past and future.

‘Crowding out’ is the term the IfG trackers use for what adult and children’s social services, with their statutory base, high costs and increasing demand, are doing for local spending on these ‘neighbourhood’ services – just as health care is crowding out other public service spending nationally.

Radical tax and funding reform is the obvious long-run requirement, but, to quote John Maynard Keynes, in the long run, in or out of the EU, we’re all dead. And that situation, I suggest, is what prompted Dawn Baxendale’s thought-provoking contribution to last week’s SOLACE conference

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