I’ll be honest: it was a slightly intimidating experience initially. The sheer weight of intelligence and experience in the room was something to behold, from senior NHS directors and media figures to the heads of numerous NGOs, thinktanks and specialist organisations. It was a room full to the brim with big names and heavy hitters; the only notable absentees were the major political parties, at least on the Commons side of things.
It immediately became clear why this was the case, on both counts. As Dame Kate Barker outlined the core recommendations of the report, I was struck by how bold and ambitious they were; surely the sort of thing which demands high-level attention and debate, but which could also give your average Whitehall spin doctor the odd heart palpitation.
The Commission’s central argument is that the division between health and social care, as devised in 1948, is now utterly unfit for purpose in the 21st century. It’s failed to keep pace with demographic and medical change, it’s unfair and overly bureaucratic, designed around institutions rather than people. Most importantly, it’s responsible for heaping unnecessary confusion on vulnerable patients (and their families) who have to navigate the complex landscape of funding criteria without adequate support.
In particular, we heard from Becky Huxtable, one of the Commission’s Experts by Experience. Becky’s family faced hideous difficulties in trying to provide effective care for her father’s dementia, repeatedly falling into the gaps between the NHS, private social care providers and local authorities, all caused by a disjointed and divisive funding system.
According to the Commission, that system should be abolished, and replaced with a single ringfenced budget under the responsibility of a single commissioner, covering both health and social care. Creating a simpler and fairer pathway for patients would, at a stroke, allow for better and more easily-targeted care, without any overall increase in cost.
What’s not to like about this? A patient-centred approach, cutting through a convoluted and long out-dated bureaucracy, reducing the burden on patients, health practitioners and carers: it’s a radical move, for sure, but the hugely compelling arguments in favour of it make it something of a slam dunk. As far as I could tell, the only controversial question was why someone hadn’t done it already.
Going beyond the proposal of a combined budget, the report also addresses broader questions of how to fund ongoing care. It argues that care defined as ‘critical’ should become free at the point of use, regardless of whether it’s currently defined as health or social in nature. Eventually, care for those with ‘substantial’ needs should also be centrally-funded, and means-tested for those with ‘moderate’ needs by 2025.
Such a system needs to be paid for, of course, and it’s here that thornier issues of political expediency and public perception rear their heads.
The Commission has several suggestions for meeting these increased costs. Some, such as the efficiencies created by merging health and social care budgets, or means-testing free TV licenses, strike me as relatively uncontroversial. Others are markedly more ambitious: an end to National Insurance exemptions for those over the state pension age, for instance, or increased NI contributions from those over 40.
Suddenly, the lack of politicians in the room made more sense. This is exceptionally contentious stuff: while the huge reward of better ongoing care is there for the taking, there are also colossal risks involved.
Steve Richards, the columnist and broadcaster, summed up the challenge in pithy and incisive style. “We’re onto something big here” he said, but with an imminent election, and the inevitable trench warfare over each party’s tax-and-spend policies, the likelihood of increased taxes on the baby boomer generation is zero. “You’ve got to remember” said Richards, “these people vote”.
This, for me is the central question over what happens next with the Commission’s recommendations. There is a powerful moral argument that those who will benefit first from improved care should expect to contribute more upfront through taxation. And yet, how can we sell that message to the electorate, or the politicians with their eyes on next May, let alone to the Daily Mail?
Of course, the BGS and its members have a crucial role to play here. As experts in the care of older people, who are a key audience for the Barker Commission’s recommendations now and will be the most widely-affected group should they be put into practise in future, we have a duty to speak up forcibly for the interests of our patients, even in the face of political reluctance.
The changes envisaged here are bold, but they are driven by demographic challenges which are not going away. Increasingly complex and demanding levels of care will need to be provided, and paid for, one way or another. We should not shy away from ambitious and inventive proposals such as those proposed by the Barker Commission, or those launched yesterday by the Burstow Commission on Residental Care.
Several attendees noted, in the Q&A session which ended this morning’s launch, that the question is no longer whether or not these changes are needed, but how they can be realised. As geriatricians, we will need to sell these bold, imaginative proposals to the people we work with and treat, as well as to our nervous and self-interested friends in Westminster and Fleet Street.
So then, Jeremy Hunt, Andy Burnham, Paul Dacre et al: what’s it to be?