Yesterday our Into the Red? report revealed worrying signs about the future funding of the NHS in England. This was echoed in the results of our first survey of leading figures from the field of health and social care, with around half of respondents saying they felt it was unlikely that the NHS would be free at the point of use in ten years’ time.
But the NHS is only half the picture. Our survey – and the make-up of our panel – reflects the reality that it is no longer possible to talk about health and social care in isolation. One strong theme from the survey we conducted was that the social care system is under great strain. And this is having an impact on the NHS.
In 2010, faced with an unsustainable level of public spending, the Coalition Government gambled that it would be safe to maintain ‘steady’ funding for the NHS alongside deep cuts to other government departments.
The assumption has been that efficiencies and savings could be found in both the NHS and social services to offset rising demand and that the financial pressure would encourage new ways of working. It is the classic ‘burning platform’ incentive for change.
It’s like trying to get a picture of a whole room by squinting through a very small keyhole
The tragedy of this has been that until now, the effects of budget cuts in adult social care have been largely invisible to the system. The NHS does not routinely collect data on users of social care, or whether someone is a carer and certainly has no way of identifying the thousands of people who might once have received state support and are now no longer eligible.
Only small parts of the NHS-social care interface are visible, notably the data collected about delayed transfers of care. It’s like trying to get a picture of a whole room by squinting through a very small keyhole.
The NHS as a whole has no way of knowing whether an elderly, confused, dehydrated patient arriving in A&E with a urinary tract infection was the result of gaps in social care, either state or self funded.
Was it the result of rushed care from an underpaid care worker or an exhausted spouse or family member at the end of their tether, too stressed to spend the time giving drinks, sip by sip, to an elderly person? Or was this an unavoidable medical emergency arising from the complications of frailty and/or long term conditions, that couldn’t be resolved by even by the best GP or district nurse?
What seems clear from the survey is that there is a growing confidence about the cause of growing pressures in A&E and in acute hospitals: social care services “are on the verge of collapse” in the words of one respondent. And it’s going to get worse: “massive cuts are still coming our way” wrote another.
Although there were signs of optimism amongst many of our respondents that more efficiencies and better care were still within their grasp, usually from more integrated, streamlined services, a few were doubtful: “On good days I am v (sic) excited about the potential of the burning platform to really shift the system, but I do wonder how badly burnt we have to be before we jump”.
There’s no question that there is a lot of energy going into thinking up new solutions to avert this crisis: the integrated care pioneers and some of the plans likely to emerge from the Better Care Fund show that not only are many in the NHS and social care determined to work together, but that solutions will also require sustained input from the voluntary sector, particularly if they can mobilise the work from volunteers.
Volunteers might just be the only part of the sector able to step into the gaps left by social care cuts and the change in family structures that have resulted in so many older people fending for themselves. But there’s only the slenderest of evidence that all these initiatives will result in measurable reductions on emergency admissions in the short run.
The next nine months will see more and more comment and headlines devoted to the impending collision between the needs of older patients and the consequences of brutal cost savings in social care and parts of the NHS, particularly as winter approaches. Which makes even more poignant the lone voice that stood out in the health leaders survey, drawing attention to an unintended consequence of all this: the crowding out of services to other age groups.
One wrote “I am exceptionally worried about access to child and adolescent mental health services, particularly for children and young people in crisis”. Those providing services for other groups will need to have very loud voices too over the next few months.
Thorlby R (2014) ‘Only half the picture: understanding the impact of the social care squeeze’. Nuffield Trust comment, 11 July 2014. https://www.nuffieldtrust.org.uk/news-item/only-half-the-picture-understanding-the-impact-of-the-social-care-squeeze