JimKenCareKnowledge editor Jim Kennedy looks at proposals put forward by the Commission on the Future of Health and Social Care in England, and examines how they will impact the two services

The final report of the Commission on the Future of Health and Social Care in England has just been published. The Commission, established by but independent of The King’s Fund, recommends radical change to address the problems facing the system. 

The Commission’s report is a weighty one, but it is likely to be one of many that will seek to influence government thinking on this most thorny of issues and its impact on policy will only be fully seen after the next election.

The Commission’s report is thoroughly researched, and benefits from having an influential cast-list of members who led the work. It makes strong and radical proposals for real change. It seems to have a unifying concept to its thinking. It goes where Dilnot did not, and deals with the funding consequences of the wider reforms it says are needed. It seems to have good arguments about how these could be delivered without breaking the piggy-bank.

But, these debates have been going on for 20 years. I have seen countless analyses, and endless heavyweight reports put forward cogent arguments and well-thought-through proposals, but every single one – that sought an overall solution to the health and social care system’s problems – has turned to dust. Will the Commission’s report be any different?

In short, the Commission proposes:

  • Moving to a single, ring-fenced budget for the NHS and social care, with a single commissioner for local services, supporting a much simpler path through the whole system of health and social care which would be designed to reflect changing levels of need
  • The creation of a new care and support allowance which would offer choice and control to people with low to moderate needs –  while at the highest levels of need the battlelines between who pays for care would be removed>
  • A focus on more equal support for equal need, which in the long term would mean making much more social care free at the point of use

The commission largely rejects new NHS charges and private insurance options in favour of public funding and proposes funding changes, including changes to National Insurance contributions, to meet the additional £5 billion that would be required to improve social care entitlements. It also recommends a comprehensive review of various forms of wealth taxation to generate the additional resources that will be needed for health and social care in future years.

It flies in the face of the known, macro-economic stance of some of the major political parties. It demands a complete re-think of the state’s commitment to health and care. It needs leadership, and Beveridge/Bevan-like tenacity in driving the ideas, and the difficult tax-and-spend decisions, forward. If someone can spot where that will come from, please let us know.

And, as a final point, I think there’s one issue that really highlights the need for the kind of risk-taking initiative that saw the post-war settlement achieved, and that is the way in which the Commission addresses the issue of who should be the ‘single local commissioner.’ 

Here it simply says that the potential role of health and wellbeing boards should be fully investigated; but otherwise says “a sterile debate should be avoided over whether health should take over the commissioning of social care or whether local authorities should commission the NHS.”

That’s not a sterile debate, that’s one of the most central issues about how a national system can best be tuned to deliver against local needs, and carry local accountability. It is long past time for politicians to grasp this particular nettle, face up to the real dilemmas it poses, and come down on one side of the fence or the other – or bring in a wholly new joint local architecture dedicated to running the integrated system.