Statesman or Medicine Man?
Watching the Statement in the Commons Chamber about the long-awaited reform to social care, one was bound to be reminded of Dulcamara (the “Dr. Encyclopedia” in Donizetti’s L’ Elisir d’Amore), selling his cure-all to the local populace. Of course his elixir was rubbish but his salesmanship did the trick. He convinced them it needed enough time to take effect for him to make a safe escape. In the event, things worked out, no thanks to Dulcamara, but that did not stop him taking the credit. The opera buffa was first staged 89 years ago but only the dramatis personae have changed.
The plan for such a major topic as social care which has been in the “too difficult” tray for so long should have been given time for critical analysis when presented. A statesman, knowing we would have to live with the outcome for the following decades, would want to ensure it is the best it can be. He would want opposition parties to propose improvements before settling on the least bad solution. Instead, we have a social care strategy raced through the Commons faster than it can be analysed and faster than any opposition improvements can be considered. Sir Norman Lamb long called for consensus and the Prime Minister endorsed that last year but another commitment has been shredded.
Of course, one has to remember that Dulcamara –– I mean the Prime Minister –– was trained in rhetoric where numbers are used to give verisimilitude to an otherwise bald and unconvincing narrative. 2 + 2 = any number that looks impressive. In the Chamber on 8th September Mr Johnson referred to the “50 million more GP appointments that are already in our plan.” What Matt Hancock actually announced in October 2019 was “50 million more appointments in GP surgeries”, i.e. appointments with whatever staff happened to be in that day. If you appoint enough non-GP staff, the latter might be possible at some future date. The Prime Minister’s claim, however, implies a 50% increase in (full time equivalent) GPs when they have been in steady decline and new GPs take 10 years to produce. The total number of GPs may have increased somewhat but so many are part-time, notably the women, and so many now work from home, that face-to-face GP appointments are becoming a rarity.
Then he told us that 30,000 hospital beds would be freed up by his reforms of social care: “that is 30,000 out of 100,000 hospital beds in our NHS, costing billions.” There were two problems with that: NHS England has, at the last count, 141,000 beds not 100,000, and there was no explanation of how the reduction would be achieved. In fact in all his long sales pitch, there was no mention of any reforms to social care at all, whether for the elderly or those of working age. There was nothing about increasing remuneration, working conditions, the status of carers to parity with nurses or the disconnect between the department nominally responsible, the local authorities that actually have charge of it, and the Ministry of Housing that messes up the funding. Hypothecation is feasible for the NHS but not for social care.
The Prime Minister did pick up the Matt Hancock/Simon Stevens scheme that the NHS should, in effect, take charge of social care “by integrating health and care in England so that older people and disabled people are cared for better, with dignity and in the right setting.” That is cloud cuckoo-land. In practice, ICS means a huge number of committees depriving GPs of the time they need to see patients. The evidence from the 13 pilot ICS projects is, unsurprisingly, negative: “there is no evidence, across either West Yorkshire or the 13 pilot areas more broadly, of the sort of large-scale improvements the ICS reforms are supposed to bring.”
In short, Dr Dulcamara’s social care proposals focus on how much moolah the customers should hand over, not on, specifically, what they will get for their money nor how that will be better than the existing provision. 19th century medicine men were ever thus. It is even hard to disentangle how much money social care will get nor how that will divide between the elderly and those of working age – roughly 50-50 at present.
The government has long been fiddling about with ad hoc social care grants – there have been about ten in the last five years. With that ad hockery and the byzantine funding of local authorities by the Ministry of Housing, the contributions from the NHS (essentially to pay local authorities to take bed blockers off their hands) and the variety of expenditures by the local authorities themselves, it is well nigh impossible to know the total cost to the public purse now, still less what it should be. The House of Commons library estimated “total public spending on adult social care was around £18 billion in 2018-19.” In October 2020, the Health and Social Care Select Committee reckoned that £3.9 billion p.a. should be added to that.
On that arithmetic, the £12 billion p.a. from the levy should be divided two thirds/one third to NHS/social care. Although unspecified, it seems that social care will not be getting a sniff of that.
Towards the end of his time at the Dispatch Box, the Prime Minister mocked the opposition for having no alternative plan but by that time he too had provided no social care plan albeit with one notable exception: “we are investing in 700,000 training places for people in social care; and we are making sure that we invest £500 million………in the social care workforce.” But even there one has to wonder whether the figures are not just decorative.
An October 2020 report found “that 7.3% of the roles in adult social care were vacant in 2019/20, equal to approximately 112,000 vacancies at any one time. Around a quarter of the workforce (24%) were on a zero-hours contract (375,000 jobs).” Is it really likely, at a time when nationwide we have more unfilled vacancies than unemployment, 700,000 people will be hammering on the doors to be trained as carers?
A statesman would draw on the wisdom of all parties and give a plan oxygen and the time to breathe it; a medicine man would try to take the money and run.