It is time to bring social care spending in from the cold

First things first. Let us congratulate all those who worked so hard to help the NHS perform well over Christmas and the new year. The service’s aggregate performance on the four hour accident and emergency target was better than in the last two years.

‘The local authority social services, which the NHS relies on to facilitate discharge, are reeling from huge cuts and face more’

Yes, demand was lower, attention was focused on that metric and some struggling trusts received cash injections. But the scrutiny was intense and many in the media had inked in an A&E crisis story for the quiet news week between Christmas and 1 January.

Heart of England Foundation Trust chief executive Mark Newbold pays tribute to that hard work, but writes powerfully of the price the service is paying for that performance.

Dr Newbold was one of the chief executives to receive a “helpful” phone call from the health secretary on the subject of A&E performance and he despairs of a “short term” approach that seeks to tackle the problem through “pressuring acute hospitals to do better”.

Out the back door

It was ever thus, but the matter is now developing real economic and political urgency.

The issue of patient flow is a top priority for the majority of acute trusts. Dealing with demand at the hospital “front door” will take many years as it requires both a cultural re-education of the public, as well as the development of alternative primary care services that largely lie in the control of GPs − who as independent contractors to the NHS will negotiate hard before taking on extra responsibility.

‘More cash for the NHS might simply leave it building bigger care warehouses for vulnerable older people’

So the focus is understandably on the “back door” and safely discharging patients as quickly as possible. It is here the NHS runs smack into the “austerity Britain” it has been relatively protected from. The local authority social services, which the NHS relies on to facilitate discharge, especially of the frail elderly, are reeling from huge cuts and face more to come.

Yet attempts to alleviate the situation through initiatives such as the introduction of the “better care fund” results in the NHS − from David’s Nicholson, Bennett and Flory down − rocking with dire warnings about the impact on hospital services.

Funding step-change

This concern is not misplaced, the NHS has little spare cash. Most credible examinations conclude England spends less of its GDP on the NHS than the majority of Western countries with successful healthcare systems. This gap will only grow as the economy recovers − and meanwhile concern about the NHS slowly creeps up the polls.

An argument is taking place within the coalition as to whether the NHS should be given more money in the run-up to the election. Some Conservative big hitters believe the best way to win the election would be to exploit any economic upturn to boost health and education, rather than spending it all on tax cuts.

As we have seen, more cash for the NHS might simply leave it building bigger care warehouses for vulnerable older people. But increasing local authority budgets will − sadly − win few votes.

‘It is surprising few have suggested moving the £24bn of social service funding in the NHS’s direction’

The answer, of course, is to remove the artificial barriers between the health and social care systems and therefore make it easier to create the ideal experience desired by its most frequent users and their carers.

Labour shadow health secretary Andy Burnham has suggested achieving this by moving the £90bn NHS commissioning budget to local authority control − which would be both hugely controversial and disruptive. It is surprising few have suggested moving the £24bn of social service funding in the other direction − something that would cause less upheaval and be likely to win more public support.

Organisational change is best avoided and joint working grows in popularity and success. But unless entrenched public and political attitudes towards local authority spending changes soon it is unlikely to bring about a step-change in investment where it is most needed.