Robert Ede is Head of Health and Social Care at Policy Exchange and Sean Phillips is a Research Fellow at Policy Exchange.
We are a month away from the State Opening of Parliament. It promises to differ from any Queen’s Speech since the early 2010s, in containing major proposals for health and social care. The Government is bringing forward four reforms simultaneously – emboldened by the strongest parliamentary majority since 2005.
But given the political energy required to push through primary legislation, can this all be done within the next three years? And if not, will anything have to give?
The best way to answer that question is to consider each proposal in turn.
- First up is the NHS White Paper, which is to be laid before Parliament in the coming weeks. Sir Simon Stevens describes the shake-up as being composed of 85 per cent things that the NHS has asked for, plus some “bonus prizes” from the Government. The process for legislative change began in 2018, creating urgency to the Parliamentary timetable, with the NHS requesting that these new structures achieve Royal Assent ahead of the next financial year.
- Next are the changes to public health in England. Two entities are to be created out of the carcass of Public Health England – the UK Health Security Agency and the Office for Health Promotion. Whilst the legislative burden may be less pronounced here than the White Paper, it will nonetheless involve a transfer of roles and functions.
- Third are the proposals to reform the Mental Health Act 1983. This builds upon the independent review undertaken by Professor Sir Simon Wessely in 2018, which concluded that there should be changes to both the law and practice to modernise mental health services in England and Wales. A commitment to do so was contained within the Conservative 2019 manifesto, and a draft Bill is to be brought forward later this year.
- And then finally we have social care. The Prime Minister set hares running when he told the Liaison Committee that the Government would bring forward a “10-year plan” for social care this year, with speculation that it would be fast-tracked into the Queen’s Speech. The current mood music suggests this will favour a Dilnot-style cap mechanism, supported by a more generous ‘floor’ of means-tested support.
That is a packed agenda. And this is before you consider manifesto commitments around hospital building – the largest programme in a generation – and nursing recruitment, the political impact of lengthening waiting times and tussles over the post-pandemic financial settlement for the NHS (additional funding has only been agreed to September).
The ongoing review of NHS pay could soon become subject to Parliamentary skirmishes, as Labour will no doubt use one of its 17 days allocated for Opposition day debates to force a vote on giving a more generous settlement to reward doctors and nurses.
The Health Secretary has said that each of the four reforms are interlocking. This is true up to a point. The new system-level commissioning structures for the NHS should make it easier to allocate resources in a way that considers population health, thereby supporting the principles of the new Office for Health Promotion. And efforts to reform the Mental Health Act should ensure that those suffering from mental health conditions receive the dignity they deserve .
Yet there are tensions lying beneath the surface.
For example, will the new NHS Bill make it easier for someone with multiple conditions to receive coordinated care? It should. But will it make it more likely that another patient requiring, say, cataract surgery will be seen sooner?
That is less clear. Under the quasi-market system established by Ken Clarke, formalised under Alan Milburn and accelerated through Lansley’s competition reforms, high volume activity such as hip and knee replacements were rewarded in response to the spiralling waiting lists of the 1990s and 2000s.
We now find ourselves in a situation where access and waiting times will again define the NHS narrative in the runup to a general election, at the precise moment that a Bill is brought forward which signifies a big step away from a competition-based system.
The breadth of the proposals – some suggest it will supersede the 2012 Act – also create considerable scope for unintended consequences. Taken together, this could make for a bumpy ride through Parliament, where the contradictions of the Bill will be exposed and debated upon.
Tensions exist for social care too. The Dilnot cap would address the issue of catastrophic care costs, whereby around 10 percent of people aged 65 and over face lifetime costs greater than £100,000. This is important, but does nothing to address the unmet need in the system, which, like the dust on the Dilnot Commission’s report, has steadily built up since 2011.
The complexities of the scheme also makes it less palatable than other options which adopt the principles of the NHS in making care free at the point of need. As Policy Exchange has argued previously, concepts such as Free Personal Care are easier to sell on the doorstep and incentivise services to be delivered at home, which brings benefits for both individuals and the hard pressed NHS.
The most common reason for a delayed transfer of care, often described as ‘bed blocking’ is people awaiting a care package in their own home. This is not to say that it is a binary choice: free personal care and a cap could come together. However, choosing the cap alone to solve just ten percent of the problems in social care may feel like a missed opportunity.
The period from 2013-2019 represented barren years for healthcare legislation. An 80-seat majority has changed that. But a shift from famine to feast brings with it risks. If the Government cannot do it all by the next election, what should it prioritise?
The answer to this must be social care. Those who say there are no votes in it should look to Japan – where reform of the system in 2000 and expanded eligibility resulted in surging public support. In the two following elections, the governing Liberal Democratic Party returned enhanced majorities.
The electoral consequences of not acting are also clear. Polling conducted by Policy Exchange in partnership with IPPR has found that one third of Conservative voters in 2019 would be less likely to vote for the Party if a solution is not delivered by the next election. Around 90 percent of us have at least one interaction with the NHS each year, whereas only 14 percent do the same with social care.
Creating a genuine social care safety net will expand its use – this understandably worries the Treasury, which will look to Scotland where the cost of free personal care has risen over time. When this issue was identified in Japan, entitlements were scaled back, with regular three year reviews introduced.
Any solution in England must learn these lessons by designing-in appropriate financial management mechanisms from the outset, and ensuring the public knows what it is getting and paying for. Policy Exchange estimates that a package of reform incorporating a pay rise for care workers and free personal care would amount to £9 billion a year – and believe it should be funded out of general taxation.
The outcome of the 2024 election is anyone’s guess, but history would suggest another majority of this scale would be unlikely for either Party. Therefore, this Queen’s Speech is the moment to take the difficult choice and prioritise. For a Prime Minister fond of history himself, the chance to crack the issue which has eluded his predecessors is worth the political capital.