Speaking at NAEP's conference, BHTA's Director of Communications, Lord Rennard, addressed the subject of "Disability, Integration of Health & Social Care, the Care Act and the Better Care Fund:
"I’m going to talk a little about me, where I am coming from personally, and about my role for the British Healthcare Trades Association.
I want to explain how I see some of the very difficult funding challenges affecting health and social care generally, and which concern you all.
And I will also talk about some of the ways in which I see government responding to these challenges by changing procurement policies and, with the Care Act, helping to integrate health and social care, supported by the Better Care Fund.
If you are all sitting comfortably, let me start with where my personal memoirs, (available in all good book shops next year), will begin.
That is with events in 1917.
In that year a young man from Liverpool was one of the many men fighting in the fields of Flanders during the First World War. He was, a dentist by profession, but in November of that year he went ‘over the top’ with rifle and bayonet fixed to attack the German positions. Soon afterwards, there was a deafening explosion, much fire and smoke, and he was tossed into the air.
When he came round, some hours later, he was alone in “no man’s land”, his body was full of shrapnel, and his left leg was severely damaged. He lay there for thirty-six hours, believing that he would probably bleed to death. But fortunately, he was picked up by German stretcher-bearers and taken to a field hospital. He underwent many operations, and his shattered left leg was removed. When the Germans sent him back to England, he spent a long time in hospital, he was fitted with an artificial leg and he began to work as a dentist again.
His name was Rennard, and he was my father.
You might have been thinking from the timescale of these events that he could have been my grandfather. So I should explain that he was 28 when he went to war and lost a leg, and that he was obviously still going strong 43 years later in 1960 when I was born, and he was 71. And he was 73 when my younger brother was born.
My father’s life was saved by the skill of German surgeons and he enjoyed a good quality of life with his tin leg. Thereby began I suppose, my first interest in disability issues.
I was a curious small child who watched his father powdering his stump before he strapped on his artificial leg.
The shock of his amputation was probably what brought on his diabetes. He was fortunate though to have developed diabetes in the 1920s, as that was the decade in which insulin was developed. This medical innovation obviously saved his life, and enabled mine to take place.
So my childhood memories also include watching my mother, who trained as a nurse in the Second World War, sterilising the needles for his insulin injection in the flames of the gas cooker. These were strange things to witness when you are very young. But they make issues connected with disability seem very normal to me.
When I was nine, my mother became severely disabled through rheumatoid arthritis. My father had died by then, and I grew up in my teens undertaking many of the duties expected of a carer, including pushing her in a wheelchair and assisting with things like bathing. Going to the toilet meant that I had to push her hips in order to help her to get upstairs.
So in the House of Lords, or wherever I speak about disability issues, I do feel that I am speaking about something that I care about, and that people may understand why I feel so strongly about the rights of disabled people to be able to live happy, rewarding and independent lives.
1917, when so many young men were becoming disabled as a result of war, was the year in which the British Healthcare Trades Association was founded. So I am very pleased to pursue my interest in disability issues as their Director of Communications. In this role, people sometimes ask me where my wider interest in politics comes from.
My mother was fairly contemptuous of politicians, unless she knew them personally. But I do remember pushing her in her wheelchair to the polling station, because she always felt that it was her duty to cast her vote. And she was angry when access to the polling station was up a flight of stairs.
These experiences gave me the benefit of an early education about how disabled people feel when they are discriminated against, and when for no good reason they are unable to do many of the things that other people generally take for granted.
My work with the BHTA involves advising it on how to make many different representations to government. These often begin by making the point that the BHTA represents businesses wanting to see high standards in the industry.
The BHTA maintains a binding Code of Practice, agreed with the Chartered Trading Standards Institute, to ensure that individuals, government and charities buying from these businesses can do so with confidence.
It represents nearly 500 member companies providing goods and services that help enable people with disabilities to live more independent lives. But the task of explaining to Government how it can best help with this aim is not always straight forward, especially when it is seeking to reduce public expenditure, and deficit reduction is the overarching aim.
So part of what I do with the BHTA is to help them explain to fellow politicians the many benefits of doing things like providing equipment for disabled people.
- It enables more of them to live at home, or at least out of hospital, giving them a better quality of life, and saving on secondary care costs.
- It may help them to work productively, make their lives feel more fulfilled, and possibly enable them to pay more in taxes to Her Majesty’s Revenues and Customs.
- And it may also, therefore, help them to be less dependent upon the Department of Work and Pensions.
So providing more support for people with disabilities, is not just a moral responsibility to help them avoid discrimination, it can also help our economy.
The benefits of being able to live better and more independent lives can be seen significantly in terms of the physical and mental health of disabled people, their families and those who support them. These factors need to be taken into account when any cost benefit analysis of such investment is considered.
We also need more understanding about the costs of injuries such as broken hips when people don’t have the stair lift or grab rail that they need, and the costs of stress, and the resulting breakdown of relationships that it sometimes causes, when we can’t support disabled people properly.
Above all, we need to explain that the costs of failing to help achieve emotional well-being can be much greater than it is ever possible to calculate in simple monetary terms.
So we need governments to take a much longer term view of such support than the Treasury has traditionally allowed. And we need to continue working to avoid the problem that nationally funded NHS services have been able to say that it is local government’s responsibility to pay for something, whilst local government says that it is the responsibility of the NHS.
Local government has too often been reluctant to invest in equipment or support that may result in considerable savings to the NHS, if the council has to pay for it, but the NHS gets the benefit of the saving. That’s why devolving much greater responsibility for overall budgets is so important. All the major political parties now seem to be agreed that the principal of integrating health and social care is absolutely right, but the crucial question still remains about how increasing demand is to be funded in future.
Achieving integration will be an essential part of the answer to funding Health and Social Care. But the scale of the funding problem is very large and growing.
At the BHTA Conference three years ago, your Conference Chair, Roy Lilley, presented us with a devastating insight into the huge costs of demographic changes taking place. I have been very struck by statistics showing that when I left school in 1978, male life expectancy in this country was about 67. But in the United Kingdom now, a man who is 65 can expect to live to the age of 83.
This man can expect to be in good health until about the age of 75 - and then to be in relatively poor health, perhaps requiring significant support, for the last 8 years of his life.
A woman who is 65 today can expect to live for another 20 years, until about the age of about 85, enjoying another 12 years of good health, but then also to be in poor health for her last 8 years of life.
So the number of years in which people are living, and needing support from the health and social care system, to say nothing of old age pension benefits, is increasing dramatically. The number of people aged 85 or over in this country will double in the next twenty years, and this will result in far greater demands being made on the health and social care system.
Governments, in all countries, face increasing demands for equipment and healthcare services. But many of these governments, like ours, are still facing the very difficult financial problems that follow from recession whilst there is only a fragile recovery. Tax receipts have not increased as hoped, whilst the benefit bills have failed to drop as expected.
All politicians know that most people are very reluctant these days to pay more in taxes. The recent election, and the somewhat surprising result of it, demonstrates to them all just how unwilling many people are to pay either an increase in income tax, or any more money if their money in indirect taxes such as VAT.
During the recent election campaign, no political party really had the courage to explain some of the country’s fundamental financial problems. They did not of course want to explain the consequences of a considerable drop in the proportion of people of working age who are able to pay taxes and provide the resources to support the pensions and services of the rapidly increasing number of non-working, older people.
So to try and meet growing demands, without raising taxes, the governments is looking hard for solutions. These will include, I believe, much greater use of personal budgets in future.
Two years ago, I got the highly respected Health Minister in the Lords at the time, to address the BHTA Conference. Earl Howe referred to the challenges about ageing populations, lifestyle diseases like diabetes and also how people are much less deferential towards healthcare professionals than in the past. He described how people see themselves “more as informed consumers, with access to news and views on their various conditions via the media and the internet”.
This view is now, in my opinion, the prevalent one - and together with all the issues about financial constraints, will lead to a pattern of provision based much more on personal budgets than in the past. It will be argued that personal budgets can provide for the possibility of putting the patients, their family or their carer in direct control over their care and treatment. But they are also a way in which the state can cap its costs, as demand rises faster than the economy grows.
It is also clear that Telecare and Telehealth systems will become much more prevalent. Innovative technology will help to save lives, improve the quality of life for many people, and save taxpayers’ money. But it seems to me that Government will have to recognise that technological innovation needs to be funded in the first place, not just to produce cost savings, but to increase the quality of patient care and of people’s lives.
The Chief Executive of NHS England, Simon Stevens, set out a five year plan for the NHS last autumn. The scale of the NHS has of course grown enormously since it was created in 1948, when in today’s prices its annual budget was around £9 billion pounds. The budget for this year is just over £115 billion. In spite of significant increases in expenditure in recent years, he warned that by 2020, there could be a mismatch between resources and needs of almost £30bn a year. His plan says that upfront investment is required to achieve more significant efficiency savings, and that major reform is required to avoid this mismatch, including the integration of social care and health.Real integration of health and social care will, of course, only occur when they are funded from a single budget, and the process of achieving this will require considerable decentralisation from Whitehall - something that has always been opposed in the past by the Treasury. But we are now beginning to see this decentralisation happening with the Greater Manchester City region and some of the big cities leading the way.
The pattern in future I believe will be for “combined local authorities” to take on enhanced powers and responsibilities, including in relation to finance. This will enable decisions about levels of funding, and levels of taxation, to be taken without those in power at Westminster taking the blame or the responsibility, depending upon your point of view. It will mean further changes to funding arrangements following the change in the last Parliament from Primary Care Trusts to Clinical Commissioning Groups.
There was of course much unhappiness in many quarters with key aspects of the Health and Social Care Act of 2012, and the “top down” re-organisation that it entailed. As a result of my own party’s participation in the coalition however, some of my friends were successfully able to make very significant progress on the vitally important issue of the integration of Health and Social Care. This began with the creation of Health and Wellbeing Boards, based on current local authority boundaries, and responsibility for this happening lay with Paul Burstow, who was then the Care Minister. He was then also responsible for drafting the Care Act. In Paul’s words, the Care Act created “new rights and protections for people who need care, and new rights for the friends and family who selflessly care for them. It puts in place for the first time national rules to determine when a person is eligible for care.”
The Act itself says that it “provides a single legal framework for charging for care and support”. It enables a local authority to decide whether or not to charge an individual, when meeting either the needs of the individual or those of their carer. Under the Act, individuals are entitled to financial support from the local authority, on the basis of means-testing. Should a local authority decide to charge an individual for care services or equipment, it must undertake a financial assessment. Under this assessment, a local authority will investigate the income and capital of an individual.
However, should an individual have more than the ‘upper capital limit’ for means-tested support, which is set at £23,250, then they are not entitled to receive financial assistance from a local authority.
In contrast, where a person’s financial resources are below the ‘lower capital limit’, currently set at £14,250, then they will not need to contribute to the cost of their care and support.
Similarly, under the Act, local authorities must not charge for certain services and provisions. These include the provision of community equipment, such as walking aids and minor adaptations. Minor adaptations are those considered to cost less than £1,000.
Securing finance for this was a major achievement by Paul, and his successor as Care Minister Norman Lamb.
Additional funding is clearly required and the Better Care Fund was announced as part of the Spending Review in 2013, and it is provided for in last year’s Care Act. This will distribute £3.8 billion to local care and health services. NHS England describes the aim of the Better Care Fund as being to “transform local services so that people are provided with better integrated care and support”. Local authorities and Clinical Commissioning Groups must jointly agree as to how this money will be spent.
So progress is being made in a difficult climate and this is acknowledged by he respected Kings Fund who recently said that more progress had been made on social care in the last five years than in the previous thirteen.
Organisations like NAEP, the BHTA and the many organisations concerned with these issues will all need to work closely together to sustain this progress.
The shock of a Conservative overall majority is still being felt around Westminster. For my own party, the Liberal Democrats, the results were bitterly disappointing, especially considering our role achieving such progress on these issues. I had to remind a few friends after the election of the words of an American Congressional candidate shortly after his defeat. “Well”, he said, “the people have spoken….the bastards.”
The result means, however, that there will be no repeal of the Health and Social Care Act.
Progress made towards integration will continue.
But the issue of resources, given increasing demands on health and social care, and a renewed squeeze on local authority budgets generally, will mean that there is much for us all to fight for in future."