Socialism and Health the magazine of the Socialist Health Association May2013 Editors Opening The Labour Party is beginning to formulate proposals for the policies it will campaign on in the 2015 General Election, and the SHA is contributing to that process. So far we have been pleased with the direction that looks like developing. There are still key areas of policy that need careful thought and as ever there will be a lot of detailed work required to support the big themes and announcements that will be used for campaigning. The SHA is doing all it can to support that process. Andy Burnham has made a number of significant speeches centred on the need to bring Social Care, Mental Health and Physical Healthcare into a more integrated package. Whole person care is starting to get wider attention. Diane Abbot has been touring the country talking mostly to Labour Councillors about how the new Public Health responsibilities of local authorities are working. Meanwhile the Government continues to dither about public health measures on smoking and alcohol. Diane is to speak at our forthcoming AGM. Liz Kendal has made some key speeches about the future direction for social care and gave us some ideas about current thinking at a recent SHA seminar. With the Care Bill now starting its journey and S75 established the emphasis should shift to policy development rather than structures. In the SHA we have more to do around social care, mental health and public health and some lively debate can be expected. We are looking for ways to involve as many members of the SHA as we can in this work.
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This issue: Page 1 Page 2 posals Page 4
Editor’s Opening Social Care Government proPublic Health for 2015 election
Page 6 How does the NHS in England work now? Page 8
SHA Events Page 8
Editor Irwin Brown Socialist Health Association 22 Blair Road Manchester M16 8NS 0161 286 1926 irwin@sochealth.co.uk Please send contributions or ideas for articles
Social Care: Protect the inheritance. In February 2013 the Government published the details of its plans to reform the state subsidy for long-term care of the elderly in England, the basis for the Care Bill. 1. 2.
3.
A cap of £75,000 on the cost of care anyone would be expected to pay. An increase to £123,000 (from £23,250) in the amount of savings you can have and still get help with the cost of care. A guarantee that no-one has to sell their home in their lifetime to pay for care
The scheme will cost an extra £1 billion a year by 2020 and help an extra 100,000 richer people and their heirs with the cost of long term care in old age. £75,000 only covers the cost of the care given in the residential care home. It does not cover hotel costs—accommodation and food. That is capped at £12,000 a year. Those have to be met even when the Government meets the cost of the care itself. £75,000 is not what you have spent. It is the amount of care that could be bought at the rate paid by the local authority. So if a local authority was willing to pay £430 a week for the care then £75,000 would buy about 175 weeks of care. To reach the cap you would have to buy 175 weeks of care. To buy that privately the cost would be around £530 a week. For the cap to come into play you would have to spend 175 weeks at £530 - a total of £92,750 on care. In addition throughout the 175 weeks you would have spent £12,000 a year on hotel costs, another £39,600. So you would have paid out £132,350 before the '£75,000' cap was reached. After that the £12,000 a year hotel costs would continue. Because the cost of care varies throughout England, the actual cost that has to be met before the cap is reached will different in every local authority area. If you reached the cap in your £530 a week
care home the council would still only pay £430 a week. If the home refused to renegotiate a lower figure then you have to find another £100 a week towards their costs. At the moment a top up cannot be paid by the resident themselves, only by relatives or friends. Care Minister Norman Lamb has indicated that rule will be changed to allow the resident to pay. With the hotel charges that would mean an annual cost of £17,200 even after the cap was hit. The £123,000 savings limit means that anyone who has capital (including an empty home) worth more will have to pay all of their care home costs, until of course the cap is reached. Below that figure a sliding scale will determine the contribution they make. Someone with £100,000 savings would have to pay £330 a week towards their fees. Someone with £50,000 would have to pay £130 a week. When your savings fall below £17,500 the council pays the whole bill and the income means test takes all your income except £23.50 a week personal expenses. Selling Your Home This claim “Your home is safe” is disingenuous. No-one can be forced to sell their home to pay for their care now. Some of the 19,000 who do so each year are deceived into it by local councils who tell them they must. But some use the value of their home to pay for better care than the local council will give them. Instead of selling your home you can enter into a deferred payment arrangement, which was introduced by the Labour Government in October 2001. It was “to ensure that people… are not forced to sell their homes as soon as they enter residential care.” It would “help… people who do not want to have to sell their homes in their lifetimes to pay for their care by making loans more widely available”. In 2009 the Department of Health issued a circular LAC (DH)(2009)3 which said Ministers
expected councils to offer deferred payment schemes and “it is the Department’s view that if a local authority were to have a policy of never exercising its discretionary powers to make deferrals, it is likely the courts would find this to be unlawful.” 8,500 people are currently in such schemes with a total debt of £197 million – an average of £23,000 each. Anyone who insists on a deferred payment arrangement will get one. But even if you don’t all you have to do is refuse to pay. The council still has to provide care and take a charge against an empty home so the bill is paid after death - s.22 of the Health and Social Services and Social Security Adjudications Act 1983 (HASSASSA). In either case no interest is charged on the debt while the resident is in care and that concession lasts for an extra 56 days after death with a deferred payment scheme. Those are the rules now and they apply throughout the UK. The Government plans to replace them in England by a universal deferred payment scheme that local councils will have a legal duty to apply. Under the new scheme interest will be charged on the debt from the moment it begins. And the backstop provision under HASSASSA will be repealed. That new scheme will begin in April 2015, two years before the other reforms. How is it paid for? The extra cost of the new scheme will be around£1 billion a year in 2019/20 rising to almost £2 billion by 2025/26. It will be paid for by two sources of money. 1. The Chancellor has reversed a promised rise in the threshold at which inheritance tax becomes payable. It will now not rise in 2015/16 but stay frozen at £325,000 until the end of 2017/18. That will pay for about a fifth of the cost—an extra tax of £1600 on estates in 2015/16 and £7120 or more by 2019/20. 2. The other four fifths will come from the
extra revenue generated by changes to National Insurance. The changes to inheritance tax and national insurance apply throughout the UK. So unless some specific provision is made, the tax generated from Scotland, Wales, and Northern Ireland will be used to fund the care reform package in England. Who Benefits? The new expenditure will go mainly to the richest—and their children. Department of Health analysis shows that in 2025/26 the extra cost will be nearly £2 billion and of that about £710m will go to the richest fifth of the population and an extra £640m to the second richest fifth. So that richest 40% of people will get more than two thirds of the extra money. About £420m extra will go to the middle fifth, and £210 million to the second to poorest fifth. That 40% of the population get just under a third of the extra subsidy between them. The poorest fifth will get no more money spent - their care costs are met in full already. The new scheme will still be a highly complex mixture of a means-test on income and assets topped off by a cap fixed in terms of care provided which will differ in amount in every local authority area. The biggest share of the extra cost of the new scheme will go to the better off - more than a third of it will go to the richest 20% of those in care. The new scheme for protecting the value of a home will cost more than the present scheme. Everyone (including self-funders) will need to be assessed by the local council and the costs of the care that the LA would have provided estimated, in order to work out when the £75K 'cap' is reached, even if they never benefit. This article is based on Paul Lewis’s excellent Money blog.
Public Health for 2015 election West Midlands Socialist Health Association has discussed public health at three meetings over the last year or so, with presentations by Dr. John Middleton (Director of Public Health, Sandwell MBC), Diane Abbott MP (Shadow Minister for Public Health), and most recently Cllr. Steve Bedser (Cabinet Member for Health & Wellbeing, Birmingham City Council). Following the last of these it was agreed that issues and ideas arising from these discussions should be circulated as an input to strategies for a future Labour government. That is the aim of this paper.
However, on the plus side:
Many Local Authorities have a strong ‘municipal socialist’ public health tradition to draw on[4].
Significant budgets have come with the public health function[5], and there is an opportunity to make better use of money by linking planning and commissioning across the social/health-care interface.
Tackling poverty has a huge public health benefit, which has not been exploited.
Context: Public Health is important to people in its own right, but also crucial to managing the demands placed upon the NHS when money is in short supply. Among the challenges:
The whole health system is now very fragile. Clinical Commissioning Groups took control of most NHS funds on 1 April 2013, just as the money ran out. The four huge regions of NHS England are too distant and disparate to help them[1], tending rather to impede communications with the front line. Public health (and healthcare outcomes generally) are strongly related to income and social class (however defined). There are extreme and longstanding social contrasts within cities[2], and market forces and social policies are combining to make these worse. Powerful economic forces (including globalisation and neo-con economic policies) are increasing inequality, particularly between North and South but also between inner cities and suburbs. This fuels growing healthcare demand, just as money is diminishing, so as well as being important in itself, public health success is crucial to NHS solvency.
Local authorities have become responsible for public health at a critical time, and may be blamed for circumstances beyond their control[3]. Within LAs, there will be pressure to divert public health funds to other urgent purposes.
Ideas for the Labour Health team We are two years from a crucial Election, so how can the Labour Health team best prepare the ground for an incoming Labour government? We might need to start tying things down a bit more – including saying some things which may not be instantly agreeable to everyone. Some of the early policy statements are starting to do this, and should be supported. The political narrative on public health and the NHS should centre on the health and well-being benefits of tackling social inequalities. This not some sort of naive successor to ‘Big Society’, but links to the practical vision of economic development being developed by Chuka Umunna with productive jobs, real innovation and locallybased investment across the whole country[6]. Labour should support and strengthen the move of public health to local authorities. The key test of public health devolution will be ability of local authorities and local NHS to manage change, working across institutional boundaries[7].However, public health funds need to continue to
be ring-fenced, at least until the habits of collaboration are well bedded in Hospitals are a public health resource, and the acute sector needs to use its power to pursue the public health agenda (eg tackling diet and smoking with patients and families alongside acute treatment). In general Labour should be very careful about further organisational change as a policy lever, but there are a few exceptions:
Clinical Commissioning Groups with boundaries that do not correspond to the other agencies involved in public health are not sustainable. Uniting health and social care around the local authority platform will give planning for health real muscle. the other thing that will need to go is the ridiculous NHS England ‘regions’.
Other important legislative changes would be:
Repeal of the current competition provisions in health and social care; Reinstate the Secretary of State’s duty to provide and secure comprehensive health services; The third sector has an important contribution, which should be better recognised in future contracting and commissioning arrangements for social health/welfare[8];
Birmingham is a young city – but children will die before their parents unless we do something urgently about diet/obesity. Powerful lobbies oppose even small steps (eg food labelling, alcohol pricing). Labour should legislate. Finally, much bigger public health challenges may be on their way: eg food and energy scarcity, and antibiotic resistant infections. The public health agenda needs to include creating the resilience to deal with these challenges. A genuine commitment to tackling climate change would help public health resilience by addressing fuel poverty and our vulnerability to world energy markets.
Notes [1] ‘Middle England’ goes from Great Yarmouth to the Welsh borders; South from Dover to the Scilly Isles; and North from Sheffield to Berwick [2] eg in Birmingham, north from Ladywood to Sutton, and to the east from Sparkbrook to Solihull (cited by Eversley in 1970s as the steepest social gradient in the UK); either side of the A45, Solihull itself is currently the most socially polarised borough in England. [3] eg H&WB Boards have become responsible for post-Francis inspections – but without resources to do the job [4] In Birmingham this goes back to the municipal housing, water and sewerage enterprises started by Joseph Chamberlain. In the 1970s Birmingham pioneered clean air, noise abatement and leadfree petrol nationally, and West Midlands was (and remains) a leading area for water flouridation. [5] Birmingham’s Health & Well Being Board directs £78m for public health; £38m for specialist housing; and £9m other [6] There is an important contrast to be drawn with the present Government’s policies favouring the City financiers responsible for the recession, pumping up another property and development bubble and relying on the private sector for vital infrastructure and services like the NHS. [7] For example ‘Be active’ scheme has overall (Local Authority + NHS) Benefit-Cost ratio of 21, but the £1 has to come from LAs while most of the benefit is to the NHS acute sector (and there are long time lags) [8] Working with Brook, Local Authorities and NHS did well on teenage pregnancies under Labour – this is a good example
How does the NHS in England work now?
Now the Health and Social Care Act, which we all fought against, is in force, what can we say about how the NHS operates?
much more like a real market, with more separation between suppliers and the commissioning of services than we have seen before.
There is no agreement about what effect the legislation will have. The Secretary of State may no
NHS England—the name adopted by the National Commissioning Board—still has some responsibilities for managing the service as a whole, but it is not clear how the power struggles between the various organisations will work out in practice.
longer be responsible for providing the service, but that doesn't seem to make much difference in the short term. The new arrangements are more less centrally dominated, giving more scope for local decision making , and so more possibilities for local involvement in decision making. A lot of power is in the hands of local Clinical Commissioning Groups. So campaigning now seems to be much more local. We need people to understand how the NHS actually works and help them to get involved locally. Just putting a lay person on a committee with load of doctors and managers isn't enough. We need to build a network which will support people. Local Councils now have some responsibility for health, but most councillors know little about how the NHS is organised. The diagram above illustrates the set up on the commissioning side. The internal market, established by the Thatcher government in 1990 has now become
There are opportunities for organising and campaigning using local Healthwatch and Foundation Trusts, and the CCGs and GP practices and we need to encourage and support people to do this. Total NHS spending on healthcare services supplied by the independent sector in England covering private companies and voluntary organisations - was estimated at £5.9bn in 2011/2012. Growth of the private sector looks most
likely in the community sector where services were floated off from PCTs into various local arrangements, often on a temporary basis. The drive to save money is reducing the scope for making profits in hospitals, and the proposed deals for private management to run failing hospitals are all for hospitals in real difficulty, where closure is clearly an option. It’s hard to see what
private management can deliver which hasn’t already been tried, and even harder to see how a profit could be made. Andy Burnham’s proposals, as far as they have been articulated, consist of:
Abolition of the competition element in the 2012 Act—but continue the internal market
Return of the NHS as the preferred provider of services
Preservation of the structures we find in 2015—ie no more reorganisation
Amalgamation of health and social care services. Social Care should be free at the point of need, financed by charges on the estate of the care user. a system of national entitlement, but also a system that allows flexibility for local innovation on delivery Joint budgets for health and social care to be allocated to local authorities. Clinical Commissioning Groups to continue in advisory role District General Hospitals to co-ordinate care in their area
Though Andy is keen to stress that there will not be another huge reorganisation it does seem clear that neither mental health nor community trusts will continue in their present form. Between now and 2015 we need to get more people involved in local decision making structures. In particular we need people to get involved with their local Clinical Commissioning Group, and their local Healthwatch. However there are no standard models for either, so its hard for us to offer guidance. Every area is operating in a different way. The best we can do is to help people to share experiences. Foundation Trusts are rather more comparable. Most hospitals in England are now run by Foundation Trusts, though there are probably 50 NHS Trusts which will not make Foundation status. Foundation Trusts have individual members, divided into constituencies. This always includes the local area, but for many it includes the whole of England and Wales, as many offer specialist services to a wide area. The Foundation Trust model doesn’t have much credibility. Most of those involved see it as more decorative than functional. But it does give us opportunities for campaigning among people with an interest in the health service. We need candidates who are prepared to stand for election as Governors, and people who will join up as members to vote for them.
Socialist Health Events We have developed a set of slides showing the development of the NHS over the last 65 years which are very helpful in guiding discussion about what exactly the NHS is, whether it’s under the threat and how it could be defended. We call this “Defending the NHS”. It’s supposed to be a discussion, not a lecture. It doesn’t work so well with a large audience.
8th June 12:00 - 15:00
Socialist Health Association Central Council, Unite Building, Theobalds Road, London Discussions on the Social Care Bill and Labour’s Public Health Policy With Diane Abbott MP All members welcome
So we are on the look out for opportunities to run such a discussion. Let us know if you’d like to arrange one. We’ve done all sort of audiences, - universities, councillors, Labour Parties, even Townswomen’s Guilds.
14th June 14:00 - 16:30
Defending the NHS Vintry House, Bristol 15th June 11:00—14:00
Whither the NHS Debate?
A Call to Action for progressive health advocates: invitation to join People’s Health Movement-UK You are invited to attend an open meeting for health organisations, campaigners and advocates for health & social justice organised by the People’s Health Movement-UK
Organised by Gloucester Labour Party Professor Gabriel Scally, UWE Martin Rathfelder, SHA Sophy Gardner, Gloucester Labour Party Wheatsone Hall, Brunswick Rd, Gloucester, GL1 1HP
Saturday 15th June 2013 from 10am - 5pm Grayston Centre
19th June 19:00 - 21:00
28 Charles Square
Labour's approach to Public Health
London N1 6HT
Islington Town Hall
RSVP to phmukcoordinator@gmail.com
Membership of the Socialist Health Association Martin Rathfelder—Director
Free entrance to local branch and central council meetings; reduced fees for our conferences; SHA
Journal Socialism & Health and frequent email bulletins about developments in health politics; voting rights as a member of a Socialist Society affiliated to the Labour Party; opportunities to contribute to the development of health policies. Membership costs £10 for individuals with low income, £25 for Individuals , £25 for Local Organisations To join post or email your details to : Socialist Health Association 22 Blair Road, East Chorlton, Manchester, M16 8NS.