The central proposal in Damian Green’s recent paper on social care is that care provision should be treated like pensions. In ‘Fixing the care crisis’, he argues that everyone should be entitled to 'a decent standard of care' funded by the state – in the same way as they are entitled to a state pension - but could then choose to 'top up' from their own resources to add what he calls 'bells and whistles'.
The benefits from such a system, as he sees it – and I agree – could be manifold. It should eliminate the patent injustice, according to which cancer care is fully state-funded while dementia care is not, and many other chronic conditions, such as MS and Parkinson’s fall somewhere (often disputed) in between. Removing the social care funding responsibility from local authorities should also remove the disincentive to build adapted housing for elderly people and care homes. (They are reluctant to give planning permits to new developments, apparently, because the pound signs for care costs flash before their eyes.)
Most of all, though, it could encourage those who can afford it to contribute more to the care system, quite willingly, because they would be getting 'something for something'. Under the present, frankly confiscatory, system, those with assets over £23,000 must not only fund their own care, but may actually get nothing for something, as they may be charged higher fees to cross-subsidise those funded by the local authority. What sort of a perverse message does this send about saving for retirement and general prudence? Any 'nudge' is in precisely the wrong direction.
What Damian Green does not point out anywhere in his paper, however, is that 'topping up' could be equally useful elsewhere in public services, but most of all in the NHS. If you can 'top up' for a bigger room or a sea view or chauffeured transport in social care, why not be able to pay for a hotel-style room in hospital, or for a wider choice of catering, or for TV or internet not linked to the complex and extortionate system bought-in by your NHS trust, or for email communication with your GP?
To suggest any of this, however, is anathema. It is regarded as a violation of one of the most sacred tenets of 'our' NHS: its 1950s-style egalitarianism. This was a time, it should be recalled, when consumer choice and expectations in everything were infinitely more restricted than they are today.
The supposed iniquities of 'topping up' in the NHS came into the news a decade or so ago, when a cancer patient was told he could buy advanced drugs privately, but would then have to pay for private treatment, too. How could the same nurse, it was argued, be expected to administer one drug to one patient, but another, more expensive, privately prescribed, drug, to the patient in the bed next door? In the end, that decision was fudged, with some patients receiving refunds for their private treatment. But the issue remains unresolved.
In the mostly insurance-based health systems on the Continent, gradations of coverage – for better accommodation, particular drugs, a particular doctor – are routine. In the UK, there is no middle way between (free, take-what-you-are-given) NHS and (very expensive) private. Medics can straddle the system – work in the NHS for their training, their job security, their gold-plated pensions, and 'top up' handsomely (if they are in the right place and the right discipline) from private work. Patients can’t.
The BMA acknowledges that there is increasing interest from patients in 'topping up'; most GPs have been adamantly opposed. And official hostility to the idea is clear from the Department for Health and Social Care’s 'Guidance for NHS patients'. 'There must,' it says, 'be as clear a separation as possible between your private treatment and your NHS treatment'. For instance: 'You can't have a cataract operation on the NHS and pay privately for special lens implants that are normally only available as part of private care. Instead, you either have to have both the operation on the NHS and standard NHS lens implants, or pay for both the operation and implants privately.' So there. (And, by the way, why can’t you?)
In his blueprint for social care, Damian Green says his model 'solves all the major problems facing the social care system, as well as those other areas it impacts'. Something similar could be said of encouraging 'top-ups' in the NHS, not least in the additional middle-class money it could attract into a system always hungry for more. If that eventually produced a fusion of our two not-quite separate health systems, that could be another plus.
Returning to his parallel with the state pension system, Green says: 'It is fair, it is politically attractive and widely supported – and it is a model we need to move across into social care.' The challenge to the existing system would be a lot greater, but it is a model that could usefully be 'moved across' into the NHS, too.