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Health and social care: what are the challenges after COVID?

What’s on offer?

This hour-long online event will feature a series of short talks by IFS researchers and policy experts from the Health Foundation and King's Fund on post-COVID challenges for the health and social care system. Talks will be followed by time for your questions.

What’s it about?

What impact has the pandemic had on the NHS? How much activity has been missed, and what does this mean for waiting lists and the elective care backlog? What are the likely pressures on the NHS going forward - not just from COVID-19, but also from an ageing population? How much funding might be needed to meet these? And will the government's latest reforms really be enough to 'fix' social care?

Who’s leading the event?

Chaired by IFS Research Economist Ben Zaranko, it will feature presentations from:

  • Stephen Rocks, Health Foundation
  • Max Warner, Institute for Fiscal Studies
  • Sally Warren, King's Fund

Open to

Anyone who is interested in finding out more about the pressures facing our health and social care systems.

Health and social care: what are the challenges after COVID?

Video transcript

good afternoon everyone and welcome to this event as part of the esrc's festive level of social science thank you very much for coming my name is ben zaranco i'm an economist at the ifs and it's my great pleasure today to welcome three speakers who are going to talk to us about the challenges facing health and social care during and indeed after covid uh we'll first of all be joined by my colleague max warner of the ifs will talk about some of the immediate challenges facing the health service during the pandemic heading into what could be a particularly difficult winter we'll then be joined by steven rox of the health foundation who will talk about some of their work modeling some of the pressures facing the nhs that predated the pandemic in particular some of the underlying challenges associated with an aging population and then finally we'll have sally warren who is director of policy at the king's fund talked to us about some of the very topical issues in and around social care the plans for that to take all in all around half an hour so we should have plenty of time for questions if you'd like to ask a question you should all have been sent a link to the slider page or it should be available on the page or wherever you happen to be watching this so please do pipe up with any questions you have you can also vote for other people's questions that you like look of and hopefully we'll have a wonderful discussion um so without further ado i'll hand over to max and we'll go through those sessions in turn and we'll be back for q a thank you ben so as ben said i'm going to spend the next 10 minutes or so talking about ongoing covered pressures on the nhs and clearly the nhs faces many covet related pressures and so we've found in our work it's really useful to distinguish between direct and indirect effects so direct effects of pressures coming directly from the virus itself such as treating covid patients delivering vaccinations and infection control measures indirect effects are those coming indirectly so they're coming from our response to the pandemic or other changes and as we're going to see indirect pressures are large too and they'll likely last much longer so even if covert disappeared tomorrow and these direct pressures disappeared the indirect pressures because they've been accumulated over the course of the pandemic would remain and these include things like catching up on missed activity mental health changes and workforce challenges and this is on top of pre-existing long-run pressures that stephen is going to talk about more in his presentation so the most direct pressure on hospitals is that they have to treat covert patients so this chart here shows the number of covered patients in english hospitals throughout because health has devolved i'm going to look at english data but these issues apply to all four nations of the uk so you can see quite clearly the rise of both the first and the second wave of the number of coded patients in hospital and if you look to the right you can see that right now there are still about 6 000 covid patients in hospital now this is far less than the first and the second wave but given that the england has about a hundred thousand hospital beds that still represents about six percent of hospital beds right now having covered patients in them this would likely actually be much higher had it not been for the success of the vaccination program that has clearly reduced pressure on the nhs overall but nonetheless the nhs itself still needs to deliver vaccines so this chart here shows the number of covered 19 vaccine doses delivered per day in england you can see it fell in the summer as most people had already received their first and second dose but then has risen in the autumn mainly due to the booster jab program and this is happening on top of the standard winter flu vaccination program and therefore taking up a lot of resources in gps and primary care more broadly luckily although coded vaccinations and treating copic patients are very visible emotive signs of the pandemic infection control measures are also particularly costly these include things like keeping covered and non-covered patients separate in hospital staff need to take time changing pp between treating patients there's reduced capacity even for non-covered treatment as patients still need to be kept apart and certain treatments require additional measures on top of this so as well as all the effort and resources going to treat encoded patients these infection control measures reduce the number of available beds and the productivity of staff again and importantly high levels of covered in the community i mean that even in a hospital without copic patients these measures are still really important to prevent kobe being brought into the hospital a couple of other direct effects so we have long covered which affects many people according to survey evidence so long covered is continuing to have symptoms many weeks after the original infection and although for some people this seems to be very debilitating it's likely not to put too much pressure overall on the nhs in particular because most of it can be treated in primary care by gps but according to the nhs its own guidance only relatively few people needing specialist rehabilitation another really big direct effect is test and trace but this is actually funded by despite the name department for health and social care just like the procurement of pp so it isn't coming directly out of nhs's budget now i'm going to focus a bit more on these indirect effects which as i've said are actually equally if not larger particularly in the medium one so i've got one slide here on mental health which is a really important aspect of the pandemic so this orange line on the left axis shows the number of people in contact with adult mental health services both before the pandemic and then you can see that sharp drop off in march april 2020 and then what's happened since then so that's a fall of about 10 from the onset of the pandemic and although this has increased you can see quite linearly it's nowhere near even this many months into the pandemic nowhere near where it was pre-pandemic so fewer people both during the pandemic and still right now receiving fewer people are receiving mental health care at the same time though demand for mental health care has if anything increased so this chart here the green lines on the right axis so the percent of adults with moderate to severe depressive symptoms the dashes are when the ons surveys have taken place and you can see pre-pandemic that was about 10 and post or during the pandemic that's risen to just under and then just over 20 now of course depression is only one area of mental health demand but it's a large one and we also think this is symptomatic of a wider issue the the pandemic has caused more people to have mental health problems or need care but also fewer people to actually receive care and that's likely to cause problems for mental health services for the coming years another really important area is to care other forms of care that will miss and as we're going to see millions miss both hospital and gp treatment during the pandemic and hospital care was missed for a number of reasons so hospitals for example shut down non-essential services to free up resources to treat covered patients patients avoided seeking care maybe because they were scared about perhaps encoded in hospital maybe because they wanted to protect the nhs but also there were some genuine changes in care needs because of lockdown and because of other changes in behavior millions lost care but it's important to emphasize that some groups lost more than others and ifs have done a lot of work on this and in some cases that risks those who are already disadvantaged with healthcare inequalities potentially in some cases lost more care exacerbating those inequalities much of this care is still going to be needed particularly if we think patients missed care for the two first two reasons i gave many of them are likely to still need care but we don't know how many and we also don't know given that they've missed care how much sicker they're going to be now than if they've been treated originally and this is therefore a huge and perhaps the biggest challenge for the nhs is to do two things it's first got to return to delivering routine care because new people are becoming sick every day but as well as that is not a catch up on all the care that was missed during the pandemic and so returning to kind of pre-pandemic levels will not be enough to achieve both of those executives and as i said millions missed treatment during the pandemic so to put some kind of numbers on this in the first 12 months of the pandemic we estimate there are three and a half million fewer elective so pre-planned hospital admissions 1.6 million fewer non-covered emergency admissions and 20.2 million fewer outpatient appointments some activity has now bounced back so for example the latest data we have is that gp appointments and a e arrivals are between two and three percent above their 2019 levels but there's actually a little little sign of a surge in elective activity although it's got better than it was during the first and second wave the latest data suggests that admissions from the waiting list are still 12 below 2019 levels and as i said they're going to need to be far above 2019 levels to actually catch up this means all this missed care means that waiting lists have grown so this shows the total nhs waiting list in england in green we have those waiting less than 18 weeks in yellow we have those waiting between 18 and 52 weeks and in dark green we have those waiting more than a year and you can see the total number it dropped off a little bit at the beginning of the pandemic but then has risen quite rapidly by about 1.4 million people and not only are there more people on the waiting list you can see the growth in the yellow and particularly the dark green bar people are waiting on average much longer but as i've said in the title this has actually only grown by 1.4 million and despite that being a large number it's far fewer than we'd expect to miss care so we'd have expected maybe another 7 million people to join the waiting list during this period who haven't so as i say millions have lost care and most of them never even made it onto the waiting list and therefore if and when these patients start to return waiting lists are likely to rise rapidly much faster than we've seen so far and that's behind sajid javid's repeated warning about this and ifs have published some quite detailed analysis on waiting lists even in the kind of best case scenario it's therefore likely going to take years to get waiting lists back to their pre-pandemic levels and it's worth remembering that pre-pandemic levels were relatively high particularly compared to say the previous decade the government through a number of announcements has now announced about eight billion pounds for catch-up over the next three years our best estimate is that this is probably enough to deliver this treatment but really staffing is the real constraint even if hospitals are funding to do the treatment if they don't have staff to actually do the procedures it won't get done another really important point is actually there's currently very little evidence that patients who missed care are returning so despite these millions missing care we're not yet seen them come through the system so for example gp referrals are still well below their 2019 levels and just the number of people joining the waiting list are only at their 2019 levels despite us expecting them to be much higher one area where we do see patients returning is coming to a e so those who've missed care and are now very sick some of them are coming to a e and this puts pressure on top of emergence onto emergency services on top of the standard winter pressures that would soon begin so there are many different ways to measure pressure on emergency services but this is one of them so this is the average ambulance response time for what are called category 2 incidents so these are serious conditions like a suspected heart attack or a stroke the average time the target for the average time in the nhs constitution is 18 minutes and you can see pre-pandemic we were a little bit above but quite close to that but since about april of this year you can see that the mean waiting time has risen really quite dramatically and right now the latest month's data is over 50 minutes more like 55 minutes average response time for these very serious conditions which is just a symptom of the kind of pressure that both ambulance services and anes and hospitals are under before the kind of full winter pressure has even begun so to conclude the nhs is still facing direct pressure from covid less than during the two peaks but it's still a very substantial pressure and these invariant pressures are even larger so millions of people have missed care during the pandemic and it will likely even in the best case scenario take years to catch that all back up our best estimates are that the government probably has provided enough money so that depends on quite strong assumptions at least in the short term and as i say there are many unknowns here and crucially staffing remains a really important constraint there are other major pressures that have both pre-existed and been exacerbated by coverage such as staffing and an aging population and stephen's presentation is going to cover those in much more detail so thank you for listening and i'm going to hand over to stephen thanks very much for that presentation max i'll just share my slides um as max said i'm going to focus not on covert pressures uh rather something we call underlying pressures on healthcare funding in england so i should have introduced myself i'm stephen rox i'm an economist in the health foundation's renal center so my first chart here it just shows uh health funding from 2000 2001 up to 2018-19 so prior to covered and what you can see is it's rising over this period something i find quite remarkable has actually doubled so it rose by 103 in less than two decades and that's about four percent growth a year and this isn't untypical we tend to find healthcare spend rising over time about 3.7 a year since the 1950s and what our projections that the real centre uh show us is that more funding would be needed uh in 2030 31 to deliver the same rate of care as in 2018-19 and when i say rate of care here i mean care per head of the population by age gender and by morbidity so why is that i'm going to concentrate on two reasons in this presentation so one is increased demand that follows from a growing aging population with greater morbidity and the second is rising costs of care over time so first thinking about increasing demand so i'm sure this will be familiar to a lot of people we have a growing aging population uh by 2030 there's projected to be 3.2 million more people in england according to the ons principal population projections the actual growth in the total population isn't that great so 0.5 a year but the thing that's possibly most significant is about 90 percent of this increase is among those age 60 plus so you can see that in the charts here these are population pyramids and broad age groups 2018 and 2030 and you can see the the main change in the shape there it comes in that category of 60 plus so why is this significant for healthcare spending well healthcare spending generally increases with age and what i'm showing here are age cost curves for males and females so this is the average cost at different ages across the lifespan you can see it's slightly higher at the very start of life but generally flattens and then increases around about that point that i mentioned they're in about the age 60 and rises quickly thereafter now i've said in the title here that healthcare spend increasingly or does it uh and the reason why i flagged that is age might be something of a red herring so you can think about this if we had many more 75 80 year olds and so on but they were in good health that didn't necessarily put pressure on the health care budget so age sorry spend health care span has been found to depend more uh on two things on morbidity and proximity to death i'm going to concentrate a bit on morbidity now so if we look at past trends uh and the chart on the left hand side here shows for females changes in life expectancy and healthy life expectancy so it's indexed to 2009 to 11 starts at 100 so if it's above 100 it's rising uh and what you can see very clearly here is that life expectancy is above healthy life expectancy uh gains in healthy living certainly haven't kept pace so a person uh boundary can expect to spend longer in poor health and we can see this as well in terms of hospital usage so the chart on the right hand side is showing hospital admissions and i've done this for a particular age group so it's not a change in the composition by age so this is females 85 plus and its admissions with multiple morbidities and you can see the rise between 2008 9 to 20 18 19 and then our projection is for that to continue to rise thereafter so we expect to see rises in morbidity and especially in multimobility so an aging population with greater levels of mobility we expect that to read through it that's an increase in demand and activity will need to increase to meet that so this shows our projections by service area for different uh areas of activity and you can see the highest growth here is in non-elective and elective care both rising above two percent a year but you can see particularly for elective care that's in line with past trends but that's higher for non-elective care interestingly as well some other categories where with high rises and activity or community care and social care both of which saw falls addictivity in the past decade so i'm going to turn now after uh rises in demand to looking at rises in cost of care so the two things that i'm going to concentrate here on are pay and productivity so pay is vital for the nhs the health service is labor intensive labour costs account for about 65 to 75 of all costs depending on the service area that you're looking at and i can in this chart we're showing past trend and pay in red leading up to 20 20 21 and what you can say is that real pay so adjusting for inflation has been flat or falling over this period and that's a result of public sector austerity going forward we use the obr's projection for all economy earnings so assuming that health pay keeps up with the rest of the economy and you can see that rises going forward now if pay drives up the cost of care productivity has the potential to reduce it so an increase in productivity means you can get more output with the same or less inputs and looking back we can see productivity in the purple line has in fact been quite high there's been high productivity growth in fact in this period it was above the rest of the economy and going forward in our projections we use the long-term average of about 0.8 a year but what you can see going forward is that pay growth it would be expected to exceed productivity growth and if that's the case then unit costs will rise and that means that funding growth will rise faster than activity growth so the table on the right hand side here is showing the same thing again so the funding growth now that we'd expect for different service areas and you can see that funding growth again is high for non-elective and elective care and this goes somewhat against policy aspirations so we're seeing this increase in the funding needs for hospital care in particular i will say that this is only one of the possible scenarios and the pressures could be different which i'm just about to discuss so in particular the combination of pay and productivity is crucial i set out our medium term projections there but they could obviously differ so this chart shows just for acute costs the pay that's needed the funding that we needed across time so in the medium you have the red line here but it could be higher or lower depending on the combination of pay and productivity so if you had low pay paying high productivity pressures to be significantly lower if on the other hand you had high pay and low productivity growth pressures could be significantly higher so that would add about 7 billion to acute care costs by 20 30 31 but what i will say is when we review all the cost pressures and again this is across acute care we find that morbidity emerges as the biggest factor in increa acute care costs so you can see in a red bar there is acute care in 2018-19 uh population alone adds about five billion so that's just pure uh population increases in aging pay productivity and prices they somewhat net each other uh off there um but chronic conditions adds by far the most significant amount so what's the implications of this so in particular and again max flagged this one of the main implications is the workforce so our projections suggest that if there are no changes in how care is delivered up to almost half a million more healthcare staff could be needed by 20 30 31. i will say then if i said no no changes productivity gains in particular can help alleviate some of this pressure but we're still likely to need uh significant workforce growth and this comes on top of existing recruitment challenges so for instance there's a 10.3 vacancy rate in june for registered nurses there's obviously a lot of talk at the moment about burnout of healthcare staff so going forward workforce is going to be one of the main challenges so in conclusion then there are significant underlying pressures on the nhs i hope i've shown that in the nhs the budget would need to grow by about 2.8 percent a year just to keep up with these underlying pressures so that's before considering the covert pressures both direct and indirect as max built in again somewhat against policy ambitions much of this pressure is on hospital care morbidity and a combination of price and productivity are really crucial in our modelling and workforce will be a major constraint and i thought it would just finish just to some ideas of what can be done at least following from our modellings that were to reduce some of these long-term pressures there's a range of possible factors here some are perhaps more desirable and less desirable so for instance increasing thresholds for care is one way to reduce pressure but that might so for instance for hip replacement surgery but that might not be popular or desirable um reducing unwarranted care for instance so around 15 of emergency admissions are considered unwarranted promoting healthy aging that particularly follows from our modelling aiming for a compression of mobility where people spend more of their life in good health and increasing productivity so for instance over the last 20 years we've seen reductions in length of stay if that can happen going forward that would help alleviate some of the pressure particularly then on the workforce side all right so i'm going to finish there and hand over to sally great thank you very much stephen a fascinating presentation if you could just stop sharing your steam screen stephen that'd be great um so good afternoon everybody i'm sally warren the director of policy at king's fund i decided i wasn't going to be able to compete with max and steven slide so you've just got me to look at whilst i talk to you about social care this afternoon and obviously please do keep sending your questions into slido um because it'll be great to get into a bit of a debate and discussion uh after after our presentations as well so i was going to talk about adult social care um and really try and answer the question that the prime minister said he's going to fix adult social care kind of does the current set of government proposals do that and i'm going to talk about three different aspects of what's needed to help fix social care or get it on the right track the first is around funding available for the existing system the current means test system we have in england the second is around system reform so how to improve the quality of the service that people get and then finally funding reform so that that long vex question about how do we share the cost between the individual and the state so if i take each of those in turn the first on the existing system um so the spending review last month announced a three percent increase in spending power of local authorities over the course uh three percent per year over the course of the spending review period it's important to say a couple of things about what that three percent is and isn't um that three percent included significant new responsibilities for local government that we'll come on to in a moment so on a like-for-like basis this is a 1.8 increase in spending power it also relies on large increases in council tax to be able to reach that level of spending power so it assumes two percent increase on council tax each year and in addition to that two percent a one percent social care precept each year as well this is obviously in addition to the health and care levy that we will be paying from april uh next year as well so if we if we think about the funding review being a 1.8 increase in spending power that's uh based on an increase in council tax which obviously central government cannot require local government to do what does that kind of look like in terms of how does it stack up against potential pressures well as steven's presentation really helpfully showed even in just the demand for adult social care we can expect that to increase at 1.9 a year so we already have a a potential mismatch between the level of spending power available and just the cost of meeting demand there's then obviously considerably considerable extra cost pressures uh for social care as well the most significant ones being around pay so the social care workforce is one that is predominantly paid at or near the national minimum wage so announcements around increases to that whilst really obviously very very welcome for those staff getting paid more does increase cost pressures for them there's a whole set of wider cost pressures for example energy costs in care homes that will make a big difference so in comparison to that 1.8 increase um in uh in spending power i was speaking to a council last week who said they were estimating their cost pressures were a minimum of six percent um a year for adult social care so for the funding to add up in this spending review you'd have to make a couple of pretty brave assumptions one is that every single council does utilize the full increased council tax that they'll be allowed to do secondly that council tax rise means that the money goes to the right places across the country and as i'm sure a lot of you will know where where local authorities are best able to raise money through council tax does not always correlate to where the need is for social care particularly where means-tested social care is needed and then finally given pressures in social care are about six percent and growth is only 1.8 local government would yet again have to prioritize social care adult social care at the expense of all other local services this is something local government has been doing for the last decade and i think there's got to be serious questions about whether that's still something that's possible for local councils to be able to do given how much they've had to really strip back some of their other services so funding for the existing uh mean status system feels like it's going to remain under quite considerable pressure just to meet minimum cost pressures and to keep up with demand the second area i talked about was system reform and this is where to be honest we are still waiting for a lot of the detail from government so we've been promised a white paper on system reform and that they uh the government has said that will cover um improvements to the workforce and it will look at how to better support carers through support advice and also respite care um it will look at housing in particular through the disabled facilities grant and other ways of supporting supported housing they want to improve information available for people to make decisions and are introducing a new assurance framework to local authorities and wanting to support improvement more across the system so all really really good kind of aims and aspirations but we haven't yet seen the detail we're expecting the white paper within the next days weeks we've been promised it by the end of the year those of you that have followed social care a lot over the last decades will know we quite often get promised white papers and green papers um and they don't always appear but this we are hoping it will appear but if i just give a bit of a sense of what's the potential scale of changing in the white paper so as part of the september build back better commitments around social care that were connected to the new health and care levy government announced 5.4 billion pounds for social care over the next three years it now looks like now we've seen the tables around 1.8 billion of that is for system reforms in the social care sector that's 1.8 billion over three years so around about 600 000 uh 600 million a year that's obviously not a huge amount of money for a social care sector that has 18 000 providers 1.5 million people working on it nearly a million people being supported so i think i think some real questions when the white paper does finally arrive about what's the pace and level of ambition and improvement and to give you a more specific example of that 1.8 billion government has said 500 million of that will support the workforce they've said that that will include looking at improving the provision of training the staff working in the sector which is really welcome it will be some measures around well-being as well but they have explicitly said that will not be about pay in the sector so we have the potential of a white paper that's trying to transform and improve social care but doesn't look like it's going to seriously tackle one of the key issues that's um a key constraint for the social care sector which is its workforce shortages so stephen talked about some of the vacancy rates in the nhs in social care they are just as brave and getting worse and obviously in social care particularly for care homes we've just had the requirement of mandatory vaccinations which is also meaning that people are are leaving the sector so very high vacancy rates very high turnover rates and we now have a sector where people can get paid more in hospitality and in retail than in social care so we see those problems continuing unless something is done about that so that's the the white paper which is pretty much a let's let's wait and see um over the next few weeks but an expectation that it's not going to be radically transformative if that's the only money that's on the table finally we'll come to funding reform um and that kind of big question about how we balance the cost between the individual and the state and this is something that a lot of you would have seen in the news over the last few days because there's been quite a considerable change in what was understood to be the proposal and mps are voting on it today so let me just recap what the cap is what the principle behind it is but then talk about and the change that was made last week so the cat cost model is based on andrew dillmot's recommendations from back in 2010 the idea being when andrew looked at the issue he thought it was reasonable for individuals to plan and prepare to make some provision for social care by themselves but it wasn't reasonable that everybody had the fear of the absolute worst case scenario happening to them are facing very catastrophic costs so in the same way that in other fields of our life we might buy insurance products for our car or a house that's not available in social care for all sorts of um very sensible reasons about what financial services can and can't cost and what risk they can take so andrew said that what we should do then is is concentrate government spend on those the small proportion of us who face very very high costs if that risk is taken away all of us get that piece of my benefit that we will not face those catastrophic costs so the government in september confirmed that it was wanting to implement that cap cost model it set the cap at 86 000 pounds um it then also extended the means test threshold to that support for individuals with lower levels of assets and it extended the upper threshold from 23 000 to 100 000 so a significant increase and the lower threshold from 14 000 and a bit of change to 20 000 and what that means is if you reach a point of having a hundred thousand pounds in assets or less you start to get some support from government on a sliding scale it's set by a taper i think the closer you get to twenty thousand the more support you'll get from government and then you are always left with your final 20 000. um our perspective at the king's fund is that that is the right principle model to base a kind of new deal a new partnership between the individual and state because it concentrates government fund at supporting people with lower level of assets through the means test and providing that protection for everybody against catastrophic costs so we think it's the right principle and it's a significant improvement on the current system but it's going to now be a very big but um so the change that was announced last week was a technical um and quite complicated but very important change to how the cap and the means test interact the simplest way to describe it is whereas before um your personal contribution and the contribution that government makes through the means test both of those counted towards your cap government wants to change that and mps will be voting on this evening to say it's only your personal contribution what that means is individuals of lower and moderate levels of wealth so somebody with you know for example in hartley pool with an average house price of 128 000 pounds the vast majority of them their savings and assets would go to paying for care if they had a long care journey so they're not really protected from catastrophic costs at all they still get that slightly more support through the means test they'll be able to keep twenty thousand pounds rather than fourteen thousand pounds so they are there's benefits for them from this scheme but it's mainly through the means test but they still are faced with that catastrophic cost and the prime minister have said he'd remove that for people and remove that fear of having to sell your house to pay for care so if i just kind of summarize overall where we where i would say the pm is on that promise to fix social care um in terms of adequate funding for the existing social care system through the spending review we do not think that's an adequate level to be able to meet demographic pressures and cost pressures in the system on transforming the existing system to mean it delivers better quality and better support we've yet to see the detail through the white paper but the level of funding available makes us feel like that's going to be quite a low level of ambition white paper and then finally on funding reform it's the right model in terms of a cap cost model but the detail announced last week does mean it's considerably less beneficial to people of lower and moderate levels of wealth who still now face the very real risk of catastrophic costs from social care but at that point i will hand back over to ben thank you wonderful thank you very much sally um and i just remind to remind everyone that you can go to slido and ask questions um there's anything that's popped up there which you'd like to follow up on um perhaps i might start uh just in response to something you just said sally on um on the funding reform aspect of social care and uh this question about the the cap model being the right one i guess it's sort of a philosophical question about how we think how should you think about catastrophic care costs and this current cap is proposed in terms of pounds sterling and no one should face spending more than a certain number of pounds um but clearly people this week seem to be getting um wondered by the fact that that could still mean a much bigger percentage of someone's assets if they're of modest means and a much smaller percentage of their assets if they're a millionaire now just do you think that thinking about the cap in pounds is the is the right way to go is that when you save things as the right model is that what you're thinking or would a cap in terms of percentage of initial assets there are obviously different ways you could approach this i wonder if you had any thoughts yeah a really good question ben and i think these are um i've worked on the cap on and off for sort of a decade and you can get to a point where you can um design it so it's it's perfectly more fair but then it's very very complicated to explain or very costly to administer so i think the two most um not most normally raised alternatives is a percentage of assets or time so if you think about percentage of assets yes that would be strictly speaking much more fair at 65 you determine or at the start of somebody's care journey you determine their asset level and then determine what 15 is that does actually require a very very considerable amount of assessment of people's financial assets that at the moment i think we've got to remember most people don't pay inheritance tax most people don't have that really detailed assessment most people needing social care don't even get the social care means tested part so our view has always been that would create very very considerable administrative cost burden you also then how do you deal with people's assets changing over the course of their uh later life or particularly over the course of their care journey so think that the principle i understand by saying of course catastrophic means a different thing to all of us because we all start with something else but practically it's more challenging the other one then is time and time you know is much simpler you know three years in a care home and you'll get care for free i think in particular the one bit that um would suggest time isn't quite the right way to do it is recognizing that people have different care journeys so most people actually don't just go straight into a care home they will get support in in their own home so how do you count kind of how many years of home care equate to a year of care homes so what what the kind of cap cost does by talking about pounds and pence it really is pounds and pence representing your accumulated care need and pounds and pence's is the easiest way to do it but it's kind of in that trying to recognize the fact that it's you know three years of needing a few hours of home care is a very different financial burden on you than three years of being a care home so it is really tricky um none of them are completely perfect and you have to do that balance of how can you how you can administer it but also how you can explain it and then what does that mean about how perfectly fair is it yeah and i think it's also important to bear in mind that what you said no system is perfect but they're almost all improvement on where we are now so yeah even don't let the don't let the perfect be the enemy of the good i guess we've been waiting 20 years for a better system let's just go let's jump to one now yeah yeah yeah and i think you make a very important point there as well about the sort of the admin burden for local authorities or who can actually have to there's a big gap between announcing a policy and actually having it work in the real world and councils will play a crucial role there and there's also a question popped up on the and the silo which i think i'd like to broad and slight it's a question from jess at bernardo's asking about um how most of when we talk about this it's about adults in particular in social care we talk about as it is almost like a problem exclusively affects the elderly but of course we know about half of all social care spending goes on younger adults and jess also mentions explicitly children and i know children social care is a whole different field but um is there do we need to think make sure we don't lose those uh important areas when we're thinking about the issues facing the elderly yeah um a great question really good question jeff so um absolutely children's social services also under a lot of pressure we we don't cover children social care so we don't have the detailed analysis uh from the king's fund but i suppose where i kind of think about social care and the kind of different age groups is most but not all working age adults with disabilities will receive some form of means tested support so the most important area of reform for that group is the system reform stuff it's the how are we going to improve the quality the personalization where's the workforce that's going to deliver good quality care and to make sure that there's enough funding for local authorities to meet the needs that are presented to them so i think that's really important the reason why we tend to talk an awful lot about how older people pay for care is because at the moment they are paying for it themselves whereas obviously for working age adults it already means tested support for children services it's provided by and paid for by the government so you end up with that kind of big debate about is it reasonable for an individual to pay for their own care should it be a more collective risk pooling like the nhs is what's the appropriate transfer from private spending of wealthier people because they have a care need to a collective risk pool so that's why you tend to have the funding conversation be about older people but absolutely the wider system improvement needs to be really important and there's a major issue with transition from children's social services to adult social services as well to make sure that really works for children and they can live the lives they want to as young adults in our communities absolutely um stephen perhaps i might come to you now there's a question about um well two really first of all you have a nice chart showing sort of underlying co-morbidities and the number of chronic conditions with which people are living rising over time and this also occurred to me as well so that's a believe resource from looking at hospital data and looking at those records of those people and there's a question here asking whether that's because maybe underlying habits like diet or obesity might have changed meaning those are genuine increases we're seeing or is it just better detection or changes in data recording that might be might be driving that thanks ben yeah um so there's reason to believe that over a longer time span recording would have improved so for instance uh in general practice and gps are partly remunerated on the performance against something called the quality outcomes frame but the cloth which involves some measurements of patients and so on so there's reason to believe that would have happened i think most of that would be further back and so from at least 2009 we would believe that it's a real increase especially in his recording yeah and also in in general practice as well um i think there are some changes obviously in risk factors so obesity going up which we hear a lot about but a really interesting uh reason uh which i think some research that the health foundation funded uh found is that some of the people that might be surviving uh so increase survivorship so as a result of better treatment in the nhs people living longer some of those that are surviving might be people that would otherwise have developed long-term conditions later in life um so increased survivorship that might actually be like just a good story as it were and it's another contributing factor thank you very much um there's a question then about um sort of related um about the impact of sort of a dark question i suppose but the impact of higher mortality during the pandemic and what that might mean for care demand um and i guess probably max and stephen i'll ask you for your thoughts perhaps stephen first and max sure because i think you may have some of the detail on this but we did look at taking some of the the excess deaths and stripping that out over population projections so they're i mean again yeah you're right and it's a very morbid uh factor is it where that's yeah but it could be that some of those older groups are slightly smaller as a result of excess deaths during the pandemic um but we didn't find it was actually that sizeable an impact in terms of funding and i think because earlier on in the pandemic there was a kind of logic that some of the people that were dying are people that would have died anywhere would have multiple conditions and so on um and that isn't necessarily the case obviously the age ban was a bit more spread out than maybe was expected at a certain point um basically we didn't find it was a very big factor but it would be a factor and it would slightly reduce some of the demand for instance for non-elective and elective care and max i know uh well i know for a fact you've looked at this um in the past so perhaps you could talk for a few seconds about that yeah so we looked at this more from a kind of slaughter-run perspective of just over the next couple of years how much could the mortality save as you say it's a morbid question but it's a valid question and obr have for example looked at savings to public pensions again from this mortality um it's quite hard to estimate accurately we i think came up with a figure that it might save the nhs 200 million a year for the next couple of years so that as steven says is in this branch scheme of things not that much money it's quite hard because as steven says that was based on age and mortality we might expect these people to be somewhat sicker than average but that kind of has two effects it means in the short run we might be saving more because they might have been heavy uses of healthcare but they might have also already had sort of life expectancies and so maybe that kind of concentrates the benefits in the slaughterhouse but it's a really kind of complex how you'd model that uh but yeah i agree with steven that it will have an effect but not a very large effect great uh there's a question again i think this is probably one for you stephen about thinking about so i thought this as well but nhs productivity trying to reduce it to just a single number to capture all sorts of different inputs and are we measuring it based on the output that it just produces how does quality enter it uh it's quite an abstract concept to sort of get your head around so the question is specifically about how you measure it but um it's clear key input into your model as you make clear and how might we achieve a world where those productive numbers are better and so the ons and the office for national statistics and also the the academic health economics unit up in york they both measure productivity in the english nhs and and you do it as you say there's a range of different activities across the energies ranging from a primary care consultation through to an emergency admission and procedure and so on so it's cost weighted output so you weight it by the unit costs of those different activities to come up with a series for output and likewise for inputs you have a range of inputs mainly staff as i mentioned and it's staffed by different bands and so on but also drugs cost as well so that's weighted too and you compare those two measures so it's input compared to output uh across time um i think in terms of upside i should say something else about productivity there in so far is i think productivity is a slightly distinct factor compared to efficiency for instance so one of the interesting things i mentioned there it's output so it's cost weighted so if you're able to avoid an unnecessary attendance for example that might be an efficiency saving but it wouldn't really show up in productivity figures because that activity no longer took place it would no longer feature in the cost weighted output so i think it's quite interesting thing there about the the difference between productivity and efficiency yeah in terms of how to improve uh productivity i think we have seen over the last two decades in particular for elective care we've seen falls in length of stay and also an increase in the proportion of elective treatments that have been delivered as day cases so we're seeing shorter stays in hospital and what that means in effect is that you can do more with your existing bed base for instance and so you can get more activity and get through more activity with the same number of inputs and that's been a big driver of productivity improvements another would be task shifting so for example in primary care we've seen specialist nurses taking on more tasks that might otherwise have been delivered by gps and that's probably shifting down in terms of the cost of the person delivering that so that would again show up as a productivity improvement i would stress i mean productivity has been high in the nhs in the last 10 years so it's actually been a very successful period uh for nhs productivity uh and going forward maybe maintaining some of those uh changes um would be helpful so reducing them to stay and obviously there's a prospect of technology uh doing more and the removed to say remote consultations uh potentially uh contributing to productivity although it's not wholly clear how that would happen because for instance a remote consultation might save time on the part of the patient but if you have the gp still spending the same amount of time for instance delivering a remote primary care consultation that wouldn't necessarily constitute a saving but you might have for instance lower did not attend rates dna rates and that could be an improvement so it seems to me that that sort of relates in part to some of the questions that are popping up here on um in the slider is obviously a clear focus on workforce and this isn't true for health and for social care and some of the things you talked about sally about pay in the care sector sometimes struggling to keep pace with that in retail or hospitality or you hear sometimes stories about workers going to work in amazon warehouse because the pay is much better and i guess my immediate thought was to look at this immediately through the lens of economics and there's a very famous idea called balmoral's cost disease about where very labor intensive industries struggle to keep pace productivity with more capital intensive industries and but the pay has to rise to match and it seems that healthcare might might suffer from that and i guess the question is how do we go on there's a question you're asking about how we might create the care workforce of the future and how when there are other alternatives available for people how can we make sure that we have enough people working in health and care to deliver these levels of activity and pay is clearly one factor there's also a question for the role of immigration there's a question here specifically about the vaccine mandate well that might lead to staffing pressure um so i wondered if uh perhaps you first sally uh quite a broad funny question i realized but some thoughts perhaps on the challenges we're facing and what might help address them great thanks a lot but yeah i'll try not to do a 45 minute answer today 10 questions um so absolutely critical challenge around uh the workforce and i'll particularly focus on social care because i'm sure others will come in on on the nhs so there are some there are some particularly unique challenges for social care in comparison to the nhs so for example we have 18 000 employee employers in england in social care uh with all of their different terms and conditions as opposed to kind of one set of terms conditions in the nhs there's a much clearer career path pipeline and pathway in the nhs even if you're moving between hospital trusts or between trusts and gps it's a much more established pathway whereas in social care it quite often isn't and quite often you're having to repeat all of your training every time so i think there's a whole host of things that we need to do one is being um yes pay is an issue and i'd say i'm not going to debate economic theory with economists because i'm not one but i would say there's one particular issue for social care which is the reason it can't keep up with pay from other sectors is that government isn't paying enough for care so if you look at how much government's been paying its fee rates for the last decade it hasn't been keeping up so that means all providers can afford to do is just the bottom bring everybody up to the new national minimum they can't do anything else so we've done some analysis at the king's fund that shows the pay differential between a brand new entry into social care and somebody who's been working for five years is six pence an hour that's all the differential then really you risk losing your more experienced people to other sectors so pay is a really important part there's a really important thing for me about um career progression and how we can make it that you can make a career and move throughout your career in your lifetime that requires providers to be thinking more collaboratively about what's the skills possible what the values and skills we want how can we encourage people to move around rather than kind of it feeling more challenging to jump this whole set of things around well-being how we can better support staff so pay is important but it's not the only thing would sell immigration and social care um one slightly tricky thing is i think immigration is part of the solution for social care but unlike with the nhs where people actively come from another country to work in the nhs what we've tended to find was social care it was immigrants who had arrived in the uk who then for various reasons chose to work in social care but it wasn't the primary reason they they were uh they moved here in the first place so i think just changing the visa system for social care isn't likely to be as simple as an answer as it might be for some of our nhs uh workforce shortages but i think at that point i answered enough of those ten workbook questions to throw the ball to um either stephen or max if that's okay i did just have um a couple of thoughts that i thought had come in on something i think on the the nhs side thinking about staffing shortages it's likely to be a combination of training more domestic workers foreign recruitment and also retention so again keeping workers in the workforce that echoes some of the points that sally was raising about the potential of people leaving and so on um i thought just on the normal point more generally because it's interesting to reflect that in the last decade again productivity in the health service unusually was higher than the rest of the economy but the reason in part for that was that you had low economic growth for instance and it's interesting because that meant that you have less pressure on the health care budget but you also have lower economic growth lower growth in government revenues and so on and so it kind of gives us one hand in takes with another answer so in some respects we do want an economy that's growing we do want a high productivity growth in the rest of the economy and that would drive up wages which is one cost in the nhs but would also mean that the economy is expanding and tax revenues are going up so i think it's quite a complicated issue i think that's right basically what part of the reason why nhs productivity since 2010 has on paper performed well as because the budget was squeezed pay was squeezed input costs are held down whilst output was still growing so that it was not bound to have good looking productivity numbers it shouldn't be a pure price effect so i mean again because it's chain weighted and so on it shouldn't just be the reduction in pay um but i think where you've had again substitution of task shifting as it were so where perhaps a lower band staff member is performing those tasks and that might as well yeah that's certainly some of that will have contributed in the last 10 years yep i agree not all of the uh the gains in productivity uh have been uh how do you say probably from the best source and perhaps some of the what looked like lower productivity in the 2000s when we had very high growth in healthcare spending um and we didn't see the same productivity but we did have an expansion in the workforce and in some ways that probably put in place the seeds of when you were able to reap some of those gains in the 2010s so it's perhaps a little bit cyclical as well in terms of how you can achieve productivity gains yeah sure and the point you make about the skill mix changing is is important and perhaps max could bring you in here so um clearly there's lots of scary things floating around and covid has had enormous impacts on huge parts of the of the health and care sector but um one thing people have talked about is that there might be you know permanent lessons the nhs is itself said there might be permanent benefits that we can lock in and some of that might be to do with around skill mix and experimentation that we've had to do and perhaps we never would have done otherwise um and so if you're taking a glass half-full approach uh what might some of the benefits or lessons we can learn from the nhsb from the pandemic yeah that's a really good question because obviously the pandemic has been terrible for the health service given that it's a pandemic but yeah there are some potential silver linings and i think as you say even in kind of april 2020 to just a month in the pandemic nhs england were kind of pushing the some of these big disruptions and changes if they were beneficial could kind of be locked in in their terms um so there are many different potential benefits steven already mentioned one for example which is remote outpatient or remote gp appointments again this is unlikely to save potentially might not save much clinician time but one of the potential big benefits is reduced uh not arrivals which um so we've modeled that could save actually quite a lot of money um you know it's amazing how much outpatients has been shifted as we said earlier there have been 20 million fewer outpatient appointments but actually they would have been like probably double that it's just that many have been moved to um remote and telephone and so if that kind of maintains that could be a potential benefit of course it would have to be implemented well and i think health foundation have done some work on that there are many other potential benefits again and how you different staff doing different things again coming back to this point about staff mix the pandemic meant that if people were doing what they wouldn't normally be doing in hospital and maybe some of those benefits some of those things were beneficial and again could be carried forward so yeah i think it's really hard to know actually right now but there are potential benefits here if i could just quickly jump in on this ben to link some of the benefits to the current um legislation that's going through the house one of the things that we saw a huge amount over the pandemic was a real collaboration and joint working amongst different hospitals so sharing of staff across just difficult different sites shifting of pathways to mean that one hospital was sort of what we called hot the other was cold and i think for ages we talked about the potential benefits of integration but a lot of people hadn't touched it and smelt it and actually doing that under the pressure of the pandemic meant that they started to see that they could work differently and with organizations they had before been meant to be competing against so actually they finally were not just collaborating in theory they were doing it they were thinking about it on monday and they were doing it on tuesday that sort of how quickly it was happening so quite a lot that's in the new health and care bill about integrated care systems and integrated care boards that's about trying to lock in that different way of working that says we're not all competing units we're actually trying to think how to best use our resources in a different way and some of that's also between being across the nhs and social care boundaries with nhs leaders thinking the quickest way for us to increase our capacity is to get more social care workers into the sector then that means more people can be supported at home rather than thinking the answer to the nhs problems is more nhs stuff so some really creative thinking as well well it's great to have some positive news for once um there's also a question which relates to the top uh the top one on slido actually which is not just about sharing hospitals and workforce between different nhs trusts but also one thing that happens um is the sharing of workforce between the public and private sectors and we know for example lots of nhs doctors do private sector the work as well and there's a question here about uh whether the role what's the rule of the private sector effectively in trying to deal with the waiting list backlog and perhaps i'll say a few words if anyone wants to join please do um i guess clearly the private sector even pre-code was playing a role in performing lots of routine elective surgeries i know that work from some of my colleagues here at ifs has shown that um that boosted public sector capacity allowed the public sector to do more hip replacements for example than otherwise would have been able to and there's no reason to think that uh there wasn't a role for the private sector in dealing with the backlog i guess my one concern i have is that first of all it's not obvious that always more private sector activity increases the net amount of care if the doctors doing the prior sector activity are doing less nhs work as a result so i've got to clearly take all of this in the round and then secondly there's lots of um we've seen i think there's the data on this is fairly poor but anecdotally we know there's been a big increase in demand for out-of-pocket payments for private care so people going sick of the nhs waiting list i'll go and pay for my own uh my joint operation whatever happens to be and if that's happening private sector hospitals may find that to be more lucrative than taking nhs contracts so i'm sure the private sector will play a role but uh precisely how big a role and you know that all remains to be seen um i don't think anyone else has any other thoughts on that sadly you've gone off mute gone i would just just to reiterate the point about kind of how much of that is genuine additional capacity so a lot of the staff who make up the private sector are nhs staff so you know they're already exhausted through what they've done over the last 18 months i think the idea that they're both going to be able to maintain current levels of nhs activity and do more in the private sector is i don't think very reasonable plus you add in all of the pension and tax complications for consultants and they're not particularly incentivized to do extra work at the moment so i think yeah it's easy to think about kind of imagine these are an entirely different separate system with all of their staff and all of their facilities the facilities are there but the staff is a much more shared resource than i think most people would understand any final thoughts stephen or maxwell it's about almost time for us to wrap up i just mentioned on that as well there might be a mismatch between supply and demand in the sense that there's a lot of private sector capacity for instance in london uh that might not be where the the patients who miss care are likewise i think the private sector does a lot of some procedures but not all procedures so again that might not match up um but otherwise i could work your own points and sally's okay um i think we're not going to have time to get to every single question on slido so i'm sorry if you didn't get round to yours um clearly we should have booked in two hours rather than just the one um but thank you very much everyone for joining thank you ever so much to sally steven and max and i hope you all have a wonderful afternoon right thanks everyone