THE 2021 FESTIVAL OF SOCIAL SCIENCE RUNNING 1-30 NOVEMBER 2021
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?
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