The prime minister and chancellor have bolted themselves together in a mutual destruction pact. Come hell or high water, the national insurance rise will happen, rudely snubbing a campaign by the Daily Mail. The Tory right wants no tax rises and no spending, while Labour wants the highest tax burden to be paid by those who have the most. But instead of hitting older people, or the unearned income of rich people, this tax will be paid by young people.
It’s a political shocker: the NI rise will take £255 a year from typical earnings, in perfect synchronicity with the explosion in fuel bills, council tax rises and inflation, which is on track to reach 6% by April. The government has also ruled out abolishing VAT on fuel, another regressive tax. This is an epic case of political and policy mismanagement.
The tax hike is intended to keep Boris Johnson’s pledge to solve social care “once and for all”. But virtually none of the money from this tax hike will reach care. Most of it will be consumed by the 6 million-long NHS waiting list. Johnson’s promise that “nobody needing care should be forced to sell their home to pay for it” is so badly framed that it will reverse his promises to “level up” the UK: the regressive £86,000 cap paid by everyone with property or savings is a flat tax, so those in the north with cheaper properties may lose everything, while owners of more valuable southern homes can expect to pay just a portion of their wealth. Every aspect of this policy seems designed to anger almost everyone while failing to tackle the real crisis that leaves a million and a half people with no care, while care homes and domiciliary services tumble into bankruptcy.
The government has proposed no real reforms to this chaotic system. One of Margaret Thatcher’s most destructive privatisation programmes was forcing councils to shed care homes by only subsidising residents in private homes. The result was that a hotch-potch of private providers emerged in the following years, from small family businesses to huge private-equity companies and property asset-strippers that loaded care homes with debt.
There has always been tension over the division between NHS and social care. The health and care bill now bumping through parliament creates “integrated care systems”, designed to pool resources between councils and the NHS. This may work in some co-operative areas, but it’s already clear that merging two hard-pressed sectors is too fraught to work. Who’s to blame for record numbers of NHS beds blocked this winter by patients waiting for social care? Even before Covid, these numbers were rising. From 2014-15, there were 1.6m total delayed bed days in England, when frail people languished in hospital due to the lack of a care package or care home place. Gaining only a nugatory share of this new levy, local authorities, which have suffered severe cuts over the last decade, still won’t be able to afford to put more money towards social care.
But here, for once, is a bright glimmer of light. As far away from Westminster as NHS England stretches, Northumbria Healthcare trust is showing how health and social care can be merged – and it is doing so by reversing Thatcher’s social care privatisation. It is insourcing care, bringing it under the wing of the NHS. Sir James Mackey, chief executive of the Northumbria Healthcare NHS Foundation, returned in 2017 from a secondment to a national role as head of NHS improvement, full of innovations.
Here’s how the Northumbrian plan works: Mackey’s trust has bid for social care contracts from local authorities that would usually be awarded to private providers. The NHS foundation will seamlessly integrate domiciliary care within the health service. Mackey plans to build care homes to take over residential contracts too, if he can raise the capital. Here is a smooth transition without bottlenecks between the two sectors, with health and social care funded from the same budget, with every incentive to stop people needing a hospital bed and to get them home quicker when they do.
Better still, Northumbria is integrating what will be 250 care staff between the two services, so they are all on the same NHS agenda for change pay scale, preventing the flight of underpaid care workers to other sectors. Where care was often a dead-end job, Northumbria offers an NHS career path with training for everyone from porters and cleaners upwards. How can Mackey afford more generous pay, I ask? “Private equity takes 8-10% in profit, but we can spend that on better conditions for staff. I want home carers to have the chance to become directors of nursing,” he says. To this end, he is building a health and care training academy with Northumbria University and has helped to set up a profitable factory making scrubs and PPE. “Why buy from China when we can employ people here?” Next comes a laundry and a sterile services unit, such as the NHS used to run in the days before outsourcing.
What’s the catch? This fortunate trust is exceptional. It has less debt than most, fewer vacancies and a waiting list backlog so short it will probably be gone by April. Northumbria’s problems are social, Mackey says: “High unemployment, inequality, poor education cause the worst disease burden. Levelling up? Give us the money to do what we need locally.” Trusts around the country are flocking to see how Northumbria does it, though most are too sunk under debts, mile-long waiting lists and workforce crises to follow this path.
Imagine if they could. The NHS could solve the social care crisis with a seamless gold-standard service that is as good for care staff as it is for patients. But first the health service needs to be freed from the crushing pressures it faces after a decade during which it has received the lowest ever level of funding. Instead, the Johnson-Sunak NI tax rise comes with no plan for any solution.
Polly Toynbee is a Guardian columnist
