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What?s behind the crisis in the NHS and social care?
by Andy Cowper

You?ve seen the badges: ?I heart the NHS?. And it?s confirmed by opinion polls, which repeatedly find that the British public say the NHS is our biggest sources of national pride, ranking above the monarchy, let alone victories in the Second World War and the 1966 Football World Cup.
The NHS featured prominently in the London 2012 Olympic opening ceremony, in a way it?s difficult to imagine any other country?s health system doing. And the Brexit campaign made significant traction with its promise that the £350 million a week we ?send? to the EU (over half of which comes straight back) could ?fund our NHS instead?
Why, then, does the object of our national love seem to be in a state of ongoing near-crisis? And what is likely to happen next?
Several big factors play in to the problems facing the NHS. The first of these is that we have an ageing population, for whom medicine and healthcare can do far more (and at higher cost) than ever in the past. One of the most-feared diseases, cancer, is - if diagnosed early - now more amenable to treatment than ever thanks to new and highly expensive drugs.
The increase in our lifespans is striking: the UK population currently has over three million people aged over 80. By 2030, it is suggested that this figure will almost double, and reach eight million by 2050.
Today, one in six of the population is aged 65 and over: by 2050, it will be one in four. A man born in the UK in 1981 has an estimated life expectancy at birth of 84 years. But for a baby boy born today, that increases to 89 years, rising to 91 years by 2030.From 2012 to 2032, the populations of 65-84 year olds and the over-85s are set to increase by 39 and 106 per cent respectively, whereas 0-14 and 15-64 year olds are set to increase by 11 per cent and 7 per cent respectively.
This hits healthcare use, and thus costs, hard. The oldest old (aged 85+) accounted for 585,057 of the 12.2 million (4.8%) first attendance to English A&E departments in 2008-9, and 62% were admitted to hospital. Around one in three people over 65 admitted acutely to hospital are in fact in their last year of life.
The longer we live, the more likely we are to have one or more long-term conditions (such as asthma, lung disease, heart disease, dementia) for which no cure exists and which can make other health problems worse and harder to treat.
Our increasing old age is a result of economic success as well as healthcare success. But the economic growth has not been an unalloyed blessing, coinciding as it has with easy access to cheap, energy-dense ?junk? and processed foods. Alongside the demand pressures of our ageing population, we have also seen a rise in lifestyle diseases, such as obesity and Type 2 diabetes (caused by an unhealthy and over-sugary diet). The health impact of lifestyle diseases are spread across all age groups, and are heaping on the pressure to the NHS (as well as worsening the quality of life of those who fall into this trap).
Then there is social care, an area poorly understood by many people. While the NHS is free at the point of use, social care is means-tested and is chargeable for anyone with total wealth (including the value of their house) of over £23,250.
Part of the reason for our generally poor understanding of social care is that its name is woolly (and far less self-explanatory than the National health service). Social care is basically support with the activities of everyday living (dressing, washing, eating, etc.), and is commissioned (planned and funded if eligible or charged for if not) by local authorities, who set thresholds for what makes an applicant eligible. It is generally needed by frail older people and the disabled, to help them remain living independently in their homes.
Austerity (the Government?s reductions in public spending which follows on from the 2007-8 global financial crisis) has meant that local authorities have lost over 30% of their core central government funding since 2010, and more is to be taken from their central budgets. This has meant that eligibility criteria for those entitled to state funded social care have been higher.
The consequence of this has been felt in the NHS. People who ten years ago would have received support to dress, wash, cook and eat can no longer get it: consequently they are more likely to have falls or develop illnesses, and have to be taken to hospital, often through A&E. Once their medical problems are resolved, many then enter a ?Catch-22? situation where they are medically fit to be discharged but are assessed as being too vulnerable to live independently without ? social care support.
Such people are often marooned in hospital until a package of social care can be arranged. Many deteriorate fast if they are left in bed: older people?s fitness and abilities to move decline sharply if they are left in a hospital bed without being helped and encouraged to get up, walk around and (where safe) do things for themselves.
Although NHS funding (alongside education and overseas development) has enjoyed relative protection since 2010, the increases for the NHS have been only just above the rate of inflation. Meanwhile, NHS demand and activity have been rising each year, and the national waiting time targets have not been relaxed. Expert analysis suggests that the NHS would on its normal funding trajectory expect to have £30 billion higher annual funding than it is set to receive.
NHS leaders developed a plan called the Five-Year Forward View to deliver £22 billion of the £30 billion through quality improvements and efficiency gains, and the Government agreed to provide the other £8 billion in finance. However, real-terms Government cuts to other non-NHS budgets (such as those for training and public health) have led expert health analysts to conclude that the real financial increase is closer to £2.8 billion, once inflation is taken into account.
To try to help the NHS act in a more system-wide way and work more closely with social care, the 44 regions of the NHS in England have drawn up local stabilisation and transformation plans (STPs ? jokingly known by some as ?sticky toffee puddings?, and by others as ?sell the premises?!). These are meant to deliver difficult service changes ? which will undoubtedly include some closures ? to allow the NHS to meet demand while staying within budget.
A key contributor to the NHS?s almost achieving financial balance in recent years has been seven consecutive years of pay restraint, with a 1% maximum uplift for most staff. This means that NHS wages have been rising below the rate of inflation.
Meanwhile, not only are there some early signs that Brexit may be slowing the UK economy and therefore tax revenues, but nursing bodies have recently pointed out that the rate of recruitment of nurses from within the EU has collapsed over the past year.
The likelihood is that the current public anti-austerity mood will raise pressure on politicians to raise funding for the NHS and indeed social care. Local authorities have already been allowed to raise council tax to support social care funding, and many have done so to the maximum amount allowed. The consequence of this is that taxes are likely to have to rise, in the middle of an economic slowdown. Forget talking about a perfect storm ? this promises to be a very nasty storm indeed.
Andy Cowper is a Hampton resident and a journalist who writes about the politics and management of the NHS.

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