Summary: A principles-based national framework for social care
The recent £20bn birthday present to the NHS was welcome, if underwhelming, but the more pressing question facing the UK is how to fix social care. The two are connected of course, ‘bed blocking’ costs up to 8,000 lives a year. In today’s ageing society there is a growing awareness of the ‘social determinants’ that drive health outcomes and therefore impact both social care and the NHS. This note suggests that in today’s world we need a new approach is needed, based on four design principles: person-centric, holistic, ageless and market-driven. It then suggests a plan to fund a national care strategy with three components: universal long-term care insurance, devolution, and a personal purpose platform.
An increasing recognition of the ‘social determinants’ of health…
The NHS was designed to fix people up and get them back to work. It was not built for the chronic, incurable, diseases of today’s ageing populations. As the Robert Wood Johnson Foundation (among others) have shown, 80% of health outcomes are due to non-clinical factors namely behavior, social circumstances / income, diet, exercise, transport, housing, environmental / physical influences and genetics. Living impacts health, before the reverse is true. Today’s soaring income inequality in the West is reflected in gaps in life expectancy between rich and poor that have widened to 8 years, up to 15 years in some places, and even more in America. Addressing this is an urgent, political, economic, and moral priority.
…yet increasingly overlooked and underfunded by government
These multifaceted determinants are unique to the individual and their local environment. In the UK, today’s patchwork social care system is inefficient and unfair – a postcode lottery dictates available services, while many are seeing cuts in funding. These social factors are not, and should not be, in the realm of medical industrial complex. As the largest employer in Europe the NHS already has a problem with scale. It has proven unwieldy and hard to manage (e.g. the £10bn botched IT rollout), and its sheer size crowds out private sector innovation. As a result, keeping people healthy and out of the healthcare industry is an important goal, but there is no organization, funding body or ministerial career track responsible for owning or advocating this vital goal.
Design principles for a new approach to care
As we look to fix social care, let’s step back and ask what a new system would be like if designed for today’s world. In an era of unprecedented demographic change, exponential technological growth, urbanization and globalization, four design principles can frame a new approach:
Person-centric | Putting the individual and their needs at the centre
At a recent CQC meeting I attended, someone made the point that in the era of smartphones, the internet and self-diagnosis, it’s time that people took back the term ‘primary’ care to mean self-care. GPs and hospitals should be play support, not lead. This has multiple implications. The doctor is not in charge of your health, you are. The local council is not in charge of your ailing mother, you are. But you need tools, expertise and resources to support you in the journey for you and your family, and you need to have access to and own your own data. Systems should be designed around the needs of individuals, not political priorities, local budgets or industry segmentation.
Holistic | Combining health, wellness and social determinants
Any system needs to integrate the full range of health and social care aspects that impact lives. A population health strategy that does not have access to data or insights about the demographics, income levels, housing or transportation services is not fit for purpose. Overcoming traditional silos and in-built antipathy to sharing data and insights must be overcome in the service of a common mission of better health for all.
Ageless | A proactive, preventive approach to serve the whole lifecourse
An approach that addresses the ‘life course’ i.e. from cradle to grave is needed. There’s no point suggesting that an unhealthy 90 year-old get 10,000 steps a day if they’ve done not exercise for the past half century. This suggests we need to build and maintain high-quality, longitudinal health records which also includes data about an individual’s activities, diet, genetics, exercise and other aspects that make up the social determinants. It also suggests that products and services should be age agnostic – people shouldn’t be discriminated against based on their age, or struggle with products that are not designed to work for 8 to 80 (and 90) year olds.
Market-driven | Unleashing the power of the market for public benefit
The ‘silver economy’ is not a simple homogenous market but a combination of markets and niches which together reflects an enormous and largely untapped opportunity. 70% of consumer purchasing power is in the hands of the over 50s, equating to an estimated €3.7 trillion of market activity across Europe in 2015. People are being underserved via lack of access to consumer insights, inefficient capital markets and broken business models; there is market failure that needs to be addressed. However, when harnessed, the public benefits that accrue from a fully functioning market economy will be significantly better than anything public schemes could or should be implementing.
With these four principles in place we can start to design a plan that works for people, comprising three elements:
Element 1. A universal long term care insurance scheme
A core paradox facing policy makers is that while it’s being recognized that health is a factor of one’s local environment, funding to local councils has declined in recent years (grants to local government declined by 49% from 2010-2017, sending many to the edge of bankruptcy). A new national scheme would require a bold new social compact – a commitment to care for people in later life based on their need, not their postcode – and a requirement to fund this with a compulsory insurance scheme. To avoid the burden falling unduly on the young, this would not come out of general taxation, but a means tested contribution payable only by people over 40, similar to the Japanese model (see box).
Unlike many private insurance schemes which are increasingly cherry-picking (such as John Hancock’s new approach to ‘personalized’ life insurance), a public insurance option spreads the net to all members of society in order to maximize funds and minimize the ability for people to game the system and avoid adverse selection that bedevils private schemes in the US and UK. A universal fund, paid in a means-tested way, would generate significant premiums that could be then directed to those who need it. Unlike the Japanese scheme which apparently is still highly regulated, a UK version could draw on the ‘customer-centric’ principle and have insurance money follow the individual. Once a need is independently assessed, the individual would be able to claim benefits on their terms – either going to a nursing home or having care in their home (for example funding a home modifications program such as in Johns Hopkins) or personal budgets (such as in Australia).
| Box: Japan’s Long Term Care Insurance Scheme.
In 2000, facing a difficult economy and a health system on the verge of breakdown. According to a comprehensive report by the Nuffield Trust on the scheme, the average length of hospital stays for the over 65s in Japan was over 50 days in 1990, turning hospitals into de facto expensive nursing homes. After much political haggling, the Japanese instituted a compulsory, universal long-term care insurance scheme. It required everyone over 40 to pay into a national scheme that was designed to fund the majority of care needs for older people based on an independent assessment on a 5 stage scale. The mandatory insurance policy (administered in a means-tested way, and connected with employers’ other social security contributions) contributed to about half of the running costs of the scheme, the rest coming from the federal government. Although there have been challenges getting the scheme up and running, and now the sheer weight of numbers is putting pressure on the funding, it has largely been seen as a success, reducing the number of older people in poverty, the pressure on family members (especially daughters) and holding the costs of healthcare in Japan down to only 14th highest in the OECD, while its population is the oldest. |
Element 2. Devolution to the regions
In the case of successful and healthy ageing, it really does take a village. In today’s society families are often broken up geographically, and while there are things we could do to encourage multiple generations to live together under one roof (for example in providing tax relief to granny flat conversions), it’s quite unrealistic to expect this to change dramatically. Instead, providing a new emphasis for local community building with successful intergenerational living will be key. This could include:
- Increasing budgets to fund local community building interventions that unite health and social care, such as intergenerational housing, transport infrastructure, volunteering and time-banking projects, ‘Frome’-like care coordination schemes. Local level coordination and funding of joint social care and health projects is more likely to succeed than large national programs, and early indications are from Manchester that a combined approach have the makings of success.
- Support for physical local community hubs that unite all generations and provides useful services, such as the Common Room concept by Age of No Retirement, and city-centre locations to providing tech training and social engagement to adults such as Senior Planet in Chelsea, New York.
- Age-friendly cities and communities programs that unite communities behind local strategies to ensure that local products and services are ageless and allow maximum participation across all ages.
Element 3. A personal ‘purpose platform’
We have known smoking is dangerous for decades, yet still millions smoke. We know overeating is bad, yet a third of people in the UK and the USA are obese. Health messaging is boring and rarely followed. Instead, a more personalized approach is needed that takes the time to craft a unique plan for every individual. If an older lady wants to attend her daughter’s wedding next year, but is currently too sick to walk, a focused plan to get her to the aisle is more likely to succeed than bland admonishments. Doctors and nurses already know this, yet have few tools to do this (social prescribing notwithstanding). Part of the social compact, funded by the long-term care insurance is the creation of a personalized purpose platform that articulates and meets the needs of people living independently. This platform is a tangible benefit of the long term care insurance that they’ve been paying.
The platform would be tech agnostic, and it’s not in scope of this paper to specify it. However, it’s clear this is not a robot that beeps angrily if people don’t take their pills, but will be a form of personalized experience, enabled by both technology, people and the latest behaviour change science, that supports the individual on their journey, and helps the family manage their healthy, independent life. This platform or platforms is yet to be built but we can already see elements that could work.
One example in this direction is AgeWell Global, which trains older people to go out into the community and help other older people (say those who’ve just been discharged from hospital with a daunting list of todos) to use personal technology (such as vital sign monitoring) and manage their own care.
Another is the phone help line SilverLine, which gets 10,000 calls a week. This could become a powerful aggregator of older people’s needs – and purchasing power – to stimulate entrepreneurs to meet their needs. A final example are the emerging open data models (e.g. Tim Berners Lee’s Solid project, Finland’s IHAN, or health analytics platform MySense) are building platforms to enable people to own their data and utilize the power of big data to develop powerful models that learn and evolve.
The government’s role here is inevitably going to be relatively lightweight, limited to general guidance, metrics of success, funding and potentially standards setting. Tools such as the forthcoming £98m Industrial Society Challenge Fund could be used to test and reward innovators looking to construct such models.
Fixing social care in the UK is not for the faint – or feint – of heart. A new approach is needed recognizes the world has changed since the beloved NHS was born. These design principles will apply to many developed countries with similar demographics, and many countries are asking themselves the same question. As the UK finds itself at an existential crossroads, however, wherever we land in respect to Europe fixing our system of care is going to be an increasingly urgent challenge. The country has an opportunity to build on its tremendous data sets, cutting-edge expertise and (not insignificantly) the global brand value of the NHS to piece together a social care system for the 21st century that it can be proud of. The longer we wait to act, the harder it will be.
