(As an experiment, try reading this piece but substituting ‘co-productive process’ for ‘commission’. You may like it more).
My good friend Mervyn Eastman is sceptical about Independent Age’s campaign for a commission on health and social care funding and just before Christmas challenged me to explain the benefits of having one.
This is my response and it’s basically this: what is there not to like about the idea of thoroughly, openly reviewing health and social care and proposing a way to fund it for the future?
Let me answer my own question: the stated oppositions tend to come down to four, inter-linked arguments:
- A commission would take too long
- It’s a way of putting off decisions
- We’ve already had lots of commissions
- We know the answers already
These are all understandable counters but – to me - none of them holds up under examination.
Firstly because a commission doesn’t have to be a long process. It could easily report in a short time period – say, 6-12 months.
Secondly because a commission gives a route to the thing that’s most needed – an honest, open conversation with the public. Yes, we’ve had previous reports and commissions but we know that even the basics of what constitutes – for example - social care are poorly understood. Yet we still want to rush to judgement on the future of health and social care without that engagement (something that Sustainability and Transformation Plans have, of course, been rightly criticised for).
Partly we make that mistake because we imagine we know how best to sort out health and social care already. But we don’t. Ask 100 people in the sector what we need to do and the only consensus you are likely to get is around ‘more money’ and ‘more integration’. Those are necessary factors but not in themselves sufficient (even if you could get people to agree on what ‘integration’ looks like).
There is not even agreement on the most basic question: where do we get more money from. The default answer is ‘general taxation’ but we simply have to be prepared to discuss other, additional options. That’s partly because any solution that is a) affordable and b) genuinely long-term will also need to have cross-party support (something a commission is best placed to deliver) and that is highly unlikely if the only funding proposal is tax. Yet we don’t get on too well with more difficult funding solutions, do we? The Barker proposals around additional taxes but also other sources of revenue were met with a wall of silence when they were released. The choices were too difficult, the decisions too hard for many to engage.
So a commission, far from being a route to put off decisions, should be a way of coming to the best ones. That, after all, was the successful role played by the Turner Commission on pensions around a decade ago. And surely it is preferable to the only other obvious route on offer – a green paper. Does the Department of Health (DH) really have capacity to do generate the sort of ideas that are needed? And how co-productive a process would development of a green paper be? While DH was exemplary in its engagement around the Care Act, times and personnel have changed.
But the publicly stated reasons for not wanting a commission are not the only ones. The other one - sometimes stated explicitly, sometimes not – is:
- We might not like what a commission recommends.
The most obvious example of this is the fear that a commission would be a back door to ‘privatise’ the NHS. This is a blow that to land properly has to be wrapped in a conspiracy – the belief that politicians, on all sides, are looking for an opportunity to sell off the NHS.
If you are convinced of that conspiracy then I will not be able to dissuade you – indeed you will probably see me as part of it. If you are more open-minded, though, you might be as confident as I am that our publicly-funded, free-at-the-point-of-use NHS is equal to any in the world in terms of value and efficiency, and expect to have that demonstrated independently by a fair-minded commission.
So that’s it. A case for a commission. You will realise that it depends upon some pretty clear ideas about the type of commission that is called for. What I want is a commission that provides the route to a genuine, open, honest process that engages the public. That outlines the options facing us as a country on health and social care and allows a wide-ranging debate, leading to real, long-lasting decisions. It does not even need to be called a ‘commission’, if we struggle with that word. But we do need the process and, my goodness, we need to get it underway quickly.
So there you go Mervyn, I’ve given it my best shot. How did I do?