We all know about the different long term challenges facing our public services. The ageing population and the increase in people suffering from long term conditions, for example, have huge consequences for the NHS and a social care system that, despite the best efforts of a neglected workforce, is widely seen as woefully unfit for purpose. The scale of these challenges as they gather pace is truly staggering. One recent report suggested that there will be:
- 51% more people aged 65 and over in England in 2030 compared to 2010
- 80% more people aged 65 and over with dementia by 2030 compared to 2010
- 50% more people with three or more long-term conditions in England by 2018 compared to 2008
Added to this is the challenge of rising expectations, with surveys and studies telling us that members of the public want more personalised, relational public services, and greater involvement in decisions that affect them as users and patients.
But as UNISON’s new publication, ‘Securing the future of our public services’, makes clear, the capacity of services to respond and face up to these challenges is being constantly undermined by all out political attack from a government committed to unprecedented spending cuts and a smaller outsourced / marketised service delivery model.
So, at a time when public services, those that use them and those that provide and support them, should be confidently and boldly debating about how we adapt our NHS, social care provision and all parts of our public services to a more complex and demanding set of needs, we are instead struggling to do more with less in a state of continued upheaval. The effect on patients and service users is already profound, even though most of the cuts are still to come.
What to do? One approach is to come up with new models for service delivery that address the challenges outlined above whilst sticking with the goal of clearing the deficit over the next parliament. Proponents of this approach would call it ‘fiscal realism’ rather than austerity. Others say it will lead us to a situation where the choice at the next election is simply a choice between different models of austerity rather than one between different varieties of economy and society.
Key propositions from advocates of the fiscal realism model include the suggestion that government needs to concentrate the fewer resources it has on prevention and earlier, more effective and collaborative interventions rather than the costly consequences later down the line. Another is that power needs to be devolved to local level, where people develop the public realm together rather than have things done to them by an ineffective, old style social democratic state designed around Whitehall silos.
Whist different aspects of these ideas are clearly worthwhile, there are obvious problems too. One is that it sidesteps the problem of transition costs. As ‘Securing the future of our public services’ points out, upfront investment will be needed to shift successfully to a system that is more oriented towards collaboration and prevention. In health and social care for example, service improvements will require large scale levelling up, rather than a simple shift of a dwindling resource.
Another problem is that whilst advocates of this approach see letting go of power as part of the solution, they still want to place tight constraints by not letting go of the purse strings. So, even where a local authority has more responsibility for public health, to take one example, it will still be constrained by cuts at a time of rising need.
But a second approach, which is the one advocated by UNISON in ‘Securing the future of our public services’, starts with the proposition that we can make different choices about how government deals with the national debt, local and national taxation and how much we, as a society, spend on public services as we face the challenges set out at the start of this article.
As such UNISON is calling for sustainable funding for public services underpinned by:
- a new deal to repair the public finances. This should include more progressive taxation (including higher income tax on high earners and a clampdown on avoidance and evasion) and the kinds of reforms that Adair Turner and others have been calling for on writing off national debt and using Quantitative Easing to invest directly into the real economy
- reform of local authority finance, including freedom to borrow to invest in housing and increase council tax and create higher bands for higher value properties
- a thorough review of funding options necessary to ensure that we get the social care system we need so that we, as a society can meet the care needs of an ageing population.
Some will see this as unrealistic. They will point to the way in which David Cameron was all over Harriet Harman’s supposed LBC gaff in which she said she simply supported progressive taxation. Let’s not let the Tories re-run the 1992 election they will say. Others will argue that the public made up their mind on this issue in 2010. They do not like cuts, but they have accepted they are going to continue.
But the challenge to fiscal realism should be laid at the door of all parties – not just Labour. We need to open up a space in the public debate for choices to be explored (polls suggest there is an appetite for this). To not do so risks disengagement, as voters switch off because of the lack of alternatives. It let’s the current government off the hook for the chaos that austerity is now letting loose on all of our public services. But most importantly of all, it lets down the millions of people who rely on decent public services that are funded according to their needs.