It is time for a new settlement for health and social care in England

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Part of Commission on the Future of Health and Social Care in England

Coming new to the topic of health and social care, I have found the past nine months, as the chair of the Commission on the Future of Health and Social Care in England, surprising, moving and very challenging. Surprising because of the stark difference between the public funding of health care and social care; moving because of the stories from patients and their carers; challenging because we are seeking to narrow a deep-rooted divide. In the interim report of the commission, published today, we explain why there are some truths here which must be faced, and then propose some options for change.

It’s time to face facts. A health service with a ring-fenced budget and free at the point of use is not likely to work well with a social care system funded through local authorities and heavily means-tested. And indeed, the evidence we collected for the interim report, including meetings with stakeholders and first-hand testimony from those who have to grapple with the two systems, proved that too often the present state of affairs does not work well for patients and their carers.  Additionally, both parts of the system are under financial pressure, which means that even the present unsatisfactory situation may not be sustainable.

The Dilnot reforms to social care funding are a step in the right direction. But for many people the costs of social care will remain high, with access to public funding limited to those with high needs for care and low incomes. 

It is the Commission's belief that the nature of illness and care today has changed so much since 1948 that the original settlement establishing the NHS and social care system urgently needs to be re-visited. Our stake in the ground is that England should move towards a single, ring-fenced budget for health and social care that is singly commissioned, and within which entitlements are much more closely aligned. Inevitably, this leads to questions, two of which we will address in our final report: how should entitlements to publicly funded health and social care be aligned? And how should this be financed?

In addressing these questions and considering the options, we have used – and will continue to adhere to – some key criteria. Any new settlement needs to be equitable (similar needs today do not receive equal treatment), to be efficient in terms of value for money, to be financially sustainable, and to strike an appropriate balance between collective and individual responsibility. Crucially, it must deliver better care for patients and carers and be a system they can understand.

We are looking for responses that discuss how the boundary between eligibility for public funding might shift. In the past this boundary has been less fixed than many assume, and it ought to move in response to the changing nature of care needs.

We are looking for views on how the new settlement could be financed. In round numbers we spend about £150 billion – or 10 per cent of our national income – on health and social care, about a fifth of which is paid for by individuals and families. In addition there is a lot of unpaid care, and we want to consider whether these carers should be better supported.

Some options for funding are set out in the interim report – and range widely from big tax proposals, to changes to tax or benefits for the elderly and increases in user charges for health care. We are clear, however, that we would only support higher user charges if these were linked to an improvement in entitlements. A couple of options – a wholesale switch to social insurance and tax relief on private medical insurance – have been ruled out as not meeting our criteria. But otherwise we are open-minded and would welcome other funding suggestions.

These are uncomfortable choices. But the health and social care systems are currently structured and funded in a way that is both inequitable and financially unsustainable. We need to act now to develop a clear vision for health and social care in the 21st century.

This blog is also featured on the Guardian website.


David Richard Wallis

Position Systems Limited (PSL)
Comment date
03 April 2014
There is wide scope for radically improving the productivity of the NHS, which would enable Health and Social Care to be given the same merit,
financial resources and value. This radical improvement would also allow unpaid carers to be awarded the same value and financial support. A much greater effort needs to be made to investigate and analyse those NHS services (in both hospitals and care-homes) which can very easily be automated, thus saving many £millions: infection-control monitoring and management is one of numerous examples. Radical improvements in productivity can also be achieved by investigating and analysing those top-performing industries that are not currently involved in Healthcare, but can offer solutions through technology-transfer and emulation of their methods and procedures: supply-chain management at Tesco is again a typical example. Additionally, Universities and their closely -associated Teaching Hospitals should encourage the convergence of Medical and Engineering Science, so that the latest developments in Electronics and Wireless Engineering, etc. become familiar to Medical Practitioners. Likewise, more Engineering Scientists need to be encouraged to think along BioMechEng and Biotech lines - a strong suit for UKplc, with significant export potential, thus generating more enabling funds. This logical direction-of-travel is being pursued by PSL, in conjunction with well-informed organisations like techUK, Surrey University and the newly-formed AHSNs, but our pace needs to be accelerated.


Care home manager,
Singleton Nursing and Residential Home
Comment date
07 April 2014
I agree with many comments David has made about the real need for improvement in current systems used in health and social care.As a nursing home manager I witness so much waste,not only in product use but resources use.I am conducting a mini process mapping exercise next week regarding the waste involved in medication management.There are sooooo many aspects of social care that have to change in order to keep up with demand.Unfortunately the current system feels like a broken down bus being pushed uphill by lots of weak people.Why don't we just get the bus fixed and get a good driver to drive it ,it could wiz up the hill then and all on board could enjoy the journey.


Gainsborough Baths
Comment date
24 April 2014
very good analogy Julie! I couldn't agree more!

MAGS Dowie

Community Matron,
Comment date
21 August 2014
Medicines management plays a large part of patient management in my role when dealing with patients who have many long term conditions. As part of an MMed Sci I looked at medicines waste and found huge losses with wasted medications for a number of reasons. If we could tackle this issue alone the NHS would save millions of pounds. Patients will be educated regarding medication actions and reasons for taking, when and how. This in turn would reduce hospital admissions 9another drain on NHS budgets) due to improved health taking prescribed medications. We have to start looking at the basics, when they are corrected and systems and processes are applied huge savings could be saved.

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