A new settlement for health and social care: Interim report

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

This is the interim report from the independent Commission on the Future of Health and Social Care in England. In it, the commission explains why it believes England needs a single health and social care system, with a ring-fenced, singly commissioned budget, and more closely aligned entitlements. Drawing on accounts from patients and their families, the commission argues that the current system is no longer fit for purpose.

At the root of the problem is a lack of alignment in funding, organisation and entitlement. The report analyses the historical divides between the two systems, the effects of our ageing society, and issues of affordability, before exploring options for change in meeting the costs ahead. It concludes with a call for responses to these options. 

Key findings

  • The problems of the current settlement for health and social care are systemic, in the commission's view. They stem from a lack of alignment in entitlements to care, between funding streams, and in organisation/commissioning of care.
  • There is a problem of adequacy, with too little public money spent on social care and too much demanded of at a time of rising needs. 
  • The public has a poor understanding of the present system of social care. The current system is heavily dependent on unpaid carers and is inequitable, with shifting boundaries on entitlements. 
  • Greater life expectancy, an altered disease burden, and medical advances have all resulted in more people requiring health and social care. 
  • Economic growth means that better health and social care are not unaffordable. But intense short-term pressures and long-term changes mean hard choices will need to be made on funding.

Policy implications

  • The problems of alignment and adequacy raise the issue of affordability – how to fund the type of health and social care system fit for the 21st century.
  • The broad options for raising extra resources are: using existing health and social care resources more efficiently; raising more public funding; and raising more private funding.
  • Improved productivity, improvements in end-of-life care, better integration, ensuring NHS money is spent on what is cost-effective are explored (option 1), but considered insufficient to meet all the costs.
  • Proposals are considered for the ‘harder’ long-term choices, including extending NHS charges, developing a health insurance market, and introducing a hypothecated tax for health and social care. Responses to these are requested.



Comment date
05 January 2015
Scrap thw NHS and its name. Bring all healthcare to local authorities with an amalgamation of health and care workers, Make all Local Authorities and Healthcare bodies unto mutuals/cooperatives. Have higher gambling taxes with these and all the money from gamblingd and lotteries to be given exclusively to Healthcare and not through the National Government, In each hospital or suitable place build local care homes in every vicinity with relatives making a major support for the inmates. Scrap all private organisations dealing with the elderly and infirm. Bring combined health and care back to the local communities and apart from gambling, all taxes from alcohol and tobacco should also go exclusively to healthcareiyvZL

Terry Roberts

Member of the public - ex health,
Comment date
29 May 2014
I certainly mean no offence against the writer but the public are so very weary generally of meeting upon meeting, report upon report and valuable professional time being taken up when all we, at the sharp end, want is action.
It is embarrassing to think how often integration has been talked about and half attempted with a few well meaning experiments but nothing really changes.
There again I guess as long as more and more reports are allowed to be contemplated without someone really grasping the nettle and do what managers are paid to do - manage and manage well, the hope must be that all will go away if heads are kept low enough for long enough.

Ian Penfold

Disability Advocate,
Comment date
05 April 2014
I certainly do not agree with many of your proposals. Simply trying to combine Health and Social Care is a gross over-simplification of the problem in my opinion. There are many issues within Health and within Social Care that require extensive effort to put right.

People do not generally work well together. There are many divisions between teams, contracts, CCGs, County boundaries, age groups (child/adult). Just joining Health and Social Care won't address any of this. People tend to work in 'tribes' so the effort need to go into making people work together better and focussing on the needs of the individual rather than the needs of the tribe.

The real cause of the issue is a lack of Government funding. This is causing us all acting like turkeys voting for Christmas trying to treat the symptoms and not this cause.

The population is getting older, whoopee what a surprise. Most people have paid all their working lives for their health and support and it should be no surprise that costs will increase but much of the money for this has been received, in proportion to the demand, over the lives of it's citizens this is not just money coming from the public purse.

We now have a system where, due to failures caused in part by a lack of funding, resulting rationing of services is doing great damage. This is exactly what the Government wants so they can justify increased use of the Private sector and all the lovely profit.

Other problems that need to be addressed include free movement of people within the EU which means many EU citizens can now move to the UK having paid no taxes and obtain free care and support. You need to be campaigning for the EU to provide the UK with substantial funding if we are to be expected to be the EU's health and social care service.

Good public services can be cheaper and better than private ones, the motive in providing these services must always be to deliver the best result for the patient/client and the tax payer. I do not believe that you can do this when profit is the primary driving force.

I admire much of the work that you do but this report could well have been written by a Conservative right wing think tank. Please think carefully about what you are suggesting. Providing the best services possible should be what drives us all, if we are pretending that we cannot afford essential, reasonable and appropriate services for our citizens because some politician says we cannot afford it then we are all wasting our time.

They can afford plenty of other nice to haves but they can't look after their own people. Very sad isn't it?

Chris Sterry

Retired to be a full time family carer,
Not applicable
Comment date
04 April 2014
What is the future of health and social care in England, over many years much work has been undertaken on joint working, but this is mainly only involving some front line services. This has not necessarily been run inconjuction with joint working on management, governance and funding.

In many areas the working of both health and social services over lap, but in some instances each are still progresses this work separately, this creates duplication of work and is not cost effective as each service is paying for the same work to be undertaken. If pure joint working was followed with a pooling of financial resourses as well as staffing and other resources, this would result in a reduction of the unit costs.

However, this will not be easy to achieve, as both health and social services have their own ways of working, certainly on the administrative systems they use.

As to the concept of fundamentally changing the funding of health to reduce the areas of free at point of delivery. It is being considered to bring in charges for attending GP surgeries, but there will have to be exemptions and who would be within these exemptions. How will it be administered, as the GPs and others have already stated that they would not be able to do this, as was their reaction when there was the suggestion of enforcing charges at GP surgeries, hospitals and other areas for persons who are not supposed to be within the current free at point of delivery. It is well known that in many instances persons who are not UK and EU citizens have not paid for their treatments from UK hospials, even thoulg they may have been invoiced. There appears to be no facility to chase payments or a complete unwillingness to do so.

If charging is to be seriously considered then what would be the outcome impact assessments, would the charging not only dissuade persons who could be seen to be misusing the services, but in fact stop some who delay contacting services resulting in increased costs when their conditions deteriorate to serious or terminal.

The other factor when charging is introduced is that the initial charge will not remain as UK governments will increase the charge to supplement other revenues.

Currently many families are being hit by many increases in costs and reductions in service and the more services you use the greater impact these increases and reduction will have on these families.

There is in fact a large section of the community who while saving much costs to the UK or not effectively recognised by the authorities, although they are mentioned frequently by them. These are the family carers who care for their relatives for no monetry allowance. There is the Carers Allowance, but when you factor in the hours of care they provide, the allowance is effectively less than a quarter of the minimum wage. Then when the family carer is on retirement benefit this allowance is no longer paid.

To bring in charges would be, certainly another tax on the persons of limited income, whose income is currently being eroded by other financial increases they are bearing. But they will not only be the ones to suffer financially, for there are those persons, who currently can manage financially, but any new charges will mean they will not be able to do so.

So what is the answer, do we ration the services or withdraw them from persons who do not seem to be helping themselves. Do we only charge the super rich. Or do we charge all and then deal with the consequences.

bob williams

Comment date
04 April 2014
So Ms Archer, CBE, has noteworthy experience working for a bank. Not just a bank, in fact, but the Bank of England. According to the Haldane Report, published by Ms Archer's previous employers, the Bank of England, bankers, a multiplicity of economists and banks made quite a mess of the world's financial system. And, you know, that just might have determined the 'austerity' agenda this report addresses. Nevertheless, from a banking perspective, why not get poor working class people to pay more for the NHS? They clearly are doing swimmingly at the moment.

Deborah Chinn

Health services researcher and practitioner,
Comment date
04 April 2014
This report is driven by neo-liberal ideology, not common sense book-balancing. There are far more equitable ways of raising revenue to fund public services that are not palatable to the current government - the Robin Hood tax on financial transactions and a reform of the ridiculously outdated and unfair council tax bandings for example. There has been a sustained attack on the NHS, its staff and its principles for a number of years now, paving the way for a dismantling of the whole institution. Charging for consultations would be an expensive system to administer and apply (like increased university fees), and because of delayed presentations would result in many more expensive difficulties down the line (like the spare bedroom tax). However these coalition measures fit in neatly with neo-liberal principles of individual responsibility for well-being and opportunities for commercialising the welfare sector.

Mary E Hoult

community volunteer
Comment date
03 April 2014
I agree with Ian Richardson,the best way forward is for collaboration for high impact.Simple rules that patients and the public and existing staff can understand makes for better implementation for change.

Peter West

Freelance Health Economist,
Peter West Associates
Comment date
03 April 2014
A £10 charge per GP consultation would generate only limited funds and would be bound to have some exemptions. Based on some old data, I do not not see how it could raise more than £3.6 billion in England and, with exemptions, potentially much less. An alternative is to give us all an NHS "credit card" which we use when we consult. This could have a means-tested sliding scale of charges, with the better off potentially paying £30-40 to see a GP, a rate that can be found in much of Europe, including Ireland. Given the inevitable exemptions, it might be pitched higher than £10 anyway and at this rate, could reduce demand. But what of the late diagnosis of conditions that needed to be seen at once? The inevitable conflict when charging for a first diagnostic assessment. Delays have a cost too and that should be estimated.

Ian Richardson

Comment date
03 April 2014
Collaborating for High Impact

Very few community benefits can be achieved through a single agency, collaborations are essential, health is no exception. These can be complex but the secret to their success is recognizing the complexity and adopting simple rules, as outlined in Validating Strategies by Phil Driver, OpenStrategies.

The OpenStrategies approach recognizes that ‘anyone can design a complicated strategy system but a good designer will develop a simple one’. The resulting OpenStrategies’ system is compellingly simple yet powerful, even for very complex, large scale strategies. Crucially, OpenStrategies doesn’t just underpin the design of strategies – it also guides their validation and implementation.

PRUB it or BURP it! OpenStrategies gives you a validated strategy (BURP) with a rationale AND an Action Plan (PRUB).

The OpenStrategies approach can be explored at the Validating Strategies website http://openstrategies.com/ and through the book: Validating Strategies - Linking Projects and Results to Uses and Benefits, published by Gower http://www.gowerpublishing.com/isbn/9781472427816. The book launch and seminar is to be held in London, on the 15th April 2014, hosted by OPM.

Additional publications can be found:
A) Written evidence Public Administration Select Committee (PASC): Building Civil Service Skills for the Future (aka. Civil Service Skills)
1. UK Parliament: PASC web link http://www.parliament.uk/business/committees/committees-a-z/commons-select/public-administration-select-committee/inquiries/parliament-2010/civil-service-skills1/
for the evidence go to the GREEN box at the bottom of the page and select ‘Written Evidence’, then GO
2. To download the evidence, ref: CSS0002, http://data.parliament.uk/writtenevidence/WrittenEvidence.svc/EvidencePdf/6973

B) Challenge on the Standards Hub, sponsored by GDS the Cabinet Office, the Governments Digital Service (GDS),

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