Does it make sense for the state to pay tens of thousands of pounds for a drug that might keep a patient with cancer alive for another six weeks and leave frail elderly people alone and lonely? Is it the right use of resources to keep a 23 week old fetus alive and probably severely disabled for life at a cost of millions when those who care 24 hours a day for doubly incontinent parents cannot afford a break? Very practically, is it sensible for the state to foot the bill for an unnecessary, disorientating, and dangerous admission to hospital for an elderly person with dementia because their social care is inadequate?

There is a simple logic for making healthcare free and expecting people to pay for social care. All our lives we have to pay to clothe, wash, and feed ourselves, so why shouldn’t that continue when we need help to fulfil those basic social functions? In contrast, healthcare costs can be massive, come out of the blue, and bankrupt families if they have to pay the costs themselves. It was also hoped when the NHS began that overall health costs would fall because existing health problems would be quickly mopped up and the health service would make people healthier, so leading to reduced costs.

This last argument for making healthcare free now looks horribly naïve. As it has turned out the “health” service has become a “sickness” service (at least in part because doctors are interested in disease not health) and many people are kept alive at considerable cost beyond the point where their lives have value. And it seems crazy that, for example, they can be given expensive and largely ineffective drugs for free for their dementia but cannot be provided with basic services that would make their lives more tolerable and possibly stop them being admitted inappropriately to an acute hospital. Hospitals have become the sump for the socially unsupported in the way that prisons are for the mentally ill.

Health or sickness care is, of course, not free, rather it is funded by the state from taxation. It is a choice about the use of resources, and some sort of national insurance system makes huge sense because none of us knows who may be struck by an extremely expensive condition. (In fact we increasingly do know through measuring epidemiological and genetic risk factors, and that knowledge is the best argument for a national system that includes everybody rather than an insurance based system where those at high risk might be excluded.)

But the nature of health and social care needs have changed dramatically since the founding of the NHS in 1948. The classic medical model of “diagnose, treat, cure” is largely finished because most patients have long term conditions and they are not curable. The costs of healthcare are largely driven by frail elderly people with multiple long term conditions, and for many of those people social care is much more important than disease care. “I don’t care what my HbA1 is, I want to be able to put my clothes on, be fed, and stay in my own home.”

There seems now to be universal agreement that England’s social care system is broken. People are not receiving basic care, and the system is grossly underfunded. And without considerable change things are going to get rapidly worse as the population ages.

So far there is no debate about changing healthcare being free and social care means tested, and there are, as I’ve rehearsed, strong arguments for keeping most of healthcare free; and I can’t see that it should be an expectation that you should be able to give your children most of your estate—for most of the population it wasn’t an expectation until very recently. My grandparents had nothing to leave my parents.

But its very clear to me that there are much better ways to allocate scare resources than we allocate them at the moment. The binary division of free healthcare and means tested social care leads to silly allocation of resources. How might we move to something more sensible? One way might be to define a basic package of healthcare as free excluding some of the more expensive and futile interventions and then leave a combination of NICE, commissioning groups, and local authorities to decide on relative state expenditure on social care and extra healthcare.

RS was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.