Integrating health and social care in England—when the sum is not greater than its parts

The government’s announcement that the Department of Health and its Secretary of State were to have “social care” added to their titles was presented as a step forward in achieving much needed integration of England’s health and social care systems. It was met with scepticism and described in some quarters as little more than “window dressing.” More significant was the assignment of the responsibility for the development of a green paper on the future of our social care system to the new Department of Health and Social Care. After years of piecemeal initiatives, strategy for both health and social care now lies with the same department.

In practice, little has changed in the cause of integration. The division of funding and management of health and social care remains in place, and responsibility for delivery of social care and public health remains with local authorities. This is further complicated by a fragmented regulatory landscape. More importantly, both the NHS and the care system are still funded at austerity levels. While the NHS faces a growing deficit, our social care system leaves many with unmet needs, with 23% in the lowest income bracket not receiving the care they need. Despite meagre, means-tested entitlements, the funding gap in social care is expected to increase to £9.2bn in the UK by 2030/31—40% of the projected budget. The sense of crisis will only deepen as the population ages, while the cost of providing care to working-age adults is also increasing and may soon outweigh spending on over-65s. No amount of wishful thinking can override these realities.

Beyond the ongoing split between health and social care, NHS England is trying to encourage greater integration within the health sector through piloting Integrated Care Systems (ICS). These are intended to bring together commissioners and providers with sharing of care protocols, capacity planning and resource allocation, performance and financial management. Such integration within the health sector is a pre-requisite for integration of social care, which would require a further joining up of local workforces with improved skills in allocating resources and understanding risk, supported by unified information systems. NHS England was planning to introduce Accountable Care Organisations (ACOs), a form of contracting in which a single organisation would deliver the majority of health, care and population health services in a locality. These plans appear to have been put on hold for now. However, these initiatives have no statutory basis, and in the absence of a supportive policy framework it is doubtful that such pilots can be extended to integrate local authorities on a national level.

Furthermore, while greater integration might improve outcomes and patient experience, there is little evidence that it reduces costs. Only interventions closely targeted at patient groups with complex needs may be effective in this regard, which might have significant investment requirements or increase costs by addressing hitherto unmet needs. Notably, the costs of care for working age adults and those with learning disabilities will not fall as a result of policies aimed primarily at improving coordination of services for older people. Any efficiencies generated are thus likely to fall short of bridging the funding gap.

England is far from alone in grappling with these issues, which are common across the UK, although efforts to integrate health and social care are more advanced and better supported by legislation in Scotland. While the question of how to foster integration is a near universal concern, other countries have made more progress in addressing funding challenges. Several OECD countries provide some form of universal coverage for social care needs, but generally leave users with large out-of-pocket costs, with little uptake of private insurance. Some countries have experimented with social insurance schemes for long term care, including the Netherlands, Germany, and Japan, while Nordic countries fund universal social care through taxation. The advantages of dedicated financing channels are that they provide a reliable and predictable source of future revenue and can encourage greater realism in terms of funding requirements and entitlements.

The forthcoming green paper is an opportunity to set out a clear vision for the future of our social care system. However, no plan that proposes reform, without explaining how it intends to raise additional funds to address unmet needs, should be taken seriously. Tellingly, despite warnings of the risk to public services already stretched to breaking point, the Chancellor’s timetable for reviewing public spending indicates that local authorities should not expect significant extra cash until 2020 at the earliest. Furthermore, for “bottom-up” initiatives such as ICSs to be extended to the care system they need to be matched by new thinking for the governance and delivery of health and social care. With the widespread disruption caused by the Lansley reforms still fresh in the memory and Brexit negotiations ongoing, major reorganisation can probably be ruled out at this stage. Cosmetic changes such as renaming Whitehall departments will not suffice.

Elias Mossialos, Professor of Health Policy, Department of Health Policy, London School of Economics; Professor of Health Policy and Management, Imperial College London, UK




George Wharton, Senior Lecturer in Practice in Health Policy, Department of Health Policy, London School of Economics, UK




Emma Pitchforth, Senior Lecturer and Senior Research Fellow in Primary Care, Primary Care Research Group, University of Exeter Medical School, UK

Competing interests: None