Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Social care crisis needs meaningful solutions, not tinkering and soundbites

BMJ 2017; 356 doi: (Published 27 January 2017) Cite this as: BMJ 2017;356:j436
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

Last year brought overdue public acknowledgment of the serious crisis in England’s adult social care. The parliamentary Health Committee flagged the grave impact of underfunding, not only on social care but on the wider NHS.1

The Care Quality Commission concurred.2 So did NHS England’s chief executive.3 The King’s Fund produced a searing analysis of the extent and impact of social care cuts.4 And a National Audit Office report on delayed transfers of care from hospital showed a 31% increase over just two years, social care cuts being the main contributor.5

Getting here has taken years of politicians making serial bad decisions, ducking big ones, and applying sticking plasters to major haemorrhages. It’s no accident.

Our essentially arbitrary divide of “free at point” NHS healthcare from means tested (often self funded) social care goes back to 1948.6 The coalition government of 2010-15 deliberately cut funding to local authorities. These authorities, not the NHS, have statutory responsibilities to assess individual needs and to commission means tested care at home or long term residential care. Local government funding fell by 28-40%.78

Local authority social care spending is not formally ringfenced, but most local authorities have protected it in relation to spending on other services. But factors including an ageing population, a national living wage, workforce shortages, and the financial viability of contracted providers have hit hard. The Care Act 2014 set out a national framework and patient rights to support.9 But tighter rationing had already excluded many people with “moderate” needs from support they would previously have received.410

The government’s “Better Care Fund” made for superficially reassuring soundbites but didn’t nearly bridge the funding gap

Around 900 000 fewer people over 65 now receive care than in 2010, and fewer than 5% of carers for older people receive statutory support. The government’s “Better Care Fund” (transferring funding from NHS capital to social care with conditions attached) made for superficially reassuring soundbites but didn’t nearly bridge the funding gap.11

These cuts affect people deeply, as the Richmond Group’s Real Lives report and Healthwatch England’s Safely Home attest.1213 As does personal evidence to the King’s Fund’s Barker commission,14 which proposed a series of costed solutions. Already stressed people navigating a fragmented system are bewildered by contrasting rules, by multiple organisations and assessments, and by one need being “health” and another “social.” They just want responsive support that works—not unfunded, unstaffed promises about personalisation.

The response? A chancellor’s autumn statement ignoring central government solutions and giving local authorities power to levy marginal extra local taxation as a “precept.”15 This won’t solve the yawning funding gap. It’s also regressive, “inverse” care based on property values, where the wealthiest areas raise most money.1617

It’s time to simplify the system, fund it properly, and end the divide from healthcare. This takes political vision, will, and courage. Recent omens aren’t good.



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