Intended for healthcare professionals


Are radical changes to health and social care paving the way for fewer services and new user charges?

BMJ 2017; 358 doi: (Published 27 September 2017) Cite this as: BMJ 2017;358:j4279
  1. Shailen Sutaria, specialty registrar in public health medicine1,
  2. Peter Roderick, principal research associate2,
  3. Allyson M Pollock, director2
  1. 1Global Public Health Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, E1 2AB, UK
  2. 2Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
  3. Correspondence to: A M Pollock

Current reforms to health and social care services, and radical redesign of the local government finance system, may signal the end of the NHS and local government in England as we know them, argue Shailen Sutaria, Peter Roderick, and Allyson M Pollock

Seismic changes in the organisation, delivery, and funding of health and social care services have been underway since the secretary of state’s duty to provide key services throughout England was abolished by the Health and Social Care Act 2012.

One of the acts’ major changes was to transfer public health responsibilities to local authorities—described as “one of the most significant extensions of local government powers and duties in a generation.”1 The Cities and Local Government Devolution Act 2016 allows further health functions to be devolved to local authorities.2

At the same time, NHS England is implementing sustainability and transformation plans (STPs) covering 44 geographical “footprints” in England.3 These have been reported to be required to cut 26bn (€29bn; $35bn) from health and social care costs over five years.4 STPs are intended to pool the budgets of health bodies and local authorities for joint commissioning of health and social care services, creating new organisational forms and care models, such as newly proposed accountable care organisations.5

The devolution deals and STPs are being presented to the public and health professionals as a way of integrating health and local authority social care. But missing from the picture is their fundamentally different funding bases: social care is a local authority responsibility and subject to means testing and user charges, whereas NHS services are free at the point of delivery.

These changes are taking place while the NHS undergoes the largest sustained reduction in spending as a percentage of gross domestic product (GDP) since 1951,6 NHS providers …

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