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

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.” The Cities and Local Government Devolution Act 2016 allows further health functions to be devolved to local authorities. At the same time, NHS England is implementing sustainability and transformation plans (STPs) covering 44 geographical “footprints” in England. These have been reported to be required to cut 26bn (€29bn; $35bn) from health and social care costs over five years. 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. 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, NHS providers have recorded their highest ever deficit, and there has been a 37% real terms reduction in local authority funding from central government grants from 2010 to 2016 (excluding public health and the Better Care Fund), alongside the ongoing radical and regressive reform of local government finance. How will these changes and reductions in funding affect access to care, equity, and already widening inequalities? Experience from the last major transfer of responsibilities from the NHS to local authorities suggests they are likely to lead to reduced services and entitlements, more private provision of publicly funded services and, potentially, the introduction of charges for health services. Effects on services and entitlements