It’s time to see the bigger picture The NHS and social care need to be prepared for the future

17 October 2020

Sir Andrew Dilnot
Sir Andrew Dilnot

If we are to get the best out of the NHS and social care, we need more and better understanding of what has happened in the past, and what might happen next, writes Sir Andrew Dilnot.

Health and social care are huge. Together they account for more than one tenth of the economy, whether we look at money or employment. The NHS is a ‘national treasure’, while social care is widely seen as a major national problem. Given their scale and complexity, we need more and better analysis of the past and consideration of the future if we are to set the right objectives and plan effectively for the long term.   

As cases of COVID-19 rise, the government is understandably focussed on the here and now. The immediate need, to manage the spread of infection and support the NHS and social care, is unavoidable. Now may not seem like the moment to be thinking about the longer term, but even as we tackle COVID-19 we have to face longer-term choices about our future health and care.  

The NHS and social care sectors had different experiences of the first wave of the pandemic. Less obviously urgent care in the NHS almost ground to a halt, but care for the most critically ill, including those with COVID-19, continued and was largely hailed as a success.  

Social care struggled, and support was widely seen as too little, too late. Despite the valiant efforts of staff, COVID-19 hit hard in an already vulnerable sector – with over half of all excess deaths among care home residents.

While the fortunes of health and social care appear very different, both sectors are captive to decision making that focuses on the short-term at the expense of adequate long-term planning. 

For social care, we have had 20 years of promises but inaction. By contrast, NHS spending and output have grown much more quickly than the population. New research from the Health Foundation’s REAL Centre shows the amount of health care delivered over the last 20 years has doubled. This growth has varied widely across different services, with some areas such as routine planned surgery like hip or knee operations increasing five-fold, while others, such as GP activity, have remained largely flat. 

And with these diverging fortunes across different services it is far from clear that the outcomes were even what policymakers intended, let alone optimal. Plans to shift the balance to care in the community and primary care, for example, which were key declared aims at the start of the century, have clearly not been delivered.  

Without a proper long-term planning infrastructure, health and care policy lack coherence. The shape of the NHS is rarely rationally planned out and implemented. Rather, it is influenced by a wide range of known and unknown factors, not just what the population needs, but the availability of staff, what the public is willing to pay in taxation, the state of the buildings, the latest advances in drugs and technology, and what will play best with the electorate and in the media.  

If we are to get the best out of this large and critically important part of our society and economy we need clearer goals and a better understanding of how different services contribute to those goals. To get there, we will need more and better understanding of what has happened in the past, and what might happen next. We should be as well informed about health and care as we are about the economy, and we are a long way from that now. 

The response to COVID-19 has had to be short term, but some of the problems it has highlighted, not least in social care, have underlined the lack of a clear set of health and social care goals, and a strategy to achieve them.

What we lack is a long-term vision for how we will deliver better care in the future. We need it. Now.


Sir Andrew Dilnot is Warden of Nuffield College, Oxford, and Chair of the Health Foundation’s oversight board for the REAL Centre.

This article was originally published in The Times Red Box on Thursday 15 October 2020. 

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