Sir David Behan CBE, Chief Executive, Care Quality Commission

This article forms part of the LGA think piece series 'Towards a sustainable adult social care and support system'.

I have spent the past forty years working in social care. Even before I started my career there had already been attempts to reform and reorganise health and social care. In the reforms of 1970 and 1974, the goal was to join-up the planning, funding and delivery of services.

What has changed since then? Our population has grown, and it has grown older. The good news is that we are living longer, but healthy life expectancy has not kept pace with life expectancy. This means people’s care needs have become more complex, as more of us are living with multiple health problems for longer as we age. Society has grasped the importance of treating people as partners in planning and delivering their care, which should be personalised and joined-up to meet their individual needs and choices. And, partly as a result of these changes, there is not enough funding to meet growing demand.

So what can we do?

Firstly, the adult social care system needs a short-term injection of funding now. Estimates suggest 1.2 million people are not receiving the help they need (equivalent to one in eight older people) – an increase of 48 per cent increase since 2010.

But, alongside this, we also need a sustainable, long-term funding solution to stabilise the adult-social care system for the future. This has, quite rightly, been provided for the NHS, and the same is required for adult social care. The two – NHS and social care – must be treated as a single package. Very often, health services and social care services are serving the same people. If we are to ensure that health and social care work together to jointly meet people’s needs, then we need to align not only their plans but also their resources. We need a long-term solution that addresses the long-term funding of health and social care, together.

Many reviews over many years have proposed alternative funding models for social care. None has resulted in significant or sustained change. Meanwhile, the public has little understanding of how social care operates and many people assume social care will be free – like the NHS – when they need it.[1]

We need a fairer system that spreads the risk and responsibility for funding care, just as we do with other public services – from welfare benefits and pensions, to fire and rescue services and policing.

And money from a reformed funding system must go into a reformed system of planning and providing care, where health and social care organisations work together to ensure that people experience personalised care that is joined-up around the individual. In our review of care for older people in 20 local authority areas in England, the Care Quality Commission (CQC) found that change is required locally and nationally to make this possible.

We need incentives that drive local leaders to work together, rather than push them apart. For instance, we must measure the performance of whole systems, as well as the individual organisations that commission and provide health and social care services. For the CQC, this means we want the power to look at the quality of care across a local system, alongside our regulation of individual providers. For local authorities, this means collaborating with partners in the NHS and beyond to agree how you will measure your collective performance at serving the interests of people who use health and social care services in your area.

And funding alone is not enough to support a sustainable system. Local government and NHS organisations must keep building the trust and relationships that allow joined-up planning, commissioning and oversight of health and care services. We must not allow a sense of competition to create a stand-off between health and social care or undermine the outcomes we are trying to achieve for people. Collaboration must be based on organisations’ shared responsibility to meet the needs of people and communities. As local leaders are working in an increasingly volatile, uncertain, complex and ambiguous environment, the strength of these relationships becomes ever more important.

Nationally, the barriers to collaboration between local authorities and NHS organisations must be removed. For instance, the way in which funding flows into health and social care is a barrier to collaboration because health and social care commissioners are usually restricted in how far they can align or pool their budgets. Similarly, workforce planning for the NHS must be conducted as part and parcel of workforce planning for social care and other local public services that have a significant role to play in supporting people’s health and wellbeing. This means planning for job roles and staff skills that allow people to work flexibly across a system.

The ways in which care is funded, commissioned, provided and overseen matter because they affect people’s experience of care. It is in the best interests of people who use health and care services – i.e. all of us – to ensure that the planning, resourcing and delivery of care are joined-up.

And as reform takes place we must not lose sight of the opportunity to improve the quality of adult social care. At its best, high-quality social care transforms people lives. It allows us to be more independent, to improve our wellbeing, and to reach out to others. This is what we have seen in many of the adult social care services the CQC has rated Outstanding – a remarkable achievement given the funding gap and a workforce challenge that has led to 90,000 vacancies in the sector.

But as long as 2 per cent of adult social care services are rated Inadequate and a further 17 per cent are rated Requires Improvement [2], there is work to do. Last year, CQC was amongst more than 40 organisations who committed to Quality matters – a shared commitment to high-quality, person-centred care.

Reform of social care funding, commissioning or delivery will mean little, unless we also see a sustainable improvement in the quality of care that people experience. And that will be possible only when we act on the knowledge that the NHS and social care and part of the same package, providing support for the very same people; we cannot successfully or sustainably reform one without the other.

2018 marks the 70th anniversary of the creation of the modern welfare state through the NHS and the National Assistance Act. These remarkable changes demonstrated a bold vision for the future. Their realisation required political courage. As we look ahead to the next 70 years, will we see similar boldness and courage in addressing one of our nation’s great unresolved social issues? The social care question is an extraordinary challenge. How can we create a high-quality, compassionate future for people who need care and support? To find a fair and sustainable answer to that question, we must match the extraordinary boldness and courage of 1948.

Sir David Behan CBE, Chief Executive, Care Quality Commission


[1] Health Foundation, A fork in the road: Next steps for social care reform, 2018.

[2] Ratings correct as at April 2018.