Health care is devolved in the UK with separate public health care bodies for Scotland, England, and Wales referred to as the ‘National Health Service’ (NHS). NHS Scotland and Health and Social Care in Northern Ireland (HSC) differ from NHS England and NHS Wales in that they provide both health and social care services; in England and Wales social care is the responsibility of local governments. Health care in the UK is free at the point of use and paid from general taxation and provided mainly by NHS, which is made up of a wide range of organisations specialising in different types of services. Private health care, although marginal, is available for those able and willing to pay (Department of Health 2013).
Due to an ageing population and increasing demand for care, there are widespread concerns that the NHS is facing long-term financial difficulties which need to be addressed through improved cost-effectiveness and investment in preventative services and early intervention. A widespread programme of reforms has been started to deliver better value services, although different approaches to reforms have been adopted in different constituent parts of the UK. England, Scotland, and Northern Ireland have protected NHS spending whereas in Wales health spending has been reduced in real terms. NHS England has experienced the most extensive period of reforms in recent years, characterised by strict performance management regime (Nuffield Trust 2015). A performance comparison across the four UK countries between 1999 until 2013 noted that, on a number of indicators, NHS England performs marginally better than the others, although the systems in other countries have improved in recent years and the performance gap is narrowing (Bevan et al. 2014).
The Health and Social Care Act 2012 introduced substantial changes to the way the NHS England is organised, for example, groups of General Practitioners’ practices and clinical commissioning groups (CCGs) were given budgets to buy care on behalf of their local communities with the aim of stimulating more cost-effective resource use. The Act also created a health specific economic regulator (Monitor) with a mandate to safeguard against anti-competitive practices and to ensure that procurement of services, choice, and competition operate in the best interests of patients and to promote quality and efficiency (HM Government 2015a, Nuffield Trust 2015). Measures are also being implemented to control provider spending, e.g. by controlling staffing costs, strengthening of regulatory controls, and measuring how efficiently providers use resources. Significant emphasis has been placed on improving efficiency in hospitals, greater productivity in hospital workflow, and early discharge of patients (The King’s Fund 2015).
The NHS Five Year Forward View sets out a new shared vision for the future of NHS England based around new models of care and emphasis on prevention, integration with other agencies (particularly social care), integration of primary and acute health, giving greater choice and control to patients, and engaging with communities and voluntary and third sector organisations (NHS 2014). One of the first steps towards delivering the Five Year Forward View and supporting improvement and integration of services was the creation of 50 ‘vanguard’ sites in 2015 for the development of new care models, which will act as blueprints for the rest of NHS England (NHS 2015).
The NHS England is characterised by purchaser-provider split and competition between providers unlike the other countries[2[. English commissioners contract services with any qualified provider on the basis of Best Value principles and patients are empowered to exercise choice in a system where money follows the patient. The NHS in Scotland and Wales operate more as state monopolies run by organisations funded to deliver care to local populations, which also largely applies to the health care system in Northern Ireland (Bevan at al. 2014).
The majority of long-term care (LTC) in the UK is provided by unpaid carers; formal provisions are delivered mainly by health and social care services. Formal LTC services include residential/institutional care, day care, home-based care services, professional support services such as social work or occupational therapy, or aids and adaptations (Wittenberg 2015).
Rising demand for LTC combined with public austerity measures has led to the expansion of care at home to reduce reliance on institutional care (Lombard 2013; Marczak et al. 2015). There are concerns over bed blocking in institutional and acute care settings when adequate homecare services are absent. Particularly where social and health care are provided by different agencies, as in England and Wales, the prioritisation of homecare leads to greater responsibilities for LTC placed on social care services. In England the integration of social and health care systems has been a policy priority over the last few years to provide better-coordinated care across the systems; and the government established Better Care Fund, which created a pooled budget between social care and health care from April 2015.
The financing of LTC in all parts of the UK is based on taxation and means-tested user charges. There are many differences, however, between the four countries in the principles for means testing. Homecare is free for people over 75 in Northern Ireland and over 65 in Scotland. Means testing operates in England and Wales regardless of service user age; in Wales the local government can charge a maximum of £60 per week for homecare. In Scotland in residential care the government makes flat rate contributions towards any personal and nursing care people require, based on physical/care needs and not financial means-testing, and individuals only contribute to accommodation/hotel costs. In other parts of the UK all costs of residential care, accommodation, and care/nursing are means-tested (Age UK 2015; Advice on Care 2015).
In England publically funded LTC services are limited on the basis of income and assets-based means test, and publically funded LTC services have become increasingly rationed, and concentrated on those with the highest needs (Fernandez et al. 2015). In the means test, capital and savings below £14,250 are disregarded at present, and people with capital and savings above £23,250 have to fund their own LTC, whereas from 2020 people with less than £118,000 in savings will be entitled to at least some financial support to pay their care costs according to a sliding scale (HM Government 2014; Age UK 2015). In the Care Act 2014, the government adopted proposals for a lifetime cap on private contributions to care costs in England set at £72,000. Nonetheless, the cap will only apply to direct care costs. Accommodation costs in residential care will still be the responsibility of private individuals. The cap on care costs and changes to the means test were due to come into effect in 2016, but in 2015 these were delayed until April 2020. In 2015, the Government announced that local authorities in England will be allowed to increase the local council tax on property by up to 2 % in order to fund adult social care. This announcement brought about concerns about the equity of provisions of social care services in different parts of England as more affluent local authorities would be able to collect more funds through the tax than others. To address the concerns the government promised to devote additional £1.5 billion to the Better Care Fund and to distribute the extra money to compensate councils unable to raise enough from the new 2 % council tax precept (HM Government 2015b).
Within publicly funded LTC there is a trend in all parts of the UK toward more customer choice and personalisation. This involves direct payments, available in all UK countries, which provide cash to eligible users of homecare to purchase their own services or employ a personal assistant, who can be a relative. From 2011 in England and 2012 in Scotland all new publicly funded users of homecare are provided with a personal budget that can be used as a direct payment or managed by the local authority on behalf of the user, taking the user’s preferences into account (Marczak et al. 2015; Nidirect 2015). Self-Directed Support is a new initiative in Northern Ireland along similar lines to those in England and Scotland, which offers people with LTC needs and their families more choice over the use of the direct payments and ways in which their care is provided (Cilni 2015).
- Advice on Care.“Long-term care”. 2015. Available at: www.adviceoncare.co.uk/what-is-long-term-care.html
- Age UK. “Home and care”. 2015. Available at: http://www.ageuk.org.uk/home-and-care/care-homes/.
- Bevan, G., Karanikolos, M., Exley, J., Nolte, E., Connolly, S., & Mays, N. “The four health systems of the United Kingdom: how do they compare?”. The Nuffield Trust, London (2014).
- Cilni. “Self-directed support”. Available at: http://www.cilni.org/content/self-directed-support-and-personal-budgets.
- Department of Health. “Guide to the Healthcare System in England Including the Statement of NHS Accountability”. 2013. Available at: https://www.gov.uk/government/publications/guide-to-the-healthcare-system-in-england.
- Fernandez, J.L., & Nadash, P. “The long-term care financing problem”. In Gori, C, Fernandez, JL, & Wittenberg R. “Long-term care reforms in OECD Countries: Successes and failures”. Policy Press, Bristol (2015).
- HM Government. “Care Act 2014”. The Stationery Office, London (2014).
- HM Government. “Monitor”. 2015a. Available at: https://www.gov.uk/government/organisations/monitor.html
- HM Government. Spending review and autumn statement 2015. 2015b. Available at:
- Lombard, D. “Preventing need and maximising independence: Literature review”. Research in Practice for Adults, Dartington (2013).
- Marczak, J., & Wistow, G. “Commissioning long –term care in OECD countries”. In Gori, C., Fernandez, J.L., & Wittenberg, R. “Long-term care reforms in OECD countries: Successes and failures”. Policy Press, Bristol (2015).
- Nuffield Trust. “NHS Reform”. 2015. Available at: https://www.nuffieldtrust.org.uk/our-priorities/health-and-social-care-finance-and-reform/
- NHS. “Five year forward view”. 2014. Available at: https://www.england.nhs.uk/ourwork/futurenhs/.
- NHS. “New care models-vanguard sites”. 2015. Available at: https://www.england.nhs.uk/ourwork/futurenhs/new-care-models/.
- OECD. “OECD health data statistics”. OECD, Paris, 2015.
- The King’s Fund. “NHS Reform”. 2015. Available at: http://www.kingsfund.org.uk/topics/nhs-reform.
- Wittenberg, R. “Funding: Demand for care and support for older people”. In Gori, C., Fernandez, J.L., & Wittenberg, R. “Long-term care reforms in OECD countries: Successes and failures”. Policy Press, Bristol (2015).
-  Including amenable mortality rates, life expectancy, and ambulance response times.
-  There is purchaser/provider split in Northern Ireland but without provider competition.
-  Local plans for the use of this money [£5.3 billion] had to be agreed between the local authorities and Clinical Commissioning Groups.