This blog is from Dr Guy Turnbull from CASA: Care and Share Associates.

I’m hoping the up-coming general election focuses attention on the crisis that is our health and social care system. It is broken: the ‘canaries in the coalmine’ are dead and buried! For example, both delayed hospital discharges in many localities and A&E waiting times are at record highs.

 More tellingly perhaps:

  • The private sector is exiting the social care market.
  • Many people no longer want to work in the care sector – a BBC analysis of data gathered by the charity Skills for Care found that 928 people are leaving their care job every day. (
  • How health and social care is currently funded and organised is inherently unfair and wrong.

For example, if you are a billionaire, get cancer, you can be cured on the NHS for free.  On the other hand, if you aren’t a billionaire, but have worked hard all your life , saved, and own your own house: well, if you get dementia you’ll virtually lose the lot. This surely can’t be right?

We currently have a National Disease Service, rather than a National Health Service. Hospital income is highest when they are full up, yet it is often cheaper, more efficient and delivers better outcomes if people are supported in the community, in their own homes. 

More of the same is not an option because the ‘inevitability’ of demography in the UK means that currently 10 million people are over 65 years old, and 3 million over 80. By 2030, the figures are estimated to be 15 million over 65 and 6 million over 80. But these statistics about an aging population are only part of the challenge facing health and social care delivery systems. For example, advances in medical technology mean more infants with complex needs are surviving into child and adulthood.

There are also huge labour market challenges – with the demographics set to change as they are, it all begs the question: how will we meet the growing demand and labour market requirements of a health and social care sector that is characterised by poor terms and conditions? Does it make sense that I can earn more working on the shop floor in Aldi than providing compassionate palliative care to support a person’s wish to die at home? This isn’t fake news – it is fact; and it’s a concern shared by respected organisations such as ADASS and the Care Quality Commission who have taken to using terminology such as ‘jeopardy’ and ‘tipping point’ to describe the state of the (health) and social care market. 

Put simply, how will we as community, deliver quality support to the most vulnerable in our society? Three solutions come to mind:

1) Whether it will be increases to national insurance, other taxes, ‘Death Tax’, or market development for insurance products, etc, we need a long term funding solution for health & social care.  All of us are going to have to pay more – let’s all be honest about this, commit to it, and move on.

2) Health and social care must genuinely integrate: it is nonsensical that people are ‘trapped’ in expensive (and inappropriate) hospital beds because of lack of capacity in the homecare sector, but the budgets and incentives and working on the ground mostly aren’t aligned.

3) A significant part of the solution to these monumental societal challenges is to develop a mutualsolution (of which more below).

But rather than start at the mutual solution, let’s consider what ‘good’ might look like in terms of a response to the challenges set out above. It is simply not good enough to simply just respond by stating the value of social enterprise or ethical business provision of health and social care; rather it is crucial to define what ‘ethical health and social care’ actually means in practice.  I think it means: 

A) No financial leakage- surely all money spent on health and social care should be focussed on delivery – is there room for excessive external shareholder dividends?

B) Profit motive & incentivisation- profit is not wrong, but a reasonable profit should be generated by delivering a quality service, NOT by cutting costs, corners and ultimately, quality. Profit should be (re)invested in service delivery.

C) Financial accounting should be open and transparent to all – employees, service users, and commissioners should all be able to see where the money goes and why.

D) Efficient – a commercial and enterprising approach needs to be the default position.  Health and social care has become an increasingly precious and scarce resource, so  innovative approaches need to be deployed to ensure its impact is maximised.

E) Co-produced– we need to move away from the traditional commissioner provider split, to approaches where all stakeholders get together to work out what’s best.

F) Inclusive – we have to find ways of making a job in social care more attractive, offer incentives for skilled workers to stay within a professional career structure, and ensure the workforce is better represented by younger and older people and other marginalised labour market groups. 

If, as I have done, you put commissioners, providers, and patients / citizens into one room and ask what they want out of a health and social care system, they all want the same thing: quality, safety and security, value for money. I don’t believe that ‘for me to win, you have to lose’: I believe in mutuality.

This mutual model of health and social care provision is exactly what Care & Share Associates Limited (CASA) is trying to roll out in the UK.  CASA is an award-winning employee-owned health and social care provider that operates across 9 locations and delivers over 24,500 hours of personal support per week, principally commissioned by the public sector. 

For CASA, being a social enterprise means being a successful business that is viable and sustainable in a tough competitive market. Although as a social enterprise, its main aim is not the maximisation of profit, CASA does not describe itself as being ‘not for profit’, as profit is shared out to employees.  A better description is to say that CASA is about ‘more than profit’. 

Workforce is key in health and social care, and employee engagement is increasingly being seen as key in terms of driving patient satisfaction and clinical outcomes.  Indeed a recent IPA report (Meeting The Challenge: Successful Employee Engagement In The NHS; ) stated that: ‘It’s increasingly clear that (employee) engagement is vital to high quality care in the NHS’. CASA’s clear view is that genuine employee engagement is borne through investment in employee training, providing clear and accessible business information, offering, encouraging and supporting career progression and ensuring an equitable share in the outcome.

CASA regards itself as part of the community, rather than simply coming into an area to make money for shareholders and owners. It aims to ensure that social and environmental impact is always positive, for example by targeting areas of high unemployment, working in sustainable ways and using other social enterprises as suppliers, where possible.

Finally, CASA is about providing value for money, working in close partnership with loxal authorities, health authorities and other commissioning organisations to help them make better use of finite resources. Employees of CASA are trained and encouraged to help reduce people’s dependency on more expensive and intrusive services, which not only contributes to their quality of life but also saves money. Partnership working also means being transparent about our structures, finances and policies. 

The demographic challenge of an ageing population cannot be ignored and will not go away.  It is also often said that a society is judged as how it supports its most vulnerable members.  Our current systems of support are broken now, and ‘more of the same’, will not address the significant demands ahead.  We as a society therefore need to take a long hard look at how we have chosen to organise, both in the public, and private sectors, and seek to embrace a more innovative and mutual solution.  

The 2017 General Election allows this debate to become action – I wonder which party is brave enough to grasp the health and social care nettle?

Dr Guy Turnbull from CASA: Care and Share Associates