In the jungle that is the politics of public spending, there are few bigger beasts than the NHS. Rarely out of the news this winter, it emerges from recent polling evidence as the top issue of public concern.

It was unsurprising that Theresa May recently told the Commons liaison committee the NHS was “a critical priority” and she intended “to come forward with a long term plan ahead of next year’s spending review”.

The prospect of the NHS leapfrogging competing claims for extra resources should ring alarm bells for local government, having already taken the biggest hit since 2010 largely because of the relative protection afforded to the NHS.

There are many unanswered questions about the prime minister’s commitment but perhaps the biggest is: “what about social care?”

Many in the NHS and virtually all independent commentators – including The King’s Fund – agree that a long term plan for the NHS will not work unless social care funding pressures are addressed as well. But so far the prime minister and Jeremy Hunt have talked only about the NHS, with social care the subject of a separate consultation promised by the summer.

It is almost certain that any new money for the NHS will come with strings attached

Recent history offers an important lesson here. A great mistake of the 2010 spending review was to protect the NHS from real term reductions but leave social care exposed to swingeing cuts in the local government grant.

The resulting pressures led to the better care fund, in effect taking the wire cutters to the NHS ringfence to let some money through for social care. But the National Audit Office’s forensic dissection of the BCF last year concluded that although it has encouraged joint working in some places, it has created fresh problems, adding another layer of central oversight and failing to deliver the expected benefits for patients, the NHS and local authorities.

The BCF illustrates the dangers of a piecemeal response that sees social care as a secondary adjunct to the NHS, overlooking the deeper problems in local government finance.

It is almost certain that any new money for the NHS will come with strings attached. That will go for any new social care funding as well. Routing it through the NHS is one possibility but raises the grim spectre of the BCF on steroids.

While there are cautious grounds for optimism that the government understands the need for a joined up plan covering social care as well as the NHS, it should avoid past mistakes, adopt a single timetable and seek more imaginative opportunities to align health and social care based around place.

Richard Humphries is senior policy fellow at The King’s Fund. This article was first published on