Cashable savings in health and social care: a red herring?

Published: 28 September 2023

A cardboard cutout of an older couple besides a pile of coins. A small tree is sprouting from the top of the coins.
A big part of my role is speaking to finance directors in the NHS about social investment. 

And one sticking point I keep coming across is whether the financial benefit provided by social investment can be spent elsewhere – in other words, if the savings are cashable.

We’ve all seen the photos of ambulances queuing up outside A&E. And we’ve all heard the stories of hospitals having to buy beds in hotels or take over private hospital wards just to have somewhere to hold patients. 

With so much backlog and with everything so maxed out and overstretched, and demand only set to increase, other services can’t simply be reduced to fund new investment in service redesign. Although you could reduce overspend on agency staff, escalation wards and private beds. 

A successfully redesigned service will reduce non-elective demand, and in doing so, more capacity could be available for elective activity, which is a more efficient use of spend. In England the efficiencies could be amplified by attracting more funding into the system from NHS England and the Elective Recovery Fund. More planned and less unplanned care, on the whole, delivers improved outcomes for the patients.

It’s one of the reasons we’ve partnered with Macmillan to deliver social investment in transformational adult end of life care services. But before I explain how we’re doing this, it’s important to know why.

Where to start?

End of life care is a good place to start when looking at opportunities to improve care and make cost efficiencies. We’re all going to die and generally, we’ll use the NHS the most in our last year of life. It is projected that the number of people dying each year in the UK will increase by 12% over the next ten years, and by nearly 25% by 2043.

This means, that addressing the demands of end of life, will generate efficiencies today that will increase each year as the population grows. Lessening the impact of future growth, reduces the need for increasing capacity in hospitals. We need to look beyond an annual budget and prepare now for what’s coming down the line. 

With population growth, backlogs, block contracts and maxed out services, we need to look beyond the red herring of in-year cashable savings. I’ve already seen how social investment is driving transformation in the health and social care sector, enabling experts to respond to the unique needs of different places and to accelerate the move to community-based care. 

We need to look beyond an annual budget and prepare now for what’s coming down the line

Linsey Lambeth, End of Life Care Fund Lead, Health + Social Care team

So what is social investment?

It is neither a loan nor a grant. Social investment is the use of repayable capital to achieve impact in social issues and better outcomes for people. Essentially, it’s funding to support change. 

We all plan to succeed, but sometimes there are delays or challenges that impact negatively on success. The benefit of social investment is that it builds in flexibility to adapt to operational challenges rather than plough on with delivering pre-agreed inputs that aren’t really working. And you repay less while you iron out your approach. This gives you time to embed change, to continuously improve the service so it’s optimal and, once it is optimal, to gather evidence to decide if it’s suitably impactful and affordable to continue.

To make social investment work in the NHS, our model has three principles:

  1. No interest is ever charged. The fund covers the cost of the service and the NHS will never repay more than we invest.
  2. Our focus is on outcomes over activity. Busy doesn’t always mean impactful. Let’s focus on evidencing improved care.
  3. The repayments come from creating value – those cost efficiencies we talked about – as opposed to generating income. 

Of course, social investment still needs to be repaid (if not in full, then in part). And yes, there is little or often no new money for these repayments. And with block contracts and backlogs there are limited options for releasing immediate cashable savings. However, investing in such services would reduce demand on contingency budgets now, whilst lessening future cost pressures. 

Something needs to change. That’s why I’m excited to be working with Macmillan Cancer Support to do just that.

Macmillan Fund For End of Life Care

We have partnered with Macmillan Cancer Support to deliver social investment in transformational adult end of life care services. The Macmillan Fund underwrites the new or redesigned service and absorbs the financial risk should outcomes not be delivered in whole or part from day one. Service costs will only be repaid in full if 100% of predicted outcomes are achieved. 

We know change takes time to embed, teething problems occur with recruitment, and bumps in the road can appear through slow referrals, data issues and delays in IT systems. That’s why a typical three-year funding agreement gives you three years to iron this all out. At the end of year three, your decision to continue the service (or not) will be evidence-based. And in the meantime, Macmillan will absorb the cost of any delay or shortfall.

Throughout, Social Finance provides pro-bono support with data analysis, clinical expertise and recommendations to ensure the impact of the service is maximised. This is particularly valuable at a time when ICB running costs are subject to a 30% real terms reduction.

In an ideal world, there would simply be more money in the system. But budgets have never felt more constrained. With inflation, pay rises and population growth compounding the issue, it’s hard enough just maintaining the status quo. Is it not time to try something different? 

The Macmillan Fund is designed to absorb your risk and to provide capacity to your team. It’s like a free insurance policy with free expert support! The Macmillan fund is already helping partners establish services to be less expensive to run than the cost of the avoided admissions and we want to help you achieve this too.

Find out more about how to apply. The deadline for applications is 31 October 2023. We know you’re busy so we’ve kept the process light! 

If you are keen to explore further, please contact us at

We look forward to hearing from you.

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