3 Separation of health and social
care
23. The separation of health and social care has
meant that both the funding and provision of continuing care is
beset with complexities. Our predecessor Committee summed up the
background to, and consequences of, this divide in its report
into the Relationship between Health and Social Services,
published in 1999:
If we were building a new service to provide
long term care to vulnerable groups it would seem logical to have
a single, integrated community care provider so that service users,
their carers and families could move seamlessly between services
they may require over time. However, in Great Britain, nursing,
medical and health care is provided by the NHS and social care
is provided separately by local authority social services departments
(SSDs). This separation developed in 1974 when local authority
public and community health functions were transferred to new
Health Authorities. For various reasons—historical, professional,
administrative and financial—barriers have arisen between
these services. These barriers frustrate the goal of "seamless"
service provision and the division often appears confusing to
the users of the services.
An effective relationship between health and
social services is important for a variety of reasons. Since the
implementation of the 1990 NHS and Community Care Act, and the
subsequent transfer of elderly long-stay patients from NHS hospitals
to residential care or their own homes, the number of people affected
by co-ordination problems at the interface between health and
social care services has increased.[19]
24. In nearly every inquiry undertaken in recent
years, the absence of a unified health and social care structure
has been identified as a serious stumbling block to the effective
provision of care.[20]
The problems relate to structure, financial accountability and,
fundamentally, to the distinction between health care, which is
mainly free at the point of delivery, and social care, which is
means-tested and charged to the individual. The evidence we have
received in this inquiry once again indicates that the artificial
distinction between health and social care lies at the heart of
most of the difficulties that have arisen concerning eligibility
for continuing care funding.
25. It is clear that over the last twenty to thirty
years, the gradual reduction in the number of long-stay hospital
beds has meant that people who would previously have been looked
after without charge in a hospital are now instead being cared
for in fee paying nursing or residential homes, or in the community.
The Minister did not dispute this:
Chairman: Would you accept that
if a person may not necessarily need care by a registered nurse
- would you accept that 25 years ago a person with those needs
would probably be in hospital getting care?
26. As our evidence pointed out, this shift is in
many respects a positive one as long stay wards were often dismal
places, and care can often be delivered far more appropriately
and effectively in a non-hospital setting, enabling people to
maintain independence and in certain circumstances remain in their
own homes.
27. However, what this has meant is that care that
was previously provided in the NHS by doctors, nurses and others,
and paid for from NHS funds, is increasingly being provided outside
the NHS, whether in a nursing or residential home, or in people's
own homes. The means of paying for this care, which was once simply
automatically funded by the NHS free at the point of delivery,
as any other NHS care would be, has now become infinitely more
complex. If a patient is eligible for NHS continuing care, the
entire costs will be met by the NHS. However if a patient is not
deemed eligible for NHS continuing care but requires long-term
residential care, the 'hotel' costs, for board and lodging, and
'personal care' costs, will be funded either by local authorities
or by the resident themselves, or by a combination of the two.
Nursing care needs will be paid for separately by the NHS, according
to the fixed, three-banded tariff of the Registered Nursing Care
Contribution (RNCC).[22]
28. The confusion now arising from these complex
and in some senses artificial definitions of different aspects
of care is self-evident. Trish Longdon, the Deputy Ombudsman,
told us:
The complainants who come to us come to us very
confused about the whole issue: confused about what health care
is; confused about the terms that are used; and confused about
the distinctions that many people as providers make but which
of course are meaningless to the users of those services. We
have a very large amount of evidence to demonstrate that there
is a real issue.[23]
29. Barbara Pointon, a carer looking after her husband
who has Alzheimer's Disease, gave a compelling description of
how largely irrelevant these definitions of different types of
care are for those actually receiving the care:
As a carer, as a receiver of this process, I
am strongly of the opinion that the assessments are designed more
to discover who should be funding the care rather than the level
of care that should be provided to this patient. You talked right
at the beginning about the division between social, personal and
nursing care; and if only that were abolished, then a lot of this
palaver and professional time would be done away with. I have
a vision of the future that care is care is care whether you are
talking about someone who is unable to dress themselves or about
palliative care.[24]
30. In evidence to a previous Health Committee, Frank
Dobson MP, the then Secretary of State for Health, was asked to
give a definition of the division between health and social care,
and responded that he could not.[25]
Over six years on, representatives from SHAs and PCTs and Local
Authorities, all senior officials working at the interface of
health and social care on a daily basis, were similarly unable
to supply a definition:
Chairman: Are we any nearer establishing
a division?
Ms Gilley: I think we are nearer
but I do not think … any of us could give you a categoric
definition[26]
31. Nor did the Minister provide us with a clear
definition. Instead, he argued that:
In the end it comes down to how closely social
care and health professionals are working together; how well they
understand each other's needs and are discussing these issues
and are making sure they understand where funding of particular
types of care should come, and the structure does not much matter.[27]
32. However, the Minister's assertion that "the
structure does not much matter" was not borne out by the
evidence we received in this inquiry. John Pye, a community nurse
from Liverpool representing the Royal College of Nursing, told
us that for all his experience in the field of continuing care
he could not supply a definition of the distinction between health
and social care, and argued that this distinction instead distracted
from what Mrs Pointon had argued should be the central concern
of caregivers: the care needs of the patient:
I have been in the Health Service 37 years and
I am no closer to finding the answers to what is health and social
care. That is a perversity we have in dealing with probably our
most dependent population. These people require continuing care.
Whether it is continuing healthcare or continuing social care
is a bit of a red herring really … You suggested we move
the demarcation line between health and social care, and I think
we need to do that. We need to look at people holistically and
see what their needs and care needs are.[28]
33. As well as a move away from delivering ongoing
care in NHS long-stay hospitals, the past two decades have seen
a dramatic move away from traditional medical models of providing
care. Tasks which were once the preserve of doctors and nurses
are being competently carried out by others, including relatives
and carers. Mr Pye gave several helpful illustrations:
As a couple of previous speakers clearly said,
they provide quite a high level of nursing care to their loved
ones and their families and friends. [In some circumstances]
the vast majority of their care is provided by the mother and
father. They carry out tracheotomy changes; they carry out ventilatory
procedures on their own children.[29]
34. Nursing tasks are also increasingly being delegated
to care assistants, and some nurses are beginning to take on traditionally
medical tasks, including prescribing. However, while these more
flexible ways of working are clearly beneficial both to professionals
and to patients, they have brought an attendant set of difficulties,
as definitions of types of care tend to be based on who is delivering
the care. Mr Pye explained the problem:
It does not stop becoming a nursing task simply
because the carers do it, but they do so under the guidance, supervision
and training of the qualified nurses. It does not stop becoming
a nursing task. The 2001 definitions of nursing care included
those tasks delegated and supervised by nurses; however, when
it comes to the funding issues around that care it ceases to be.
The continuing health care and the RNCC clearly specify it is
the work carried out by registered nurses. If you are not a registered
nurse, you cannot carry out nursing care.[30]
35. Mrs Pointon described how, in practice, defining
care by who gives it can result in people wrongly being denied
funding:
Malcolm was assessed three times for continuing
care, and one of the criteria that was being used was that it
was not nursing care because I was not a nurse, so the care was
being defined by who gives it, which is fine in an institutional
setting but does not work if you are working at home because you
do not have a nurse on tap.[31]
36. Mrs Pointon successfully took her case to the
Ombudsman, who ruled in her favour, agreeing that she was providing
a level of care at least equivalent to that which her husband
would have received as an inpatient, and Mrs Pointon was subsequently
awarded continuing care funding for her husband.
37. Cath Attlee of Hounslow PCT also agreed that
in today's changed healthcare landscape, it is not helpful to
establish rigid divisions between health and social care:
As policy and practice change, the boundaries
are shifted, so we are looking more and more at different professionals
taking on different skills and mixing those. It is not helpful
to define things specifically as a health input or a social care
input.
38. The Ombudsman told us that in her view, professional
joint working between health and social services which is now
occurring in many areas, has largely left health and social care
demarcation lines behind, as those working at the interface between
health and social care strive to find innovative solutions to
the problems caused by the distinction between health and social
care. As Mr Pye described:
I was a community nurse in Liverpool way back
in the 80s and 90s where we did merge the carers, the health and
social care staff, because we had those disputes about who gives
eye drops, who washes hair and their feet, and all those issues.
We created a generic worker at that time, and they are spread
round the National Health Service, the social services now anyway,
particularly around the elderly. The only way forward is to come
together and provide a generic workforce for the elderly with
the specialist people involved in their care as well. Continuing
health care gives an opportunity now towards the creation of that.[32]
39. Similar developments are occurring in mental
health, where mental health professionals are increasingly working
across the rigid demarcations of health and social care.
40. In recent years,
in inquiries addressing as diverse a range of issues as the health
needs of children and young people, inappropriate use of NHS acute
beds, elder abuse and care for the terminally ill, this Committee
and previous Health Committees have time and again been confronted
by the problems caused by the current division of systems for
funding and providing health and social care. Nowhere are these
problems more evident than in the area of funding for continuing
care, an area in which confusion has reigned for over ten years,
resulting in frustration for health and social care professionals,
and suboptimal care and financial hardship for some of our most
vulnerable populations.
41. In practice
the boundary between the two services has shifted over time, so
that the long term care responsibilities
of the NHS have reduced substantially, and people who in the past
would have been cared for in NHS long stay wards are now often
accommodated in nursing homes. This means that responsibility
for funding long term care has to a major extent been shunted
from the NHS to local authorities and individual patients and
their families.
42. The question
of what is health and what is social care is one to which we can
find no satisfactory answer, and which our witnesses were similarly
unable to explain in meaningful terms. The policy division between
health and social care lags far behind practice in a number of
areas, where, born of necessity, health and social care professionals
have commendably developed innovative joint working practices.
We welcome these developments and the use of pooled budgets and
other flexibilities, which are beginning to break down the division
between health and social care.
43. Debates about
where the boundary between health and social care should be drawn
have been complicated by further debates around the definitions
of 'personal care' and 'nursing care', and have led to the absurd
position where carers providing complex medical support for their
loved ones are denied fully funded continuing care at home because
they are not registered nurses. If the same care were to be given
by a registered nurse, it would be regarded as nursing care and
fully funded. Barbara Pointon, caring for her husband who has
Alzheimer's, argued that in her experience the struggle to establish
who should fund care has eclipsed the crucial issue of the patient's
actual needs. She also emphasised that from a patient and carer
perspective, 'care is care is care, whether you are talking about
someone who is unable to dress themselves or about palliative
care'.
44. We are convinced
that so long as there are two systems operating according to quite
different principles, the highly controversial issue of which
patients qualify for fully funded NHS care, and which have to
contribute some or all of the costs of care, will remain. We strongly
recommend that the Government remove once and for all the wholly
artificial distinction between a universal and free health care
service operating alongside a means-tested and charged for system
of social care.
45. Removing the boundary between health and social
care would clearly have financial implications, as NHS services
are currently free at the point of delivery, whereas social care
is means-tested, with most people having to contribute towards
the costs of their own personal or social care. According to Help
the Aged, this would resolve many of the problems around continuing
care:
If the Government committed to providing free
care on the basis of need, then some of the difficulties relating
to continuing care could be significantly alleviated as the debate
about which agency is responsible for different aspects of care
receded.[33]
46. As we have noted previously, the Royal Commission
on Long Term Care for the Elderly, set up by the Government to
address the specific question of funding, concluded in 1999 that
all personal care, including nursing care, should be free. The
Government did not accept the Royal Commission's recommendation,
and in evidence to us the Minister explicitly ruled out the possibility
of re-opening discussions around this, arguing that cost pressures
and demographic change would make a system of free personal care
"unsustainable":
Will we go down the route of free personal care,
which would be a way of resolving this point at a stroke? No,
absolutely we will not. It would cost £1.5 billion at today's
prices … We know roughly speaking that there will be four
times as many people needing care by 2050 … by 2050 at today's
prices the cost of free personal care will rise to somewhere between
£8.5 billion and £10 billion. That will be close to
1 per cent of gross domestic product. There is just no way that
that is a sustainable system.[34]
47. The Minister emphasised the important distinction
between free personal care and free long term care, pointing out
that in Scotland, where all personal care is free, if a person
goes into residential care, they still have to pay for their board
and lodging, and are not entitled to collect attendance allowance.
In the Minister's view, many of those currently campaigning for
free personal care are doing so under the misapprehension that
free personal care and free long term care are synonymous.[35]
The Minister also argued that a system of free personal care
could have significant disadvantages over the existing system.
Firstly, in 2001 the Government introduced a policy to prevent
people from having to sell their homes to fund residential care.
Under this scheme, councils can put a charge on people's homes
to be sold after their death. The Minister stated that in his
view, this scheme would have to be abolished to cover the costs
of introducing free personal care.[36]
Secondly, the Minister argued that in Scotland, where personal
care is free, someone being cared for in their own home may be
forced to move to a residential care home if it became cheaper
to care for them in an institutional setting than to care for
them in their own home, despite the fact that most elderly people
prefer to be cared for in their own homes.[37]
48. This inquiry has focussed in the main on securing
improvements to continuing care under the current system, and
for this reason we have not sought detailed evidence on the most
up-to-date estimates of costs of free personal care. However,
using the Minister's own figures, the £1.5 billion he estimates
it would cost to provide free personal care today is dwarfed by
the current £60 billion spend on health care[38];
equally, in his report Securing our Future Health, Sir Derek Wanless
estimated that even by 2023 at least £154 billion per year
is likely to be spent on the NHS, and over 10% of GDP on health
care.[39] It is also
worth noting that after a year long inquiry into this subject,
the Royal Commission on Long Term Care for the Elderly concluded
that the UK was not facing a "demographic timebomb",
and that as a result of this the costs of providing free personal
care would be affordable.[40]
49. Managing and defending the boundary between health
and social care carries significant administrative costs, and
the costs of free personal care, if introduced, would have to
be offset against the cost savings that would be generated from
eliminating these administrative costs. The disputes over delayed
discharges from the NHS into social care, which have had to be
addressed through legislation, are just one example of this. When
we put this point to our witnesses, they agreed. Elaine McHale
of the Association of Directors of Social Services told us that
in her view,
There is lot of public funding being spent on
legal definitions, particularly around this policy guidance, and
much wasted time and energy in trying to achieve an outcome for
individuals in different local authorities.[41]
50. Although the Minister told us the Government
had no estimate for how much this might be, he concurred with
the view that there were costs: "I agree with you that there
must be a cost to it", but said he thought the cost would
not be substantial.[42]
51. We are aware that the Kings Fund has commissioned
Sir Derek Wanless to undertake a review of the challenges and
demands facing social care, and the resources that will be needed
to deliver social care fit for the 21st century.[43]
52. During this
inquiry, we have heard renewed calls for personal care to be provided
free of charge, which would be a way, to use the Minister's phrase,
of resolving many of the difficulties arising from the boundary
between health and social care "at a stroke". However,
the Minister stated categorically that the Government will not
reconsider this option, arguing that it would be financially "unsustainable".
While we have not focussed in depth on this issue during this
inquiry, we dispute the Minister's argument that funding personal
care would be financially "unsustainable". It is clearly
for Governments to decide their own spending priorities - however,
we maintain that with political will, the resources could be found
to fund free personal care. Moreover, the costs of providing free
personal care need to be offset against the current administrative
costs associated with policing the divide between health and social
care. We recommend that debate in this area is informed by the
outcome of the Kings Fund study into future social care resource
requirements which is currently being undertaken by Sir Derek
Wanless.
53. We recognise
that a unification of all health and social care responsibilities
would require primary legislation which is not an early prospect,
and we have therefore framed our subsequent recommendations about
continuing care in the context of to-day's statutory provisions.
However, we urge the Government to accept our central conclusion
that removing the structural barriers between health and social
care is the only way to satisfactorily address these, and a great
many other problems, in the long term.
19 Health Committee, First Report of Session 1998 -
1999, The Relationship between Health and Social Services,
HC 74 - I Back
20
As above; see also, for example, Health Committee, Third Report
of Session 2001-02, Delayed Discharges, HC 617 - I Back
21
Q318 Back
22
These contributions may not meet the full costs of the nursing
care provided to an individual as the bandings are derived from
a national average, notionally updated by inflation, and are not
related to the staffing requirements imposed by the regulator
(CSCI) Back
23
Q193 Back
24
Q108 Back
25
Health Committee, First Report of Session 1998 - 1999, The
Relationship between Health and Social Services, HC 74 - II,
Q661 Back
26
Q2 Back
27
Q266 Back
28
Q133 Back
29
Q135 Back
30
Q135 Back
31
Q94 Back
32
Q134 Back
33
CC28 Back
34
Q321 Back
35
Q317 Back
36
Q317 Back
37
Q317 Back
38
Department of Health, Departmental Report 2004, Cm 6204, April
2004, Figure 3.1 Back
39
Derek Wanless, Securing Our Future Health - Taking a Long Term
View, April 2002, Summary Back
40
Royal Commission on Long Term Care, With Respect to Old Age:
Long Term Care - Rights and Responsibilities, Cm 4191 - I,
March 1999, Executive Summary and Summary o f Recommendations
Back
41
Q3 Back
42
Q267 Back
43
http://www.kingsfund.org.uk/news/news.cfm?contentID=276 Back
|
