Select Committee on Health Sixth Report

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?

    Dr Ladyman: Yes.[21]

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  Back

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2005
Prepared 12 April 2005