Health and Social Care Bill

Memorandum submitted by Age UK (HS 25)

1. Age UK

Age UK is the new force combining Age Concern and Help the Aged. We are a national charity and social enterprise working to transform later life in the UK and overseas. Our vision is of a world in which older people flourish. We aim to improve later life for everyone through our information and advice, services, products, training, research and campaigning.

2. Summary

2.1 The overall vision for healthcare set out by Government is one Age UK supports. Developing a much clearer focus on the outcomes the NHS achieves in terms of treatment and patient experience is a positive step. Increased emphasis on public health and prevention is equally welcome.

2.2 We are less convinced that the strategy articulated by Government and the provisions set out in the Bill will deliver improvements in health outcomes or succeed in eradicating the serious barriers older people face in accessing high-quality care.

2.3 The NHS does not deliver optimum treatment outcomes for older people, lagging behind other EU countries in successful treatment of cancer, stroke and heart disease for example. Nor does it deliver on experience of care for older patients. There are clear indications that ageist attitudes remain entrenched amongst health professionals and that substandard levels of care are tolerated in too many care settings. We need to see a real step-change in the way that the NHS views and treats older people.

2.4 Older people often struggle to access the basic care they need as the NHS continues to under-commission essential community and preventative services such as falls prevention, continence care and audiology [1] . In addition, there are simply service gaps for many older people. Evidence also shows that nearly 400,000 older people living in a care homes face real difficulty accessing GP and primary care services [2] . Commissioning is failing to reflect the reality of the NHS’ largest patient group.

2.5 The NHS also has a poor track record of providing joined-up care, personalised to meet patients’ needs or respect their preferences. Services and professionals operate in silos and fail to provide a coherent package of support across organisational boundaries, the most obvious example being between health and social care.

2.6 We urge caution in proceeding to undertake wholesale change on such a tight timetable. We are concerned that current plans are moving quickly without demonstrating sufficient strategic planning or the support and engagement of NHS staff. For older people with complex health needs any disruption to care or loss of services could have very serious consequences. We want to see a robust process put in place for monitoring the impact of these changes on older patients and ensure that risks are well managed.

2.7 While the NHS reforms will impact on everyone to a greater or lesser extent, they are likely to be most keenly felt by older people as frequent service users. Getting it right for older people is fundamentally about getting it right for everyone.

3. Improving outcomes

3.1 The Bill establishes provisions for the Secretary of State to set out a mandate for the NHS Commissioning Board and commissioning consortia. In turn the NHS Commissioning Board and commissioning consortia must demonstrate how they have sought to meet the mandate in their plans and strategies, and report annually on their progress.

3.2 The draft NHS Outcomes Framework, which we presume forms the basis of the Secretary of State’s mandate with regard to health improvement, adopts a population wide approach to setting health improvement areas which we fully support. However, we know that older people’s needs are currently under-prioritised and under-recognised within the NHS. We also know that ageism in clinical practice persists, with older people lagging behind in terms of health outcomes. We are concerned that, unless there is a clear obligation to demonstrate improvement is being achieved across the whole population, the needs of older people will continue to be obscured.

3.3 In setting the mandate and outcomes for the NHS Commissioning Board the Secretary of State should have a duty to clearly demonstrate that she or he has taken into account the needs of the whole population, including those aged over 65. In order to demonstrate this, the Secretary of State should be able to justify how and why the improvement areas they have selected will contribute to improving the health of the whole population and should report annually on progress towards improvement. They should also be able to demonstrate that the improvement areas are balanced and fair in their focus.

3.4 The NHS Commissioning Board and commissioning consortia in turn should be under a duty to demonstrate how they plan to deliver continuous improvement in outcomes and the provisions set out in the Secretary of State’s mandate in relation to each section of the population; this should form part of their annual reports. For example, in cancer improvement they must disaggregate and demonstrate how plans and strategies will drive improvement across all age groups. They should also be able to demonstrate that activity across the population is balanced and fair in its focus. The risk otherwise is that the mandate incentivises commissioners to invest their efforts in driving improvement for those groups where they believe they can make the easiest and quickest gains.

3.5 GP commissioning consortia and local health and wellbeing boards should also be able to demonstrate how they have considered the needs of their whole population in setting their commissioning priorities. The NHS Commissioning Board should have the power to conduct thematic reviews of commissioning performance and outcomes in relation to different areas of patient care (such as footcare services or falls prevention). The NHS Commissioning Board should be under an obligation to do this if there is a persistent failure to deliver improvement in relation to an area of health care provision or a particular subsection of the population.

4. Health and social care integration

4.1 Services frequently fail to offer a coordinated package of support across health and social care. It is this lack of integrated delivery that causes difficulties for so many older people living with long term conditions and co-morbidities, and impedes better management of their care. Under the provisions laid out in the Bill, local health and wellbeing boards will take responsibility for producing the Joint Strategic Needs Assessment (JSNA) and a local health and wellbeing strategy. Consortia and local authorities are under an obligation to demonstrate that they have taken both the strategy and JSNA into account in developing their commissioning plans. However, we are concerned that this does not give the local health and wellbeing board sufficient power to ensure that actual service delivery matches up nor to challenge gaps in services.

4.2 We believe that local health and wellbeing boards need to be given the power to undertake an inquiry into local service provision and publish independent public reports. Local authorities and commissioning consortia should be under an obligation to cooperate with any inquiry and have a duty to respond to any recommendations set out in a report.

5. Clear lines of accountability for delivery and powers to deal with failure in the system

5.1 Age UK believes that accountability for how well the NHS serves the needs of its users should lie with the Secretary of State for Health. Ultimately, it is the Secretary of State who should be responsible for transparent reporting of the activities of the health service. Parliament should have an opportunity to comment on how well the health service is meeting the needs of the population. So, Age UK believes that it is the Secretary of State who should lay before Parliament an annual report on the performance of the NHS not the NHS Commissioning Board. In light of the current financial challenges facing the NHS, the Secretary of State’s report should also include information on the financial and productivity performance of the NHS.

5.2 Under these proposals the NHS Commissioning Board will take responsibility for primary care contractors through direct commissioning of general practice, dentistry, pharmacy and optical services. This responsibility is currently held by PCTs. Where contract management currently works well, PCTs – working with professional representatives and expert advisors – take an active role in performance managing contractors. PCTs develop a direct relationship with providers and have regular communication to make sure they are appropriately supported, and that any emerging problems are identified and managed before they impact adversely on patient care. This function is distinct from the role of CQC and Monitor as regulators who gather information about quality after the fact and are not as well supported by professional or specialist expertise. Equally some PCTs have played an important role in developing and managing clinical networks, for example, and sharing best practice. We are very concerned that this day-to-day provider management will be lost if overseen remotely by a single national board. Although the Bill creates provisions for the NHS Commissioning Board to establish a regional presence, we believe that this will be essential if it is to adequately fulfil its obligations to properly performance manage primary care contractors.

6. Real power for patients and public to drive service user-led change

6.1 Patient advocacy in health care will be vital if all patients are to benefit from the opportunities to exercise greater choice and control. Whether choosing a health care provider or making decisions about the management of their care, patients will require information and support. We know that information provision and patient involvement in decision making works best where patients are supported to interpret information and apply it to their specific circumstances. Many patients will be easily able to access online information and may feel confident to participate in decision-making with limited support. However, other patients with complex cross-cutting needs, or who may experience cognitive or sensory impairment, will need access to advocacy and advisory services able to provide them with additional support they need.

6.2 The Bill currently limits mandatory advocacy services to complaints, we believe that this is a very narrow interpretation. Local authorities should have the responsibility to commission or provide a suitable advocacy service that delivers appropriate advice and support across health and social care to any person who needs it.

6.3 Currently provisions for patient and public engagement in the Health and Social Care Bill are weak. We want to see mandatory patient representation on all commissioning consortia and on the NHS’ Commissioning Board as part of their governance framework. If there is truly ‘no decision about me, without me’ this principle should extend to every level of the NHS.

6.4 In addition, we believe that there should be a public right to petition the NHS Commissioning Board to undertake a review into a particular health service at a national level or a thematic issue, such as health inequalities.

6.5 The NHS Commissioning Board and commissioning consortia should be under an obligation to publish all information relating to their commissioning strategy and planning, results and outcomes including their rationale and justification for decisions. The minutes of meetings must be open to public scrutiny (with the same ability to restrict certain categories of business as would apply to a local authority). Meeting details should be published in an accessible format and made available in hard format on request, not just online.

7. Supporting vital social care services

7.1 The Bill offers support should a foundation trust collapse financially and we believe this support should be extended to cover some social care services. The Bill should be amended to broaden the scope of ‘special administration’ to include all regulated health and social care services where continuity of service is desirable in order to safeguard service users in the event of a provider experiencing business failure.

7.2 Amending the Bill in this way would enable the protection offered by special administration to be extended to other regulated health and social care services where continuity of service is essential to the safety and wellbeing of service users. This protection stems from the role of the special administrator which includes ‘securing the continued provision of the designated service’ and ensuring that any regulated activity carried on in providing the designated services is carried on in accordance with any requirements or conditions imposed by virtue of Chapter 2 of Part 1 of the Health and Social Care Act 2008 (which refers to minimum standards).

7.3 Continuity of service provision is particularly important for long term care services such as residential care homes where service failure, particularly if it results in a sudden or forced move, can be extremely harmful to service users.

February 2011

[1] p67 Centre for Policy on Ageing, Ageism and age discrimination in primary and community healthcare in the UK (2009)

[2] p20, Ageism and Age Discrimination in Primary and Community Healthcare in the UK : A Clark, Centre for Policy on Ageing (2009)