Public Expenditure - Health Committee Contents

4 Interface between health and social care

33. Improving the interface between health and social care will be essential if the unprecedented savings in both sectors are to be achieved. Adass noted that there was plenty of potential for improving the interaction between these services:

[most people] want seamless services which ignore organisational boundaries. There are some excellent examples of integrated working between health and social care but they are, in general, exceptions other than the rule. They also tend to focus on specific areas of spending such as adults with learning disabilities or with mental health problems. Most of the £120 billion spent on health and social care is spent on older people with long term problems and/or complex problems. Very little of this is spent in an integrated way. This means that public resources are at times wasted or spent unnecessarily.[39]

34. The potential was clearly recognised in the Government's evidence[40] and by the Secretary of State:

It is very clear, when we look at where efficiency, quality and productivity can be best improved, that the interface between health and social care has for a long time been one of the areas that is most susceptible of improvement. The resources that we are making available through the spending review - even this year we have found £70 million in savings to support reablement - are specifically directed at delivering those gains in efficiency.[41]

35. Improving the interaction between health and social care will be very important if the necessary cost savings on both sides are to be realised. The potential to make savings in this area has long been acknowledged, but has not yet been properly realised. We believe that it is mission-critical to successful delivery of the Nicholson Challenge to achieve a quantum leap in the efficiency of this interface.

36. Although the Secretary of State rightly recognised that movement in this area has been slow, the NAO has found examples of improvement in recent years:

In our discussions with a number of PCTs and local authorities, they reported that integrated working and joint commissioning had increased in the last few years and provided a number of examples of how effective joint working was being facilitated:

they have reciprocal places on each other's committees;

representatives from the PCT may meet as a board with the council's cabinet in order to facilitate better joint working;

many Directors of Public Health are joint posts;

their finance departments meet regularly, usually around once per quarter;

they shared targets e.g. NHS vital signs indicators; and

their Chief Executives meet regularly.[42]

37. The LGA and Adass agreed that the relationship between health and social care was improving, and that discussions on improving the interface were gradually becoming more positive, although they noted that this was often dependent on individual relationships and that negotiations were often set back when key individuals moved on or left the service.[43]

38. The NAO found that particular complications to improving the interface further included the 'grey areas' that result when it is not clear which organisation should be responsible for a particular item of expenditure, and instances when the cost is incurred in one organisation and the benefit realised in the other.[44] The LGA also flagged up the complexity of the interplay between the two systems (especially with tightening resources and charges in the social care sector meeting the 'free at the point of use' NHS).[45]

39. The King's Fund noted that NHS reorganisation could have a negative effect on the interface, as 'the abolition of PCTs and consequent loss of co-terminosity with local authorities is likely to undermine progress made in building relationships at the local level. Nevertheless, the creation of local health and wellbeing boards [proposed by the White Paper]- which will require a different approach driven less by top-down direction and more by locally determined solutions - could create an opportunity to improve on the current situation'.[46] This links into concerns about the abolition of Local Area Agreements, which the NAO had found to be one of the biggest factors in facilitating partnership working between the NHS and local government in tackling health inequalities.[47]

40. Although many witnesses have stressed the benefits to both sides that may come from improving these relations, it was striking that most examples we heard involved additional spend on the social care side to realise cost savings on the healthcare side. In general, this involved preventing unnecessary admissions to hospital and allowing earlier discharge from hospital. As Nigel Edwards of the NHS Confederation noted: 'the most cost-effective way, often, of preventing that admission and moving patients on are well-designed packages of social care'.[48] This was supported by Sir David Nicholson, who told us 'at the end of the day, the people that social care are providing services to are the very people we have in our hospital beds. So I have encouraged the NHS to look very carefully at social care, to think jointly between health and social care, about how they might use that resource and not to revert behind their boundaries'.[49]

41. The Department of Health has stated that improved care of patients with long-term chronic conditions could save up to £2.7 billion, for example by avoiding unnecessary emergency hospital admissions.[50] The NAO has also said that 'economic modelling for our reports on dementia and end of life care found that there was scope to reduce the number of hospital admissions and length of stay; for example, we identified that around 40% of beds were occupied by elderly people who no longer had a clinical need to be there'.[51]

42. Sarah Pickup of Adass told us that the situation had certainly been problematic in the past, but there were signs it was improving:

I think that, for a long time, there has been a lot of measurement in local government about how well we work with the Health Service and there hasn't been, in a sense, equal measure in the NHS about how well they work in partnership with adult care because the ways the systems work and the priorities and the indicators are different. But I think we are hearing a different language coming out of the Department of Health in terms of the NHS and the partnership working and that £1 billion shift of resources is part of that language. If we talk to colleagues now in Strategic Health Authorities and in the Department of Health and in PCTs, I feel there is a more genuine intent to move forward with some of the partnership things that perhaps have been a bit not quite the top of the list of priorities before. If you look at the QIPP processes, the Quality, Improvement, Productivity and Prevention processes, that Health are going through to achieve their efficiencies, they are increasingly featuring those interface services because we recognise that we will all benefit and they are being measured on the extent to which those overlap into adult social care.[52]

43. We strongly support the objectives of improved partnership between health and social care but doubt whether the current institutional or policy structures are fit for the purpose of achieving them. The examples which are quoted often involve demonstrating how better developed social care services will relieve the burden on the healthcare system as well as improving outcomes and experience for patients. There is ample evidence to support these objectives, but delivery involves more than cooperation and improved discharge procedures. It requires a serious commitment to plan and deliver coherent delivery systems ('pathways of care') which are complicated by institutional differences.

44. The allocation of £1 billion to social care through the NHS budget is a step in the right direction in that it formally recognises the interaction between health and social care, but we are concerned that it may be too tightly focused to bring about a genuine wider improvement in the interface between the two services. In general, there is a risk of the 'better interface' becoming a by-word for the health service seeking to achieve its own efficiencies by asking social care to take on more. The Government must do more to bring about improved relations and interaction more generally between the two sectors, as this could ultimately contribute to broader cooperation, more imaginative efficiencies, and more significant savings on both sides. It is not enough for the Government to exhort change in this area: there must be a formal policy infrastructure that recognises the importance of achieving this.

39   Ev 125-126.  Back

40   Ev 88 Back

41   Q 311 Back

42   National Audit Office, Briefing for the House of Commons Health Select Committee - Health Resource Allocation, December 2010, paragraph 5.3 Back

43   Q 223 [Mr Cozens] Back

44   National Audit Office, Briefing for the House of Commons Health Select Committee - Health Resource Allocation, December 2010, paragraphs 5.4 and 5.5. Back

45   Q 194 [Mr Cozens] Back

46   Ev 107 Back

47   National Audit Office, Tackling Health Inequalities in life expectancy in areas with the worst health and deprivation, HC 186, Session 2010-11, July 2010. Back

48   Q 170 Back

49   Q 98 Back

50   Department of Health, NHS 2010-2015 From Good to Great. Preventative, people-centred, productive. Cm 7775, December 2009, p10 Back

51   National Audit Office, The NAO's work on the Department of Health, June 2010, p9. Back

52   Q 223 [Ms Pickup] Back

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Prepared 14 December 2010