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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