Social Care - Health Committee Contents

2  The fragmentation of services and commissioning

The consequences of fragmentation

5. When thinking about the structure and delivery of health and social care services it is important to have clearly in mind the "typical" service user. This individual is often, wrongly, characterised as a normally healthy adult who relies on the health and care system to provide an episode of care which allows them to resume a normal, healthy life. Such patients, like all patients, are of course important, and the system must meet their needs. But estimates suggest they constitute a small proportion of all hospital activity. The main focus of this report is the needs of those individuals often, but not only elderly people, who suffer from long term and chronic conditions and who need coordinated packages of care to allow them to lead fulfilling lives. It is important to remember that it is these individuals who constitute the "typical" users of services—accounting for 29 per cent of the population, but 50 per cent of all GP appointments and 70 per cent of all inpatient bed days.[3]

6. The statistics relating to adult social care underline this point. Some 51 per cent of people receiving state-funded personal social services are over the age of 65 years,[4] three quarters of adults in residential care are aged 65 and over, and 91 per cent of people in nursing care are aged 65 and over.[5]

7. The NHS Confederation told us that the main job of acute hospitals now is looking after older people:

People with long-term conditions are major users of the NHS. Greater life expectancy means patients can typically have several long-term conditions. One of the most challenging of these is dementia. 70% of acute hospital beds are occupied by older people, 20% of acute beds are occupied by people with dementia and 75% of residents of care homes have dementia.[6]

8. David Orr from the National Housing Federation also made the case that older people are the principal "customers" of Housing Associations when he told us that:

Something like half of all housing association tenancies are now held by people who are 60 or over.[7]

9. Many older people have multiple needs across this spectrum of services. The Nuffield Council on Bioethics expressed this in their evidence to the Committee, using the example of dementia:

[…] after a diagnosis of dementia, people will still need help in accessing what is inevitably a fragmented support system, given the wide range of health and social services which people with dementia and their families may potentially use.[8]

10. The evidence is therefore clear—many older people, and those with disabilities and long-term conditions need to access different health, social care, housing and other services, often simultaneously. Unfortunately the evidence is also clear that these services are fragmented, and those who need to rely on them often find that they are hard to access and that there are inadequate links between them. Indeed, on our visits to Torbay and Blackburn with Darwen the Committee heard evidence that before integration it was commonplace for multiple assessments of older people to take place. The result is that assessments are duplicated, opportunities to provide necessary help are not taken and the condition of individual patients deteriorates in many cases where this did not need to happen. Apart from a few notable exceptions, the provision of services to individuals takes place in unconnected silos—by the NHS, by local authorities and by the voluntary and independent sectors. The BMA told us that because of England's ageing population and increasing levels of long-term conditions "there are dangers in creating fragmented services that separate their management from others within the system".[9]

11. This "silo" mentality among service providers is reinforced by fragmentation of commissioning budgets. Instead of looking at their services from the perspective of the user, and challenging providers to deliver "joined-up", efficient services, the development of separate commissioning budgets for health, social care, housing and other services has tended to entrench the fragmentation of services. Responsibilities lie across several different organisations, from Primary Care Trusts, to local authorities and individual citizens. The Committee does not believe that the proposals in the Health and Social Care Bill will simplify this process. Many older people, people with disabilities and those with long-term conditions need to access a wide range of services, from the NHS through to housing services and care and support. Their experience of these services is often fragmented. The Committee believes that there is a link between the fact that people experience fragmented services and the fact that there are multiple funding streams and multiple commissioners of the services that they use.

Defining social care

12. At the heart of this fragmentation lies a key issue—the distinction that has been drawn between what is health care (commissioned and largely delivered by the NHS), and what is social care (mainly commissioned by local authorities and individuals, and provided by many different sources). This distinction, much discussed but little understood, arises from a succession of political compromises stretching back to the 1920s.

13. The latest attempt to define the concept of social care comes from the Law Commission's recent report on reforming the law governing adult social care. Although the existing law does not establish a clear definition of social care, the Commission sets out the existing definition of social care as:

Adult social care means the care and support provided by local social services authorities pursuant to their responsibilities towards adults who need extra support.[10]

This definition goes on to establish the settings in which social care is provided.

14. Furthermore, the Law Commission is clear that social care is currently defined "largely by reference to what services are not being provided by other organisations under different legislation".[11] Its proposals for the future lie in not defining social care but in identifying a single "unifying purpose" around which social care should be organised—the "well-being principle". This approach would establish in law that "the overarching purpose of adult social care is to promote or contribute to the well-being of the individual".[12] A further checklist of issues that decision-makers would need to take into account would also be in the statute including involving users in decision-making, safeguarding adults from abuse or neglect and finding the least restrictive solution to any problems.[13]

15. During their evidence to us the Law Commission further clarified this issue and underlined the difficulty in clearly defining what social care is. They stated that:

The second issue is that we decided, quite early on in the report, that it would not be possible to define adult social care. We could only define its purpose, which is what the well-being principle aims to do. A lot of what adult social care currently provides is what other organisations do not provide—health services that are not provided by the NHS or housing services that are not provided by housing. In that sense, it was important for us to keep a very dynamic definition of the purposes of adult social care that did not exclude those sorts of matters at the margins.[14]

When asked if what they were defining is the obligation to fill in the gaps other people are not providing, the Commission told us "That is right".[15]

16. The Committee found the evidence provided by the Law Commission instructive. Faced with the challenge of providing a coherent definition of social care the Commission clearly felt it was building on sand. The Committee was not surprised that the Commission found it impossible to express 80 years of political compromises as a coherent legal principle.

17. In fact, in the Committee's view, the Law Commission's attempt to define social care underlines the central problem. The overarching aim of social care as defined by them, to "promote or contribute to the well-being of the individual", could just as easily be applied to health care or housing services. The conclusion we draw from this is that attempts to draw a distinction between these services and social care will fail because such distinctions are artificial and unhelpful, and because they directly contradict the policy objective. This objective is the same whether it is seen from the point of view of service user preference, objective outcome measurement or cost efficiency. It is to deliver a joined-up, integrated service that aims to deliver the best outcomes for the patient and in the most efficient manner possible. If that is the objective—and the Committee found that it is an objective shared between users, staff and policy makers—it seems perverse to attempt to build integrated service delivery on a fragmented commissioning system.

3   "Ten things you need to know about long term conditions", Department of Health website, Back

4   The NHS Information Centre for Health and Social Care, Community Care Statistics: Grant Funded Services for Adults, England 2010-11, 2011 p 6 Back

5   The NHS Information Centre for Health and Social Care, Community Care Statistics: 2009-10: Social Services Activity Report, England, 2010, p 4 Back

6   Ev 200 Back

7   Q 498 Back

8   Ev 174 Back

9   Ev 183 Back

10   The Law Commission, Adult Social Care, HC 941, para. 1.5 Back

11   Ibid. para. 4.15 Back

12   The Law Commission, Adult Social Care, HC 941 para 4.16 Back

13   Ibid. Recommendation 5 Back

14   Q 295 Back

15   Q 296 Back

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© Parliamentary copyright 2012
Prepared 8 February 2012