Social Care - Health Committee Contents

3  Integrating around older people

The case for integration

18. Despite its importance, the integration of health and social care services has been a matter of debate for decades. As the King's Fund told us:

Integrated care has been a recurrent goal of public policy under successive governments for more than 40 years.[16]

The Committee notes that there are some recurring themes from the history of integrating health and social care. Numerous research reports and policy papers have been published on this matter, signposting the value of integration, and our predecessor Health Committees inquired into this issue in 1999 and again in 2010.[17] For instance, 50 years ago to the month:

[…] a Circular was sent to local authorities highlighting a section of the [ten year] plan that described the development of hospital services 'as complementary to the expected development of the services for prevention and care in the community and a continued expansion of those services has been assumed in the assessment of hospital provision to be aimed at' (cited by Sumner and Smith 1969 p.43). Accordingly, local authorities were asked to produce plans for developing their health and welfare services over the same ten year period.[18]

Our predecessor Committee took evidence on the historical context of integration:

There was growing concern in the 1960s about the lack of co-ordination of health and social services. This led to the appointment of the Seebohm Committee on Local Authority and Allied Personal Social Services which reported in 1968 commenting that 'Although for many years it has been part of national policy to enable as many old people as possible to stay in their own homes, the development of the domiciliary services which are necessary if this has to be achieved has been slow', partly due to the shortage of appropriately trained social workers. It recommended new, unified social services departments to assess local needs and resources and plan accordingly, taking account of and supporting the contributions of independent organizations, relatives and neighbours. The report stated: 'Services for old people in their own homes will not be adequately developed unless greater attention is paid to supporting the families who in turn support them...If old people are to remain in the community, support and assistance must often be directed to the whole family of which they are members'.[19]

As noted in a forthcoming article on the issue of integration, once the decision had been made to separate health (NHS) and local authority (social care) provision and commissioning in the 1970s, plans were drawn up to facilitate greater collaboration:

This exercise led to a number of statutory provisions, some of which remain in force today. The package included requirements for each authority to make its respective professional services freely available to the other and forbade them from directly employing staff from professions allocated to the other. In addition, on the grounds that collaboration was 'too important to be left to be left to good administrative practice', it proposed that health and local authorities should work under a statutory duty to collaborate through a statutory Joint Consultative Committee (JCC).[20]

19. We also note the provisions of the National Health Service Act 1977 which went on to develop further the role of the JCC to advise the Area Health Authorities and local authorities on the performance of their duties, and "on the planning and operation of services of common concern".[21] This "bridging" function will be reincarnated in the different form of the Health and Wellbeing Board. The Committee is struck that despite repeated attempts to "bridge" the gap between the NHS and social care, that, aside from a few notable exceptions, little by way of integration has been achieved over this 40 year period.

20. The King's Fund told us about the successes that had been achieved through integration in Torbay Care Trust in Devon:

Torbay's Integrated Care Project (Thistlethwaite 2011) has highlighted low rates of emergency admissions, emergency bed day use and discharges into residential care compared with other areas in the South West.[22]

On our visit to Torbay the Committee also heard examples of people being assessed quickly, risks identified and equipment, aids and adaptations being made available to people in very short timescales.

21. David Orr from the National Housing Federation gave us an example of integrated housing options reducing costs from health and social care and improving outcomes for older people:

We gave a very small example in our written evidence of Havebury Housing Partnership, which has come to an arrangement with a local hospital about discharge. They provide a flat, at a cost of £150 a week, which stops someone potentially having to stay in hospital while the discharge programme is properly set in place, at a cost of £2,800 a week […] There is research evidence of the value of having a warm and secure home, in terms of reducing demand on the health service. There is research evidence about the impact of the supporting people funding, for example: £1.6 billion generating £3.4 billion of savings, and many of those savings are in health.[23]

22. In a report on integrated care, Turning Point outlined the potential economic savings from integrating a range of health, housing and social care services. They found that integration created efficiencies and savings, with early intervention services potentially saving the NHS up to £2.65 for every £1 spent.[24] The consequences of not integrating are no less stark. As the recent report from the King's Fund and the Nuffield Trust states, "Without integration, all aspects of care can suffer. Patients can get lost in the system, needed services fail to be delivered or are delayed or duplicated, the quality of the care experience declines, and the potential for cost-effectiveness diminishes (Kodner and Spreeuwenberg 2002)".[25]

23. The Government's vision for adult social care emphasises that there are clear benefits from integrated health and social care.[26] The Health and Social Care Bill places the Joint Strategic Needs Assessment and the Joint Health and Wellbeing Strategy at the heart of joint working between health and social care, alongside the new duties to promote joint working.[27] The Government has stated that it will:

[…] identify and remove barriers to collaboration and to pooling or alignment of budgets across health and social care and bring together funding streams for employment support and consider the barriers to market entry for micro and small social enterprises, user led organisations and charities, and the proposed role for Monitor to play in market shaping.[28]

Integration is clearly not an end in itself. Rather, it is an essential tool to improve outcomes for individuals and communities.

24. In recognition of the need to achieve four per cent efficiency gains in the NHS over four years which equates to £20 billion in savings, the Department of Health initiated the Quality, Innovation, Prevention and Productivity challenge (QIPP),[29] which this Committee refers to as the "Nicholson Challenge", after the Chief Executive of the NHS/Chief Executive of the NHS Commissioning Board Authority Sir David Nicholson. A recently published joint report by the King's Fund and the Nuffield Trust has stated that "moving towards a new model of integrated care will help to create the foundations for sustainable delivery against the Quality, Innovation, Prevention and Productivity challenge in the longer term".[30] They went on to state that:

Put simply, integrated care should become the main business for health and social care.[31]

25. This Committee has previously recommended that the delivery of the Nicholson Challenge requires fundamental changes to the way health and care services are delivered.[32] However, during our Public Expenditure inquiry the Audit Commission told us that their "analysis of adult social services efficiencies in 2009-10, and those planned for 2010-11, shows that integration and working more closely with the NHS was one of the least common ways of achieving savings".[33]

26. The Committee is concerned that whilst integration is vital to the financial sustainability and quality standards of the health and care system, some evidence suggests that current pressures are encouraging organisations to adopt a defensive stance which is undermining delivery of the objective of integration. In evidence to the Committee, the NHS Confederation has stated that:

[…] members of our Mental Health Network already report growing numbers of local authorities withdrawing from integrated older people's and other adult services. We are concerned that as financial problems become more profound, it will become harder for individual organisations to look outwards and invest in cross organisational collaborations that deliver more efficient, more integrated, better patient care.[34]

More generally, there is also a growing body of evidence that the quality of services delivered, in particular, to elderly people is being undermined by defensive institutional responses to current pressures. A recent inspection of acute hospitals by the Care Quality Commission found that twenty per cent of the establishments inspected failed to meet basic standards for dignity and nutrition.[35] Too many people are being admitted to hospital from entirely preventable causes. For example, we know that the NHS spends £600 million on treating injuries from falls and other preventable accidents at home.[36]

27. Integration between the NHS and social care systems has been the explicit policy objective of successive Governments. It is not an end in itself, but can deliver real benefits to people who use multiple services across the health and care systems. It is also an essential tool in delivering quality and efficiency in the public sector. This Government has recently restated its commitment to integration in its acceptance of the Future Forum recommendations on this issue.[37] The Committee welcomes Government support for this objective but is concerned that progress continues to be disappointing.

28. The potential consequences for the individual of a continuing failure to integrate both commissioning and provision are clear—disjointed care, more hospital admissions, later discharge and poorer outcomes. The consequences for the health and social care systems are no less stark—as we stated earlier in this report, the NHS will fail to deliver on the Nicholson Challenge unless it achieves greater integration between health and social care. The King's Fund, the Local Government Association and others have told us that the NHS and social care systems are facing unprecedented pressures, particularly from the impact of an ageing population.[38] During our public expenditure inquiry, Sir David Nicholson told the Committee that:

If an acute hospital thinks they can carry on as they are and, in a sense, salami-slice their service through efficiencies, it will not work for them. They will have more and more difficulty. They increasingly need to look at how they integrate with health and social care and to think about what sort of organisation they are going to be.[39]

29. Pursuing the "salami-slicing" of services, coupled with a failure to improve quality and efficiency through integration, will have very serious consequences for standards in both health and social care.

30. Delivery of the Nicholson Challenge (four per cent efficiency savings in the NHS over four years) requires a fundamental rethink in how health and social care services are commissioned and provided. As Sir David Nicholson told us, NHS organisations that "salami-slice" services and fail to integrate with housing and social care could have very serious consequences for standards in both health and social care.

The case for a single commissioner

31. Support for service integration that has been expressed consistently over many years by successive governments; the Committee has therefore sought views about why progress has been so disappointing.

The recent Future Forum report on integration states that services must be integrated "around the individual".[40] However, the current system has multiple commissioners and multiple funding streams. The policy has been to tolerate separate services and seek to build bridges between them. Given the failure of that approach, a single commissioner should now be established to create integrated services.

32. The evidence presented to us leads us to the conclusion that when commissioning responsibilities are divided between different bodies, the effect is to undermine the ability of the system to deliver truly integrated services. Each commissioner is inevitably subject to different pressures and priorities, with the result that it becomes impossible to focus on the key objective, which must be to integrate services around the individual.

33. During the course of its inquiry the Committee has visited a number of locations in the north-west of England (Lancashire County Council, Blackburn with Darwen Care Trust Plus and Cumbria County Council and Clinical Commissioning Group) and Torbay Care Trust in Devon. This and other evidence we received about integrated organisations demonstrated that integrated commissioning had clear advantages in the delivery of better outcomes.

34. The Committee believes, however, that it is the policy objective rather than the precise institutional framework which is important. It is wary of recommending a single structural solution—particularly in the light of the very slow progress which has been made with service integration over a long period. It agrees with the King's Fund which told us that:

A more ambitious approach is required. This should avoid an over-prescription by central government, with the emphasis instead on developing financial, performance and outcome frameworks that create incentives to integrate care.[41]

35. The Association of Directors of Adult Social Services reinforced this approach in their evidence to us:

[…] any integration must be bottom up rather than purely just England -wide prescribed structural reform. The dynamic of localised commissioning provides the vehicle for real integration which is referenced against a localised JSNA and articulated as a local Health and Wellbeing Strategy, subject to local democratic scrutiny and endorsement.[42]

36. In the Committee's view the key is that real progress towards integrated care must begin with a clear commitment to create a fully integrated approach to commissioning. The precise model will depend on local circumstances. Integration could take place around a local authority or a clinical commissioning group.

37. In an earlier report this Committee was critical of the creation of Health and Wellbeing Boards (HWBs), arguing that they represented an unnecessary cost and complication in the NHS commissioning process.[43] However, the NHS Future Forum report of June 2011 argued the case for strengthened Health and Wellbeing Boards, suggesting that:

[…] health and wellbeing boards' role should be strengthened. They should agree commissioning plans, be able to refer concerns about commissioning consortia's commissioning plans to the NHS Commissioning Board and contribute to their annual assessment.[44]

38. The Committee also recognises that many local authorities have welcomed the establishment of HWBs, believing that they provide an opportunity for greater local engagement in the commissioning process for healthcare.

39. We note, however, that the Government has not encouraged the development of the HWB as the holder of a single integrated budget. The Committee believes this could be a lost opportunity. In those areas where good working relationships have been established between NHS and social service partners, HWBs would seem to represent an obvious starting point for a radically strengthened commitment to integrated health and social care commissioning. The Committee would strongly urge that if the HWB is to be developed in this way, its membership and scope should be extended to include social housing.

40. The NHS Future Forum recommended that Health and Wellbeing Boards should agree commissioning plans and refer these plans to the NHS Commissioning Board where they have concerns. Enabling HWBs to develop integrated commissioning budgets would be a positive first step towards integration and the Committee recommends that the Government re-examines this issue.

41. The Committee does not, however, support the imposition of a single statutory framework for the achievement of the objective of service integration. It proposes, instead, that the Government should place a duty on the existing commissioning structures (including the proposed new NHS structures) to create a single commissioning process, with a single accounting officer, for older people's health, care and housing services in their area. This pooling of resources will encompass the Government's contribution (in the form of the budgets and grants it makes to support local health, housing and care services), the local authority contribution (from national and local sources) and the contribution of individuals (from charges for social care services).

42. A single commissioner will have multiple lines of financial accountability, including to the NHS Commissioning Board, local authorities and service users. Central Government, NHS bodies and local authorities will need to establish robust procedures to ensure effective financial accountability.

43. The holder of a single commissioning budget will also need to demonstrate proper local democratic accountability for its decisions. The Committee sees the development of the Health and Wellbeing Board, as an agency of the local authority, as a means of achieving this objective.

Care Trusts

44. Provisions in the Health and Social Care Bill will establish Clinical Commissioning Groups and the NHS Commissioning Board as the commissioning bodies for NHS services throughout England. Care Trusts will no longer be able to commission health services on behalf of their populations as this function will principally pass to local Clinical Commissioning Groups and the NHS Commissioning Board. Some existing Care Trusts clearly believe this development will threaten the service integration they have been able to achieve. The Committee welcomes the Government statement that PCTs and local authorities ensure that succession plans are in place for existing joint commissioning arrangements,[45] but is concerned that some Care Trusts still feel that the progress they have made is at risk.

45. On our visit to Torbay Care Trust, for example, the Committee heard that, while the integration of social care and community health was being maintained, the local authority felt that the effectiveness of the Care Trust had been diminished by the transfer of NHS commissioning to the PCT cluster.

46. When the Committee questioned the Minister of State for Care Services about the future of these highly integrated organisations, he told us:

I think that they proved to be an interesting experiment, but as an experiment they did not really get out of the lab. One of the problems with the care trust model is that it did not lead to any significant transformation across the service. I think they can teach us lessons about how you can orientate organisations around people. The interesting thing about visiting Torbay was their model of saying, "How do we get this organisation to change the way it works? We have to think about Mrs Smith." That is their sort of way of mobilising that. It was not just the structure; it was about the culture and behaviours within the organisation. Those are the lessons I take away from my visit to Torbay.[46]

47. Although Care Trusts have not been widely rolled out across the country, the benefits that they are capable of realising are significant, both for those who use their services and for their local care economies. Torbay Care Trust supplied us with data showing that it had been able to achieve real benefits for local people. The average length of stay in hospital is low, they have few delayed discharges and there is rapid access to equipment and services that keep people out of hospital.[47] The Committee believes that these achievements are the result of positive cultures and behaviours that have been able to take root within a flexible organisational structure. This structure allows resources from different funding streams to be deployed in the most effective means possible, across permeable budgetary boundaries. The challenges of doing this in a system that is not integrated are outlined in the findings of the Partnerships for Older People Programme (which was commissioned by the Department of Health and states):

Moving monies around the health and social care system was a huge challenge, and proved an insurmountable one where budgets were the responsibility of more than one organisation. For instance, monies could be moved from residential care budgets to home care budgets within a local authority, but a claim for monies by a local authority from either primary or secondary health care budgets did not prove possible.[48]

48. The Care Trusts that exist in England are, generally speaking, the most integrated health and social care organisations. Alongside the provision of services to people, some Care Trusts also combine parts of the health and social commissioning budgets into one statutory body.[49] The experiences of Torbay, Blackburn with Darwen and other integrated organisations suggests that the cause of integrating services around the individual can be best served by integrated funding streams and integrating commissioning.

49. The Committee notes that the Minister of State for Care Services sees Care Trusts as "an experiment that […] did not really get out of the lab" and that he argues it is not the organisational form of Care Trusts that makes a difference but the behaviours within the organisation. Nevertheless there is clear evidence that some Care Trusts have made progress with the integration of services and the Committee recommends that the Government should allow communities to have the option of retaining Care Trusts as commissioners of health, housing and social care.

Integrating outcomes

50. In 2011 the Department of Health published a social care outcomes framework, which includes process targets and outcome measures through which social care commissioners will be held to account, and which will support local comparison and benchmarking.[50] In terms of integration, the framework seeks to overlap with two other outcomes frameworks, one for the NHS and the other for public health:

The first version of the ASCOF [adult social care outcomes framework] provides a strong basis for further alignment with the other frameworks, as they are finalised and implemented. Whilst there are few areas in which social care outcome measures are replicated exactly with other frameworks (the impact of reablement on supporting people to stay at home, and delayed transfers of care being the examples), there are several other areas in which the outcomes focus is complementary, for instance in relation to quality of life for people using services and carers. There are also a number of placeholders which offer an opportunity for alignment and joined development of measures.[51]

51. The new NHS Outcomes Framework and indicator set are the means through which the NHS Commissioning Board will be held to account for what it achieves in the NHS.[52] It seeks to recognise the complexity of measuring outcomes across separate health and social care systems:

In terms of adult social care, the NHS Outcomes Framework continues to include outcome indicators which complement or replicate indicators in the Adult Social Care Outcomes Framework. The complementarity between the NHS and adult social care is often different in nature from that between NHS care and public health. Better outcomes will often be delivered through contemporaneous integration of service provision, including particularly for those with long-term conditions. Again, it is likely that greater alignment between these two frameworks can be achieved over time.[53]

52. The NHS Outcomes Framework goes on to state that "We hope [our emphasis] that this clearer focus on alignment, collaboration and integration at a national level will cascade down to the local level."[54] The Committee does not share the Government's view that the outcomes frameworks for the NHS, public health and social care are sufficiently aligned at national level, nor that the degree of alignment will "cascade" down to local level. When asked if there should be a single outcomes framework for older people, encompassing the NHS, wellbeing, social care and housing, the Minister replied:

When you come to grapple with how you boil those down into one document without making it more confusing, we concluded that having three that do overlap in terms of mental health and frailty is the best way to incentivise different parts of the system to work collaboratively, where working together is an essential part of achieving their own outcomes and assisting others to achieve theirs […]We won't have a single one [outcomes framework] because we think there are still discrete elements of social care, and the model that is there as part of social care, that are different from the health service.[55]

53. The new outcomes frameworks for the NHS, public health and social care systems are crucial as they will become the primary means through which the Government will establish whether services are delivering better outcomes for the public. In the context of integrated service provision and integrated commissioning, the degree of alignment between these frameworks looks disappointing. We are particularly concerned that the Government merely "hopes" that national alignment "will cascade down to local level". It follows from the recommendations of this report that the Committee recommends that the Government move quickly to adopt a single outcomes framework for health and social care for elderly people and that it will abandon the attempt to create artificial distinctions between health, social care and social housing.

16   Ev 153 Back

17   Health Committee, First Report of Session 1998-99, The Relationship between Health and Social Services, HC 74-I, Health Committee, Third Report of Session 2009-10, Social Care, HC 21-I Back

18   Wistow, G. 2012 (in press) 'Still a fine mess…?' Journal of Integrated Care, 2012 Back

19   Health Committee, Third Report of Session 2009-10, Social Care, HC 21-I, Ev 148-153 Back

20   Wistow, G. 2012 (in press) 'Still a fine mess…?' Journal of Integrated Care, 2012  Back

21   National Health Service Act 1977, Section 21 Back

22   Ev 153 Back

23   QQ 500-1 Back

24   Turning Point, Benefits Realisation: Assessing the evidence for the cost benefit and cost effectiveness of integrated health and social care, 2010 Back

25   The King's Fund and the Nuffield Trust, Integrated Care for patients and populations: improving outcomes by working together, 5 January 2012. Back

26   Department of Health, A Vision for Adult Social Care; Capable Communities and Active Citizens, 16 November 2010, p 23 Back

27   Explanatory Notes to the Health and Social Care Bill, [HL Bill 92] Back

28   Department of Health, A Vision for Adult Social Care; Capable Communities and Active Citizens, 16 November 2010 Back

29   QIPP is defined by the Department of Health as "a large scale transformational programme for the NHS, involving all NHS staff, clinicians, patients and the voluntary sector and will improve the quality of care the NHS delivers whilst making up to £20billion of efficiency savings by 2014-15, which will be reinvested in frontline care." Back

30   The King's Fund and the Nuffield Trust, Integrated Care for patients and populations: improving outcomes by working together, 5 January 2012. Back

31   Ibid.  Back

32   Health Committee, Thirteenth Report of Session 2010-12, Public Expenditure, HC 1499-I, para. 9 Back

33   Health Committee, Thirteenth Report of Session 2010-12, Public Expenditure, HC 1499-I, Ev 56 Back

34   Ev 198 Back

35   Care Quality Commission, Dignity and Nutrition for Older People, October 2011 Back

36   The NHS Future Forum, Integration, 10 January 2012, p 12 Back

37   Department of Health, Government Response to the NHS Future Forum's Second Report, 10 January 2012 Back

38   See SC 19, SC 66 for example Back

39   Health Committee, Thirteenth Report of Session 2010-12, Public Expenditure, HC 1499-I, Q 121 Back

40   The NHS Future Forum, Integration, 10 January 2012, p 3 Back

41   Ev 153 Back

42   Ev 196 Back

43   Health Committee, Commissioning : Further Issues, HC 796, para. 48 Back

44   NHS Future Forum, Recommendations to Government, 11 June 2011, p 27 Back

45   Department of Health, Government Response to the NHS Future Forum's Second Report, 10 January 2012 Back

46   Q 577 Back

47   See Annex for data Back

48   Personal Social Services Research Unit, National Evaluation of Partnerships for Older People Projects: Executive Summary, 18 January 2010 Back

49   The Audit Commission, Means to an end. Joint financing of health and social care, October 2009 Back

50   Department of Health, Transparency in Outcomes: A Framework for Quality in Adult Social Care, 31 March 2012 Back

51   Ibid. para 2.46 Back

52   Department of Health, The NHS Outcomes Framework for 2012-13, 9 December 2011 Back

53   Department of Health, The NHS Outcomes Framework for 2012-13, 9 December 2011, para. 1.19 Back

54   Department of Health, The NHS Outcomes Framework for 2012-13, 9 December 2011, para.1.20 Back

55   QQ 572-3 Back

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© Parliamentary copyright 2012
Prepared 8 February 2012