Social Care - Health Committee Contents


Conclusions and recommendations


Introduction

1.  This report will highlight several significant issues that the Committee has identified from the substantial body of evidence received during our inquiry. Our aim is to paint a picture of how a fully integrated system could be achieved with more efficient use of resources and the improved outcomes that it could deliver. The Committee recommends that the Government respond to the issues we have raised in its forthcoming White Paper and its proposed bill as well as in its progress report on funding reform. The Committee plans to revisit social care in the light of these documents, with a view to reviewing the progress that has been made. (Paragraph 4)

The consequences of fragmentation

2.  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. (Paragraph 11)

Defining social care

3.  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. (Paragraph 16)

4.  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. (Paragraph 17)

The case for integration

5.  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. (Paragraph 19)

6.  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. The Committee welcomes Government support for this objective but is concerned that progress continues to be disappointing. (Paragraph 27)

7.  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. (Paragraph 30)

The case for a single commissioner

8.  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. (Paragraph 32)

9.  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. (Paragraph 36)

10.  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. (Paragraph 40)

11.  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). (Paragraph 41)

12.  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. (Paragraph 42)

13.  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. (Paragraph 43)

Care Trusts

14.  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. (Paragraph 48)

15.  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. (Paragraph 49)

Integrating outcomes

16.  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. (Paragraph 53)

A social care system in crisis?

17.  As the Committee reported in its recent report on Public Expenditure, there is clear evidence of resource pressures on social care authorities. The Committee welcomes the Government's commitment of an additional £2 billion per annum to social care by 2014-15, but recognises that even this substantial additional commitment is only sufficient to meet additional demand if social care authorities are able to deliver an unprecedented efficiency gain of 3.5 per cent per annum throughout the spending review period and does not allow for any progress in responding to unmet need. (Paragraph 66)

18.  The weight of evidence that we have received suggests that social care funding pressures are causing reductions in service levels which are leading to diminished quality of life for elderly people, and increased demand for NHS services. Although the transfer of £2 billion from health to social care is welcome, it is not sufficient to maintain adequate levels of service quality and efficiency. (Paragraph 73)

19.  As it reported in its recent report on Public Expenditure, the Committee believes that the levels of efficiency gain which have been planned by the Government will not be achieved unless there are fundamental changes in the way care is delivered. In particular the Committee believes that successful delivery of the Government's plans requires a dramatic strengthening of its commitment to deliver more integrated services. (Paragraph 74)

Rebalancing public sector spending

20.  We noted earlier the Dilnot Commission's conclusion that the social care system is 'inadequately funded.' Andrew Dilnot was also clear that the separate funding streams for health, social care and welfare mean that resources are allocated in an inefficient way. At a time of scarce resources and rising demand the Committee believes that this structural inefficiency, which has been recognised for decades, can no longer be ducked. Too much is spent treating preventable injuries like falls, which can have a catastrophic impact on the lives of older people, some of whom may never regain independence again. If we are to create a sustainable, high quality support system for older people, commissioners need to rebalance the entire expenditure on services for older people across the NHS, social care, housing and welfare. This will be a process, rather than an event; the purpose of creating integrated commissioners, is to create agents within the system who have both the ability and the incentive to drive the necessary process of fundamental change in service provision. (Paragraph 76)

Personalisation

21.  While the Committee remains sympathetic to the cause of greater personalisation, it believes the Government needs to be clear-sighted about the likely impact of personalisation on total demand for social care —and therefore on social care budgets. This is an issue to which the Committee will return. (Paragraph 80)

The Dilnot Commission

22.  The capped cost model proposed by the Dilnot Commission represents an important element of the total funding model, but it is not the whole answer. The Committee recommends that in its forthcoming "progress report on funding", the Government should accept the principle of capped costs and outline proposals on where the cap should be set. (Paragraph 88)

23.  Dilnot also recommends that there should be a separate cap on living costs of between £7,000 and £10,000 per annum. We support this and recommend that the Government accepts it. (Paragraph 89)

24.  The Committee believes it is important that the future shape of social care is not dominated by a debate about the technical details of funding. It is essential that services are shaped by the objective of high quality and efficient care delivery, and the funding structures are fitted around that objective, not vice versa. It is, however, unsurprising that there is a focus on funding issues given the current financial stress on the care system. (Paragraph 90)

25.  Although the Committee supports the implementation of the main recommendations of Dilnot, it believes the narrow terms of reference given to the Commission meant that the more fundamental issues about the need for a more integrated care model were only addressed in passing by Dilnot. (Paragraph 91)

Capping care costs

26.  It has been suggested to the Committee that some of the disadvantages of the cap expressed as a cash sum could be addressed if the cap was expressed as a period of time. The Committee understands that the Dilnot Commission considered this approach and rejected it on the grounds that it would make the actual cost of the individual's contribution dependent on the acuity of their care needs during the period involved. (Paragraph 95)

27.  The Committee recommends that the Government should look again at the principle of expressing the cap on care costs in terms of the length of time that people fund their social care for themselves in its progress report on funding, ensuring the equivalence of care standards before and after the cap is reached. Further work however is required to address unintended anomalies caused by regional variations in housing values and the difference between domiciliary and residential care costs. (Paragraph 96)

Financial products

28.  The Government should clarify the likely market for pre-funded insurance, equity release, and immediate needs annuities, as well for pension-related and other products. It should also articulate how it will work with the industry to stimulate the market for these products. (Paragraph 101)

Supporting carers

29.  The Committee welcomes the Government's recognition of the importance of support for informal carers and carers' assessments. The Committee is however concerned that the effectiveness of the policy is too often undermined by the failure of GPs, social workers and others to identify carers. The Committee believes the Government needs to find new and more effective ways to identify carers in order to ensure that their needs are properly assessed and met. (Paragraph 112)

30.   The Committee supports the need for reform of the law governing social care, but is clear that this cannot take place in isolation from the law governing health, housing and welfare services. It believes that a new, integrated legal framework is required which supports integration of care around the needs of the individual, with a focus on driving forward quality and improving outcomes. (Paragraph 115)


 
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© Parliamentary copyright 2012
Prepared 8 February 2012