5 Re-imagining care
84. This report has repeated many themes which
have featured in the Committee's previous reports. In this chapter
we aim to set out our ideas about how policy should respond to
the challenges we have identified.
85. Although total funding for health and care
has been the subject of extraordinary growth in the last 50 years,
and though it is likely that in the longer term taxpayer preferences
will sustain continued increases in future, the Committee does
not consider that it is realistic to plan for significant additional
taxpayer resources in the short to medium term. Against that background
the Committee has developed its ideas on the basis of current
funding levels for health and care, including the additional resources
provided to the care system by the Government's recent decision
to fund a modified form of the recommendations of the Commission
on Funding of Care and Support (the Dilnot Commission). [65]
86. The heart of the Committee's
approach is that the care system should treat people not conditions.
Services should adapt to people, not the other way round.
The Dilnot Commission
87. The main recommendations of the Dilnot Commission's
report concern the introduction of a series of caps on the contributions
required from individuals to the cost their own social care. They
recommended a cap of between £25,000 and £50,000 on
the amount that any individual has to pay for their care, after
which the state would bear the costs. They also recommended that
this capped figure would not include costs associated with accommodation,
food and other living costs, but that these should subject to
a separate cap of between £7,000 and £10,000 per year.
[66]
88. The Government has accepted
the key principles set out in the Dilnot Report with the key exception
that it proposes that the cap on individual contributions should
be set at £75,000 in 2017-18 prices (equivalent to £61,000
at 2010-11 prices).[67]
The Committee plans to review the implications of the Government's
proposal to introduce the cap at a higher level than recommended
by Dilnot, but it welcomes the Government's endorsement of the
principles set out by Dilnot, and its commitment to introduce
the necessary primary legislation.
Integrated care
89. There are three fundamental tests of whether
a public health and care system is functioning well and in the
best interests of the population it serves:
- Does it deliver high quality
care?
- Is it accessible to the population?
- Is it affordable?
90. The conclusion which we draw from the evidence
we have taken on public expenditure on social care, as well as
from our recent visit to Denmark and Sweden, is that these three
objectives cannot continue to be met by the NHS operating on present
lines and with the constraints on expenditure it is likely to
experience for the foreseeable future. Only greater integration
of health and care services will maintain and improve access to
the high quality care which should be at the heart of the NHS's
purpose.
91. There is evidence, for example, that 30%
of admissions to the acute sector are unnecessary or could have
been avoided if the conditions had been detected and treated earlier
through an integrated health and care system. Earlier intervention
in these cases would lead to better quality outcomes and less
pressure on stretched resources in the acute sector. Mike Farrar
of the NHS Confederation told us:
Almost every threshold assessment survey that is
done...to assess whether or not people are in hospital services
who would have needed hospital services reveals that there are
somewhere between 30% and 40% of patients who, had we had alternatives
in place, could have been treated elsewhere... it is a safe bet
that we do not need at least 30% of our acute capacity and we
would have, in my view, to be intelligent in the way that we then
distributed the services we do need to make sure we have the best
opportunity for patients to get care. The good news is that it
could probably be done without reducing quality. The downside
is that the alternatives have to be available. People cannot be
expected to support capacity being taken out if they cannot see
where the improved services are. Therefore, community, primary
and social care strengthening are absolutely critical to being
able to reconfigure hospitals.[68]
92. We asked the NHS Confederation, LGA and ADASS
jointly to advise the Committee what it would take to unlock the
pathway to integrated care, and they set out a number of requirements
that would need to be fulfilled.[69]
Two of those requirements struck us as particularly significant:
- allowing local flexibility
for the NHS and local authorities to commission and deliver integrated
care; and
- streamlining the mechanics for joint funding
mechanisms.[70]
93. Equally significant were their recommendations
about what central government should not do. It should not:
- Raise public expectations that
integrated care will be the answer to all the challenges facing
the health and care system (that is, it should be realistic)
- Over-specify what integrated care is or is not
(essentially the point about local determination in another guise)
- Engage in another major structural re-organisation
of the health service (for reasons which are largely self-evident)[71]
94. In the light of this advice (which we believe
would be widely endorsed) the Committee does not believe that
the policy objective of more integrated health and care services
would be best served by further organisational change. Nor do
we believe that such change is necessary to achieve this objective.
95. We recommend that the new
health and wellbeing boards should be developed as the forum in
which all interested parties should evolve the future shape of
health and care services in their area.
Developing the health and
wellbeing boards as the forum in which integrated care is developed
would also help to ensure that the Government's new proposals
for funding care of the elderly are implemented within the context
of a commitment to wider service system re-design. This would
help to ensure that new funds do not become locked into static
models of care but used to promote understanding and evidence
of how to facilitate independent living.
96. We have already set out in our report on
social care the principle of a single commissioning process with
a single commissioning budget derived from the shared resources
of health and social care.[72]
In response, the Government accepted that joining together budgets
made sense:
The Government recognises that integrated commissioning
budgets can be a positive step towards delivering better integrated
care. As part of the new arrangements, the NHS Commissioning Board
and health and wellbeing boards have a duty to promote the use
of joint budget arrangements between CCGs and local authorities
where it would benefit patients, service users and carers. The
Government expects these bodies to maximise the use of joint budget
arrangements where it would benefit patients, service users and
carers. Commissioners will be held to account for commissioning
high-quality services with good outcomes, many of which will only
be achieved if services are designed and delivered in an integrated
way.[73]
97. We also consider that our proposals are entirely
in line with what the NHS Commissioning Board has in mind. We
asked Sir David Nicholson if the Board would make integration
of the work of clinical commissioning groups with social services
easier than it is at present. He told us:
It is important that we do. The Health and Wellbeing
Boards, as a forum to bring everyone together to do that, are
really important. If we find that there are obstacles to transferring
resources across the system, we will take action as a Commissioning
Board to enable that to happen. We are keen to support that because
we think it is absolutely the future. Everything else fails if
we do not get that bit of it absolutely right.[74]
We also asked about our point on rebalancing expenditure
across all services for older people, to which he responded positively,[75]
and on where the budget might be held. He said;
There are things we can get over, so there is more
pooling of budget and we are absolutely in favour of it. Where
it becomes difficult is that our offer to the population is different
from that of local government. Our offer is universal, free at
the point of use and theirs is not. We get into real difficulties,
I think, when we get into that kind of area. So, from the NHS
perspective, we have to be careful that we do not by accident
introduce charging and things like that into the NHS system...
but we want to do that [pooling of budgets] very much.[76]
98. There are other signs that the pooling of
budgets is in the forefront of current thinking. It has been reported,
for example, that the Government is considering making provision
in the Care and Support Bill (currently being scrutinised in the
Commons in draft) to require clinical commissioning groups to
pool part of their budgets with local authorities as part of the
joint planning process.[77]
99. We welcome the positive approach to our ideas
which we heard from both the Secretary of State and Sir David
Nicholson. In particular we welcome their support for the development
of single commissioning budgets as the lever which will deliver
more integrated services. As the Committee stated in its previous
report on Social Care, it is does not believe that repeated promises
of cooperation and collaboration have delivered the necessary
impetus for service re-design.
100. Against the background
of a common desire to avoid further management upheaval, and recognising
the dangers of an over-prescriptive approach, the Committee repeats
its recommendation that health and wellbeing boards and clinical
commissioning groups should be placed under a duty to demonstrate
how they intend to deliver a commissioning process which provides
integrated health, social care and social housing services in
their area.
101. The key difference between the NHS and social
care - that one is a charged-for service and the other is not
- cannot be glossed over. The Committee has however been impressed
by the fact that this obvious obstacle to the development of more
integrated health and social care services has not been allowed
to prevent developments in several areas (for example in Torbay);
it believes that the key to success is to define the services
which are subject to charges and ensure that this definition is
entrenched in a way which gives patients confidence that it is
not subject to convenient bureaucratic amendment.
102. The Committee believes
that the best way to provide services which treat people rather
than conditions and services which adapt to people rather than
causing people to adapt to services is to bring together funding,
planning and commissioning of services around the forum of the
Health and Wellbeing Board. All health and social care services
in a given area should be included in this pooled process, including
those which are developed to fund and implement the Dilnot proposals.
Ring-fenced budgets
103. This chapter is focussed on the machinery
required to develop more integrated health and care services.
In particular it focusses on the need for a fully integrated commissioning
process - bringing together the resources committed to the different
traditional silos. This approach is motivated by the belief that
greater integration of these services will allow them, to a significant
extent, to meet growing demand for higher quality services through
the elimination of cost and process duplication and poor interface
management. If the health and care system to be seen as a single
system, however it is inevitable that people will also increasingly
cumulate the multiple revenue sources which fund the current service
structure.
104. In 2011-12, the NHS was allocated £98
billion by the Department of Health[78]
and local authorities spent £17.2 billion on adult
social care[79] (£115.2
billion in total).
105. The final element that is needed to encourage
health and wellbeing boards to look across the traditional service
silos is confidence about the level of budget which is available
for health and care. The Government's commitment to at least maintain
the level of spending on NHS services in real terms provides NHS
commissioners with that confidence; it would be a perverse outcome
if a commitment to participate in single budget commissioning
arrangements were to lead to a reduction in the resources available
to social care - and therefore to reduced funding of the integrated
care model which the Government is keen to encourage.[80]
106. Against this background the
Committee recommends that the Government should introduce a ring
fence to protect the current level of real-terms funding available
to social care. This approach would ensure that resources were
no longer treated as 'belonging' to a particular part of the system,
but to the local health and care system as a whole. With agreement
on local priorities, and with binding commitments on the amount
of money available to fund them, a flexible, responsive health
and care economy could be established which would use the total
budget provided for health and care more efficiently than is the
case at present with separate funding streams and different objectives.
65 Commission on Funding of Care and Support, Fairer
Care Funding. The report of the Commission on Funding of Care
and Support, July 2011 Back
66
Ibid., Volume 1, pp 33 and 34 Back
67
Oral Statement by the Secretary of State for Health, 11 February
2013, HC Deb, columns 592-94; Policy statement on care and
support funding reform and legislative requirements, Department
of Health, 11 February 2013. Back
68
Q 14 Back
69
Q 73; Ev 116-118. Back
70
Ev 117 Back
71
Ev 118 Back
72
Health Committee, Social Care, HC 1582-I, paragraphs 40-43 Back
73
Department of Health Government Response to the Fourteenth
Report of the Health Committee on Social Care, Session 2010-12,
Cm 8380, July 2012, paragraph 10. Back
74
Q 207 Back
75
Q 211 Back
76
QQ 212-13 Back
77
CCGs and councils may share budgets, Health Service Journal,
11 October 2012. Back
78
Ev 73, paragraph 20 Back
79
Health and Social Care Information Centre, Personal Social
Services: Expenditure and Unit Costs - England 2011-12 - Provisional
Release, 30 November 2012, p1 Back
80
Department of Health, Government response to Health Committee
Report on Social Care, Cm 8380, paragraph 7 Back
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