2 Social care and integrated care
5. From April 2013, NICE will have new responsibilities
in relation to social care, which will be reflected in its new
name: the National Institute for Health and Care Excellence. NICE
said in its memorandum;
Our new responsibilities in social care, set out
in the Health and Social Care Act, will allow us to apply, appropriately
adapted, a similar approach to developing evidence-based guidance
and standards that we provide for the NHS to decision-making in
the social care sector. The changes also provide us with the opportunity
to ensure that our health, public health and social care guidance
is aligned to allow a more integrated approach to the delivery
of services across these sectors. For example, in dementia, where
we have already produced healthcare guidance and standards for
the NHS, we are looking at how guidance for the social care sector
(including care homes and other services provided by local authorities)
can be joined up so that there is a single evidence-based pathway
available that describes a high-quality integrated service, from
prevention, diagnosis and treatment to longer term follow-up care.[3]
6. This is a significant change, and one that
reflects the developing recognition that in order to improve the
quality of care, and to make budgets go further, greater integration
of services across health and social care is necessary. As Professor
Haslam said during his pre-appointment hearing:
If you were designing a system from scratch, you
would not split it into health and social care. The public doesn't
recognise that. The public doesn't understand our tribalism; it
just wants decent care.[4]
7. Patients Involved in NICE told us:
If we are to move the integration of services beyond
rhetoric to reality then integrated guidance from NICE (for commissioners,
patients, carers and professionals) is a good starting place.
To produce social care guidance, NICE will need to work differently;
the clinical emphasis of its work will need to be rebalanced against
evidence regarding the personal outcomes and benefits to people
using services and their carers.[5]
8. Sir Andrew Dillon told us:
One of the great things about being given now, or
from next April, the responsibility to produce quality standards
and guidance in social care is that we have built and have access
to a resource that allows us to scope individual topics—whether
they come from a clinical guideline route or a social care referral
route—in the most appropriate way for the people who are
going to use them. In future, it will change the way in which
we can look at topics. We are going to take advantage of that
as we review existing clinical guidelines and re-scope them and
as we put together the new topics specifically for social care.[6]
9. Sir Michael Rawlins added that
one of the flaws in our guidelines, which is that
they are single conditions, and by the time people get to 80 they
say, "I will have five simultaneously." We have to produce
guidelines that accommodate that. Nobody in the world has ever
done this, but we are going to do it. We can't cover every possible
combination, otherwise it would take years to produce a single
guideline, but what we can do is provide advice on, say, the three
or four most common co-morbidities that occur in someone with
heart failure, such as chronic bronchitis, which is very common,
and so on. It will be that sort of approach. NICE is going to
be evolutionary, I hope, in the future and can't just rest on
what it has done in the past.[7]
10. It was clear from the exchanges that we had
with Sir Michael and Sir Andrew that NICE understands the need
to move beyond guidance for the treatment of conditions and embrace
a philosophy of integrated care for patients. Sir Andrew quoted
the example of NICE's original guidance on dementia, on which
"the Social Care Institute for Excellence worked with us
to produce parallel advice, which was integrated and cross-referenced".[8]
He said that it was not possible to give the same guidance to
a whole range of professionals:
The advice that you would give to a general practitioner
or to a physician in practice in a hospital for an acute episode
is not going to be the same, though it ought to be complementary
to the advice that you might give to somebody who is looking after
someone in a residential home or in a domiciliary care setting.
We want to make sure that the range of advice to everybody who
has some responsibility for looking after people with dementia
is consistent. It is a spectrum of advice, because the needs that
we might have when we are living with dementia vary, depending
on the setting that we are in. We are trying to get settingspecific
guidance.[9]
11. We welcome the fact that
NICE is to take on responsibility for producing clinical guidance
and quality standards in relation to social care. There is a real
opportunity for NICE to help evolve a different model of care
by creating integrated standards and clinical guidance. We agree
that this should not just be about providing guidance to people
in different disciplines who are treating and caring for people
with a specific condition, but should also involve advising about
the most common associated co-morbidities, including mental illness.
This broader guidance will also need to take account of what individuals
want for themselves. This approach would reflect an important
development of a philosophy which emphasises treatment of people
not conditions.
12. NICE's new role in relation to social care
poses considerable challenges. As Professor Haslam noted "NICE
has a worldwide reputation in terms of health; it does not yet
have a significant reputation in social care. That is an important
line that we have to go down, particularly because of the importance
of the increasing integration between health and social care."[10]
13. We asked him how NICE might bring the health
and social care worlds together in one system. He said:
First off, it takes time. It is not something that
you can legislate for. You have to build up trust and understanding
and bring people together. I see my role as chair very much, hopefully,
as working closely with senior people from the social care world
to understand, indeed, their fears about NICE. I suspect that,
because of NICE's reputation as a health organisation, they feel
that social care is somehow going to get lost in that—that
it is a bit of an adjunct. I do not see it that way. I see the
whole thing as very joined up.[11]
14. Professor Littlejohns talked about how NICE
should assess the evidence on how integration works best.
Where the evidence is around the clinical pathway,
including the social care components, NICE has a very strong role
to play. One of the difficulties, though, with integration is
the interface historically between the primary and secondary care
sectors within the health arena, and of course now with the social
care environment and a whole new mechanism around local authorities.
We need to develop the evidence base around what is working at
that interface. NICE can only work if the evidence is there.[12]
15. One of the key themes of
the Committee's work in this Parliament has been the need to move
to a more integrated system in order to maintain both quality
of care and access to care. As NICE takes on its new responsibilities
in relation to social care, it is important for it to work with
the full range of health and care providers to ensure that an
adequate evidence base is created on which it can base its guidance.
16. NICE should be proactive
in assessing interventions where evidence exists to support efficacy
and cost effectiveness, and should ensure that their appraisal
of cost effectiveness is based on an assessment of quality of
life as well as increased life expectancy.
17. It is not just clinicians and care staff
who need guidance to help build integrated care. Commissioners
also have a key role. One of Sir Michael Rawlins' key priorities
for his successor was to ensure that NICE was attuned to the importance
of commissioners. He said:
...a few years ago we did, on a pilot basis, produce
some commissioning guides, which, at the time, everyone said were
very helpful because an individual [Primary Care Trust] could
plug in its own population and gender and all that sort of stuff
and pull out the numbers of referrals for endoscopy that they
ought to be commissioning for. I think probably NICE should return
to that and develop, on the basis of those, some sort of clinical
commissioning group standards. We have to move forward in that
direction as well as sustain what we have been doing in the past.[13]
18. The Committee has repeatedly
underlined the pivotal role which it believes commissioners should
play in the development of the more integrated care system which
is required. The Committee has also repeatedly stated that it
believes that more integrated care delivery requires more integrated
commissioning. We therefore agree with Sir Michael Rawlins that
NICE should initiate the production of guidance for commissioners
and that the emphasis of that advice should be on how to deliver
integrated care.
3 Ev 40 Back
4
Evidence taken before the Health Committee on 11 December 2012,
HC 831-i, Q2. Back
5
Ev 55 Back
6
Q 157 Back
7
Q 157 Back
8
Q 155 Back
9
Q 156 Back
10
Evidence taken before the Health Committee on 11 December 2012,
Q 1. Back
11
Ibid, Q 4. Back
12
Q 89 Back
13
Q 167 Back
|
