Conclusions and recommendations
Strategic direction of services for
long-term conditions
1. We
note with interest the establishment of 14 pioneer sites which
are intended to address existing barriers to the integration of
health and care services and indicate where such barriers need
to be broken down by work at national level. We plan to examine
the work of these integration pioneers in greater detail in a
separate inquiry. (Paragraph 21)
2. We
welcome the commitment of the National Collaboration for Integrated
Care and Support to ensuring that all localities in England have
adopted models to commission and deliver integrated care and support
by mid-2015. We recommend that the Department of Health monitor
progress towards the achievement of this objective and publish
by July 2015 its assessment of the extent to which each locality
in England has adopted models to commission and deliver integrated
care and support, together with its assessment of the strengths
and weaknesses of different models and approaches in particular
contexts. (Paragraph 22)
3. We
note the claims made by the Department of Health and NHS England
for progress against the objectives set out in the Mandate. We
are nevertheless not persuaded that the claims made to us represent
substantive progress against the measurable objectives given to
NHS England, such as they are. The publication of a resource to
assist service users in personalising their services is not in
itself evidence of progress in their experience of care or improvement
in their quality of life. (Paragraph 30)
4. The
intention in the Mandate and the NHS Outcomes Framework to establish
measures to indicate progress in the enhancement of quality of
life for people with long-term conditions is welcome. We nevertheless
note that a number of these indicators are still in development
or have been introduced so recently that they cannot demonstrate
in any meaningful sense what progress may have been made by the
NHS in increasing the quality of life for people with long-term
conditions by March 2015. We recommend that in its response to
this report the Department of Health should quantify the "measurable
progress" it expects NHS England to have achieved against
clearly specified baseline measures for all relevant Mandate objectives
for long-term conditions. NHS England should similarly set out
in response to this report the progress it has made against each
objective against the same baseline measures together with its
estimate of likely further progress by March 2015. Where such
indicators and baselines are not yet available the Department
should be transparent about the extent to which measurable objectives
can be said to exist and consider how those objectives should
be developed and modified. (Paragraph 31)
5. We
note that the original plan to develop a national strategy for
long term conditions was explicitly cross-government in its perspective
and involved participants from 12 Government departments. This
attempt to develop a joined-up, government-wide approach to the
management of long-term conditions has been dropped following
the transfer of policy responsibility from the Department of Health
to NHS England. The Department and NHS England should clarify
how cross-departmental working is to be continued in the absence
of a cross-Government strategy. (Paragraph 41)
6. We
are concerned that the growth in demand arising from long-term
conditions and associated patterns of co-morbidity has not been
matched by the urgency with which the Department of Health and
NHS England have developed their strategic responses. This finding
is of particular concern since the long-term conditions agenda
lay at the heart of the Nicholson Challenge to achieve transformative
change in the delivery of health and care services. We recommend
that in its response to this report NHS England set out clearly:
· the changes it considers
necessary to better support people with long-term conditions;
· the strategic objectives
such changes are meant to fulfil;
· the plan it has devised for
achieving such changes;
· the steps to be taken to
engage other relevant Government departments in the delivery of
such changes, and
· the milestones it has set
for delivery.(Paragraph 42)
7. The
Secretary of State should publish, as part of his response to
this report, a statement of the changes the Government would wish
to see incorporated into the next refresh of the Mandate in respect
of long-term conditions, including a statement of the urgency
he attaches to their delivery. (Paragraph 43)
8. We
further recommend that NHS England report to the House by October
2014 at the latest on the outcome of its 2014 planning round,
setting out in detail its assessment of the aggregate effect on
the health economy of England and of each NHS England area of
the local plans made by each clinical commissioning group. (Paragraph
44)
Clinical care for people with long-term
conditions
9. We
recommend that in revising its present clinical guidelines and
developing further guidelines the National Institute for Health
and Care Excellence should routinely take into account the incidence
of multiple morbidities and the attendant risks of polypharmacy.
(Paragraph 57)
10. The
objective of the health and care system in treating people with
long-term conditions should be to improve the quality of life
of the person. At a time when increasing numbers of people requiring
support and treatment from the system have multiple conditions
combining physical health, mental health, social care and other
support requirements, it seems anachronistic that the Department's
definition of long-term conditions appears to emphasise a single-disease
approach to treatment. We recommend that the Department revise
its working definition of long-term conditions to emphasise the
policy objective of treating the person, not the condition, and
of treating the person with multiple conditions as a whole. (Paragraph
59)
11. The
evidence the Committee has taken on diabetes services demonstrates
the need for a general rebalancing of commissioning and care pathways
for long-term conditions. These should provide treatment which
is integrated across primary, community, secondary and social
care settings. We recognise the benefits to the patient and to
the health and care system of robust support for self-management
of long-term conditions. (Paragraph 80)
12. We
view with concern reports of apparent downgrading of the role
of, and reductions in the numbers of, specialist nurses. Their
expertise is vital in supporting an integrated system of care
for diabetes, from self-management through to acute and specialist
services. (Paragraph 81)
13. The
purpose of a health and care system designed to manage the care
of people with long-term conditions must be to deliver interventions
which are as effective as possible in sustaining and prolonging
the quality of life of the service user. Moreover, such interventions
are unlikely to be restricted to those within the remit of health
and social services. We wholeheartedly endorse the principle that
systems for the management of long-term conditions must be designed
to be responsive to the service user's needs and priorities for
their own wellbeing. (Paragraph 93)
14. We
consider that in order to meet its objective of empowering patients
fully in their care, NHS England should promote the introduction
of individual care planning for service users with long-term conditions.
NHS England should adopt and adapt the principles underpinning
the House of Care approach as necessary and should seek to eliminate
barriers to effective integrated working. The House of Care model
and its associated delivery system provide a sound conceptual
framework to analyse and determine an individual's care needs.
However, care must be taken to ensure that the wishes and requirements
of the service user are not subordinated to rigid and inflexible
care planning protocols. (Paragraph 94)
15. We
note that greater involvement of service users in discussions
and decisions about treatment of their long-term conditions will
inevitably increase the demand for commissioning of complementary
and alternative treatments by patients who feel that they have
gained benefit from them in managing their conditions or who believe
these treatments will be effective. The test for commissioners
and health and care professionals will be how to evaluate and
measure the effectiveness of such interventions appropriately,
and to determine whether they will deliver improved outcomes in
terms of better quality of life. (Paragraph 102)
16. We
recognise the considerable benefits to patients and the health
and care system of greater use of electronic records, better information
sharing and more supported self-management. The NHS is nevertheless
designed as a universal service and its benefits must be accessible
to all. Advances which will benefit the engaged, informed and
technologically-literate patient must not be pursued to the disadvantage
of those who are vulnerable or unable to access new opportunities
for better care. (Paragraph 108)
17. We
note with concern the shortfall in the primary care workforce
projected by the Centre for Workforce Intelligence. We recommend
that Health Education England set out clearly how they plan to
address this projected shortfall. (Paragraph 115)
18. If
care planning, integrated services, multidisciplinary working
and supported self-management of long-term conditions are to become
common practice across the health and care system, the requirement
for structural and cultural change at all levels will be extremely
challenging. Medical professionals in all disciplines who are
treating those with long-term conditions will in many cases have
to adapt their ways of working with patients and with those from
other disciplines. (Paragraph 116)
19. We
recommend that Health Education England, in response to this report,
sets out its strategy for the adaptation of the present medical
workforce, and the training of the future workforce, to the delivery
of a model of integrated care centred on the person. Such training
should also encourage those specialising in one discipline to
develop an understanding of the functioning and the capability
of other healthcare disciplines and therapies. (Paragraph 117)
Managing the system to deliver better
care for long-term conditions
20. We
doubt whether necessary change in health and care provision for
the long term will be achieved through measures which merely address
the symptoms of poor management of many chronic ambulatory care-sensitive
conditions, namely excess unplanned admissions to acute providers.
The priority for the Department of Health and NHS England should
be to address the underlying structure of services and incentives
which send so many patients with CACSCs to acute care in the first
place. (Paragraph 128)
21. While
the prevailing assumption may be that people with long-term conditions
would welcome treatment being provided through community or primary
care as close to home as possible, this approach should not be
taken for granted in the design of systems to support the management
of long-term conditions. Many conditions will continue to require
treatment to be provided being provided in specialised secondary
care settings. (Paragraph 135)
22. Robust
evidence on the long-term clinical effectiveness and cost-effectiveness
of large-scale changes to the mix of services for long-term conditions
is lacking. We consider that such evidence is vital to making
the case for, and informing the design of, any form of sustainable
service change which is to command widespread support. We therefore
recommend that NHS England commission sufficiently rigorous studies
of the effectiveness of services for people with long-term conditions
which are delivered through integrated models of care, and that
the outcomes for health and for cost-effectiveness across all
settings are regularly and rigorously evaluated. (Paragraph 149)
23. We
recommend that NHS England review the condition-specific guidance,
quality standards and support available to commissioners from
the NHS, from NICE and from third parties with a view to identifying
and filling gaps in the support available to commissioners. (Paragraph
167)
24. Guidance
from the Department of Health and NHS England will be vital in
assisting commissioners to shape the change in services for long-term
conditions, but the centre must not prescribe solutions which
local health economies are better placed to determine. The contribution
of each Health and Wellbeing Board to the determination of commissioning
priorities for long-term conditions across each local area will
be significant: Boards have a vital contribution to make to the
development of the broadest appropriate range of services across
the area they serve, taking into account the demand for patient
choice. Similarly, commissioners must be flexible and innovative
in identifying the providers to deliver the mix of services which
will best achieve the objectives for management of long-term conditions
in their area. (Paragraph 168)
25. We
recommend that commissioners should engage providers and the public
as fully as possible in discussions about objectives for health
and wellbeing outcomes in their local area and how they might
be best be achieved. Commissioners should also explicitly relate
payment to outcomes achieved. Local Healthwatch organisations
have a role to play in examining how commissioning priorities
have been delivered. (Paragraph 169)
26. The
development of a funding model which supports a 'year of care'
approach to payment for the treatment of long-term conditions,
rather than an approach to funding based on episodes of care,
is welcome. We look to NHS England and the Department of Health
to collaborate with Monitor in refining, developing and implementing
this approach to funding for long-term conditions, based on an
evaluation of the experience of the model in the early implementer
sites. (Paragraph 178)
27. Monitor
has indicated that a final version of the joint long-term strategy
on reform of the payment system will be published in the summer
of 2014. We recommend that this strategy explicitly include processes
to identify and eliminate perverse incentives in the present payment
structure and to develop systems which incentivise models of care
centred upon all the needs of the service user. We further recommend
that Monitor and NHS England evaluate the results of any tariff
flexibilities used in the 14 integration pioneer sites, as well
as the general flexibilities introduced in the 2014/15 tariff,
and that the interim and final findings of the evaluation should
be published. (Paragraph 184)
28. We
find it difficult to understand how parity of esteem between physical
and mental health services can be established, let alone maintained,
when Monitor and NHS England have introduced a pricing structure
for 2014/15 which has the explicit effect of reducing expenditure
for mental health services at a greater rate than expenditure
on acute services to treat physical conditions. We agree with
the Minister of State that the differential pricing structure
is flawed: in our view, it risks a disproportionate reduction
in funding to mental health services. Monitor and NHS England
must set out in their response to this report what steps they
plan to take to support parity of esteem, both through the present
tariff system and their proposals for tariff reform. (Paragraph
186)
29. We
note with approval that a requirement of participation in the
Better Care Fund is for local NHS areas to engage with patients,
service users and the public on proposals for new integrated services
and the consequences for acute service provision. Such engagement
should be frank and comprehensive and should make the case for
improvements in clinical outcomes and care quality. (Paragraph
198)
30. Without
an agreed package for change, and a corresponding commitment to
implementation, any large-scale attempt to vary the mix of services
for people with long-term conditions is unlikely to succeed. We
recommend that NHS England, as part of its five-year planning
round, undertakes modelling of the effect of commissioner plans
on the acute sector by 2018/19. The likely scenarios for each
NHS England area should be referred to the relevant Health and
Wellbeing Boards for scrutiny and debate. (Paragraph 199)
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