Adult social care Contents

3Organisation of health and social care services

120.Constituency casework concerning adult social care makes the complexity of the social care system, and its interaction with the NHS, very clear. At the outset of our inquiry, we asked witnesses whether it would be fair to describe the system as confusing: they all agreed.279 Richard Humphries, Assistant Director of Policy at The King’s Fund, told us that “If we set out to design a care and support system that was really difficult and hard for people to understand, we would be a world class leader”.280 The key reasons they gave were the number of agencies involved, the division of responsibilities between central and local government and between local government and the health service, the public and private split in the delivery of services and that fact that care may be publicly or privately funded.281 Integration of health and social care services aims to improve this by streamlining services to reduce gaps in service delivery and prevent people from getting lost in the system, as well as achieving efficiencies.

121.We heard that people also struggled with how social care interacts with housing services and the benefit system.282 Isaac Samuels, a social care user, said that he found himself having to be:

The person who pulls all the professionals together, the person who does all the research, the person who understands value for money, the person who is able to make a complaint. Where do I start just living my life? This is something that is supposed to help me, not make more work for me. I really struggle with the fact that housing talks a different language. No one wants to take responsibility; no one wants to be transparent.283

The evidence we received highlighted the Disabled Facilities Grant as an example of how the structure of the system hindered service delivery and we explore this below. In the rest of this chapter, we explore the progress being made on integration (paragraphs 127 to 141) and in the section headed ‘Innovation and alternative models of care’ look at ways of doing things differently within the existing system (paragraphs 142 to 155).

Disabled Facilities Grant

122.Disabled Facilities Grants (DFGs) are available to disabled people who need to make changes to their home to help them continue to live there, for example installing a stairlift or creating a downstairs bathroom. In 2014, the DFG became part of the Better Care Fund in line with its aims of joining up services to reduce hospital and care home admissions and enabling people to return from hospital more quickly. In recognition of the rising need for adaptations, funding for the DFG was increased in the 2015 Spending Review to £500 million by 2019–20.284

123.In two-tier authorities, the grant is administered by district councils, following an assessment and recommendation from a social care occupational therapist based at county level. In unitary authorities, the team that delivers the DFG is often managed separately from the occupational therapists and located in a different department. Foundations, the body tasked with improving the DFG programme, said that delivery needed to be better joined up with the provision of social care and its 2015 research found that only 30 of the 152 social care authorities could link DFG activity with their social care records.285 The Chartered Institute for Housing said that:

Anecdotally there is still variable involvement and integration of local housing authorities, particularly in two tier areas, in the development of health and wellbeing strategies and action plans to support the BCF. This is in spite of the fact that local housing authorities retain the statutory obligation in respect of DFGs.286

This division of responsibilities and lack of joined up working between district and county councils leads to delays. The main concern that our witnesses raised about the DFG was that it was a slow, costly and frustrating process.287 Anna Severwright said that she had waited more than three years to have a wet room installed, during which time she was unable to shower. She also said that she had no choice in the process: “You get no information at all. I really had to fight just to get told anything and to be able to make any kind of choices”.288 Isaac Samuels said that, in his experience, the Grant had resulted in a very costly adaptation which in the end did not meet his needs.289

124.The Department for Communities and Local Government should review the operation of the Disabled Facilities Grant, and in particular the extent to which its administration and operation is hampered by the split in responsibility between district and county councils and between housing and social care departments in unitary authorities. The evidence we received suggested that beneficiaries found the process slow and cumbersome, had little say in the adaptations and doubted that it was always good value for money.

Integration: closer working between health and social care

125.In our first report of this Parliament, on devolution, we concluded that health devolution and integration of health and social care, which in most cases is closer working between health and social care, had great potential. We continue to believe this is the right direction of travel, given the increasing demand for services as a result of demographic changes and, as we explored in paragraph 7 above, the need to improve patients’ experiences and ensure they are at the centre of how care is organised. The carers and service users who took part in our roundtable, who collectively and individually had many years’ experience of the system, commented on how they would like to see health and social care services better joined up. Many suggested that the GP should be the core of a coordinated system and that assessments should be shared between services and carried out by the member of staff who was most familiar with a person’s condition and needs.

126.Having visited Greater Manchester in October 2016 to learn about their work on health devolution, we were keen to hear from Jon Rouse, Chief Officer of the Greater Manchester Health and Social Care Partnership, about the progress made. He described the benefits an older person in Greater Manchester should see in the future as a result of integration:

They should be experiencing far more seamless and joined-up care than they experience today. Our starting point for that is to put the GP at the centre of that relationship again by really understanding their register and those who need help the most, and being equipped with all sorts of cool-off services that mean they can help to meet the needs of the people who have the greatest number of conditions or overall level of need. We do that by organising the other services around primary care. it means that we need social care services, physios, OTs and other allied health professionals, district nursing, but also services that go wider than traditional health and social care—some of our local welfare services and housing—to be much more joined up around that primary relationship between the GP and the individual. Ultimately, that is our vision for what that care should look and feel like by 2021.290

We note, however, that Greater Manchester is different to other areas, having had greater opportunity to pursue integration within the context of health devolution.291

Progress

127.In her evidence to the Liaison Committee, the Prime Minister said that it was wrong to assume that the only solution to the challenges facing social care was funding and argued that there was a “medium-term job to be done” in improving delivery of social care through integration.292 Given that the 2015 Spending Review set a target for full integration of local areas through the Better Care Fund for 2020,293 we take ‘medium-term’ to mean the next three years. The evidence we heard indicated that it would take longer than this since it was a slow process and that it could take up to ten years to achieve the necessary cultural and system changes.294 Professor Gerald Wistow, Visiting Professor in Social Policy at the LSE, said that the Government’s objective for integrated care in five years was unrealistic.295 In its recent report on health and social care integration, the National Audit Office (NAO) said that the Government’s expectations on the rate of progress of integration were “over-optimistic”.296

128.The evidence we received suggested that there are a wide range of locally-driven integration initiatives and projects in progress across the country, including joint commissioning,297 co-location and sharing IT systems,298 and providing a single point of contact for patients.299 Mark Lloyd, the Chief Executive of the Local Government Association (LGA), said:

The situation varies across the country. There are parts of the country where there is excellent good practice with councils and health bodies coming together to commission and deliver in a completely joined-up way. There are other parts of the country where the relationship is much less mature.300

He went on to say that the LGA was actively engaged in disseminating best practice in one area to another. The Prime Minister has also said that some parts of the country are doing integration of social care and health “very well and very innovatively” but that this was not universally the case.301

Challenges

129.Professor Wistow of the LSE said that, despite the fact that there have been attempts to integrate health and social care for several decades, “we still have a very chequered record”.302 The evidence pointed to various structural, cultural and financial challenges that have acted as barriers to closer working and impeded progress. These included personal relationships;303 organisational differences between the NHS and local government;304 different payment incentives;305 different regulatory, performance and outcome frameworks;306 information sharing;307 and workforce challenges.308 Furthermore, in our pre-Budget report, we highlighted evidence about the burdensome requirements and conditions which local areas needed to comply with in order to access the Better Care Fund and the NAO’s finding that this had disrupted integration work in some areas.309 In their recent report on health and social care integration, the NAO highlighted three “longstanding” barriers as misaligned financial incentives, workforce challenges and reticence over information-sharing. They concluded that Department of Health, DCLG and NHS England were not systematically addressing these barriers and needed to bring greater structure and discipline to their coordination of work in this area.310

Workforce

130.Clare Jacobs, Employment Adviser at the Royal College of Nursing, said that integration posed challenges for the workforce because of differences between social care and NHS staff in standards, pay rates, terms and conditions, pensions and pension entitlement, career progression and skill development.311 (We explore the differences in pay and conditions between nurses in social care and NHS nurses in paragraphs 88 to 91.) The NAO said that their case studies had also shown that these differences, as well as recruitment and retention of staff, particularly in community and domiciliary care, were barriers to integrating and developing the workforce.312

Social care funding

131.Lack of social care funding was also identified as a key barrier to integration.313 Professor Wistow explained the effect this had on integration:

At the time that it is more important for organisations to work together, the very conditions that make it necessary for them to work together, such as resource scarcity, also drive them apart […] the great incentives are to shunt the costs on to another organisation and argue about who is or is not responsible for particular parts of the care system.314

Hull City Council described a similar situation at the local level, saying that funding pressures meant there was:

A significant risk that the agenda of one partner will dominate and direct resources to the detriment of the other partner. […] Some of these negative effects are already being seen. Joint working initiatives involving specialist staff are being frustrated as budget cuts actively undermine relationships between the City Council and its NHS partners.315

Jon Rouse, Chief Officer of the Greater Manchester Health and Social Care Partnership, said that in some areas (although not Manchester) NHS bodies were reluctant to “truly risk share with social care” because of concerns about social care cost pressures impacting on the NHS.316 He also said that funding was needed to implement integration and that Greater Manchester had been given front-end loaded transformation resources, which had given them a “better chance than most” at integration.317 We note the observation made by Sir Amyas Morse, Comptroller and Auditor General, that in the context of austerity, lack of joined-up decision-making and funding arrangements can give rise to “unforeseen conflicting objectives for local bodies; cost shunting between parts of connected systems; and ultimately risks of financial, or service, failure locally”.318

Evaluation and outcomes

132.We heard that evaluation work on integration was continuing,319 and that how integration was monitored and evaluated depended on its objectives, which might vary and related to a wide range of organisations.320 For example, Jon Rouse of the Greater Manchester Health and Social Care Partnership said that his organisation used a “balance scorecard” which contained metrics on levels of non-elective admissions; readmission rates back into hospital; the number of people who are dying in the place of their choice; delayed transfers of care; and people’s experiences of their GPs and primary care services; and their ability to get a GP appointment in good time.321 However, reducing emergency admissions and delayed transfers of care have become the main performance indicators for integration and local areas are expected to set these, as well as reducing admissions to residential and care homes; and increasing the effectiveness of reablement, as targets for their use of the Better Care Fund.322 The Government has highlighted the variation in local delayed transfers of care performance between councils as an indicator of local progress on integration.323

133.Given the scale of the changes and the barriers that we have identified, it may take some time before outcomes from integration are evident. The evidence that we heard on whether integration could improve patients’ experiences and outcomes was not strong,324 and we note the NAO’s recent finding that the Government has not yet established a robust evidence base to show that integration leads to better outcomes for patients.325 The evidence on whether integration could save money was clearer,326 but there was uncertainty over the amount that would be saved.327 Jon Rouse explained why it was difficult to gauge:

You have to shift care over time from acute and into the community. If you do not do that, it cannot save money. You do that by reducing demand for those services, which means that it is then safe to turn down some of that supply. You have to choose really carefully which of those services in which locations you turn down in terms of the supply. That is why it is so hard, because it has to lead to reduced costs within the acute system.328

He said that Greater Manchester was one of the “few places [that] have done systemic, placed-based integration over a long enough period of time to know whether that is true” and that, because of this, the combined authority’s progress was being followed nationally and internationally.329

134.The Government should be more realistic in its expectations for integration. The time needed for such large scale changes to take place is significant and there is little evidence available yet on the benefits of integration, both in terms of patient outcomes and efficiency savings—the recent National Audit Office report on health and social care integration reflected this. Furthermore, progress, which is dependent on good local relationships between health and social care, varies across the country.

135.There are various barriers to integration which the Government must address. These include organisational differences between the NHS and local government; different payment incentives; different regulatory, performance and outcome frameworks; information sharing; workforce challenges and lack of funding for social care. Lack of social care funding is undermining integration, with reduced budgets causing tension between local partners.

136.The differences between the health and social care workforces in terms of culture, pay and conditions, career development and progression are stark. This presents a significant challenge to closer working, which is also inhibited in many local areas by difficulties in recruiting and retaining staff. The Government should acknowledge the challenge that this presents and with Skills for Care and Health Education England set out a strategy for aligning the two workforces.

Accountability

137.One of the aspects of health and social care integration that we are particularly interested in is accountability; this is an issue which also arose during our inquiry last year on devolution. Then, we found that the Minister’s explanation as to how accountability for integrated health and social care services worked lacked clarity and concluded that:

Unless this is carefully considered, we risk both not having the flexibility to use budgets to reflect local priorities and facilitate joint working and replicating locally the silos that exist at national level.330

We therefore asked NHS witnesses in this inquiry who they thought should have responsibility for spending decisions from integrated budgets. We were reassured that Simons Stevens, Chief Executive of NHS England, said that “the right place to make decisions about where and how budget pooling should occur is locally”.331 Stephen Dorrell, the Chair of the NHS Confederation, went on to make the further point, with which we wholeheartedly agree, that local accountability and political engagement in decisions about public services and the use of money across budgets are very important.332 He went on to say that he was:

Strongly opposed now to the idea that we should make decisions about the shape of local health services divorced from the decisions made by local government for the rest of public services. It was a mistake when purchaser-provider was originally introduced to remove local government from that […] process.333

One of the participants at our roundtable said that the current configuration meant that organisations could ‘pass the buck’ and therefore wanted to see a single integrated organisation with local accountability. Jon Rouse said that, because of the wider local political involvement in Greater Manchester’s integration plan, it has a much “richer population health approach” and covers work, health and early years.334

138.Place-based planning on health and social care which has had input from local politicians is more likely to take into account other local services, such as housing, benefits and public health, and therefore result in wider integration of services and better outcomes for the people who use them. Decisions on pooling health and social care budgets should be made locally. If this is not the case, there is a risk that local areas will not have the flexibility to use their budgets on local integration priorities and progress on integration will be impeded. Furthermore, we agree with Stephen Dorrell of the NHS Confederation that local government should be involved in the commissioning of local health services. This would further ensure that decisions about local health services are informed by the needs of the local population and the shape of existing local public services.

Sustainability and Transformation Plans

139.Although local areas have been tasked with driving implementation, several integration-related initiatives have emanated from central government and NHS England. These include Health and Wellbeing Boards; New Care Models; Integrated Care Pioneers; and Sustainability and Transformation Plans (STPs). In addition, there is the Better Care Fund, which requires local areas to plan spending of a pooled budget for health and social care on integration. We heard that this rapid succession of policy developments had made it difficult for people to “find new ways of working and embed those ways of working before the next initiative comes along”.335

140.In December 2015, NHS England asked 44 STP areas across England to produce area-based plans for integration to 2021. Simons Stevens of NHS England highlighted the longer-term approach of STPs, saying that they were a “structured way of driving those kinds of shared conversations and taking a view beyond the cut and thrust of this year, the next year and the year after”.336 However, some councils were concerned by the involvement of local government in those ‘shared conversations’. South West England said that local authorities needed to be seen as “an equal partner in the STP process and not just a stakeholder”337 and Rutland County Council said that the STP guidance “does not go far enough in mandating the local authorities’ roles in the process. It is essential to the integration agenda that health and local authorities have an equal say in driving local plans”.338 Mark Lloyd, Chief Executive of the LGA, said that local government involvement would make “a big difference to solving the dilemmas that we face in social, health and wellbeing more generally”.339 The NAO concluded that, without full local authority engagement in the joint sustainability and transformation planning process, there is a risk that integration will become sidelined in the pursuit of NHS financial sustainability.340 We further note that the geography of the 44 STP footprints does not in all cases align with combined authority areas and, in some cases, councils are working with three STPs.341

141.STPs are an important opportunity for places to take a longer-term approach to integrating health, social and other local services and, therefore, to be a success, local government should be an equal partner in planning. The Government and NHS England should review the STP footprints with the aim of making them better aligned with local authority boundaries.

Innovation and alternative forms of care

142.We took evidence on innovation towards the end of our inquiry and therefore approached it in the light of the other evidence we heard about funding pressures, demographic change and the difficulties presented by the structure of the system. We explored the extent to which councils were able to innovate given the funding pressures they faced; the use of digital technology; and innovation in the voluntary sector, focusing on the Shared Lives scheme.

143.Given the pressures on councils’ adult social care budgets, we were interested to find out whether they were willing to invest in innovations. We heard that there were two different approaches; for some councils the funding constraints were a driver to innovation because they were looking for ways to save money by doing things differently, while others were in “panic mode”342 and did not have the “space or resources to step back” and consider and try out innovations.343 Adaptive Technology Europe Ltd, which provides technology to commissioners, said that commissioners were a “constant barrier” to innovation and that, “bewildered” by the financial challenges they faced, they were reluctant to try out solutions which could lead to efficiencies.344 Karen Kibblewhite, Head of Commissioning Health and Wellbeing, Rutland County Council, said:

One of the lessons that we have learned in Rutland from looking at other authorities is that often, when people try to be really innovative, it is brilliant if it works, but if it does not then you can cause a lot more problems. At times when we have limited resources, it is quite difficult to run a twin-track approach, which is what you really need to do: to start the innovation, while keeping something else going on in the background just in case it does not work how you envisage.345

Alison Rogan, External Affairs Director at Tunstall Healthcare, said that increasing demand was also a key reason for councils pursuing innovations: “they have looked to the future and realised that they just cannot cope with the demographics”.346

144.Funding constraints and demographic pressures are acting as a driver for some councils to innovate and change the way they deliver care. However, due to budget pressures, most councils are in panic mode and are not ready to rethink the way they do things. The Government should create an innovation fund to encourage and give councils the capacity to consider how innovative approaches could be applied in their local area.

Technology and digital

145.‘Telecare’, assistive devices, such as smoke and carbon monoxide detectors, medication dispensers and help buttons, and ‘telehealth’, remote monitoring of conditions, are widely used in social care and have been available for many years.347 There is strong evidence to show that they help people to stay in their own home longer and reduce admissions to hospital348 and are therefore widely used by councils.349 Karen Kibblewhite of Rutland County Council said that her council had decided to use its Better Care Fund funding on assistive technology,350 and that it had provided reassurance and safety for some people which meant that they were “not reaching crises where they become eligible for social care services”.351

146.We were interested in how the next generation of telecare and telehealth, apps and smart technology, could add to the care that people received and promote their independence and wellbeing. For example, Alison Rogan of Tunstall said that the technology her company provided could:

Liaise with all the agencies involved. We have very personal information about their data and their care provider, so we are able to co-ordinate that care, as long as we know about it. If somebody has not been into that home when we know they should have been, we know about it, through certain sensors in the home.352

According to The King’s Fund, the potential of this kind of technology in adult social care is “still far from fulfilled” and “digital therapies, online peer-to-peer support networks and smartphone apps to link people together around care needs are all emerging and deserve to be further explored”.353 However, we heard that the use of this technology very much depended on preference and abilities of the person involved and their carers, friends and family,354 as well as broadband coverage.355

147.Digital technology is also increasingly being used to share data between services. London Councils described how Sutton Council and its Clinical Commissioning Group use an ‘Integrated Digital Care Record’, accessible by acute, community health, mental health trust and adult social care professionals, to work more efficiently and improve patient care.356 They said that working in this way had reduced delays in the delivery of care and unplanned hospital admissions, and enabled quicker delivery of care and reduced clinical tests. We also heard that places were making increasing use of technology to share information to support commissioning. Karen Kibblewhite said that Rutland County Council had started to use the “Pi tracking tool” which would eventually allow them to track individuals through the health and social care systems and identify areas of need and gaps in provision which would, in turn, enable them to target resources more effectively and further integrate commissioning.357

148.Assistive technology is already helping people stay at home longer, reduce hospital admissions and coordinate care between different agencies, and smart technology will be an important part of improving care in the future. At the moment, however, very widespread use of digital technology is limited by the extent of broadband and 4G coverage. It also needs to be usable by and acceptable to service users and carers.

149.Councils are also starting to use digital data platforms which, by drawing together data from different sources, helps them track individuals’ journeys through the health and social care system and target resources and commission more effectively.

150.The Department of Health, NHS England and the Local Government Association should explore how best to bring together centrally and regularly update information on innovation in the delivery of health and social care in local areas.

Alternative models of care

151.Alex Fox, the Chief Executive of Shared Lives, said that councils were more likely to innovate if they had strong links with local voluntary community and social enterprises and that the people who used services and their families were a source of new ideas and approaches.358 The need for closer working between councils and community groups, and involving service users in the design of services, was a theme of the discussions we had with service users and carers at our roundtable event.

152.The King’s Fund said that community-based approaches to adult social care were a “vital development for people who want smaller scale, less transactional forms of care”.359 The evidence suggested that councils were already employing this approach to delivering care; for example, Thurrock Council said that it had ten local area co-ordinators in the community identifying people in need of help and connecting them with “community-based interventions to ensure they can live a ‘good life’”.360 We took evidence on Shared Lives, a model of care in which an adult who needs support moves in with or regularly visits an approved Shared Lives carer, after they have been matched for compatibility.361 There are 150 Shared Lives schemes in the UK, being used by 13,500 people with learning disabilities, people with mental health problems, older people, care leavers, young disabled adults aged 16 and 17, parents with learning disabilities and their children, people who misuse substances and offenders. Alex Fox of Shared Lives said that:

It is a model that does something really unusual in regulated social care. It combines what people find valuable and what they love about family and community with the resources, infrastructure and training of a CQC-regulated care service.362

153.We asked what would happen if the relationship between the people involved broke down and whether it might lead to vulnerable people going ‘off the radar’, but were told that there was lower turnover of people, fewer numbers of safeguarding alerts363 and that the Care Quality Commission’s inspection data showed that the safety was good.364 Alex Fox of Shared Lives argued that the scheme’s success depended upon properly resourcing and taking enough time over recruitment, approval and matching.365 The Health Minister, David Mowat, who had visited a Shared Lives scheme in Merton, said that the scheme was cost-effective, created “a quality of life that is difficult to emulate in other situations” and that more councils should be participating in Shared Lives.366 We note, however, that local demographics and need mean that not all innovations will be right for councils; for example, Karen Kibblewhite of Rutland said that, because Rutland was a small county, the costs of setting up the scheme would be high.367

154.Shared Lives appears to be an exciting innovation which enables care provision within family and community relationships. The Government should commission a wide-scale evaluation on the outcomes and cost effectiveness of the scheme and, where appropriate, care commissioners should consider it as one of a range of available care options.

155.We received a substantial amount of evidence about the benefits and cost effectiveness of another non-mainstream form of care, ‘intentional life-sharing communities’, in which adults with learning disabilities receive housing, support and day activities in community settings.368 The evidence revealed significant concerns among the families of adults in one such community, Botton Village, that funding pressures, commissioning practices and regulation posed a threat to the continuation of these communities. We greatly sympathise with the families’ concerns, but are not well-placed to investigate or adjudicate the matter. But the amount of evidence we received on this one issue, and the strength of feeling expressed, exemplifies the reasons why it is essential to get the country’s social care system right in the short, medium and long terms.


284 HM Treasury, Spending Review and Autumn Statement 2015, (November 2015)

285 Foundations (SOC078)

286 Chartered Institute for Housing (SOC041)

292 Liaison Committee, Oral evidence: The Prime Minister, HC 833 (20 December 2016), Q117

293 HM Treasury, Spending Review and Autumn Statement 2015 (November 2015)

296 National Audit Office, Health and social care integration, 8 February 2017, HC 1011

297 London Borough of Haringey (SOC159), Liverpool City Council (SOC127), South East Strategic Leaders (SOC172)

298 Isle of Wight Council (SOC109)

299 London Borough of Newham (SOC133)

301 Liaison Committee, Oral evidence: The Prime Minister, HC 833 (20 December 2016), Q117

309 Communities and Local Government Committee, Eighth Report of Session 2016–17, Adult social care: a pre-Budget report, HC 47

310 National Audit Office, Health and social care integration, 8 February 2017, HC 1011

312 National Audit Office, Health and social care integration, 8 February 2017, HC 1011

315 Hull City Council (SOC048)

322 Department of Health and Department for Communities and Local Government, 2016–17 Better Care Fund: policy framework (January 2016)

323 HC Deb 11 January 2017 c308

325 National Audit Office, Health and social care integration, 8 February 2017, HC 1011

326 Q215 [Mark Lloyd]

330 Communities and Local Government Committee, Devolution: the next five years and beyond, HC 396 (February 2016)

333 Q268

337 South West England (SOC100)

338 Rutland County Council (SOC138)

340 National Audit Office, Health and social care integration, 8 February 2017, HC 1011

344 Adaptive Technology Europe Ltd (SOC003)

349 See, for example, Hull City Council (SOC048), Association of Directors of Adult Social Care South Eastern Region (SOC171)

353 The King’s Fund and the Nuffield Trust (SOC198)

356 London Councils (SOC149)

359 The King’s Fund and the Nuffield Trust (SOC198)

360 Joint submission from Cambridgeshire County Council, Essex County Council, Hertfordshire County Council, Norfolk County Council, Suffolk County Council, Southend Council and Thurrock Council (SOC195)

361 Shared Lives Plus (SOC019)

368 Botton Village Families Group (SOC179), Alliance for Camphill (SOC124), Camphill Families and Friends (SOC076), The Camphill Village Trust (SOC049)




29 March 2017