3Accountability and integration
Accountability
19.NHS England acknowledged that there was fragmentation in the care system following the Health and Social Care Act 2012. It said there are a range of organisations with different statutory accountabilities, with some organisations within the NHS and others such as local authorities outside. It went on to say that this accountability structure was making it more difficult to drive forward change and it was doing its best to work around this structure.32
20.At a local area level, NHS England said there was no single person or organisation with overall responsibility for delayed discharges across the local health and social care systems. It cited the example of ‘system resilience groups’ where it said the group chairs are accountable to NHS England, but the directors of adult social services, that sit on these groups, are not.33
21.NHS England set out that, at a national level, NHS England and NHS Improvement are responsible for improving services and the implementation of good practice across NHS organisations. However, they have not got responsibility for, or control over, local authorities, who are accountable to their local electorate.34
22.The Association of Directors of Adult Social Services and the Local Government Association emphasised that, irrespective of the local organisational structures in place, strong leadership was a vital part of improving the way local health and social care organisations work together.35 NHS England has established system resilience groups as the key local forum for planning capacity and overseeing the coordination and integration of local services. The Local Government Association cited the example of Oxfordshire where strong leadership within the system resilience group had resulted in a significant improvement in relationships across local organisations and this was starting to improve the performance on delayed discharges. However, both the Association of Directors of Adult Social Services and NHS England said that there was variability in the effectiveness of system resilience groups across the country. NHS Improvement stated that, during 2016–17, it would be jointly leading with NHS England a review and refocusing of system resilience groups with the aim of improving their effectiveness.36
Integration of local health and social care organisations
23.Witnesses highlighted the challenges that organisational boundaries pose for patients. Independent Age talked about the ‘crazy paving’ of health and social care services across the country which makes it more difficult to advise patients and families about issues such as who is responsible for services and who to contact about the choices available. In its casework, Independent Age has seen examples of: delays due to conflicts about funding between the NHS and local authorities; poor co-ordination in assessing care needs which result in older patients receiving the wrong care and ultimately being readmitted to hospital; and a lack of co-ordination in the provision of equipment and re-ablement services (care aimed at maximising people’s independence).37
24.The Department stated that some of the systems that are doing the best in reducing delayed discharges were those that are fully integrated—where local providers have come together so that ‘all the system owns all of the problem’.38 One example of this is Northumbria Healthcare NHS Foundation Trust which has very few delayed discharges (see Figure 1). The Trust manages both the acute and community hospitals in Northumbria. In addition, since September 2013, it has managed the adult social services for Northumberland County Council. The Trust set out its experience of working across traditional organisational boundaries and the benefits of doing so. It cited the example of its seven-day working across physiotherapists, occupational therapists, speech and language therapists and social workers within its multidisciplinary teams. The whole multidisciplinary team are coordinated, monitored and actively managed.39
25.There are other areas that have introduced a similar structure to that of Northumbria, such as Salford and Torbay, and the Department stated it had a growing interest in this approach. It said that the number of areas where an NHS trust was running adult social services was currently in single figures and this was likely to grow to about 20 based on those areas that were currently making preparations for such an approach.40 However, the Department, NHS England and the Local Government Association explained that this model may not be replicable across all areas and therefore it was not appropriate to impose a single top-down approach. NHS England added that it was not in favour of new legislation or a statutory reorganisation of health and social care. The Department explained that some health organisations were not ready to take on the control of adult social services. NHS England and the Local Government Association stated that the proportion of individuals funding their own care, as opposed to local authority funding, would also influence the appropriateness of the local organisational structure.41
26.The Better Care Fund promotes closer joint working through a pooled budget for health and social care services with individual areas having plans to reduce delayed discharges. The Department said that, in the first six months, only 40% of local authority areas had achieved their planned reduction in delayed transfers of care.42 The Department said that one of the things the Better Care Fund has struggled with is a lack of alignment of incentives between the different local organisations. It stated that, due to the lack of progress to date on delayed discharges, it was taking a tougher approach in 2016–17 and requiring organisations to put in place risk-share mechanisms so that there is a joint and agreed responsibility for delayed discharges.43
Incentive mechanisms
27.NHS England stated that in some places there was a disconnect between hospitals and community health services in terms of incentives and the availability of community services. It also agreed with the NAO report that many local authorities do not have response time standards in their contracts with care home providers and this was an important part of making the system work more effectively. The Local Government Association said that there was no incentive for local authorities to leave people in hospital for longer than was needed as the longer older people stay in hospital the more their mobility and ability to perform everyday tasks will deteriorate; increasing their long-term care needs and therefore the costs.44
28.As outlined in the NAO report, short-term financial incentives to discharge older patients as soon as possible from hospital are not aligned across local health and social care systems. The report found that hospitals have financial incentives to minimise the length of stay for emergency attendances and keep space free for elective procedures for patients. However, community health providers and local authorities are not incentivised financially to speed up receiving patients discharged from hospital. Most of the community health providers the NAO spoke to were on a block contract without any activity-based payments.45
29.The Department confirmed that there is a statutory mechanism for acute hospitals to fine, on a discretionary basis, local authorities if the authority is responsible for a delayed discharge. NHS England said that the level of fining was minimal. The NAO report showed that only 23% of local authorities were fined in 2014–15: for a total of around £2 million. The Local Government Association said there was a lot of evidence that, where a fining system was in place, local authorities had to put money aside to pay fines rather than invest to improve services such as home care.46
30.NHS Improvement thought that there were better ways to improve incentives than the use of fines. It cited the example of some vanguard sites, set up under NHS England’s Five Year Forward View, that were looking at establishing ‘whole-population’ budgets. NHS Improvement also said that, rather than using fines in a punitive way, local agreements should be made on using the money to invest in initiatives to help reduce delayed discharges.47
34 Qq 75, 139, 145–146; C&AG’s Report, para 3.26, figure 19
36 Qq 38, 53, 57–58, 71; C&AG’s report. Para 3.11
42 Q 117; C&AG’s Report, para 3.18–3.19
45 C&AG’s Report, para 3.23
46 Qq 112–113, 118; C&AG’s Report, para 3.25
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19 July 2016