Conclusions and recommendations
1.The Departments do not know what is the most effective balance of limited funding across health and social care. We heard from the Local Government Association that over the period 2010–11 to 2015–16, local authorities in England reduced spending on adult social care by 10% in real terms. The Association asserts that there is now a very significant shortfall in funding for adult social care. In contrast, between 2011–12 and 2015–16, spending by NHS trusts and NHS foundation trusts increased by 11% in real terms. The relationship between the adult social care budget and the NHS budget is not well researched. The Department of Health and NHS England provided two different estimates for the impact on spend in the health sector of changes in spend on social care, which they acknowledged were, respectively, out-of-date and vague. We note that the recent Budget has found £2 billion additional funding for adult social care over the period 2017–18 to 2019–20.
Recommendation: We re-iterate the recommendation from our February 2017 report Financial sustainability of the NHS that the Department and NHS England should assess the impact that financial pressure in social care is having on the NHS, so that it can better understand the nature of the problem and how it can be managed. It should publish the findings of its analysis by July 2017.
2.The Better Care Fund was little more than a ruse to move money from the health sector to social care, disguised within an overly bureaucratic initiative that purported to integrate health and social care services. NHS England said that the Fund was simply a way to get funding from the NHS into social care. NHS England and the Local Government Association agreed that the Better Care Fund had increased the funding available to local authorities for social care in 2015–16. However, the Local Government Association told us that the Fund was simply plugging a gap in money that had been cut from local authority budgets, while demand for care was rising. While it had helped local authorities reduce cuts in services, and in some cases to set up new initiatives, the Association cautioned that it should not be assumed that by transferring some money into adult social care, improvements will inevitably be made. The Fund also created a significant bureaucracy, which some local areas found was disproportionate and had in some cases disrupted other integration work.
3.The Better Care Fund has been rendered largely redundant as a means of building integration by the sustainability and transformation planning process. NHS England is planning to roll out new care models through sustainability and transformation planning across the 44 sustainability and transformation plan footprint areas as the primary mechanism for integrating health and social care. NHS England assured us that the NHS delivery plan for the next 2 years, due to be published a month after we took evidence, would be explicit about what integration through sustainability and transformation planning will look like. The Departments have dropped requirements for local areas to produce separate plans showing how they would integrate health and social care by 2020.
Recommendation: The Departments and NHS England should reassess whether the Fund in its current form is still necessary and should identify what has worked well so this can be brought into sustainability and transformation planning.
4.We are unconvinced that sustainability and transformation planning will succeed where the Better Care Fund has failed in building successful integrated services. The Fund did not achieve planned-for benefits for the NHS and therefore to patients and service users. Its targets for reducing emergency admissions and delayed transfers of care were missed by a large margin, and in fact both increased. Planned savings of over £500 million were not achieved and emergency admissions and delayed transfers of care alone ended up costing around £460 million more than planned. NHS England confirmed that £5.4 billion of the £7.9 billion available in the Sustainability and Transformation Fund between 2016–17 and 2018–19 will be used to offset hospital deficits, rather than transform health and care services. As we commented in our recent report on NHS Financial Sustainability, very few areas have so far developed credible, robust and rigorous plans. We heard that areas trialling the new care models have seen slower rates of growth in admissions and delayed transfers of care; however they are being rolled out before they have been properly evaluated.
Recommendation: The Departments and NHS England should set out criteria for measuring success of integration by July 2017. They must set realistic targets for initiatives that aim to integrate services, within a credible timeframe for achieving them by July 2017.
5.Sustainability and transformation planning is neither inclusive nor transparent enough. We heard from the Local Government Association that in some areas NHS England has not been engaging sufficiently with local government. We heard from NHS England that, conversely, in some areas local government has declined to get fully involved. Engagement can be complicated because the 44 sustainability and transformation planning areas do not all align with local authority boundaries. Nevertheless, without meaningful engagement with local authorities, integration is an impossibility. Furthermore, local people are not yet being fully involved and consulted with in decisions about how their local health and social care services will change. The NHS has a duty to consult with local people but can find this challenging as it lacks the history of, and mechanisms for, engaging with the populations that local authorities have. NHS England agreed that sustainability and transformation plans can be jargonistic and therefore not clear and transparent to the public.
Recommendation: By May 2017, NHS England and the Local Government Association should encourage and support the full involvement of local government in the sustainability and transformation planning process. Working with their local authority partners, local health bodies should improve the involvement of local populations in the planning process.
6.It is deeply unsatisfactory that the Departments and NHS England washed their hands of any accountability for the Better Care Fund. NHS England’s Chief Executive seemed to reject any accountability for the performance of the Fund over its first year. He dissociated himself from the targets set for its first year, saying that it had not been designed by any of the witnesses at our evidence session. No other witnesses demurred from this assertion. The Committee is very disappointed by this response; as we reported in February 2015, the arrival of NHS England’s new Chief Executive in April 2014 was the stimulus for the pause and redesign of the Fund. Accounting officers cannot disown the plans of their predecessors.
Recommendation: The Departments, NHS England and the Local Government Association must take responsibility for the performance of their programmes, including the Better Care Fund while it continues. We expect greater accountability and more realistic objectives, which the Departments and partners will stand by.
25 April 2017