Integrating health and social care Contents

1Funding

1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health, the Department for Communities and Local Government (the Departments), NHS England and the Local Government Association.1

2.The Department of Health is responsible for health and adult social care policy in England. The Department for Communities and Local Government has responsibility for the local government finance and accountability system. NHS England is responsible for supporting clinical commissioning groups and for the commissioning of NHS services overall. Rising demand for care services and the demographics of an aging population are putting pressure on the capacity of local health and social care systems. The two Departments and NHS England are trying to address funding and demand pressures by supporting local authorities and NHS bodies to integrate services.2

3.We heard from the Local Government Association that over the period 2010–11 to 2015–16 local authorities in England have reduced spending on adult social care by 10% in real terms.3 In contrast, the National Audit Office report found that between 2011–12 and 2015–16, spending by NHS trusts and NHS foundation trusts increased by 11%.4 We reported in February 2017 that trusts’ deficits had increased from £91 million in 2013–14 to £2,447 million in 2015–16.5 National Audit Office analysis shows that emergency admissions to hospital rose by 14% between 2011–12 and 2015–16. The number of people stuck in hospital increased by 76% between August 2010 and November 2016, with most of this increase due to people not being able to access social care services, in particular home care and nursing care.6

4.The Department of Health told us that for every £1 spent on adult social care, 34p is saved in the health service.7 We also heard that NHS England estimates that reducing spend on social care by £1 creates 50p worth of additional pressure on the NHS.8 These estimates are, however, based on a study published in 2008 by the University of Kent which estimates that increasing spend by £1 in health or social care respectively have the same effect (a saving of 35p) in the other sector.9 The study concludes that a transfer of funding from health to social care would only have a net benefit if patient outcomes are better through receiving social care rather than care in hospital. The Department of Health conceded that that the relationship between the adult social care budget and the NHS budget is not a very well researched subject, and that the relationship depends enormously on how funding is spent.10

5.NHS England told us that the Better Care Fund (the Fund) was simply a way to get funding from the NHS into social care.11 NHS England and the Local Government Association agreed that the Fund had helped increase the funding available to local authorities for social care in 2015–16.12 The Association said that in some cases local authorities had used the money to set up new integrated services.13 However the National Audit Office found that local areas that were more advanced with their integration work found the Fund had acted as an inhibitor by requiring protracted negotiations to commit money that they felt could be better used elsewhere.14 The National Audit Office also concluded that a key assumption of the Fund, that funding could be transferred from the health sector to social care without adverse impact on the NHS, has proved not to be the case because the health service itself is under financial pressure.15

6.The Local Government Association told us that the Fund was just a little bit of funding on the side of a much bigger problem; that councils face a £5.8 billion funding gap by 2020, £1.3 billion of which is needed for social care.16 The Department of Health and NHS England told us that in 2015–16 the Fund had been comprised of existing resources. The Association said that this money was already being spent on social care and was just plugging a gap in money that had been taken away while demand was rising.17 NHS England said it thought the Fund’s prospects would be much better from 2017–18, when the Fund will have additional money, rather than just money taken from the NHS for social care.18 However the Association said that this money was back-loaded and investment was needed now to sustain services and prevent cuts.19

7.NHS England told us that the Better Care Fund was not the principal vehicle for delivering integrated care across England but should be regarded as “the fuel in the tank” for social care funding.20 NHS England said that its new care models programme was producing results and that it wanted to accelerate their roll-out using sustainability and transformation plans as the vehicle for doing so.21 The National Audit Office found that local areas will be required to include a statement in their sustainability and transformation plans to explain how they will integrate health and social care services by 2020.22

8.NHS England said it would publish its delivery plan for the next two years at the end of March 2017. NHS England told us this would set out what integration in each of the 44 sustainability and transformation plan footprints will look like. The delivery plan would also include a range of new governance rights for sustainability and transformation plan leaders over other organisations including clinical commissioning groups and NHS England staff in their area. Local areas will also have the ability to move towards accountable care systems which integrate funding and delivery of primary, secondary and mental health services in a given geographical population.23 The University of Birmingham and the NHS Confederation both told us it was important to allow enough time to develop new governance structures and the relationships that underpin them.24

1 C&AG’s Report, Health and social care integration, Session 2016–17, HC 1011, 8 February 2017

2 C&AG’s Report, para 3

3 Q50

4 C&AG’s Report, para 8

5 Committee of Public Accounts, Forty-third report of Session 2016–17, Financial sustainability of the NHS, HC 887, para 5

6 C&AG’s Report, para 1.6

7 Qq42–43

8 Q44

9 J Forder, Long-term care and hospital utilisation by older people: an analysis of substitution rates, Health Economics, vol. 18, February 2009, pp. 1322–1338

10 Q42

11 Q49

12 Q50

13 Q51

14 C&AG’s Report, para 2.11

15 C&AG’s Report, para 24

16 Q50

17 Q51

18 Q39

19 Q132

20 Q45

21 Q83