Integrating health and social care Contents

2Accountability for improving services for patients

9.The National Audit Office’s report shows the Better Care Fund did not achieve its principal target of reducing of demand for hospital services. Local areas planned to reduce emergency admissions by 106,000, saving £171 million. However, in 2015–16 the number of emergency admissions increased by 87,000 compared with 2014–15, costing a total of £311 million more than planned. Furthermore, local areas planned to reduce delayed transfers of care by 293,000 days in total, saving £90 million. The number of delayed days actually increased by 185,000 compared with 2014–15, costing a total of £146 million more than planned.25

10.At our 2014 evidence session on the Better Care Fund, the Department of Health and NHS England assured the Committee that they had robustly and rigorously tested local areas’ plans and they were completely confident that they would achieve over £500 million of savings, around £300 million of which would come from reducing emergency admissions by around 3%.26 NHS England has now told us that it was not claiming a reduction in emergency admission was ever achievable but that the Fund would instead reduce the growth in emergency admissions and thereby produce around £55 million of savings.27 The University of Manchester said it was important for the Government to recognise the limitations of what integration in any form is likely to achieve in terms of cost saving, and that there were other means of managing demand for expensive hospital services, for example ensuring additional funding for public health and primary care.28

11.NHS England told us that over their first 18 months its new care model ‘vanguard’ test sites were showing slower rates of growth in emergency admissions. Emergency admissions in hospital-based vanguard areas are growing at about half the rate compared to the rest of the country, and at two-thirds the rate in GP-based vanguard areas compared to the rest of the country.29 The National Audit Office found in its report that NHS England plans to roll out the new care models rapidly, achieving 20% coverage by the end of 2016–17 and 50% by 2020. However, NHS England plans to evaluate the effectiveness and value for money of the new care models programme will not be complete until the end of 2018.30

12.We asked NHS England if it was confident that sustainability and transformation plans, as the now principal delivery vehicle for integration, would deliver and be on budget. NHS England confirmed only that they expected the sustainability and transformation plan process to improve local planning.31 However, as we heard as part of our financial sustainability of the NHS inquiry, very few trusts think they have a credible, robust and rigorous plan for their area which sets out how they will meet the financial targets they have been set.32

13.Despite clearly making commitments to the Committee in 2014 that the Fund would achieve its targets and save over £500 million, NHS England’s Chief Executive said none of the present witnesses had claimed that the Fund would achieve what was now being suggested it should have achieved. NHS England’s Chief Executive also refused to accept responsibly for the performance of the Fund, saying it was “not designed by any of us sitting here”.33 However, 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.34 Managing public money requires accounting officers to take responsibility for their organisation’s business, even if delivery was delegated or if the events in question happened before he or she was appointed.35

14.Both the Department for Communities and Local Government and the Local Government Association said local authorities were very engaged with their local populations about how they use their local services.36 The Association told us that it was therefore critical that local authorities were involved in the sustainability and transformation plan process.37 However, The National Audit Office’s report warned that so far engagement of local government in sustainability and transformation plans had been variable.38 We also received evidence from London Councils, the UK Homecare Association, NHS Providers, Independent Age, the British Medical Association and the Royal College of Nursing who all expressed concern about the lack of engagement of local authorities in the sustainability and transformation plan process.39

15.NHS England said local authorities were actively involved in sustainability and transformation plans in many parts of country but conceded that there were tensions in some places.40 The Local Government Association told us social care was being missed off because it was not part of the NHS.41 The Association, the NHS Confederation and National Voices said that because sustainability and transformation plan footprints were not coterminous with council areas it was making it more difficult to engage with local authorities.42

16.In its recent report on the financial sustainability of the NHS, the National Audit Office reported that some local NHS organisations found the legislative and accountability framework to be a barrier to collaboration under sustainability and transformation planning.43 The Department of Health told us that the fact that local government and the NHS operate under very different legal frameworks and financial bases creates a big challenge.44 NHS England said through sustainability and transformation plans it was trying to operate within the exisiting statutory framework and it could develop workarounds to overcome local governance complexities.45 The British Medical Association said that integration could be successfully achieved without large scale structural reorganisations and there was a need for stability to allow greater collaboration between services to develop.46

17.NHS England acknowledged that sustainability and transformation plans can be jargonistic and therefore not clear and transparent to local people.47 NHS England said that it was right that local people were involved in discussions about how their health and care services were changing and agreed that the NHS had a duty to consult. The British Medical Association told us that many sustainability and transformation plans had not had sufficient public and clinical engagement, and in some areas both local authorities and clinicians have been totally excluded from the process.48 The Local Government Association said that, with the proper engagement of local people, sustainability and transformation plans offer real potential to improve services.49 NHS England said that in accordance with the statutory framework, public consultations would be held for any major service changes.50

25 C&AG’s Report, para 2.7

26 Committee of Public Accounts, Thirty-seventh Report of Session 2014–15, Planning for the Better Care Fund, HC807, para 14

27 Q68

29 Q83

30 C&AG’s Report, para 17

31 Q90

32 Committee of Public Accounts, Forty-third report of Session 2016–17, Financial sustainability of the NHS, HC 887, para 18

33 Qq68–71

34 Committee of Public Accounts, Thirty-seventh Report of Session 2014–15, Planning for the Better Care Fund, HC807, para 1

35 HM Treasury, Managing public money, July 2013, para 3.5.3

36 Qq105, 125

37 Q105

38 C&AG’s Report, para 21

39 London Councils (IHS 11) paras 24–25; United Kingdom Homecare Association (IHS 17) para 7; NHS Providers (IHS 14) para 21; Independent Age (IHS 21) para 3.6; British Medical Association (IHS 02) para 13; Royal College of Nursing (IHS 04) para 2.13

40 Qq97, 109

41 Q105

42 Q105; NHS Confederation (IHS 20) para 5.3; National Voices (IHS 01) p. 2

43 C&AG’s Report, Financial sustainability of the NHS, Session 2016–17, HC 785, para 3.15

44 Q78

45 Q112

47 Q126

48 British Medical Association (IHS 02) para 13

49 Q105

50 Q106

25 April 2017