96.Adult social care is part of a complex system of related public services and forms of support, which include health, housing, welfare and benefits and even leisure and wellbeing; ideally, these services should be working together to meet adults’ needs. An analysis of the challenges facing social care would be incomplete without considering this wider context and, in the following paragraphs, we consider the interdependencies between social care and health care, public health and housing.
97.Health and social care are highly interdependent; for example, inadequate social care can lead to a deterioration in a person’s health and ultimately admission to hospital, and people who are ready to leave hospital may be unable to do so if there is no home care in place for them. In December 2017, there were 145,300 total delayed days, equivalent to 4,688 daily beds occupied by a patient who was delayed in transferring, up from 4,485 in December 2014. Over a third of those delays were due to an inability to access social care packages. The National Audit Office has found that one fifth of emergency admissions to hospital were for existing conditions that primary care, community or social care could manage. NHS Providers described the impact on the NHS:
Such delays and avoidable admissions have a substantial impact on trusts, both financial and in time spent. The NAO estimates that the gross annual cost to the NHS of keeping older patients in hospital who no longer need to receive acute clinical care is around £820m. DTOCs can disrupt patient flow through the NHS with, for example, patients arriving at A&E then waiting longer for treatment or admission because there are fewer beds available elsewhere in the hospital.
Equally importantly, avoidable hospital admissions and delays in leaving hospital can also have a serious effect on a person’s functional ability, making it difficult for them to return to independent living. Older people can lose significant muscle power in a little as half a day in hospital.
98.Simon Bottery of the King’s Fund described the impact of poor integration on a person’s experience of care, giving examples of “arguments about whether a district nurse needs to apply E45 cream or whether that can be done by a care worker”, and of three or four people visiting someone at different times of day to carry out different tasks. Organisations representing both older and working age adults told us that, although integrating services meant different things for different age groups, ultimately care needed to be integrated around the individual receiving care. This is particularly the case for people with dementia; the Alzheimer’s Society said:
The web of care that they access often carries across from health to social care without people necessarily wanting to know the difference or knowing that they are going from one to the other. People will often want good care, understanding, and a friendly face, and a knowledgeable face, regardless of where they see that […] someone with dementia might come across 50 different professions as part of the support that they might need.
Age UK echoed the need for an approach to care giving which is joined up around individuals, and highlighted the crucial role of community health services, describing them as “very unsung heroes, […] such as district nurses, coming in and tending to things like pressure sores and ulcers, which […] if not treated properly, can end up precipitating someone into hospital”.
99.Scope outlined the reasons why, for working age adults with disabilities, integration needs to be broader:
Some of the touch points are different. It is not about keeping people out of hospital necessarily; it might well be about preventing isolation, which might then have a knock-on impact on mental health care, for example […] from a Scope point of view, we are also interested in integration that looks a bit beyond the health system [it] should be with the employment system and the housing system, and those things need also to be looked at because disabled people need holistic support to be independent.
100.Health and social care are highly interdependent. The debate in this area is often focused on delayed transfers of care—where people who are fit to leave hospital are unable to because social care is not available—and the increased costs associated with this. Reducing delayed transfers of care and emergency admissions through better provision of social care can generate savings by reducing the inappropriate use of hospital services. However, we are equally concerned about the impact that emergency admissions and delayed transfers of care can have on people’s lives—for both working age adults and older people unnecessary time spent in hospital can result in loss of confidence to return to independent living. From the point of view of a person with health and social care needs, improved integration between health and social care services has the potential to improve outcomes, and we recommend that local attempts to better integrate services continue apace.
101.In contrast to the NHS, social care is currently provided at a local level—local authorities commission care most care from the private and voluntary sectors. Our witnesses agreed that social care should be provided locally: “Care that is going to be sensible in the highlands and islands is going to be rather different from [that which is] sensible in Camden”. They also felt that integrating services around individuals is better done locally:
That happens in a place, so we need place-based, person-centred and population-focused services, not something that is driven from a building in London or even from buildings in regions. I think you bring those services better together in local places and you get closer to what the citizens need and want […] in fact, in the NHS there needs to be more delegated decision making at a local level, because, often, what happens is that good local partnership is undone by a top-down approach.
102.The Health and Social Care Committee has recently published a report on Integrated Care in which it describes the latest progress on improving integration as follows:
The 44 Sustainability and Transformation partnerships (STPs) are now at different stages in their journey towards further integration as integrated care systems (ICSs). Systemic funding and workforce pressures affect almost every area. Some areas have made considerable progress in light of these pressures, but those furthest behind are struggling with rising day-to-day pressures let alone transforming care. ICSs are more autonomous systems in which local bodies take collective responsibility for the health and social care of their populations within a defined budget. A cohort of 10 ICSs, made up of the leading STPs, is currently paving the way for other systems. While these areas have made good progress in difficult circumstances, they are still nascent and fragile.
103.Our evidence was supportive of the place-based approach to care being promoted through the STP process. However, a note of caution was sounded about ensuring that councils are fully engaged in the process, and that financial challenges can divert the focus from integrating primary, community and social care services:
[The STP process] is really good in some places, it is okay in others, but a lot of council chief executives and leaders are still telling us that they are insufficiently engaged; and there is a tendency to revert to dealing with the here and present issue, which might be financial deficits or potential projected deficits, particularly in trusts. For all the plans and talk about primary community, and the need for all those services to be in place, there is much less focus on that than on restructuring and financial challenges.
Witnesses also emphasised the important role in integration that could be played by Health and Wellbeing Boards.
104.There is a strong case for the local delivery of social care at a local level—this brings the important benefits of links with housing and other local services, as well as local accountability. Better integration of health and social services is key, and the potential of Health and Wellbeing Boards, as well as new arrangements including integrated care systems, organisations and partnerships, should be used to the maximum to support integration.
105.While there is significant support for integration, we heard that it would not generate the levels of savings required to reduce the need for additional funding for social care. Simon Stevens, Chief Executive of NHS England, repeated in evidence to our inquiry his argument that “putting two leaky funding buckets together does not make a watertight health and care service”. However, it is clear that the funding of social care, health, and also public health are interrelated, and that spending growth or restraint in one area has an impact on the others. The NHS Five Year Forward View, published in 2014 by NHS England, set out an ambitious forward programme for the NHS but cautioned that social care and public health services would also play a role in its delivery. With regards to the plans recently announced by the Prime Minister for a ten-year NHS funding settlement, Simon Stevens argued that an essential part of this would be addressing the availability of social care. Public health means a focus on preventing ill health from developing—for example, vaccination schemes, and healthy living support to prevent the development of heart disease and diabetes. In 2013, responsibility for public health passed from the NHS to local authorities. Despite the important interdependencies between social care, health care and public health, spending on social care and public health has fallen in recent years, compared to growth in health spending. In addition, spending on prevention in social care has fallen in recent years.
Source— Library Briefing Paper, , 19 April 2018; HofC Library Briefing Paper, , 13 April 2018; The King’s Fund, , 18 May 2017. Adult Social Care and Health expenditure figures have been converted into real terms using HM Treasury, , March 2018. Note: The public health spending changes have been calculated from a like-for-like series from the King’s Fund - these figures are rounded to the nearest £0.1bn.
106.There was significant support from our Citizens’ Assembly for considering the funding of health and social care together; however, Assembly Members were concerned “not to allow social care to become the underfunded orphan service”. This echoed the views of some of our witnesses who warned of the risk of “medicalising the care system” and the need to ensure that the “values, principles and professional ethos of the different groups” working in health and social care are protected.
107.There is no evidence as yet that integration of health and social care at a local level delivers cost savings, and integration of health and social care services will not generate funding to address the social care shortfall. Indeed, integration may result in short term increases in costs due to previously unmet need. However, better integration can deliver better services for individuals, by placing them at the heart of care. Given the interdependencies between the provision of health care, social care, and also public health, we recommend that in its discussions of future funding settlements the Government should consider all these in the round.
108.As referred to above, delivery of social care at a local level enables links to be made with housing services. This is particularly important as housing is a key determinant of health and wellbeing for people of all ages and consequently their likelihood of needing health and social care services. Well-maintained, appropriately adapted and safe housing plays a key role in keeping people healthy and enabling them to live independently. In addition, specialist housing, particularly extra care housing where care is delivered on-site, can have health and wellbeing benefits and lead to cost savings. This is also the case for high quality, supported housing for people with learning disabilities.
109.Poor quality, unsafe and poorly-adapted housing can have the opposite effect on health and wellbeing, and it can also lead to unplanned admissions to hospital and delayed discharges. Given that 78% of older people are owner occupiers, who may have low incomes and be struggling to keep up with maintenance, repairs and heating, they are particularly vulnerable. In addition, the quality of the home environment is a key factor in ensuring that home care, the type of care most commonly provided, is delivered effectively. John Jackson of ADASS explained the challenge presented by housing and why it needed to be tackled:
The reality is that we have a lot of older people living in their family homes and very much enjoying it, but there is a real question that, at some point in time, they are going to become harder to manage and there is more likelihood of things going wrong because of stairs and so forth […] having a housing strategy, which is thinking about what older people want, and not a question of forcing or nannying people, or anything like that, but giving some choices to older people as they age, is […] positive for social care.
110.Despite a clear need for integration, we heard that there was “variable progress” being made on integration between health, social care and housing services, and we note that, although most STPs mention housing, this often does not translate into their planning and analysis. This reinforces the findings of the HCLG Committee’s inquiry on housing for older people. The Committee recommended that housing services should take equal status to health and social care services in the planning and implementation of integration, and that the Green Paper must actively consider the importance of housing for older people. Its predecessors also found that lack of joined up working between district and county councils on Disabled Facilities Grants is often the cause of delays to the delivery of home adaptations.
111.The Green Paper must give due prominence and consideration to the role of housing as a key determinant of health and wellbeing and consequently need for health and social care support. In particular, it should consider how, through improvements, adaptations and wider access to specialist housing, we can ensure that the home environment better aids health and wellbeing and the delivery of social care, and how to facilitate this through better integration of social care, health and housing services.
184 NHS Providers ()
185 National Audit Office, (2014)
186 NHS Providers ()
187 NHS Providers ()
192 [Andrew Dilnot]
194 Health and Social Care Committee, , Seventh Report of Session 2017–2019 (June 2018)
197 The King’s Fund (); National Audit Office, , (February 2017)
203 It is estimated that 650,000 people receive care at home and 421,000 receive care in residential settings. Source: LaingBuisson, Homecare, Supported Living and Allied Services, UK Market Report.
206 The King’s Fund ()
207 HCLG Committee, , Second Report of Session 2017–19 (2018)
208 HCLG Committee, , Ninth Report of Session 2016–17, HC 1103 (March 2017)
Published: 27 June 2018