1.On the basis of two reports by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care (the Department), the Ministry of Housing, Communities and Local Government, and NHS England about the interface between health and social care.
2.Financial pressures and an ageing population have increased the need for joined-up working between health and social care. Between 2010–11 and 2016–17, local authorities reduced real-terms spending on adult social care by 5.3%. Between 2006 and 2016, the number of people in England aged 85 and over rose by 28%, and is projected to increase by a further 90% by 2036. Joint working aims to ensure that people receive the right care when and where they need it, in a coordinated way that minimises duplication of effort and removes the inefficiencies of a system that delivers healthcare and social care separately.
3.Better joint working between health and social care has been a government objective since the Health Act 1999, but progress has been patchy and inconsistent, partly because it is difficult to achieve and partly due to shifts in policy focus. In the last 20 years, there have been 12 white papers, green papers and consultations, and five independent reviews and commissions. Recent policy has given fresh impetus to the drive to better coordinate and integrate services across health and social care. In the Spending Review 2015, the government made a commitment to integrate health and social are services across England by 2020. In 2014, the NHS in England published the Five Year Forward View, its vision and strategy for the NHS. The strategy identified a £30 billion gap between patients’ needs and the resources available to meet them by 2020–21, and highlighted the challenge of meeting the increasing ongoing care needs of patients with long-term health conditions. To meet this challenge, the strategy set out initiatives to integrate health and social care services around the needs of the individual, such as integrating the various strands of community services together and moving specialist care into the community.
4.The NHS commissions and provides healthcare services that are largely free at the point of use. Local authorities commission social care from a range of mainly private providers. Adult social care is means-tested, with many people funding some or all of their care. The NHS and social care operate under different legislation, and therefore have different financial decision-making and accountability regimes. The Department is responsible for policy relating to health and adult social care in England, while the Ministry of Housing, Communities and Local Government is responsible for the local government finance and accountability systems. The accountability for the NHS at a national level lies with NHS England and the Department.
5.The government has been attempting to join up health and social care for over 20 years, and can point to areas of progress. However, the Department accepted that progress has been variable, with some areas having made a lot of progress while other parts of the country are behind. The Department also said that there have been too many initiatives in the past that have not made the progress or delivered the outcomes intended. In its report on developing new care models through NHS vanguards, the National Audit Office found a pattern of short-lived initiatives being continually folded into a successor initiative. The Department, together with national partners, has now set out a high-level framework for integrated care, covering the good practice it expects local areas to adopt and how this can be monitored. However, the Department told us that solutions are intensely local, so it cannot mandate one particular model.
6.In June 2018, the government announced additional funding for the NHS, with NHS England’s budget to increase by 3.7% a year on average between 2018–19 and 2023–24. NHS England is now drawing up a long-term plan for how it will spend this additional money, which will be published by November 2018. We received written evidence from the greater Manchester Health and Social Care Partnership and West Sussex County Council calling for similar long-term funding settlements for social care and for public health, which would allow local authorities to plan and prioritise more effectively. We examined the adult social care workforce in England in May 2018 and concluded that the adult social care sector is underfunded and in a precarious state. However, the Ministry of Housing, Communities and Local Government told us that local authorities still have another year remaining of a four-year funding settlement and that any funding changes will only be announced as part of the 2020 Spending Review. This includes arrangements for the Better Care Fund, a pooled fund between the NHS and local government that has supported them to work more closely together since 2015–16. The Department recognised it is important that any changes to social care funding do not place further pressures on the NHS. NHS England added that social care does indeed support the NHS, by helping frail older people to avoid the need for emergency healthcare, or speeding up the rate at which they are discharged from hospital.
7.Current legislation covering the accountabilities of local authorities and NHS bodies emphasises the need for individual organisations to balance their books, which can make it difficult for them to work in an integrated way through pooling budgets, sharing financial risks and commissioning services jointly. For instance, the Greater Manchester Health and Social Care Partnership told us that local areas have used highly complex workarounds to fully pool all their health and care budgets. The ways in which the health and social care systems are set up and funded also make it difficult to align funding, commissioning and services. NHS England described the complexity of social care funding, which has at least five different funding streams, including funds raised by local authorities, funds granted by central government, funds transferred from the NHS, and contributions from service users or the benefits system. NHS England also listed four separate means-testing arrangements - for residential care, domiciliary care, NHS continuing healthcare and benefits such as attendance allowance.
8.The Department recognised the legal, accountability and funding issues affecting integration and asserted that it had created the right framework to consider them simultaneously. The Department told us that it has asked NHS England to confirm the legislative changes it needs to accelerate progress on its 10-year plan. NHS England told us that it plans to consult across the sector between November 2018 and autumn 2019, and then develop options for consideration. The Department accepted that there are practical improvements that it can make now without requiring significant legislative change, but did not specify what these were.
9.The Department told us that it plans to publish a green paper on funding social care for older people, which was previously expected for July 2018 but has been delayed until November 2018 to align with the NHS 10-year plan. The Department told us that the green paper will also consider wider issues affecting both working-age adults and older people, including social care policy, quality, performance measurement and integration. However, the Department said that it does not view the green paper as a “grand panacea for everything”, as significant structural, funding and strategic barriers will remain.
10.One way in which the NHS has sought to break down the barriers between health and social care services, as well as between family doctors and hospitals, is through new care models. In 2015, NHS England selected 50 vanguard sites to develop five new care models - prototypes that could later be replicated quickly across England. NHS England provided a total of £329 million to the vanguards to support them in testing the new care models. It also spent £60 million centrally on supporting and monitoring the progress of vanguards. NHS England ended central financial and programme support for the vanguards in March 2018, by which time it expected individual vanguards to be sustainable without requiring further national funding.
11.Investment in the vanguards by NHS England was lower than initially planned. We reported in March 2018 that spending on the vanguards was less than one tenth of 1% of the NHS budget. Furthermore, the NHS has previously spent money initially intended for transforming services on sustainability instead, with £1.8 billion used in both 2016–17 and 2017–18 to help hospitals keep running services day-to-day. The Department said that this diversion of money had meant that integration has progressed slower than planned.
12.NHS England told us that vanguards have been successful in two key ways. Firstly, the number of emergency admissions to hospital, per capita, rose by 1.6% between 2014–15 and 2017–18 in the areas covered by a vanguard, compared to a 6.3% increase elsewhere. Secondly, on return on investment, based on current rates of return, NHS England predicts a return of £2 for every £1 spent on NHS vanguards. While these early signs are promising, the vanguards still have work to do to fully embed these care models in the long term. By December 2017, vanguards had fully implemented, on average, only one-third of a new care model framework across their respective geographic areas. NHS England developed these frameworks for vanguards to test and to inform the development and spread of new care models for the rest of the country.
13.The vanguard programme was largely based on local initiatives that had already been developed to some extent. Written evidence from the Health Foundation suggested that vanguards had already been undertaking work to establish new care models for between two and 10 years before the new care models programme started. The Department recognised that different areas will progress at different rates, and that those areas without vanguards might take much longer to adopt and embed new care models. Indeed, the Health Foundation suggested adopting ideas and practices from elsewhere will often need substantial time, resources and creativity to translate the idea into their own setting and make it work. Also, some areas may need more support than others to implement the same types of change. NHS England told us that in November its 10-year plan will set out the pace at which it will establish new care models across the rest of England. To support local areas in adopting these new models, NHS England told us that it and NHS Improvement are looking at what resources they can redirect from their other activities, including inspection and monitoring.
2 Report by the Comptroller and Auditor General, , Session 2017–19, HC 950, 4 July 2018; Report by the Comptroller and Auditor General, , Session 2017–19, HC 1129, 29 June 2018
3 Report by the Comptroller and Auditor General, , Session 2017–19, HC 950, 4 July 2018, paras 3, 1.3, 1.5–1.6
4 Report by the Comptroller and Auditor General, , Session 2017–19, HC 950, 4 July 2018, para 1.9; Report by the Comptroller and Auditor General, , Session 2017–19, HC 1129, 29 June 2018, para 1
5 Report by the Comptroller and Auditor General, , Session 2017–19, HC 950, 4 July 2018, para 2
6 Qq 91–92
7 Report by the Comptroller and Auditor General, , Session 2017–19, HC 1129, 29 June 2018, para 9
8 Q 124
9 Q 7; , para 2.5
10 Greater Manchester Health and Social Care Partnership (); West Sussex County Council ()
11 Committee of Public Accounts, Session 2017–19, HC 690, 09 May 2018
12 Qq 34–35, 98; Report by the Comptroller and Auditor General, , paras 1.11, 2.5 , Session 2017–19, HC 950, 4 July 2018
13 Q 78
14 Report by the Comptroller and Auditor General, , Session 2017–19, HC 950, 4 July 2018, para 2.8
15 Greater Manchester Health and Social Care Partnership (); Report by the Comptroller and Auditor General, , Session 2017–19, HC 950, 4 July 2018
16 Q 65
17 Qq 4, 7, 21, 73
18 Qq 10–11
19 Q 175
20 Report by the Comptroller and Auditor General, , Session 2017–19, HC 1129, 29 June 2018, paras 3–4
21 Committee of Public Accounts, , Session 2017–19, 27 March 2018
22 Q 115; , para 2.4
23 Qq 99–105; Report by the Comptroller and Auditor General, , Session 2017–19, HC 1129, 29 June 2018, para 16
24 Report by the Comptroller and Auditor General, , Session 2017–19, HC 1129, 29 June 2018, para 14
25 Q 121; The Health Foundation ()
26 Qq 110–111
Published: 19 October 2018