2Improving integration locally
Accountability and transparency
14.In 2016, clinical commissioning groups, trusts and local authorities in England formed into 44 sustainability and transformation partnership areas, to produce area-wide strategic plans covering health and social care for the period 2016–17 to 2020–21. NHS England and NHS Improvement have encouraged partnerships to go further and form integrated care systems, which involves commissioners and trusts taking control of the health budget for the entire population in their area and bringing together the services and care that they offer.27 We examined these partnerships and integrated care systems in March 2018 and raised concerns that NHS England and NHS Improvement could not clearly explain how the new arrangements will sit alongside organisations’ existing responsibilities.28 The Department told us that it expects sustainability and transformation partnerships to provide the structure for integrating health and social care, for instance through systematically promoting and developing new care models.29 NHS England similarly told us that these partnerships and integrated care systems supplement rather than replace existing accountability mechanisms.30
15.Health and wellbeing boards are the current statutory mechanism for overseeing and delivering efforts to join up care locally. However, the witnesses did not reassure us that new sustainability and transformation partnerships are not side-lining these boards. The Department told us that the 44 sustainability and transformation partnerships were selected to create wide-enough geographical areas that best enable health bodies to work together. NHS England told us that the areas covered by the 152 health and wellbeing boards are too small to use them to plan integrated care services. However, this means that most sustainability and transformation partnerships contain more than one local authority and health and wellbeing board. Sometimes the boundaries of partnerships cut across the boundaries of local authorities and of health and wellbeing boards.31 This makes it difficult for the relevant organisations and their staff to come together to support person-centred care. For instance, we received written evidence from West Sussex County Council which told us that simultaneously working in partnerships covering different geographical areas makes building consensus, planning commissioning and delivery, and developing appropriate governance more challenging.32
16.With these additional administrative and planning layers, we asked the witnesses how the public can understand decision-making about local services. NHS England publishes performance data for partnerships each July as well as performance measures for individual clinical commissioning groups. The Care Quality Commission publishes quality ratings for every health and social care provider, including general practitioners. NHS England added that these quality ratings are available on the My NHS and NHS Choices websites. However, the system, commissioner and provider performance data are not published all in the same place. We were concerned that this makes it difficult for the public to understand local performance.33
Leadership
17.The Department recognised that local leadership is important in pushing forward with integration, highlighting it as the single biggest factor determining whether new care models are implemented.34 The Departments highlighted examples from across England where local leadership is working well. For instance, simple but effective joint local governance and decision making is now in place in Bradford. In Greater Manchester, NHS commissioners and local authorities are forming single commissioning functions, and four localities have a single accountable officer in place to cover the clinical commissioning group and local authority. However, in some local areas it can be difficult to identify who is leading the system, and how. In other areas, progress has stalled due to changes in staff.35
18.The Department confirmed that the mix and will of personalities is crucial, and that leaders can choose not to work together if they do not want to. The Departments and NHS England have limited means of enforcing or encouraging the system leadership needed. For the Better Care Fund, the Departments and NHS England mandated local areas to apply a high-impact model for reducing delayed transfers of care. The Ministry of Housing, Communities and Local Government told us that they challenged areas and restricted funding until they saw progress, which has proved successful. However, the National Audit Office found that this approach has damaged local relationships in some areas.36 Furthermore, the Department and NHS England told us that different political accountabilities and the need for local solutions means they often cannot simply mandate particular models.37 Similarly, the Health Foundation told us that change in the health sector is so complex it cannot be driven centrally, and instead the centre must enable those who work in the system to drive change themselves.38 The Department recognised that it can help support local leadership by creating the right structures and aligning incentives for people to work together, in the form of sustainability and transformation partnerships and integrated care systems.39
19.We questioned whether the witnesses were able to monitor the effectiveness of leadership in local systems. The Department told us that the ratings system for providers used by the Care Quality Commission, and the performance dashboard for sustainability and transformation partnerships published by NHS England, both take local leadership into account. The Ministry of Housing, Communities and Local Government added that it monitors local government closely and intervenes where necessary, including in response to poor leadership. The Care Quality Commission does not currently inspect commissioning arrangements in local government or the NHS, although it has been carrying out thematic system reviews in 20 local health and social care systems.40 Despite these assurances, we remained concerned that the national bodies do not have sufficient oversight over how well local leaders are working in partnership and exercising system leadership. The Greater Manchester Health and Social Care Partnership said in written evidence that there was benefit in codifying in legislation a system approach to assurance and regulation.41
Integrated Workforce
20.We examined the adult social care workforce in England in May 2018 and found that the social care workforce suffers from low pay and low esteem, which leads to recruitment difficulties for providers.42 We were concerned that this also impedes efforts to join up health and social care workforces, as it makes it less appealing for NHS staff to work more flexibly and move into social care. The Department told us that the pay differential between social care and the NHS is well-known. It asserted that pay is not the only factor determining individuals’ decisions about where they want to work and pointed to the fact the vacancy rate for nurses is similar in both social care and the NHS.43 As well as pay, the Greater Manchester Health and Social Care Partnership told us that different ways in which VAT is treated and issues with transferring pensions impede staff moving between local authorities and the NHS.44 In its written evidence, the Health Foundation asserted that a staff turnover rate in social care of 25% adds a further challenge, making integration a near impossibility.45 The Care & Support Alliance said in written evidence that the workforce crisis needs to be gripped with a lot more ambition and determination than it has seen to date.46 The National Audit Office reported that the vanguards regard the workforce—for example, availability of staff with the right clinical or programme management skills—to be the greatest area of risk to the sustainability of the vanguards and to the further development of new care models.47
21.Roles in the social care sector suffer from a public perception that they offer fewer opportunities for career progression compared with similar roles in the NHS.48 NHS England acknowledged that a career ladder for care assistants in social care should be developed, similar to the apprenticeship and on-the-job type models that enable care assistants in the NHS to become nursing associates or registered nurses. The Department added that this needs to be developed in a way that allows staff to switch between health and social care, rather than as parallel models. The Department highlighted the work being done by Greater Manchester to train the health and social care workforce as a whole and to encourage people to consider both sectors for a career.49 However, the Department said that its primary focus was ensuring it trains the right number of nurses required for both sectors, rather than tackling the low esteem of the social care sector.50
22.In December 2017, the Department and Health Education England published, for consultation, a draft workforce plan for health and social care. The Department told us that this plan, and the consultation supporting it, examined both health and social care workforces together for the first time, in particular professions that exist in both sectors, such as nursing.51 We previously concluded that the plan’s section on social care was short and lacked detail, and did not include suggestions as to how the social care sector could improve.52 In response, the Department commissioned its delivery partner on workforce matters, Skills for Care, to consult with the adult social care sector on how to improve support to care providers and address the workforce issues they are experiencing. The final plan will be published in autumn 2018 to coincide with the NHS 10-year plan and the social care green paper.53
27 Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 1.11
28 Committee of Public Accounts, Sustainability and transformation in the NHS, Session 2017–19, 27 March 2018
29 Qq 93, 155
30 Q 163
31 Qq 155–157
33 Q 158–161
34 Q 124
35 Qq 93, 143–147; Greater Manchester Health and Care Partnership (IBH0008); Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 3.8
36 Qq 117, 125–128; Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 2.7
37 Qq 124, 128, 135, 148
39 Q 128
40 Qq 14, 149–151
42 Committee of Public Accounts, The adult social care workforce in England, Session 2017–19, 9 May 2018
43 Qq 36–43
47 Report by the Comptroller and Auditor General, Developing new care models through NHS vanguards, Session 2017–19, HC 1129, 29 June 2018, para 4.9
48 Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 3.14
49 Qq 37–38, 46
50 Q 41
51 Q 36
52 Committee of Public Accounts, The adult social care workforce in England, Session 2017–19, 9 May 2018
53 Q 36; Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 3.16
Published: 19 October 2018