Annex 12: Health and social care: structural
change? (See paragraphs 26 to 32 of the Report)|
What kind of health and social
care do older people want and need?
196. Older people are not well served by the
current health and social care systems, and we have grave concerns
for the future efficacy of these services as demands increase.
Older people experience health and social care services as fragmented,
underfunded, and not centred on their needs. The systems are peppered
with perverse incentives, fractured by different funding streams,
and feature a baffling array of different access levels, assessments
197. The Health Service Ombudsman for England
told us that "the NHS is failing to treat older people with
care, compassion, dignity and respect".
According to Professor Chris Ham, Chief Executive, The King's
Fund, "there is a long way to go before we can be confident
that we are providing the right standards to all older people,
wherever they come into contact with the health and social care
system", as "public services for older people have not
had the same priority in many parts of the country as other services
in the NHS".
Professor David Oliver, the Royal Berkshire Trust, Department
of Health and City University London, considered that "we
are palpably failing" to deliver the evidence-based interventions
required to achieve the desired outcomes for older people's care.
He explained that "There is endemic evidence of discriminatory
attitudes from staff; of older people getting a worse deal than
younger people when they have the same condition; of common conditions
of ageing being neglecteddementia is now an exception,
because there is a big policy push around dementiaand also
of, historically, far less investment and fewer policy levers
around the care for older people."
He also referred us to problems with patient safety amongst older
people and with a lack of respect and dignity in the treatment
of older people and their carers.
198. We heard that a new model of care is needed,
more focused on prevention, early diagnosis, intervention, and
managing long-term conditions to prevent degeneration.
Older people need care that is joined-up around the needs of the
must be person-centred, with patients engaged in decisions about
their care and supported to manage their own conditions.
The home must become the hub of care and support, including emotional,
psychological and practical support for patients and caregivers.
Older people should only go into hospitals or care homes if appropriate
care at home is not possible, but must have access to good specialist
and diagnostic facilities when needed to ensure early interventions
for reversible conditions and thereby prevent decline into chronic
ill health. Attitudes
that view older people as a burden must be rejected.
199. A remarkable shift in NHS services will
be needed to deliver this new model of care. Older people with
long-term conditions want good primary care, community care and
social care, joined up around them regardless of clinical categories
or structural splits between healthcare on one hand and social
care on the other. They want good out-of-hours services, so that
their conditions can be managed in their own homes and prevented
from deteriorating, and to make it possible to minimise upsetting,
disruptive and expensive episodes in hospital. This is not the
system we have.
The fundamental problem: the
split between healthcare and social care
200. Older people in need of healthcare and social
care often experience a complex combination of differing frailties,
conditions and illnesses. Their care requires a mix of closely
intertwined services from the NHS, their local authority and private
providers, all centred on meeting the best interests of the individual
(and, where relevant, their family and carers).
However, administrative structures, professional divisions and
financial incentives in the current systems are making co-operation
201. There is huge variability in the current
performance of health and social care services for older people,
with examples of excellent practice, average services, and services
that are unacceptable. Many witnesses argued that one of the reasons
for this variation and for poor quality care is fragmentation,
including organisational separation between local authorities
and the NHS, as well as separation between mental health providers,
acute hospital providers and primary care, a historical division
between GPs in the community and specialists in hospitals, and
split funding streams.
Professor Ham argued that the key to unlocking better quality
and more consistent care for older people was "tackling the
fundamental problem of fragmentation".
Norman Lamb MP, Minister of State for Care and Support, acknowledged
that there was "institutionalised fragmentation" and
that there were divisions between mental health and physical health,
primary care and secondary care, healthcare and social care. The
divides were "not very rational from the patient's point
According to Professor Julien Forder, Personal Social Services
Research Unit (PSSRU) at the University of Kent, having two inter-dependent
systems that are not organised or run in partnership or collaboration
results in "the potential for inefficiencies, inappropriate
services, and inappropriate balance between the services".
202. The separations between NHS money, local
authority money and private money are partly behind this fragmentation,
and there is a strong argument for bringing the social care and
healthcare funding streams together, at least on the ground.
Phil Pegler, Chief Executive, Carewatch Care Services, argued
for a joined-up budget, and Geoff Alltimes, NHS Future Forum Joint
Lead and former Chief Executive, Hammersmith and Fulham Council,
argued for "the integration of the totality of the money,
the main programme money".
Mike Farrar, Chief Executive, NHS Confederation, wanted the integration
of not just community social care funding and community healthcare
funding, but also primary care funding, through GP practices.
Professor Forder told us that pooling resources was only part
of a gamut of solutions to integrated care, but advocated personal
budgets which "facilitate [a] care manager pulling resources
from different parts of the system", and might thereby result
in integrated provider services.
However, others were sceptical about whether elderly people concerned
about their own wellbeing would want to be worrying about personal
203. Governance and accountability rules also
currently limit the capacity for integrated care. Professor Elisabeth
Paice, Chair, North West London Integrated Care Management Board,
told us that "accountability is not shared but is allocated
to different departments, people and organisations".
Dr Shane Gordon, CEO, North East Essex Clinical Commissioning
Group, considered that unless differences of priorities were resolved
between the different people he accounted to, it would be hard
to continue with joined-up commissioning, especially when funding
is under pressure.
For Professor Forder, mechanisms to bring the money together were
less important than the values and lines of accountability of
the separate parts of health and social care meaning that "those
parts of the system charged with a certain set of activities are
going to focus on those activities and not necessarily take into
account what is going on elsewhere".
204. Divisions embedded deeply into professional
cultures can also be a barrier to integrated working.
Professor Forder told us that you can facilitate joint working
by integrating structures and budgets, "but until people
want to use those budgets in an integrated way around the patient
and the service user, we are still going to get problems."
Professor Paice emphasised the importance of training to cultural
change: "We do not train healthcare professionals necessarily
to be collaborative but to be independent, autonomous beings.
Instead of the lonely hero, we need to develop a culture of collaboration."
205. Joint working had to be approached from
the bottom up rather than at the strategic level, according to
Professor Forder. The solution had to be focused "around
the individual person", rather than on the distinction between
health services and social care services.
Professor Forder argued that person-centred care is facilitated
by mechanisms like personal budgets, and an outcomes framework
that recognises the whole care needs of the person rather than
separate performance mechanisms for the health service and for
the social care service.
Incentives had to be changed to bring health and social care workers
together. For Geoff Alltimes, it would only work on a local basis,
with the coming together of GPs and local councillors.
They will also have to overcome some defensiveness within professionals:
Dennis Holmes, Deputy Director of Adult Services at Leeds City
Council, feared that "there is a risk from the NHS perspective
that any pooling will help in some way to cross-subsidise council
206. We heard from Geoff Alltimes that Health
and Wellbeing Boards, bringing together local government and Clinical
Commissioning Groups, may help with integration, as he believed
that the signs showed that people were beginning to recognise
that in order to solve their financial problems and achieve improvements
in care they would need to work together and commission joined-up
Les Mayhew, Cass Business School and Andrew Bonser, Director of
Public Policy, Alliance Boots, were hopeful that Health and Wellbeing
Boards might help in spotting and taking opportunities for improving
Dennis Holmes raised concerns about working with multiple Clinical
Commissioning Groups and a community healthcare trust rather than
a single Primary Care Trust.
Mike Farrar told us that with the recent NHS reforms, "we
stepped backwards from integrated commissioning, because effectively
in these reforms we have taken primary care spend and moved it
to a National Commissioning Board; we have moved specialist care
spend into a different bit of the National Commissioning Board;
community hospital and community services' health spend has gone
into the CCGs; and local government has health improvement spend
in one bit of it, and social care for adults and social care for
children in different bits."
However, he was hopeful that commissioning support units, by uniting
the technical support to these various commissioning bodies, might
be able to secure integrated care.
207. The barriers to integrated health and
social care explored above, and the inter-dependent nature of
health and social care, have driven the Committee to conclude
that the structural and budgetary split between them is not sustainable.
We urge the Government to accept that the structural split is
a major obstacle to the effective and efficient delivery of the
care our older society will need. Healthcare and social care must
in the future be commissioned and funded jointly, so that professionals
are enabled to work together more effectively and resources can
be used more efficiently. Further major structural upheaval of
the healthcare system at this point would be undesirable and counter-productive.
However, we consider that the Government and all political parties
will need to rethink this issue.
Encouraging innovation in the
208. There are some excellent examples of innovation
despite the structural barriers that currently exist.
Professor Paice, who chairs two integrated care pilots in north-west
London, told us how on dementia and the care of those aged 75
and over, they brought together acute and primary care, mental
health, social care, patients' organisations and community trusts
in a voluntary "club" with shared governance.
The Torbay and Southern Devon Health and Care Trust has co-located
multidisciplinary teams of occupational therapists, physiotherapists,
social workers and social care professionals, community nursing
teams and community matrons, all working with clusters of GP practices,
and enabling both GPs and the public to reach the whole team through
a single point of contact.
Local decision-making allows access to both health and social
care funding streams, although the Trust has to account for the
money to its different sources separately.
Leeds City Council is also encouraging collaboration through co-locating
adult social care workers with community NHS staff, coalesced
around GP practices, and through collective spending aimed at
outcomes shared with the NHS.
The council is fostering "social capital" through the
use of volunteers and voluntary groups providing friendly visits
to older people, and using a "whole-council approach"
which includes engaging with housing provision and planning.
We also heard about a pilot for community budgeting in north-east
209. Such examples of integrated service provision
demonstrate ways of achieving better experiences and outcomes
for older patients. We concur with Dr Jennifer Dixon, Director,
Nuffield Trust, that "we have to put more effort into trying
new and radical experiments", and with Mike Farrar that "in
the financial circumstances ... and given the demographic pressures,
we need to be achieving this at scale".
Sir Bob Kerslake agreed that there was not "some single dealbreaker
barrier" obstructing co-operation, and that progress could
be made within the existing framework.
210. The Nuffield Trust has found a common experience
of initiatives with a high level of goodwill which fizzle out
after a short while.
Dr Dixon argued for central assistance to keep momentum alive
and to "help the most promising sites accelerate".
Central support might consist of leadership, information, thinking
about the financial physiology across providers, or more community-based
services. She also recommended centralised help with evaluating
Sir Bob Kerslake has suggested the creation of a 'what works institute'
to facilitate learning from innovation.
211. Norman Lamb MP told us that he wished to
see "a culture that facilitates ... experimentation"
within a vision of what the system needs to achieve.
In the absence of counter-productive systemic change in the
near future, and because full integration cannot be achieved immediately,
there needs to be significant experimental work at the local level
over the next five years. Local authorities and clinical
commissioning groups must be allowed licence to experiment, and
they must be pushed to innovate, especially with new forms of
cross-service outcome-based commissioning, despite the local variations
that would emerge. Innovation will be crucial to solving the problems
of service integration, but innovation will not happen without
an encouraging climate.
The Government must act now to challenge the barriers to effective
and efficient collaboration, some of which we explore in Annexes
13 and 14, in order to free up the good people working in health
and social care to innovate, deliver the kind of personal, integrated
care that our older population wants, and reduce waste and inefficiency.
282 Q 216 Back
Parliamentary Ombudsman and Health Service Ombudsman for England. Back
Q 216 Back
Q 237 (Professor Oliver gave us fulsome references to the evidence
to support his statements, which are published as footnotes to
his oral evidence.) Back
Q 239 Back
QQ 238-239 Back
The King's Fund; Q 277 (Caroline Abrahams, Age UK). Back
Q 671 (Rt Hon Jeremy Hunt MP); Q 216. Back
Q 277 (Caroline Abrahams); Q 508; Royal College of Physicians;
Joseph Rowntree Foundation; Q 222, Q 270; Q 241; Q 248; Q 285. Back
Q 270; Q 277 (Caroline Abrahams). Back
Q 618 (Professor Chris Ham and Dr Chai Patel, Chairman, HC-One);
Q 598; Q 581 (Tony Watts); Q 294; Q 649; Q 99 (Professor Rees);
Dr Chai Patel, HC-One. Back
Q 239; British Academy; Dr Chai Patel, HC-One; Professor Pat Thane,
KCL, supplementary written evidence; Parliamentary Ombudsman and
Health Service Ombudsman. Back
Q 216, Q 290, Q 613 Back
Q 216, Q 219 Back
Q 216, Q 219 Back
Q 680 Back
Q 290; Andrew Harrop, Fabian Society. Back
Q 555, Q 557, Q 578 (Professor Elisabeth Paice); Q 81. Back
Q 296; Q 312 Back
Q 313 Back
Q 306, Q321 Back
Q 316 Back
Q 555 Back
Q 562; Q 578 (Dennis Holmes, Deputy Director of Adult Services,
Leeds City Council and Dr Shane Gordon). Back
Q 314 Back
Q 608; Q 303 (Mike Farrar). Back
Q 314, Q 299; Q 614 Back
Q 555 Back
Q 291 Back
Q 291, Q 314; Q 565 (Professor Elisabeth Paice); Q 578 (Tony Watts). Back
Q 312, Q 319; Q 617 (Dr Jennifer Dixon, Director, Nuffield Trust). Back
Q 558; Q 557 Back
Q 303 Back
Q 358; Q 358 Back
Q 558 Back
Q 303 Back
Q 318 Back
Q 320 (Mike Farrar); Q 557 (Professor Paice); Q 558, Q 582 (Dennis
Q 680 Back
Q 554, Q 555 Back
Q 554, Q 560 Back
Q 560, Q 561 Back
Q 554, Q 558, Q 578, Q 579 Back
Q 558 Back
Q 554, Q 562 Back
Q 608; Q 292 Back
Q 650 Back
Q 625 Back
Q 608, Q 625 Back
Q 608 Back
Q 641 Back
Q 677 Back
Q 650 Back