Ready for Ageing? - Select Committee on Public Service and Demographic Change Contents

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.[282] 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 and accountabilities.

197.  The Health Service Ombudsman for England told us that "the NHS is failing to treat older people with care, compassion, dignity and respect".[283] 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".[284] 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.[285] 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 neglected—dementia is now an exception, because there is a big policy push around dementia—and also of, historically, far less investment and fewer policy levers around the care for older people."[286] 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.[287]

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.[288] Older people need care that is joined-up around the needs of the individual.[289] It must be person-centred, with patients engaged in decisions about their care and supported to manage their own conditions.[290] The home must become the hub of care and support, including emotional, psychological and practical support for patients and caregivers.[291] 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.[292] Attitudes that view older people as a burden must be rejected.[293]

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).[294] However, administrative structures, professional divisions and financial incentives in the current systems are making co-operation very difficult.

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.[295] Professor Ham argued that the key to unlocking better quality and more consistent care for older people was "tackling the fundamental problem of fragmentation".[296] 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 of view".[297] 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".[298]

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.[299] 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".[300] 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.[301] 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.[302] However, others were sceptical about whether elderly people concerned about their own wellbeing would want to be worrying about personal budgets.[303]

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".[304] 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.[305] 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".[306]

204.  Divisions embedded deeply into professional cultures can also be a barrier to integrated working.[307] 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."[308] 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."[309]

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.[310] 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.[311] 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.[312] 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 services."[313]

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 services.[314] Professor 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 services.[315] However, Dennis Holmes raised concerns about working with multiple Clinical Commissioning Groups and a community healthcare trust rather than a single Primary Care Trust.[316] 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."[317] 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.[318]

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.[319] However, we consider that the Government and all political parties will need to rethink this issue.

Encouraging innovation in the meantime

208.  There are some excellent examples of innovation despite the structural barriers that currently exist.[320] 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.[321] 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.[322] 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.[323] 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.[324] 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.[325] We also heard about a pilot for community budgeting in north-east Essex.[326]

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".[327] 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.[328]

210.  The Nuffield Trust has found a common experience of initiatives with a high level of goodwill which fizzle out after a short while.[329] Dr Dixon argued for central assistance to keep momentum alive and to "help the most promising sites accelerate".[330] 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 integrated projects.[331] Sir Bob Kerslake has suggested the creation of a 'what works institute' to facilitate learning from innovation.[332]

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.[333] 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.[334] 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

283   Parliamentary Ombudsman and Health Service Ombudsman for England. Back

284   Q 216 Back

285   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

286   Q 239 Back

287   QQ 238-239 Back

288   The King's Fund; Q 277 (Caroline Abrahams, Age UK). Back

289   Q 671 (Rt Hon Jeremy Hunt MP); Q 216. Back

290   Q 277 (Caroline Abrahams); Q 508; Royal College of Physicians; Joseph Rowntree Foundation; Q 222, Q 270; Q 241; Q 248; Q 285. Back

291   Q 270; Q 277 (Caroline Abrahams). Back

292   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

293   Q 239; British Academy; Dr Chai Patel, HC-One; Professor Pat Thane, KCL, supplementary written evidence; Parliamentary Ombudsman and Health Service Ombudsman. Back

294   Q 216, Q 290, Q 613 Back

295   Q 216, Q 219 Back

296   Q 216, Q 219 Back

297   Q 680 Back

298   Q 290; Andrew Harrop, Fabian Society. Back

299   Q 555, Q 557, Q 578 (Professor Elisabeth Paice); Q 81. Back

300   Q 296; Q 312 Back

301   Q 313 Back

302   Q 306, Q321 Back

303   Q 316 Back

304   Q 555 Back

305   Q 562; Q 578 (Dennis Holmes, Deputy Director of Adult Services, Leeds City Council and Dr Shane Gordon). Back

306   Q 314 Back

307   Q 608; Q 303 (Mike Farrar). Back

308   Q 314, Q 299; Q 614 Back

309   Q 555 Back

310   Q 291 Back

311   Q 291, Q 314; Q 565 (Professor Elisabeth Paice); Q 578 (Tony Watts). Back

312   Q 312, Q 319; Q 617 (Dr Jennifer Dixon, Director, Nuffield Trust). Back

313   Q 558; Q 557 Back

314   Q 303 Back

315   Q 358; Q 358 Back

316   Q 558 Back

317   Q 303 Back

318   Q 318 Back

319   Q 320 (Mike Farrar); Q 557 (Professor Paice); Q 558, Q 582 (Dennis Holmes). Back

320   Q 680 Back

321   Q 554, Q 555 Back

322   Q 554, Q 560 Back

323   Q 560, Q 561 Back

324   Q 554, Q 558, Q 578, Q 579 Back

325   Q 558 Back

326   Q 554, Q 562 Back

327   Q 608; Q 292 Back

328   Q 650 Back

329   Q 625 Back

330   Q 608, Q 625 Back

331   Q 608 Back

332   Q 641 Back

333   Q 677 Back

334   Q 650 Back

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