Annex 13: Health and social care: adjusting
to changing patterns of need (see paragraphs 26 to 32 of the report)|
The current NHS model is outdated
212. The current form of NHS provision is not
fit for managing the needs of the older population we have now,
let alone coping with the greatly increased demand coming soon.
213. The current NHS model is simply outdated.
We heard from Professor Oliver that "when the NHS was founded,
48% of the population died before they got to 65" but that
this figure had now been "constant at 18% for the past two
Professor Oliver quoted the Chairman of the House of Commons Health
Select Committee, the Rt Hon Stephen Dorrell MP: "'Systems
designed to treat occasional episodes of care for normally healthy
people are being used to deliver care for people who have complex
and long-term conditions'".
Professor Mayhew and Professor Ham concurred.
Our health system, and the funding that flows through it, is dominated
by the acute hospital sector.
Dr Gordon told us that "if we carry on funding and preserving
a sickness service, we will very soon not be able to afford it"
because the knock-on effect will be a lack of funding for social
care with the consequence that more people will "become sick
and add to the burden".
214. The emphasis of the NHS, and its funding,
needs to shift to take better account of the needs of older people.
The core business of health and social care is now older people
with complex needs.
Enhancing the quality of life for people with long-term conditions
is "the biggest challenge of the 21st century",
according to Dr Martin McShane, Director, Domain 2, NHS Commissioning
Board. Mike Farrar
told us that in the community, "what we really need to do
is have a care service with a medical adjunct rather than a medical
service with a care adjunct", while Professor Ham urged "a
reinvestment in primary care services and community-based services".
215. The two most recent Governments saw record
year-on-year investments in the NHS, but nearly all the extra
spend went into acute care.
However, research suggests that more than a quarter of people
in acute hospitals do not need to be there.
Unnecessary inpatient stays bring the risk of hospital-acquired
infections and the institutionalisation of older patients who
then lose the ability to look after themselves.
Sir Bob Kerslake acknowledged the need to "prevent emergency
admissions to hospital ... [and] that pattern, that cycle that
often happens that leads to people losing independent living".
Despite this, we heard that older people comprise 70% of bed nights
and 50% of the people who are in hospital at any one time.
216. General, acute and accident and emergency
hospital services absorb nearly half of the NHS's budget.
We consider that some of that money could be better invested in
supporting older people to live well and independently in the
community. The key is to consider how to shift resources and
staff into the community. Professor Martin Knapp, London of Economics
(LSE) and PSSRU, told us that we need to "incentivise ...
the system to get money out of acute wards or out of acute hospitals"
because "It is the acute sector that is stopping things happening".
Professor Ham agreed.
This shift will have to involve reducing capacity in acute hospitals:
we heard from Professor Mayhew that when a care co-ordination
service in Brent achieved substantial reductions in days in hospital,
the rate of hospital admissions stayed level because "the
Health Service was just admitting people into the beds that were
vacated". His conclusion was that "You have to take
capacity out of one system to realise savings in another part
of the system."
217. Reducing capacity in acute hospitals may
be necessary, but it is never popular. The Secretary of State
for Health, the Rt Hon Jeremy Hunt MP, acknowledged that "every
time a politician of any party has tried to paint a picture about
why it is necessary to close hospitals, the public have not believed
Knapp summed up the problem: "Politicians do not like using
the word 'ration' and they do not like using the words 'close
and hospital', but I think that is what you are going to have
to do." For
Dennis Holmes, closing some acute hospital facilities is "a
real political challenge for locally elected members and non-executive
directors in local NHS organisations which we will need to confront."
218. NHS professionals must be supported by
politicians publicly to make the argument that rationalisation
and specialisation of hospitals will improve the quality of hospital-based
treatment, as well as allowing a shift in funding to improve community-based
Oliver told us that there is a need for an honest discussion about
reconfiguration of services rather than "hanging on to small
units that are not providing high quality care."
Lord Warner believed the medical specialists would support change
but needed to be given political permission to drive such an agenda.
The Committee asked the Government for examples of Ministers publicly
making the argument as to why the structure of our health and
social care system needs to change, and they did not supply a
single example of a Minister making the case for the closure of
a hospital on clinical grounds.
Politicians must take the lead, clearly explaining why changes
in the way that NHS services are delivered will be in the public
interest, and publish a clear vision of the care services we should
aim for and a description of the framework that will achieve them.
219. One option which might be more politically
palatable would be to move the conversation from 'closing' hospital
facilities to transforming them into units better suited to the
needs of our ageing society. Professor Mayhew argued for "small
community hospitals that look after older people for short periods
until their condition is stabilised".
Baroness Greengross argued that we should "cut out 20% of
our acute hospitals and transform them into primary-care-led hospitals."
220. A public case needs to be made for helping
people manage their long-term conditions at home. This will also
require local strategic planning. Some double-running costs will
be involved initially as there is a limit to how much it is possible
to reduce the capacity of acute hospitals while replacement services
are built up so planners will need to keep their focus on longer-term
Using financial incentives intelligently
221. The way that financial incentives currently
operate in the NHS is reinforcing the prioritizing of acute care
over primary and community care. About 60% of acute hospitals'
funding is under payment-by-results; for every activity the hospital
attracts a set fee, whether or not that activity adds value to
the patient's outcome.
Dr Gordon told us that current healthcare funding systems fund
hospitals preferentially in comparison to other services, obstructing
an effective shift of care, and Sue Redmond, Corporate Director
of Adult Services, Wiltshire Council, agreed.
While hospitals are paid according to the number of filled beds,
beds will continue to be filledProfessor Knapp even told
us of a hospital not wanting to continue with an intervention
that reduced the use of health services "because it was taking
money away from them."
222. Norman Lamb MP agreed that the financial
incentives were a barrier to progress, saying that for people
with long-term chronic conditions, payment-by-results is "not
fit for purpose and discourages
good innovation at the
To deal with long-term conditions, he said, we needed to be "more
sophisticated than that and create incentives to manage people's
care much better out of hospital."
Sue Redmond suggested that money should flow to the person who
comes out of hospital, and Dr Gordon told us that a change in
the funding mechanism to a capitated budget for a year of a patient's
care, or their lifetime of care, would change the dynamic of healthcare.
Preventing unnecessary hospital
admissions of older people
223. If healthcare funding did not incentivise
"more and more activity" in acute hospitals, more money
could be spent on preventing older people needing to go to hospital.
Dr Dixon told us that "there are a lot of older people who
are in hospital whose admission would have been prevented had
the care been better co-ordinated upstream", and John Kennedy
and Professor Paice agreed.
The Government concurred that "too many older people are
admitted to hospital as emergencies that could be avoided if the
right community services were in place".
Earlier intervention can stabilise the older person's condition
to reduce or prevent the next step down in their condition, rather
than having "older people drifting into hospital avoidably".
Better advance care planning and shared care in nursing homes
can also prevent people dying in hospital instead of at home,
against their wishes.
224. Torbay's multidisciplinary intermediate
care service (see paragraph 208) gives an excellent example of
what can be done: if a GP rings the service regarding a patient,
the service can attend quickly and offer an alternative to hospital
admission, deploying support in the home, or using block-contracted
beds in local residential and nursing homes.
Care plans kept in the older person's home allow anyone visiting,
including the emergency services, to be informed about the patient
and access contingency plans to avoid emergency admissions.
225. Funding structures may be crucial to incentivising
investment in preventive community-based care. Social impact bonds
could have a role in setting up preventive services which are
only paid for if they prove successful. If the preventive service
does not reduce hospital admission, the funds are still available
to spend in the hospital.
Current budgetary silos and funding structures can act as a disincentive:
if social care investment saves money for the NHS, but social
care budgets do not benefit, "the fruits of one's labour
land in another person's garden", of which social care professionals
can be expected to tire.
Sir Bob Kerslake told us that what is needed is a local flow of
funds so that those who invest in preventive care see the benefit.
226. A crucial aspect of the shift to a new
system of health and social care, more focused on managing long-term
conditions and with much less use of acute hospitals, is adequate
access to primary and community-based care. To meet the needs
of our ageing population, and to achieve this shift, the health
and social care system needs to work well 24 hours a day, seven
days a week. Currently, the health and social care system
fails outside working hours on working days. People go by default
to a hospital because it is the only part of the system that is
open 24/7. This
results in unnecessary inconvenience and suffering, and means
that "We have people in hospital that could be more appropriately
looked after elsewhere."
Lord Warner told us that correcting this would require "a
much more robust approach to the GP contract in terms of what
they are expected to do".
We need "a model that can be as responsive in the community
as those emergency services in hospitals."
227. We agree with the Royal College of Physicians
that the healthcare system must "ensure the availability
of primary care services whenever they are needed, including at
the weekend and at night".
One way of achieving something close to this was outlined by Professor
Ham, who told us about areas that have pooled their budgets, and
used what is nominally NHS funding to increase investment in social
care and create rapid response teams available for extended hours
who can be called in when there is a crisis in the care of an
older person to avoid hospital admission.
We were pleased that the Secretary of State for Health, the
Rt Hon Jeremy Hunt MP, agreed that "we have to have a 24/7
NHS". We are heartened by his commitment to 24/7 health services,
and we call on him within 12 months to set out how this will be
For this to have value, there will also have to be 24/7 community-based
healthcare and social care.
228. We consider that the shift in the health
and social care system away from acute and emergency services
and towards preventing older people from going into hospital should
also help with the funding pressures facing social care. Some
of the funding released from acute and emergency services should
flow into improving social care, as part of reducing the hospitalisation
of older people who could be better treated in the community.
We also note the Government's commitment to introduce a national
minimum eligibility threshold for social care from 2015: we consider
that the consequence of this must be that the Government will
address the public funding needed to make it possible, but we
consider that health and social care integration is the longer-term
solution for social care funding.
229. Helping older people to leave hospital as
soon as possible is also important. Late assessments, a lack of
step-down services, and the restrictions on social care funding
all delay hospital discharge, and can result in older people going
straight from hospital into care homes.
Again, opportunities exist for local innovation: Torbay
uses hospital discharge co-ordinators that are able to start discharge
planning with the patient almost as soon as they are admitted,
and discuss putting the necessary care in place with community
UK run "hospital to home schemes", but they are dependent
on being kept well-informed by the hospital.
Baroness Greengross referred us to the Scandinavian model of hospital
hotels for post-operative care.
Again, local professionals should be encouraged to explore these
types of integrated solutions.
The need for leadership
230. This fundamental shift in the focus of the
health and social care system will require great leadership. When
we pushed the Secretary of State for Health on how to bring about
the re-configuration of services to cope with the needs of older
people the response was, in essence, that the Government do not
believe in top-down command and control, and that the decentralisation
of budgets and responsibilities to over 200 clinical commissioning
groups and new Health and Wellbeing Boards would drive the necessary
231. In the light of the many local initiatives
we have heard about, we have concluded that organic, bottom-up
change has benefits and should be encouraged, but it will not
by itself bring about the major changes to health and social care
services that an ageing population will need. Innovation must
be combined with strategic management of the whole health and
social care system, managing the complex balances and interrelations
between the two halves of the whole so that hospitals provide
care for people who are acutely ill while primary and social care
keep people out of hospitals.
Bottom-up change cannot by itself bring about the major shifts
that we rapidly need if we are to cope with the considerable increases
in demand. The Government need to develop a new basis for health
and social care for our ageing population and create a clear vision
so that other decision-makers can work to bring it about. The
Government must set out the framework for radically transformed
healthcare to care for our ageing population as a matter of urgency,
and before the general election in 2015. All political parties
should be expected to issue position papers on the future of health
and social care within 18 months, and address these issues explicitly
in their manifestos for the 2015 election.
232. This vision for the long term must not
be undermined by short-term budgetary cycles. The health and social
care systems need to be enabled to plan more strategically and
systematically for changing long-term needs. We conclude that
the Government should consider introducing a 10-year spending
envelope for the NHS and publicly-funded social care.
233. Our older population should be concerned
about the quality of care that they may receive in the near future,
because the current system is in trouble now. It will require
substantial changes to address both present needs and future demand,
and this challenge is combined with an impending funding crisis.
Nothing like enough is being done to face up to these challenges.
335 Q 237 Back
Q 239 Back
Q 340, Q 217 Back
Q 588 Back
Q 562 Back
Q 239 Back
Q 248 Back
Q 291, Q 217 Back
Q 243 Back
Q 618 (Professor Ham), Q 598. Back
Q 581 (Tony Watts), Q 618 (Dr Patel), Q 294. Back
Q 649 Back
Q 75 (John Kennedy). Sir David Nicholson, Chief Executive of the
NHS Commissioning Board, in an interview for the 20 January 2013
edition of The Independent, said that hospitals are "very
bad places for old, frail people". Back
Department of Health, Resource Allocation: Weighted Capitation
Formula Seventh Edition, 2011. Back
Q 359 Back
Q 618 Back
Q 332, Q 601 Back
Q 676 Back
Q 361, Q 77, Q 558 Back
Q 558 Back
Q 591 Back
Q 246. In a letter to The Guardian published on 24 January
2013, Mike Farrar, Professor Terence Stephenson (Chairman, Academy
of Royal Medical Colleges), Jeremy Taylor (Chief executive, National
Voices), Dr Hilary Cass (President, Royal College of Paediatrics
and Child Health), Dr Clare Gerada (Chair, Royal College of General
Practitioners), and Professor Norman Williams (President, Royal
College of Surgeons) argued that "some hospital services
need to be centralised so that, for example, people requiring
urgent stroke care get access to the best doctors and nurses 24
hours a day". Professor Sir Bruce Keogh, the Medical Director
of the NHS in England, told The Guardian on the same day
"I really need the help of our political colleagues at times
to step above their local interests and think of the other interests
of the NHS". Back
Q 595, Q 601, Q 592 Back
Central Government (DoH and DWP), further supplementary written
Q 333, Q 364 Back
Q 72, Q 83 Back
Q 574, Q 595 Back
Q 579 Back
Q 574, Q 456, Q 77 Back
Q 601, Q 362 Back
Q 692 Back
Q 671 Back
Q 456, Q 580 Back
Q 692 Back
Q 608, Q 75, Q 574 Back
Central Government (DoH, DWP and DCLG), written evidence and Central
Government (DoH and DWP), further supplementary written evidence.
The evidence on the cost-effectiveness of preventive strategies
is inconclusive. Back
Q 618 (Dr Patel), Q 239, Q 553. Back
Q 242 Back
Q 560 Back
Q 560 Back
Q 343, Q 426, Q 81 Back
Q 650 Back
Q 650; Q 331 (Professor Les Mayhew). Back
Q 618 (Professor Ham); Q 77. Back
Q 618 Back
Q 598 Back
Q 312; Q 427 (Martin Green, Chief Executive, English Community
Care Association). Where appropriate, community pharmacies should
also be used to improve access to healthcare during the hours
and in the locations that suit local communities. Q 365. Back
Royal College of Physicians. Back
Q 618 Back
Q 679 Back
Q 581 (Tony Watts), Q 239, Q 264. Back
Q 560 Back
Q 415 Back
Q 74 Back
Q 671, Q 676, Q 598; Central Government (DoH, DWP, DCLG), written
Q 77 Back