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

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The current NHS model is outdated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  The current NHS model is simply outdated.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 decades".[335] 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'".[336] Professor Mayhew and Professor Ham concurred.[337] Our health system, and the funding that flows through it, is dominated by the acute hospital sector.[338] 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".[339]

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.[340] 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.[341] 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".[342]

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.[343] However, research suggests that more than a quarter of people in acute hospitals do not need to be there.[344] 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.[345] 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".[346] 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.[347]

216.  General, acute and accident and emergency hospital services absorb nearly half of the NHS's budget.[348] 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".[349] Professor Ham agreed.[350] 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."[351]

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 them".[352] Professor 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."[353] 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."[354]

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 care.[355] Professor 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."[356] Lord Warner believed the medical specialists would support change but needed to be given political permission to drive such an agenda.[357] 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.[358] 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".[359] Baroness Greengross argued that we should "cut out 20% of our acute hospitals and transform them into primary-care-led hospitals."[360]

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 savings.[361]

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.[362] 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.[363] While hospitals are paid according to the number of filled beds, beds will continue to be filled—Professor 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."[364]

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 local level."[365] 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."[366] 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.[367]

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.[368] 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.[369] 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".[370] 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".[371] Better advance care planning and shared care in nursing homes can also prevent people dying in hospital instead of at home, against their wishes.[372]

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.[373] 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.[374]

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.[375] 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.[376] 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.[377]

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.[378] This results in unnecessary inconvenience and suffering, and means that "We have people in hospital that could be more appropriately looked after elsewhere."[379] 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".[380] We need "a model that can be as responsive in the community as those emergency services in hospitals."[381]

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".[382] 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.[383] 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 made real.[384] 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.[385] 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 teams.[386] Carers UK run "hospital to home schemes", but they are dependent on being kept well-informed by the hospital.[387] Baroness Greengross referred us to the Scandinavian model of hospital hotels for post-operative care.[388] 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 changes.[389]

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.[390] 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

336   Q 239 Back

337   Q 340, Q 217 Back

338   Q 588 Back

339   Q 562 Back

340   Q 239 Back

341   Q 248 Back

342   Q 291, Q 217 Back

343   Q 243 Back

344   Q 618 (Professor Ham), Q 598.  Back

345   Q 581 (Tony Watts), Q 618 (Dr Patel), Q 294. Back

346   Q 649 Back

347   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

348   Department of Health, Resource Allocation: Weighted Capitation Formula Seventh Edition, 2011. Back

349   Q 359 Back

350   Q 618 Back

351   Q 332, Q 601 Back

352   Q 676 Back

353   Q 361, Q 77, Q 558 Back

354   Q 558 Back

355   Q 591 Back

356   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

357   Q 595, Q 601, Q 592  Back

358   Central Government (DoH and DWP), further supplementary written evidence. Back

359   Q 333, Q 364 Back

360   Q 72, Q 83 Back

361   Q 574, Q 595 Back

362   Q 579 Back

363   Q 574, Q 456, Q 77 Back

364   Q 601, Q 362 Back

365   Q 692 Back

366   Q 671 Back

367   Q 456, Q 580 Back

368   Q 692 Back

369   Q 608, Q 75, Q 574 Back

370   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

371   Q 618 (Dr Patel), Q 239, Q 553. Back

372   Q 242 Back

373   Q 560 Back

374   Q 560 Back

375   Q 343, Q 426, Q 81 Back

376   Q 650 Back

377   Q 650; Q 331 (Professor Les Mayhew). Back

378   Q 618 (Professor Ham); Q 77. Back

379   Q 618 Back

380   Q 598 Back

381   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

382   Royal College of Physicians. Back

383   Q 618 Back

384   Q 679 Back

385   Q 581 (Tony Watts), Q 239, Q 264. Back

386   Q 560 Back

387   Q 415 Back

388   Q 74 Back

389   Q 671, Q 676, Q 598; Central Government (DoH, DWP, DCLG), written evidence. Back

390   Q 77 Back

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