Council squeeze blocking progress on health and care integration say MPs

• - Government still lacks effective overall strategy to achieve aim of integrating sectors
• - It should set out a costed 10-year plan for social care to go with its 10-year plan for the NHS

REPORT SUMMARY

There is widespread consensus that integration and joint working is the right way forward for the health and social care system to deliver the best and most effective outcomes for people and their families.

Financial pressures and an ageing population have both increased the need for joined-up working, with local authorities reducing real-terms spending on adult social care by 5.3% between 2010-11 and 2016-17, while the number of people in England aged 85 and over rose by 28% between 2006 and 2016. 

There are examples across England where integrated working has been successfully applied. But it is a long way from being in place everywhere, with a range of longstanding legal, structural and cultural barriers hindering the pace and scale at which change can happen. 

There has been a lot of talk within government over how to support and accelerate the integration of health and social care. In the past 20 years alone, there have been 12 white papers, green papers and consultations, and five independent reviews and consultations. 

However, the Government still lacks an effective overall strategy or plan to achieve its long-held aim to integrate these two sectors.

The renaming of a Government department is a sign of intent but with local authorities squeezed (as the Committee made clear in our report on the financial sustainability of local authorities) there is no realistic prospect of progress.

Without this, people risk not getting the joined-up, co-ordinated care that they need and risk getting poorer outcomes.

COMMENT FROM PAC CHAIR MEG HILLIER MP

“The time for warm words and wishful thinking is over. If Government is serious about delivering the benefits of integrated health and social care, it must act to make it happen.

“Without this action, the array of outputs over the past two decades – consultations, reviews, Government papers – will never be matched by improved outcomes for service users.

“For this reason we urge Government to set out a costed 10-year plan for social care to go alongside its proposed 10-year plan for the NHS.

“Social care has suffered long-term underfunding and it is unacceptable that councils, under considerable financial pressure and facing growing demand for care services, must wait until 2020 for clarity.

“Government must also step up efforts to break down barriers to integration across the country.

“Its departments and agencies need to work together more effectively to support the roll-out of best practice, as well as the leadership necessary to drive change at local level.

“There remains a wide gap in pay and career structure between people who work in the NHS and those in social care, whose workforce suffers from low pay and low esteem.

“As I have said previously, social care is skilled work that transforms people’s lives. It could and should be a source of national pride.

“It is vital that the Government’s workforce plan addresses these concerns as a positive step towards achieving its aim of integrating health and social care.”

CONCLUSIONS AND RECOMMENDATIONS

Despite continued efforts for over 20 years to integrate health and social care services, the government is still experimenting with ways to join up care and agree on what local areas should be doing to achieve the government’s aims. The Department and the Ministry of Housing, Communities and Local Government have developed and supported various initiatives to join up health and care services over this period, including introducing new care models through the NHS vanguards. But the Department told us that too many initiatives have not made enough progress and that models have been developed to suit local circumstances, meaning it cannot easily mandate other areas to adopt them. The Department has made limited progress in making integrated health and social care possible. It has set out a high-level vision for what integrated health and social care should look like, secured additional NHS funding and committed to a 10-year plan for the NHS. We have previously reported that the adult social care sector is in a precarious state because of long-term underfunding, yet the government has no similar additional funding or plan in place for social care. Local authorities will have to wait until the 2020 Spending Review to get clarity on future funding, including what will happen to the Better Care Fund, a pooled fund between the NHS and local government. The Government repeatedly tells us that it has increased social care funding but this is largely through council tax increases which produce differential incomes in different areas.

Recommendation: The government should, by April 2019, set out a costed 10-year plan for social care to go alongside its 10-year plan for the NHS (expected in November 2018).

The current legislative framework makes it unnecessarily difficult for local areas to pool funds and work together, causing additional cost and wasted resources. Legislation currently emphasises the need for individual organisations to balance their books. But this does not support efforts to spend co-operatively. Another barrier is the complex funding system in place for social care, with NHS England describing at least five separate funding streams and four sets of arrangements for means-testing. The Department told us that it has created the right framework to consider simultaneously the legal, accountability and other barriers to integration. The Department is due to publish a green paper on funding social care for older people in November 2018 to align with the NHS 10-year plan. NHS England will then, at the request of the Department, consult on the legislative changes needed to accelerate progress on this 10-year plan. The Department also accepted that there is a set of practical improvements that it can make now without additional significant legislative change.

Recommendation: The Department of Health and Social Care and the Ministry of Housing, Communities and Local Government should ensure that their 10-year plans and the social care green paper address the challenges to integration presented by fragmented funding and separate means testing affecting people who receive adult social care, including consideration of any legislative change needed.

NHS vanguards have shown early promise but they risk becoming yet another short-lived initiative, supported at the start but then not adopted as widely as intended. NHS England told us that vanguards have been successful against two key measures - on slowing down growth in the number of emergency admissions to hospital, and on providing a return on investment. However, by December 2017 vanguards had fully implemented, on average, only one-third of a new care model framework across their respective geographic areas. NHS England has now stopped providing central financial and programme support for the vanguards, although it told us that, alongside NHS Improvement, it is looking at what resources it can redirect to support local areas to adopt new care models. The vanguard programme typically supported local initiatives that were already being developed to some extent rather than being entirely new models. The Department accepted that it could take longer to embed new care models in areas where there are no existing developments to build on. We have previously reported, however, that spending on the vanguards has been less than one tenth of 1% of the NHS budget. Money intended for transforming services has instead been spent on keeping hospitals running day-to-day. The Department told us this meant integration has progressed more slowly than envisaged. It is unclear whether these other areas will get the financial and programme support they need.

Recommendation: In its 10-year plan, NHS England should set out how it will support the national rollout of new care models, including how it will accelerate take-up in local areas showing the slowest progress.

There is a profound lack of transparency and accountability in local health and social care systems. In 2016, clinical commissioning groups, trusts and local authorities formed sustainability and transformation partnerships to develop and push forward strategic health and social care planning in local areas. As we noted in March 2018, some of these have now evolved into integrated care systems. The Department told us that it expects these partnerships to provide the structure for integrating health and social care. NHS England similarly told us that the partnerships supplement current mechanisms for overseeing and delivering efforts to join up care. However, we are concerned that they are instead side-lining the current local statutory mechanism, namely health and wellbeing boards. We are also concerned that the public are not yet familiar with what partnership area they live in or what information may be available for them to assess their partnerships’ performance. NHS England publishes performance data for partnerships each July, to go alongside performance measures for individual commissioners and quality ratings for every provider. However, this is a confusing myriad of structures and information for the general public to understand, particularly when not published in the same place.

Recommendation: By December 2018, the Department, Ministry and NHS England should set out how accountability will work both locally and nationally under new integrated care system arrangements, and how the public can find out about progress on integration and the performance of the health and social care system in their local area.

The quality and effectiveness of local health and social care leaders is variable, which makes it difficult for them to drive system-wide improvements in commissioning and service delivery. The Department told us that local leadership is often the biggest factor determining whether a local area has progressed with integration. We heard examples of where leadership is effective in driving the NHS and local government to work well together, such as Bradford and Greater Manchester, but these are too few in number. However, in some local areas it can be difficult to identify who is leading the system, and how, and progress can stall due to turnover of staff. Locally the mix and will of personalities is crucial, and there are not sufficient incentives to make leaders work together and the different regulatory regimes mean that these are often perceived to be a barrier to co-working. For the Better Care Fund, the Departments and NHS England mandated local areas to apply a high-impact model and restricted funding until they saw progress in local efforts to tackle delayed transfers of care from hospital. However, the independence that local authorities have through local democratic accountability makes this approach difficult to apply repeatedly without damaging local relationships. The Department acknowledged that it is important that national bodies seek out alternative ways of developing good leadership, particularly aligning incentives to encourage joint working.

Recommendation: The Department, Ministry and NHS England should write to the Committee by December 2018 to set out how they will develop and support local leadership consistently.

There is a wide gap in pay and career structure between people who work in the NHS compared with social care. We have previously reported that the social care workforce suffers from low pay and low esteem. This discourages NHS staff from working in social care and makes integrating the two workforces problematic. We remain concerned that the Department and the Ministry are not doing enough to tackle the difference in pay between the two sectors. Other factors, such as difficulties in transferring pension arrangements across the health and social care sectors, also discourage closer integration. In autumn 2018, the Department and Health Education England will publish a workforce plan that will set out requirements across both the NHS and social care workforces for the first time. We criticised the draft version of this plan, published in December 2017, for lacking detail and suggestions on how issues in the social care workforce could be tackled. We are keen to see how the Department has addressed these failings in the final plan.

Recommendation: The Department should ensure its workforce plan addresses the previous criticisms made by the Committee and make sure it tackles the longstanding barriers between health and social care, particularly disparity in pay and conditions and the transfer of pension arrangements.