Health and social care services are two sides of the same coin, even if the NHS has had a higher public profile. Roughly one in three people have some kind of relationship with social care services, which provide care, support and safeguards for those in our communities with the highest need, as well for as their carers.
The Department of Health has called for the integration of health and social care systems, partly to deal with increasing pressure on services faced with inadequate funding. NHS England expects the NHS to make £22 billion of ‘efficiency cuts’ by 2020, while money for adult social care fell by nearly a third between 2011 and 2016. A further £6.1 billion will be taken from councils by 2020.
There have been several moves over as many as 20 years to integrate health and social care, including
- the transfer of £2.7 billion from the NHS to local authorities over the four years to 2014-15, to promote better joined-up working (the 2010 Spending Review),
- the creation of the Better Care Fund in 2013, which required NHS clinical commissioning groups and local authorities to pool some of their funding and produce joint plans for integrating services. In 2015-16, the total pooled was £5.3 billion. The Better Care Fund is not new money and most of it comes from the NHS, withdrawn from hospitals in the hope that better services in the community will lead to fewer people being admitted for acute hospital care.
- the publication of the Five Year Forward View (FYFV) by NHS England (NHSE) in 2014, with plans to achieve a financially sustainable and integrated health and care system through, eg new care models, by 2020. The FYFV outlines seven new care models that ‘integrate services around the patient’, including, where relevant, social care. These models are currently being developed across England, initially with 50 ‘vanguard’ test sites, with the highly optimistic aim of saving £900 million and reducing growth in hospital activity from 2.9% to 1.3% by 2020-21.
- NHSE’s Delivering the Forward View (2015) that carved the NHS in England into 44 ‘footprints’ (Sustainability and Transformation Partnerships), each charged with improving the integration of health and social care services within its borders.
The barriers to integrating health and social care are considerable. To begin with, England has legally distinct health and social care systems. The Department of Health and Social Care determines health and adult social care policy, while the Department for Communities and Local Government is responsible for local government finance and accountability.
Health and social care systems are also funded differently, and may serve different populations. Local authorities within a ‘footprint’ fund social care services while health services are funded on the basis of the size of the lists of patients registered with GPs. Not all residents within one of the new ‘footprints’ will be signed up with a local GP (for example, as the boundaries for GP practices are being dissolved, individuals may choose to sign up with a practice that happens to fall within a different ‘footprint’). This means there are situations where there could be no health service funding for unregistered patients who are, at the same time, eligible for local authority social services. For this reason alone it’s hard to see how health and social care services can be integrated.
However, in addition, the NHS is free at the point of use, while social care is means tested and only free for those with a high levels of need and few resources. Greater involvement of local authorities in health service provision increases the risk of new charges for what were previously free NHS services. For instance, at the moment, current regulations for local authority public health services such as health checks, open access sexual health services, and child health surveillance don’t allow individuals to be charged for these services. This is because the health secretary chose to prohibit charging, and not because it’s been legally prohibited by parliament. As local authorities face more and more cuts, there’s a risk that new regulations will be brought in that bring the prohibition of charging to an end.
Many argue that in order to bring about the integration of health and social care both need to be fully funded and that social care needs to be brought into the public sector, provided on the basis of need and free at the point of use.
In the current scenario however, there is little to no robust evidence to show that integration leads to better outcomes for patients. The Department of Health and the Department for Communities and Local Government have not tested this kind of integration at scale and can’t show that any ‘success’ seen so far is sustainable or due to integration. There are some international examples of successful integration (for example, what’s known as the Canterbury model of integrated care in New Zealand) but this has been achieved in the context of very different legal and organisational environments.
Plus, according to the National Audit Office, there is no compelling evidence to show that integration of health and social care in England leads to sustainable financial savings or reduced hospital activity. There are some positive examples of integration at the local level, but so far there is no evidence of systematic, sustainable reductions in the cost of care as a result of integration.
On top of which, embedding new ways of working across organisations can take many years due to the different cultures and working practices that exist across the NHS and local authorities – even where there is strong commitment, integration may take as long as 20 years. NHSE expects huge strides towards the integration of health and social care services within a faction of this time scale.