The integration of health and social care

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 The Better Care Fund is not new money and most of it comes from the NHS, withdrawn from hospitals in the hope that better services in the community will lead to fewer people being admitted for acute hospital care.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 e.g. new care models, by 2020. The FYFV  outlined seven new care models that ‘integrate services around the patient’, including, where relevant, social care. These models are currently being developed across England, initially through ‘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. 

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. Funding for social care is especially complicated, with at least five different funding streams, including funds raised by local authorities, funds granted by central government, funds transferred from the NHS, and contributions from service users or the benefits system. NHS England also has four separate means-testing arrangements – for residential care, domiciliary care, NHS continuing healthcare and benefits such as attendance allowance.

In England, local authority funding, including funding for social care has, until recently, come from four main sources: central government, business rates, council tax, and fees and charges. In 2010, almost 80% of local authority money came from central government grants  Since then, government funding to local authorities has not only dropped dramatically, but grants are no longer allocated according to an annual assessments of needs. There will be no reassessment to reflect changing need or deprivation until 2020. And by 2020, the government plans to decrease if not discontinue central grants, leaving local authorities increasingly reliant on local business rates. These will no longer be pooled centrally and then redistributed, which will inevitably mean widening inequalities between different regions.

In addition, there has been increasing privatisation of social care provision, with a significant growth in private companies seeking to profit from running residential and nursing homes and the provision of  domiciliary care.  This has not only impacted on those in need of social care (through, for example raised resident:staff ratios), but also on the workforce. Many of those working in social care are less valued and paid less than those in the NHS. They may  have seen the end of sick pay, an increase in zero-hour contracts and receive pay at less than national wage rates. At the same time, care home operators threaten to shut up shop if they have to pay the living wage, and over 25% of care homes say they could go out of business in the near future because of rising debt.

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.

It’s expected that a costed, 10-year plan for social care will be published by the government in November 2018, to go alongside its 10 year plan for the NHS.

Information

https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/1376/137602.htm

BMJ 2017;358:j4279

October 2018

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