The question of social care has become increasingly prominent in any discussion of healthcare in recent years. An early proponent, Andy Burnham, Labour’s last health secretary and the current frontrunner for Mayor of Manchester, stating that it was crucial for the health service to ‘bring physical, mental and social care together, caring in somebody’s own home, giving them one point of contact for all usual points of care.’
Nurses working in both primary and acute care will see the impact of an uneven and overstretched social care sector everyday in the course of their role, from district nurses picking up the shortfall in at-home care, to the immense financial drain of bed blocking on the NHS. Now, a new report from the House of Lords Select Committee on NHS Sustainability has endorsed Burnham’s view – proposing the full integration of health and social care.
The report, The Long-term Sustainability of the NHS and Adult Social Care, states that while the future sustainability of the NHS is contingent on the transformation of services in both the acute and primary sectors, it is vital to drive integration of health and social care, leading to the formation of a proposed Department of Health and Care. According to the report, this would allow money and resources to be ‘marshalled and used more effectively as part of an integrated approach to health and care.’
‘Bringing together spending on the NHS and social care into a single spending review settlement would simplify departmental responsibilities and act as a further catalyst to integrate care,’ said Chris Ham, chief executive of the King’s Fund.
Broadly speaking, in England, health and social care services are separate. NHS England is responsible for healthcare and local authorities are responsible for the provision of social care services. However, with an ageing population and the prevalence of long-term conditions and co-morbidities increasing, more and more patients require both health and social care to work in tandem. Thus, the report surmises, the separation between the two is becoming increasingly problematic.
‘I think that if we continue to have a very fragmented model we will be missing many opportunities to commission much more logically for health and social care,’ said Dr Sarah Wollaston MP, Chair of the House of Commons Health Select Committee. ‘By having separated, fragmented systems for health and social care, we are wasting energy and money and are not meeting people’s needs, so I think that should be a clear priority for the future.’
Social care has been massively depleted due to cuts to local authority budgets over the past few years. While politicians are beginning to recognise the necessity of boosting funding, with Chancellor Philip Hammond committing an extra £2 billion to social care in the Spring Budget, many argue that these proposals do not go far enough to rectify the historical constraints on funding.
‘The NHS has been hampered by cycles of boom and bust while social care has been systematically under-funded for many years. We need to start planning for the long-term, and regular independent assessments of funding needs could play a key role in this,’ said Chris Ham.
However, simply boosting funds will not solve the social care crisis, without a fundamental change to methods of working. The new sustainability and transformation plans have been created across 44 areas by NHS providers and local councils, to enhance the health and social care available to those in need. According to NHS England, this model of ‘place-centred care’ has been created on the understanding that ‘collaboration between organisations will give nurses, doctors and care staff the best chance of success.’
‘We acknowledge that integration of health and social care is an important part of the solution and we agree it has the potential to bring benefits, but it is important to recognise that it is not a silver bullet and will not solve the problem of social care funding in the long term,’ said Niall Dickson, chief executive of the NHS Confederation.
The report acknowledges that ‘recent efforts to promote joined-up health and social care services have delivered mixed results, integrated health and social care with greater emphasis on primary and community services still presents the best model for delivering patient-centred, seamless care’. It goes on to state that although there is disagreement on the financial saving this integration might bring, the benefits to patients are a clear justification for continuing to pursue this agenda.
A prominent theme in the report is criticism of the restructuring of the system by the Health and Social Care Act 2012. According to several witness cited, the Coalition government’s decision resulted in an extensive fragmentation of services. This, the witnesses argued, continues to act as a serious impediment to devolution, integration and new ways of working.
‘The provisions of the Health and Social Care Act of 2012 are aimed at promoting competition, the opposite of integration. In trying to achieve the aims of the [Five Year Forward View] commissioners and providers have to ‘work around’ the Act, working against its aims but in conformity with its legal provisions,’ commented a witness from the Centre for Health and the Public Interest. The King’s Fund agreed, saying ‘amendments are needed to the aspects of the Act that were not aligned with the aims of the Five Year Forward View and sustainability and transformation plans.
Additionally, devolution to local level was cited as helpful to integration. Greater Manchester is the highest profile of these initiatives (see Box 1). the locality controls the full devolution of a budget of around £6 billion in 2016/17, and oversees 37 bodies providing health and social care, allowing priorities to be target to local necessities.
According to Howard Bernstein, former chief executive of Manchester City Council, the aim of the scheme is to join up community services with social care, mental health and primary care. This, in turn will provide integrated offer that is necessary to support a transformation in the population of Manchester’s health through prevention and early intervention but in effect, to reduce the demand for services in our hospitals.
However, evidence cited in the report stated that Manchester could be considered an exceptional case. Many, if not most, of the Sustainability and Transformation Plans are for much smaller populations, meaning that a Manchester style devolution deal for the rest of the country might be unsuitable in other areas.
‘I don’t believe there is anywhere else that has the same political impetus because it is essentially a political construct so what we are doing at the moment is we are basing our aspiration for STPs upon a hope that politicians in local areas will be able to come together in a way they are doing in Manchester,’ said Baroness Cavendish of Little Venice, a former policy chief in the Coalition Government. ‘I think it would be very foolish to expect anyone else to adopt the Manchester model.’
Devolution in Manchester
The Greater Manchester Agreement, signed in November 2014, set out new powers over transport, housing, planning and policing for the Greater Manchester Combined Authority. In April 2016 the region became the first in the country to take control of its combined health and social care budgets. Following the signing of a memorandum of understanding Greater Manchester now controls the full devolution of a budget of around £6 billion in 2016/17. A new strategic board, the Greater Manchester Health and Social Care Partnership, was created to take charge of the £6 billion health and social care budget. The Partnership comprises 37 NHS organisations and councils, including:
- 10 local authorities
- 12 clinical commissioning groups
- 15 trusts and foundation trusts
The report also identified serious long terms difficulties in the general practice nurse workforce, which may add to the difficulties of integration.
In particular, the report found that the ratio of practice nurses is failing to keep pace with increased demand and complexity with Full Time Equivalent nurses for every 10,000 patients in England in 2014/15, the same ratio as in 2010/11. As well as this, the practice nurse workforce is ageing, with 31% of practice nurses aged 55 or over in 2014/15.
Despite an increase in demand, investment in general practice has declined. Since 2005/06, the level of investment in general practice as a proportion of the NHS budget has declined from 10.7% to a record low of 8.4% in 2011/12.
‘If the Government fails to grasp the nettle and plan for the long-term, standards of care will decline and precious funds will be wasted,’ said Janet Davies, Chief executive of the RCN. ‘The RCN is ready to work with ministers to develop a world-class workforce as part of a properly funded and integrated health and care service.’
Social care often acts as the unseen cousin of the NHS, with shortfalls causing immense pressures, particularly in the acute sector. As the population grows older, and services become more strained, it is clear that the NHS will have to evolve too.
A service where the state cares for someone with cancer, but not one with dementia is not equipped for the 21st century.