SCIE’s response to ‘Liberating the NHS’ White Paper and associated consultation papers
1. SCIE is pleased to have the opportunity to respond to the proposals set out in the White Paper, “Equity and Excellence – Liberating the NHS”, and its associated consultation papers.
2. SCIE is an independent knowledge transfer charity which seeks to drive up the quality of care services by sharing knowledge about what works in all aspects of social care for adults and children throughout the UK. We recognise the central role of people who use services and carers, and we aim to ensure that their experience and expertise is reflected in all aspects of our work.
3. Given our remit, we strongly welcome the White Paper’s focus on securing good outcomes for people, on the need for more, better quality personalised services, and the crucial role that more and better information, choice and control can play in achieving these objectives. SCIE has developed a large body of evidence-based resources to assist commissioners, providers, managers and staff in social care, health and other local services to deliver high quality services. These include a range of short briefings and Social Care TV films on aspects of personalised care, products on specific issues such as the Mental Capacity Act and a popular and innovative electronic Gateway on dementia care. Our resources are also used by service users and carers. These materials – and our “offer” to the social care sector overall – are highly relevant to many of the underlying White Paper themes referred to above.
4. Whilst the White Paper and associated consultation papers are largely focused on the NHS, there are some important references to adult social care and significant implications for the sector. This response focuses on the proposals for integrating health and social care, commissioning for better outcomes, giving new responsibilities to local authorities, engaging service users and reforming regulation. SCIE clearly also has a specific interest in the proposals to develop quality standards to cover care pathways across health and social care and we are discussing these with our sponsors at the Department of Health and with the National Institute for Health and Clinical Excellence. SCIE is uniquely placed to support NICE in the development of these standards, as we have access to the best available evidence on what works in practice. We also have well-established systems for disseminating good practice widely and cost-effectively to a complex and diverse sector. SCIE has worked closely with the National Institute for Health and Clinical Excellence (NICE) to develop clinical guidelines on dementia and other topics, which may be seen as the precursor of quality standards.
Integrating health and social care
5. As the number of older people increases, along with those adults of working age living with long-term conditions, the White Paper rightly emphasises the interdependence between the NHS and the adult social care system in securing better, more cost-effective, outcomes for people, and to look for ways of making the two systems work together more seamlessly. We welcome the Government’s vision for better joint working between the NHS and local authorities. Integrated working has many potential benefits for citizens, including shared information and facilities and better co-ordination between different professionals involved in delivering care. This is a debate that has been continuing for a number of years. While there has been significant progress in some areas in delivering seamless care for people, it has been variable across the country. SCIE has produced a number of resources to help professionals and organisations work more effectively together, including an e-learning resource on good inter-professional and inter-agency collaboration. (1) More robust evidence is now emerging on how integration of health and social care services can improve outcomes for people.
6. Integrating health and social care commissioning is not simply a question of bringing local organisations together. It is important to recognise some intrinsic differences between the two sectors which need to be addressed if they are not to present major obstacles to integration. Those differences can include:
- systems of governance and accountability (though these may ease with the proposed role of councils in relation to overall health and care oversight);
- funding systems, with the NHS largely free at point of need and social care means-tested;
- the types of ‘market’ in which providers operate – the private healthcare sector remains relatively small whereas some 90% of direct social care services are delivered in the private and voluntary sectors;
- organisational and professional cultures, including very different levels of qualification between the two workforces, eg health has a much higher level of professionally-qualified staff;
- a stronger history of delivering choice and control to users of social care services.
7. These obstacles are not insurmountable, as demonstrated by those areas which have successfully tackled them. But to ignore them is to risk limiting proper integration to a few pioneering localities rather than generalising it as the White Paper suggests. Moreover, “integration” can mean different things in different sectors and can come in a variety of forms. According to a recent ADASS/NHS Confederation survey (2):
- the commonest form of integration was joint health and social care appointments (PCT and LA have some key joint appointments and teams collaborate but are not formally integrated or combined).
- second came enhanced partnerships: system-wide commitment, shared vision, integration across commissioning functions, senior and middle tier joint appointments, formal high level backing – but separate legal entities.
- Full scale structural integration (eg into a Care Trust or joint PCT and social care department) is still relatively uncommon.
8. The emerging evidence suggests that the main factors supporting integration are locally determined:
- Local leaders – political as well as professional - who have a joint vision and strategy and are committed to pushing this through. This can make it possible to develop integrated teams and working.
- Good local relationships – often between key individuals. In some instances this is formalised through senior joint posts (eg in Knowsley the CEO of NHS Knowsley is also Executive Director for Wellbeing for Knowsley Council.)
- More integrated teams can have a real impact, such as reducing delayed transfers of care out of hospital settings. And there are savings from having fewer managers.
- In other cases the integration comes at operational level, for instance in Islington a clinical nurse specialist oversees standards in all the care homes that the council contracts with.
9. Some of the lessons from more recent examples of integration include:
- Start from a clear focus on people not structures. What outcomes do disabled and older people in the local area want to achieve? What supports their well-being? How can the Council and NHS simplify systems from their perspective? Local joint working plans can then be developed based around these outcomes.
- National policies need to be flexible, to allow for the development of innovative local solutions to local challenges.
- Integrate cultures – not structures. Structural change is less important than shared vision and good relationships. Local government and health care need to understand each others’ cultures
- More creative use of funding flexibility by both health and social care commissioners. More NHS organisations and councils are using the Health Act flexibilities but formal joint financing expenditure is still small; the evidence suggests that under 5% of total adult social care and NHS spending is being pooled. This suggests these approaches may still be too complex and that they would benefit from being simplified.
10. In terms of the future these lessons suggest that:
- new GP commissioning consortia provide an opportunity to align health and care services more closely with local communities’ requirements. GPs will need to consider how to stimulate and commission new and different providers and services – both health and social care – to meet needs. Experience from personal budgets in social care is that they can deliver improved outcomes for people. As the number of those with personal care and personal health budgets increases, they will need to be able to purchase services which meet their needs and may want different services to those currently available. And individuals may do their own integration of services at a micro-level.
- But integrating or better coordination between health and social care will not fully support people’s wellbeing. Housing, education, employment, leisure, transport – all impact on wellbeing. This again points towards some form of integration based on place and need, not on organisation.
- Risks and incentives - Public sector spending reductions could result in increased silo working and cost shunting – rather than increased integration. This implies the need for stronger incentives to encourage integration.
- More knowledge about what works – SCIE has an important role to play in capturing and disseminating messages about what works – and what doesn’t. SCIE has information in a range of formats on how new ways of working can be introduced and how services can be transformed through new approaches, including personal budgets, telecare and assistive technology.
11. Despite the findings quoted above, there remains relatively limited evidence so far on whether service integration is truly cost-effective. Evidence from the UK shows that the greatest savings can be achieved through integrated working focused on early intervention. (3) Services designed to help people maintain their independence can deliver cost savings by preventing hospital or nursing home admissions. Programmes based on integrated working, such as Supporting People, Link Age Plus and Partnerships for Older People Projects (POPP), have shown they can generate savings of between £1.20 and £2.65 for every £1 spent. (4) Some of the most significant reductions were in accident and emergency admissions and re-admissions and hospital overnight stays – which raises questions about which sector attracts the best financial benefits from integrated working and investment. There will continue to be a need for more NHS investment in service systems to help at the interface with social care, such as expanding intermediate care, reablement, community rehabilitation services and other types of support. It will be important to consider separately the costs and savings that accrue to both the NHS and social care, and the implications for investment levels or inter-sector transfers.
12. We agree that local authorities are best-placed to promote closer working and to lead joint strategic needs assessments. Their remit is to take a broad view of wellbeing, in which health and social care are just one part of the picture. Councils also need to ensure that adult social care works in an integrated way with children’s services and housing, as well as with the NHS. Evidence from SCIE’s work on parental mental health and children’s wellbeing supports this.
13. The Government intends to use policy, legislation and guidance to deliver the changes in social care needed for integrated working. This will influence the current review of adult social care legislation being undertaken by the Law Commission.
14. The proposal that Foundation Trusts may be allowed to expand into social care needs much more debate. It is unclear exactly what is being proposed, and how it would work in practice. The market for social care is diverse and complex, with a variety of types of both funders (including self funders) and providers. It will be important to ensure - and to be clear - that such moves by FTs would be for the benefit of service users rather than primarily a means of securing the revenue streams of provider organisations.
Commissioning for better outcomes
15. We support the White Paper’s focus on outcomes for people. However, the proposed NHS Outcomes Framework is based on a ‘clinical treatment’ model. In an environment of closer alignment between social care and health, the framework should move beyond treatment towards overall wellbeing.
16. There is no proposed equivalent in social care to the new and independent NHS Commissioning Board. Given the White Paper’s commitment to integrating health and social care commissioning at a local level, adult social care and local government should have a substantial presence on the NHS Commissioning Board. The necessary legislation, policy and guidance framework will need to be put in place to enable local authority engagement and influence to be secured.
17. Adult social care also has a substantial contribution to make to GP consortia. The development of individualised commissioning through personal budgets in both health and social care provides an important opportunity to develop integrated services for people and to test whether such micro-commissioning can be made to work at scale. It should also help NHS commissioning led by GP consortia to take full advantage of the adult social care service contribution (as well as drawing on the experience of council- led social care commissioning).
New public health responsibilities for local authorities
18. It is vital that social care contributes fully to public health, and the proposals to give local authorities new responsibilities for public health should help ensure this happens. They also strengthen the impact of Joint Strategic Needs Assessments. Health and wellbeing boards should reflect the widest possible range of council activities, reflecting local authorities’ broader duty to undertake early intervention and prevention. This needs to include children’s health and wellbeing, as there is a risk of children’s issues being overlooked.
19. SCIE research sets out the contribution that social care can make to reducing health inequalities: social care interventions can reduce health disadvantage for individuals throughout their lives and help narrow health inequalities. (5) Social care practitioners work with some of those who are most disadvantaged and who have little “voice” locally. Such practitioners are well-placed to improve the health of those most at risk. SCIE is currently investigating preventative and reablement services for older people, delivered primarily by social care workers. Initial and developing analyses show that these interventions improve self-care, prolong independence and reduce the use of health services, including hospital admissions. Improving access to social care interventions is important to any strategy for reducing health inequality and promoting public health.
Engaging with people who use services
20. The White Paper’s proposals to increase people’s involvement in decisions about their health and care is welcome. It is an area where social care has gained a great deal of experience over the last ten years. We have found that user engagement only works if there is a strong commitment among professionals to bringing about real change on the basis of what users say. “Nothing about us without us” is an important commitment but putting it into practice will require a shift in power from professionals to people who use services, which in turn will require a significant change in the culture of organisations.
21. Effective user engagement takes time to develop. Service users and carers themselves are often the best people to teach the necessary skills. Research and evaluation are important, and SCIE has established a body of evidence and guidance that should be helpful. Joint user engagement strategies by local health and social care communities could deliver real progress.
22. Organisations that support public engagement have faced a number of barriers to operating effectively, such as inconsistent funding. Moreover, it is difficult to assess the quality of social care provision without looking directly at how staff interact with users – so public involvement should be at the heart of the health and social care system. As the HealthWatch proposals are developed, there are important lessons – both positive and negative – to be learned from the variable experience of Local Involvement Networks (LINks).
Regulation of social care
23. The White Paper’s proposed approach to inspecting and regulating health services is strongly data-led. It relies on active gathering, collation and analysis of information from various sources about the performance of particular providers, in order to identify poor standards of quality and safety. A similar approach will be even more necessary in social care, where service provision is much more fragmented and dispersed, and where personalisation will further diversify patterns of supply. Traditional formal agency-based inspection models will not work in this new environment. CQC will need to develop new arrangements to gather and analyse local intelligence, and work with local authorities on identifying problems at an early stage and intervening in failing services.
24. The proposal to extend Monitor’s remit to social care raises a number of issues. Social care already operates in a mixed economy, with the bulk of provision in the private and voluntary sector. Local authority commissioners are able to issue tenders, stimulate competition and negotiate fees. Self-funders and users of personal budgets and direct payments have less leverage over providers as individual purchasers, and local authorities should arguably be doing more to support joint purchasing by groups of budget-holders. It is not yet clear whether, or how far, Monitor might be able to use competition law to strengthen individual choice in social care. The issue of maintaining service continuity and dealing with economic failure by providers is likely to gain a higher profile in the current and foreseeable economic climate. It is part of local authorities’ role to respond to the consequences if, for example, a care home closes at short notice and new places have to be found for existing residents. Monitor may be able to play a useful role in social care by improving councils’ capacity for economic and market analysis, and enabling them to play a stronger role in proactive market-shaping, monitoring and planning.
25. Regulation of social work has developed on the basis of accountability to the public. In transferring the functions of the General Social Care Council to the Health Professions Council, it will be important to maintain the distinctive values and ethos of social work, and the primacy of service user over professional interests. There is also the outstanding issue of what form of regulation or licensing is appropriate for other social care staff, many of whom work with disabled and older people in vulnerable situations and away from direct supervisory oversight.
26. This is a wide-ranging agenda, with important implications for adult social care. SCIE is working closely with the Department of Health on the main issues affecting the sector. We look forward to providing further input in any way that would be helpful.
SCIE October 2010
- Interprofessional and inter-agency collaboration (IPIAC)
- Where next for health and social care integration? NHS Confederation/ADASS. June 2010
- Turning Point (2010): ‘Benefits realisation: assessing the evidence for the cost-benefit and cost-effectiveness of integrated health and social care’.
- Personal Social Services Research Unit (2010): National evaluation of Partnerships for Older People’s Projects: final report.
- SCIE Research Briefing 33 (June 2010): The contribution of social work and social care to the reduction of health inequalities.