Making bricks with straw. Integrating social care and health

Featured article - 01 June 2020
By David Pearson CBE, Social Care lead in the NHS for COVID-19. Chair of Nottingham and Nottinghamshire Integrated Care System

It was Sir Roy Griffiths, in his advice to the government in 1988, who made the observation that compared with the task of organising community care: "The Israelites faced with the requirement to make bricks without straw had a relatively routine and possible task". (1).

Griffiths recommended that disparate funding and accountability should be brought together under local government, overseen by a single Minister with a ring-fenced budget. Whilst the disparate budgets in local government and the benefits system (then paying separately for residential and nursing care) were brought together, the ministerial responsibility has been shared between the Department of Health and Social Care and the Ministry of Housing, Communities and Local Government and there has been no ring-fenced budget.

Over three decades later has it become easier to deliver community care?

The increasing challenges facing social care are well documented. Despite this and an acknowledgement of the need for change, successive governments have struggled to get reforms over the line. A key objective must be to ensure that the social care system can address the most significant increase in longevity of disabled people and those of us with long term conditions in a way which promotes wellbeing, independence and choice. To undertake this task in a way which enhances quality of life and ensures the quality and safety of provision.

A consistent theme in discussions about reform is the need for integration between health and social care. For some politicians and commentators this would solve all the ills, including the financial challenges.

• SCIE: COVID-19 advice for social care
• Nottingham and Nottinghamshire Integrated Care System
• Other opinion articles in this series

The poor relation

Between 2009/10 and 2016/17, NHS funding rose by 10.3% whilst social care experienced a reduction of 9.9%. (2). The Institute of Fiscal Studies and Health Foundation estimate the need for a 4% average increase need for the NHS and 3.9% for social care. This reflects demographic changes and cost increases in the sector. Whether you are a fan of local government or not, the ability of the sector to stretch its budgets whilst maintaining the provision of legally prescribed services is a remarkable feature of the last ten years.

However, resolving the funding issues - the existing means tested system and the need to pool risk to address “the catastrophic costs of care” are not buried in some formula for integration - in fact a firm financial footing is an essential prerequisite for further integration. As Sir Simon Stevens wryly commented to MP’s in 2016, it was not simply a case of pooling money, as combining "two leaky buckets" won’t provide a watertight solution.

Nor will it address the problems of the viability of the market or the low pay and stability in the workforce - with high levels of zero-hour contracts and with 40% of care workers leaving their job each year.

Why Integration then?

Every advanced economy in the world is grappling with how best to respond to the changing needs of our population - the fact that previously life-threatening conditions can be treated in day surgery; that younger adults with disabilities whose life expectancy was limited two decades ago are now living into old age. Needs and risks need to be managed through a combination of health and care services working in a person centred, coordinated way. Local public agencies need to work together to prevent illness and long- term conditions or disability. Where this is not possible, there is a need to enable people to live well, maintain independence and prevent or manage crises; using the available information to predict needs and provide the necessary treatment, care and support. This makes sense for the people who need health and care and makes the best use of resources.

An area of common agreement is that this ambition requires an integrated approach across social care, primary care, community health services and mental health to best support the needs of communities in prevention and in “population health management”. This approach utilises the modern gift of technology and information to provide a more sensitive and timely response to people’s needs and risks.

Many of the provisions of the Care Act 2014, were welcomed by those who use services, local authorities and providers of care. Some elements are world leading - whether it be personal budgets or entitling family carers to care and support services. These are very important elements of any social care and health system. They are to be preserved and enhanced.

Local or national?

The publication of Griffiths Report in 1988 was delayed as Whitehall and Ministerial battles raged over whether local authorities could be trusted to handle community care and contain the cost.

The model has been one of local determination of the budget for adult social care by Councils based on the resources available and now mainly raised through local Council Tax. As envisaged in 1988 the services are then purchased on the basis of an assessment of need and a financial assessment of eligibility for state funding.

• Health Foundation: Griffiths Report

There is a “relative needs formula” to determine the allocation of any central government grants and the Better Care Fund, the pooled budget allocated by central government through the NHS. A further national determination is a suite of indicators - the Adult Social Care Outcomes framework. Local Authorities were subject to an annual assessment by the Care Quality Commission until 2010, and previously adult social care regulators carried out assessments of particular aspects of adult social care.

As far as providers are concerned CQC carries out inspection of the quality of care and has a “market oversight” function in relation to financial sustainability of the bigger providers.

There is scope to increase central government direction over funding, oversight of the delivery of national policy and legislation for both commissioners and the social care market.

However, the NHS Long Term Plan envisages an approach to population needs through local Integrated Care Systems bringing together health and local government and wider public services to meet the needs of the population. It is founded upon a recognition that good national systems exist because local arrangements involve the effective deployment of resources and expertise at a local level. The evidence across the world is that those health and care systems that have some devolved power and responsibility make change happen more quickly and are more easily connected with local people and elected representatives.

In practice then, the suggestion that it is either a national or local responsibility is too binary. It is both and getting the balance right is the key. In practice – any level of integration requires an alignment of national expectations and local application.

What makes integration work?

The international evidence is that where it works best, local leaders work well together to implement:

• A shared and agreed vision and purpose, which is understood and owned by the workforce and population who are engaged in the design of services
• The outcomes required
• The structures, resources and other levers to achieve the vision and outcomes

Structures are the last bit of the jigsaw.

Given the moves already made towards integration in this country we have reached a point where perhaps we should progress from a “coalition of the willing” to a firmer platform for change and development. There is enough evidence of what needs to be done from this country and across the world. Local agencies working together could now be enshrined in local statutory boards. Governance arrangements would reflect a quid pro quo between health and local government, with a ring-fenced social care budget. This should be aligned with future increases in NHS budget. No longer should social care be the poor relation. The arrangements need to embed local democracy and health leaders in driving service change and improvement in the process of planning, monitoring and the deployment of resources in accordance with combined national outcomes for the NHS, public health and social care.

In the build-up to NHS 70, we were all reminded of the huge benefits we have enjoyed from the extraordinary innovation in the NHS which has helped us live longer and more healthily. Social care at its best enables us to maintain independence and otherwise to live the best lives we can. It is a powerful combination. Could 2020, a time of adversity, be the year when we all realise just how important social care is, and alongside the NHS, begin making bricks with straw?

• (1) Community Care: Agenda for Action – Sir Roy Griffiths Griffiths 1988 (pp iii ix)
• (2) Securing the Future: Funding Health and Social Care to the 2030’s. Institute for Fiscal Studies and the Health Foundation - May 2018

• David tweets @25davidpearson

David is: Social Care lead in the NHS for Covid -19; Chair of Nottingham and Nottinghamshire Integrated Care System; Chair of TEC Quality; and Past President of the Association of Adult Social Services.