Last reviewed 26 September 2014
One of the clichés of our world is that the division between the management of health services and the delivery of social care is unhelpful for older people, people with disabilities, and people with long-term conditions, which are of course heavily overlapping groups. Everyone can see the problem, writes Jef Smith, but no one knows quite how to resolve it.
Mrs Jones, who lives in a care home, but still wants to retain as much independence as possible, has a variety of needs.
She has to be helped with many daily tasks including getting up, going to bed and eating. She is a bit absent-minded so often forgets to take her medication unless the staff present her with her pills and wait until she swallows them. Her mobility is limited and she has fallen a few times even since being admitted to the home. She has several medical conditions, some of them potentially fatal, and she was admitted to hospital several times in the year before coming into the home.
Her daughter, who lives 200 miles away, visited regularly at first, but staff have noticed that her interest in her mother seems to be tailing off. Mrs Jones gets depressed, and indeed there is a good deal in her life to be depressed about.
I have deliberately listed this lady’s problems and symptoms — and the list could go on — in no particular order, because that is how it feels to be Mrs Jones: lots of difficulties, most of which will probably get worse.
It also seems to Mrs Jones that the people who help her to cope interact with her in a somewhat random order. First, of course, there are the staff of the home, some of whom understand her health problems better than others, perhaps because, she thinks, they have qualifications in nursing.
She finds it difficult to separate in her mind the numerous doctors she has seen recently, not only the GP, but also the specialists at the hospital she visits for outpatient appointments. In addition, there are various people with the term “therapist” somewhere in their titles, some at the hospital, some who visit the home occasionally.
There are also another lot of people called “social” something, and voluntary workers from various organisations, along with others, again, whom she has not clearly identified.
Although some of the people she has seen sometimes talk to each other and to the care home staff, they often ask the same questions and even give conflicting advice. She has heard references to a care plan, or to more than one care plan, but care does not seem very planned from her point of view.
It is easy to point-score in setting out such a confused picture, which is of course not a single snapshot, but a story that develops as Mrs Jones’s needs become more and more complicated. However, it is a lot harder working out how the central gap between health and social care could be more effectively bridged.
Every effort to configure agencies differently seems to open up new loopholes elsewhere, and simply creating posts of lead persons or care co-ordinators poses the question of how such supposed supremos can exercise authority over fellow practitioners who are employed in, financed by, and accountable to separate chains of authority.
King’s Fund report
The latest body to seek to tackle this hydra-headed problem is the authoritative think tank, the King’s Fund. Its independent commission on the Future of Health and Social Care in England published an interim report in the spring of 2014 as a prelude to what will doubtless be a challenging set of ideas when it finishes its work later this year.
It is certainly a formidable body, chaired by business economist Kate Barker and including in its membership Geoff Alltimes of the Local Government Association, Lord Bichard who chairs the Social Care Institute for Excellence, Baroness Sally Greengross of the International Longevity Centre, and Julian Le Grand, a professor at the London School of Economics.
Their cumulative wisdom and that of the Fund’s support team members and a further group representing experts by experience is impressive. The absence of senior doctors is striking, however, and perhaps potentially damaging given how important to residents’ experience is the gap between hospitals and care homes, and how necessary medical backing will be to the implementation of the commission’s proposals. Surely it would have been politic to find space for the chair of one of the Royal Colleges or someone of similar status.
My fear of the hostility of hospital consultants is not without base. There has been no lack of attempts over the years to crack the problem of the divide between health and social care, but many have floundered because of indifference or active opposition from the upper ranks of the NHS.
My own background has been largely on the social side of the river of division, but I can sympathise with my colleagues on the opposite bank because almost every attempt to span the flow, from joint finance in the 1980s through to the contemporary Better Care Fund has involved the transfer of resources out of health. This has been justified on the dual grounds that social care is relatively poorly resourced and that there would be savings to health in the long term if social care were to work more efficiently and more promptly.
It is certainly true that care services financed through local government have had a very poor time financially. Whatever the cuts the NHS has recently faced, they are nowhere near as severe as those suffered by local government and, however hard councillors have tried to protect adult care by closing other facilities such as libraries and sports centres, care has still ultimately had to take its share.
The damage became apparent in July 2014 when the Association of Directors of Adult Social Services produced the results of an internal survey of members that showed budgetary savings of 26% over the last four years. Residential care providers do not need to be reminded of how local authorities’ loss of purchasing capacity is cutting the volume of their commissioning or adding to the downward pressure on fees.
For service users, the rise in the criteria determining eligibility means, quite simply, that many who a decade ago would have been readily recognised as needing care in a residential setting are now having to struggle along with minimal support from relatives or neighbours.
To health service managers, however, it always seems that they are being asked to make immediate sacrifices on the strength of only vague promises of payback at some point in the future. Social care tries to sell itself to health as a preventive service, eg assisting people with disabilities to remain independent, providing enough help to people in homes to keep them out of hospital, supporting families to care so that professionals do not have to step in, and so on.
Many of the savings of such policies do accrue to the NHS but, as controversies over the Better Care Fund are demonstrating, they are difficult to quantify, and relating individual instances of early intervention to preventing crises is next to impossible.
Asking hospitals to give up staff on the grounds that the money will be used, for example, to prevent older people from falling and therefore arriving at A for treatment, strains credibility. If central government was prepared to carry the risk by putting in the resources up front, the savings would materialise in due course.
A third way?
The bulk of social care and health funding come from separate ministries — respectively the Department of Health, and the Department for Communities and Local Government — and with division at the top, what hope is there of generating trusting budgetary co-operation lower down the scale?
It was recently alleged, for example — by the King’s Fund, no less — that “half the money being transferred from the NHS budget to support better joint working between health and social care is now being spent on protecting social care services from budget cuts, rather than driving integrated care and other service changes needed to better meet the needs of patients and service users”.
As far as the commission on the Future of Health and Social Care is concerned, at this stage — the April 2014 document was, after all, described only as an interim report — it has done little more than to set out the problem and to call for views. Few will dissent from the idea of “a single, ring-fenced budget for health and social care which is singly commissioned, and within which entitlements to health and social care are more closely aligned”, but getting to that desirable end from where we are now presents formidable difficulties.
The commission poses the alternatives of making more social care free or reducing the extent to which healthcare is free. The former would be expensive; it was rejected by a Labour government at the end of the last century, although recommended by a Royal Commission and in a much more comfortable economic climate. The latter, whenever proposed, is always extremely unpopular and therefore probably politically impossible to deliver. It looks as if a third way will have to be found.
Don’t stand aside
The King’s Fund report contains a great deal of meat to be digested. This includes a thoughtful analysis of the current situation and how we got there, a discussion of the implications of an ageing society and the affordability of services in the prevailing economic climate, and then an exhaustive listing of the costing and spending options.
There are also several background papers, including one exploring the way in which 10 other countries tackle similar problems, not to mention lots of charts and statistics. This is by no means an easy read.
But these are not issues from which providers can stand aside on the grounds that their roles are to deliver services, not to fund them. They may have little influence over the systems of governance through which health and social care are managed, but local authorities, health commissioning bodies or some sort of combination of the two will continue to determine, or at least heavily influence, the shape and volume of care through their purchasing power.
In short, the managers of any home wishing to fill its places in the future need to be reacting now to this vital debate.