Last reviewed 19 August 2016
The King’s Fund Chief Executive Chris Ham returned from an annual NHS Scotland Conference in Glasgow in June with many good words to say about the work done to achieve closer integration of health and social care services in Scotland and a firm belief that England could learn from its innovation and quality improvement. Christine Grey investigates.
He also observed in his blog that, as differences grow in how the four UK countries run their services, the “appetite” for learning from each other is diminishing. He said it was “a major missed opportunity” as knowledge sharing was being “crowded out by the competitive behaviours of governments of the four countries”.
The King’s Fund report, Four UK Health Systems: Learning from Each Other, published in 2013, suggested that Scotland had made more progress on integration in part due to its relative organisational stability over the past decade and the commitment of successive ministers and leaders in the NHS and local authorities (LAs). However, Audit Scotland and an Organisation for Economic Co-operation and Development (OECD) report still focused recently on how much more could be done to realise the benefits of integrated working, despite the extensive reform to Scotland’s arrangements brought by the Public Bodies (Joint Working) (Scotland) Act 2014.
Although the legislative framework for integration in England is less prescriptive and more fragmented than those now established in Scotland, there still seems to be a consensus to move towards the integration and personalisation of health and care services, not least because both countries face similar issues, such as severe financial pressures and an ageing population. It appears to be generally accepted that the integration of services is a way to use resources more efficiently, help move care out of hospitals, improve the individual’s experience and meet a growing demand for more co-ordinated long-term care.
The framework for delivering this in England is very different to Scotland’s, England having had divisions in responsibility, funding and accountability since 1948, with social care organised locally and health care nationally. Adult social care involves both public and private spending in England and, unlike in the NHS and unlike social care services in Scotland, local authority-provided adult social care in England is subject to means testing and charging.
Market forces appearing in the NHS and means testing in social care are what sets England apart from the other UK countries and is arguably hindering greater integration. In 2014, the independent Barker Commission on the Future of Health and Social Care in England proposed a new settlement to end the divide between health and social care by moving to a single ring-fenced budget, a single commissioner of local services and an alignment of entitlements between health and social care. Since then, the King’s Fund has been pushing for something similar, probably based on reformed Health and Wellbeing Boards (HWBs), although they would need changes to their legal power, duties and expertise if they were to have a bigger role in commissioning, and become more like Scotland’s Integration Authorities (IAs).
Today’s system of accountability for the integration of health and social care in England rests primarily with LAs and the clinical commissioning groups (CCGs), which were established by the Health and Social Care Act 2012 to commission services and give a stronger leadership role to GPs. For greater independence, NHS England was created to oversee the health service rather than the health secretary, and the HWBs led by LAs were established to bring local partners together to promote integration and oversee commissioning through a local health and wellbeing strategy. The Care Act 2014 placed duties on various organisations including councils to promote integrated care.
The transfer of public health to local government and the establishment of the HWBs have given local councils and LAs more control in health. It is possible that these arrangements are enough to accommodate new developments in local models of care, with CCGs at the forefront of developing them.
To encourage bottom-up innovation and experimentation, a pioneer programme was established, with each pioneer site having adopted different and distinctive approaches to integrating local services. The Government’s Five Year Forward View vision of change for the NHS also gave scope for new approaches to be refined using 29 Vanguard sites.
The Better Care Fund (BCF) was set up as a single-pooled budget for health and social care services, and was boosted in 2014 by an extra £1.5 billion to a total of £5.3 billion a year to “help join up health and care services”. The fund is deployed by LAs and CCGs, which submit for approval, a jointly agreed plan setting out how they will use their allocation. The fund comes with requirements such as reducing emergency hospital admissions and delayed transfers of care, and better data sharing between health and care. Every part of England is required to have a plan for NHS and social care integration by 2017, to be implemented by 2020.
The quality frameworks are disjointed across English health and social care services, although collaborative work has been done to define what integrated and personalised care should look like. The Government set up the National Collaboration on Integrated Care and Support, with its first output being the new national policy framework, Integrated Care and Support: Our Shared Commitment 2013, supported by central and local government, regulators and national representative organisations from the NHS and social care. A narrative has been created by National Voices that underpins this policy framework and is aligned with the Making It Real “I” statements, developed by the Think Local Act Personal (TLAP) partnership.
In June 2015, the King’s Fund was commissioned by the Department of Health to review how to assess the performance of health services in CCG areas and how well they work with social care and public health services. This resulted in a recommendation for a radical simplification and alignment of existing NHS performance frameworks into a single one covering the NHS, public health and adult social care. Scotland has already established its “Core Suite of Integration Indicators” together with guidance and a duty on IAs to report annually on progress against them.
Comparisons between the countries of measurable effects on the health service are still difficult to make because of differing data sources and availability of evidence. The OECD also found a surprisingly limited number of indicators published separately for the different health systems, which made benchmarking within the UK nations challenging, according to its report Reviews of Health Care Quality: United Kingdom 2016.
In 2015, the first annual report by the Policy Innovation Research Unit (PIRU) was released into the progress made by the first wave of Integrated Care Pioneers (ICPs) across England since their creation at the end of 2013. It identified leadership, relationships, information governance and data sharing as key areas that enable integration when done well but which could act as barriers when done badly. Sheffield CCG Director of Partnerships and Planning, Tim Furness told National Health Executive newspaper that his impression from the report was “work in progress” and that evidence of the impact on reducing hospital admissions was “not quite proven”.
This year, England was warned that local pilots and initiatives needed to translate into action, scale up and speed up. Stepping Up to the Place was published in July 2016 by representatives from NHS Clinical Commissioners, the NHS Confederation, the LGA and the Association of Directors of Adult Social Services (ADASS), who warned that better consensus was needed on the barriers to making integration happen in England.
To support local initiatives, the document suggested that national policy makers should look at aligning the funding of health and social care more closely at a national level. It wanted policy makers to consider to what extent a fully integrated health and care system is possible while the NHS is free at the point of delivery and adult social care services are means tested, and said if means testing is retained, at what level of need should the threshold be set in order to avoid displacing demand back onto healthcare?
This chimes with the article by King’s Fund Assistant Director of Policy, Richard Humphries, Integrated Health and Social Care in England — Progress and Prospects 2015 published in the “Health Policy Journal”, which concluded: “The distinction between universal health care funded through general taxation, and social care which is means tested and highly rationed, is becoming a bigger obstacle to the true integration of the two services.”
The Government responded to the Barker review on health and social care funding in 2014 with “deafening silence”, according to the King’s Fund, at a time when the National Audit Office (NAO) was calling for extra resources to allow for the double running of some services during the transition towards integration.
NAO Head Amyas Morse criticised the BCF for its “bold assumptions” about the financial savings expected from integration, namely reductions in emergency hospital admissions. Agreeing with this analysis, NHS Confederation Director of Policy Johnny Marshall said evidence of financial saving was still at a very early stage.
By July 2015, Warwickshire County Council Leader, Izzi Seccombe’s view was printed in the Nuffield Trust’s paper, Reconsidering Accountability in an Age of Integrated Care, where she said the BCF had become “heavily NHS-focused and bureaucratised with no discernible change as a result”. She warned: “Social care needs to be placed on a firmer financial footing if it is to play its part in joining up services.”
In March 2016, many good local programmes were emerging from NHS England’s new care model Vanguard sites, according to King’s Fund Chief Executive Chris Ham, although he said the regulatory system could now be inhibiting true partnership working. He praised collaborations between NHS organisations and LAs, such as the Isle of Wight’s “My Life, A Full Life” programme, but warned in his blog, The Vanguards — One Year On, that NHS leaders needed to pay more attention to working with partner organisations. He stressed: “The challenge is how to do so when regulators are focused on organisational performance rather than the performance of place-based systems of care.”
Now that the Care Quality Commission (CQC) is responsible for regulating primary and acute health services as well as social care services, it has been able to conduct thematic reviews of co-ordinated care, which have fed into its 2016 to 2021 strategy Shaping the Future. This document sets out the regulator’s intention to “focus more on the quality of care that specific population groups experience and how well care is co-ordinated across organisations”. Whether this is enough to encourage providers to build bridges between their own organisation and others, to move from fragmented care to integrated care, remains to be seen.
The Government’s ambition for England is that, by 2020, half the population will be receiving some care through a new model. England is now at the stage where decisions need to be made urgently about how successful new models can be scaled up and used across the country, and which models have not produced sustainable ways of working. Organisations will need strong national support to build the partnerships to deliver this and localities need clear indicators and good data to measure success.
Meanwhile, with budgetary restraints arising from austerity measures, and as the BCF consists mainly of recycled money from the NHS, social care and healthcare organisations are at risk of competing for rather than sharing funding designed to encourage greater integration. Any lack of investment and co-operation between the services risks starving integration projects of funds for much needed workforce training, culture change and IT support.