Integrating Health and Social Care inquiry

The Departments do not know what is the most effective balance of limited funding across health and social care. We heard from the Local Government Association that over the period 2010–11 to 2015–16, local authorities in England reduced spending on adult social care by 10% in real terms. The Association asserts that there is now a very significant shortfall in funding for adult social care. In contrast, between 2011–12 and 2015–16, spending by NHS trusts and NHS foundation trusts increased by 11% in real terms. The relationship between the adult social care budget and the NHS budget is not well researched. The Department of Health and NHS England provided two different estimates for the impact on spend in the health sector of changes in spend on social care, which they acknowledged were, respectively, out-of-date and vague. We note that the recent Budget has found £2 billion additional funding for adult social care over the period 2017–18 to 2019–

Recommendation: We re-iterate the recommendation from our February 2017 report Financial sustainability of the NHS that the Department and NHS England should assess the impact that financial pressure in social care is having on the NHS, so that it can better understand the nature of the problem and how it can be managed. It should publish the findings of its analysis by July 2017.

The Better Care Fund was little more than a ruse to move money from the health sector to social care, disguised within an overly bureaucratic initiative that purported to integrate health and social care services. NHS England said that the Fund was simply a way to get funding from the NHS into social care. NHS England and the Local Government Association agreed that the Better Care Fund had increased the funding available to local authorities for social care in 2015–16. However, the Local Government Association told us that the Fund was simply plugging a gap in money that had been cut from local authority budgets, while demand for care was rising. While it had helped local authorities reduce cuts in services, and in some cases to set up new initiatives, the Association cautioned that it should not be assumed that by transferring some money into adult social care, improvements will inevitably be made. The Fund also created a significant bureaucracy, which some local areas found was disproportionate and had in some cases disrupted other integration work.

The Better Care Fund has been rendered largely redundant as a means of building integration by the sustainability and transformation planning process. NHS England is planning to roll out new care models through sustainability and transformation planning across the 44 sustainability and transformation plan footprint areas as the primary mechanism for integrating health and social care. NHS England assured us that the NHS delivery plan for the next 2 years, due to be published a month after we took evidence, would be explicit about what integration through sustainability and transformation planning will look like. The Departments have dropped requirements for local areas to produce separate plans showing how they would integrate health and social care by 2020. 6 Integrating health and social care Recommendation: The Departments and NHS England should reassess whether the Fund in its current form is still necessary and should identify what has worked well so this can be brought into sustainability and transformation planning.

We are unconvinced that sustainability and transformation planning will succeed where the Better Care Fund has failed in building successful integrated services. The Fund did not achieve planned-for benefits for the NHS and therefore to patients and service users. Its targets for reducing emergency admissions and delayed transfers of care were missed by a large margin, and in fact both increased. Planned savings of over £500 million were not achieved and emergency admissions and delayed transfers of care alone ended up costing around £460 million more than planned. NHS England confirmed that £5.4 billion of the £7.9 billion available in the Sustainability and Transformation Fund between 2016–17 and 2018–19 will be used to offset hospital deficits, rather than transform health and care services. As we commented in our recent report on NHS Financial Sustainability, very few areas have so far developed credible, robust and rigorous plans. We heard that areas trialling the new care models have seen slower rates of growth in admissions and delayed transfers of care; however they are being rolled out before they have been properly evaluated. Recommendation: The Departments and NHS England should set out criteria for measuring success of integration by July 2017. They must set realistic targets for initiatives that aim to integrate services, within a credible timeframe for achieving them by July 2017.

Sustainability and transformation planning is neither inclusive nor transparent enough. We heard from the Local Government Association that in some areas NHS England has not been engaging sufficiently with local government. We heard from NHS England that, conversely, in some areas local government has declined to get fully involved. Engagement can be complicated because the 44 sustainability and transformation planning areas do not all align with local authority boundaries. Nevertheless, without meaningful engagement with local authorities, integration is an impossibility. Furthermore, local people are not yet being fully involved and consulted with in decisions about how their local health and social care services will change. The NHS has a duty to consult with local people but can find this challenging as it lacks the history of, and mechanisms for, engaging with the populations that local authorities have. NHS England agreed that sustainability and transformation plans can be jargonistic and therefore not clear and transparent to the public. Recommendation: By May 2017, NHS England and the Local Government Association should encourage and support the full involvement of local government in the sustainability and transformation planning process. Working with their local authority partners, local health bodies should improve the involvement of local populations in the planning process.

It is deeply unsatisfactory that the Departments and NHS England washed their hands of any accountability for the Better Care Fund. NHS England’s Chief Executive seemed to reject any accountability for the performance of the Fund over its first year. He dissociated himself from the targets set for its first year, saying that it had not been designed by any of the witnesses at our evidence session. No other Integrating health and social care 7 witnesses demurred from this assertion. The Committee is very disappointed by this response; as we reported in February 2015, the arrival of NHS England’s new Chief Executive in April 2014 was the stimulus for the pause and redesign of the Fund. Accounting officers cannot disown the plans of their predecessors. Recommendation: The Departments, NHS England and the Local Government Association must take responsibility for the performance of their programmes, including the Better Care Fund while it continues. We expect greater accountability and more realistic objectives, which the Departments and partners will stand by. 8 Integrating health and social care 1 Funding

NHS England told us that the Better Care Fund was not the principal vehicle for delivering integrated care across England but should be regarded as “the fuel in the tank” for social care funding.20 NHS England said that its new care models programme was producing results and that it wanted to accelerate their roll-out using sustainability and transformation plans as the vehicle for doing so.21 The National Audit Office found that local areas will be required to include a statement in their sustainability and transformation plans to explain how they will integrate health and social care services by 2020.22

NHS England said it would publish its delivery plan for the next two years at the end of March 2017. NHS England told us this would set out what integration in each of the 44 sustainability and transformation plan footprints will look like. The delivery plan would also include a range of new governance rights for sustainability and transformation plan leaders over other organisations including clinical commissioning groups and NHS England staff in their area. Local areas will also have the ability to move towards accountable care systems which integrate funding and delivery of primary, secondary and mental health services in a given geographical population.23 The University of Birmingham and the NHS Confederation both told us it was important to allow enough time to develop new governance structures and the relationships that underpin them.24 12 Q50 13 Q51 14 C&AG’s Report, para 2.11 15 C&AG’s Report, para 24 16 Q50 17 Q51 18 Q39 19 Q132 20 Q45 21 Q83 22 C&AG’s Report, para 3.14 23 Qq79, 93 24 Health Services Management Centre, University of Birmingham (IHS 08) para 10; NHS Confederation (IHS 20) para 5.6 10 Integrating health and social care 2 Accountability for improving services for patients

The National Audit Office’s report shows the Better Care Fund did not achieve its principal target of reducing of demand for hospital services. Local areas planned to reduce emergency admissions by 106,000, saving £171 million. However, in 2015–16 the number of emergency admissions increased by 87,000 compared with 2014–15, costing a total of £311 million more than planned. Furthermore, local areas planned to reduce delayed transfers of care by 293,000 days in total, saving £90 million. The number of delayed days actually increased by 185,000 compared with 2014–15, costing a total of £146 million more than planned.25

At our 2014 evidence session on the Better Care Fund, the Department of Health and NHS England assured the Committee that they had robustly and rigorously tested local areas’ plans and they were completely confident that they would achieve over £500 million of savings, around £300 million of which would come from reducing emergency admissions by around 3%.26 NHS England has now told us that it was not claiming a reduction in emergency admission was ever achievable but that the Fund would instead reduce the growth in emergency admissions and thereby produce around £55 million of savings.27 The University of Manchester said it was important for the Government to recognise the limitations of what integration in any form is likely to achieve in terms of cost saving, and that there were other means of managing demand for expensive hospital services, for example ensuring additional funding for public health and primary care.28

NHS England told us that over their first 18 months its new care model ‘vanguard’ test sites were showing slower rates of growth in emergency admissions. Emergency admissions in hospital-based vanguard areas are growing at about half the rate compared to the rest of the country, and at two-thirds the rate in GP-based vanguard areas compared to the rest of the country.29 The National Audit Office found in its report that NHS England plans to roll out the new care models rapidly, achieving 20% coverage by the end of 2016– 17 and 50% by 2020. However, NHS England plans to evaluate the effectiveness and value for money of the new care models programme will not be complete until the end of 2018.30

We asked NHS England if it was confident that sustainability and transformation plans, as the now principal delivery vehicle for integration, would deliver and be on budget. NHS England confirmed only that they expected the sustainability and transformation plan process to improve local planning.31 However, as we heard as part of our financial sustainability of the NHS inquiry, very few trusts think they have a credible, robust and rigorous plan for their area which sets out how they will meet the financial targets they have been set.32 25 C&AG’s Report, para 2.7 26 Committee of Public Accounts, Thirty-seventh Report of Session 2014–15, Planning for the Better Care Fund, HC807, para 14 27 Q68 28 Centre for Health Economics, University of Manchester (IHS 07) p. 2 29 Q83 30 C&AG’s Report, para 17 31 Q90 32 Committee of Public Accounts, Forty-third report of Session 2016–17, Financial sustainability of the NHS, HC 887, para 18 Integrating health and social care 11

Despite clearly making commitments to the Committee in 2014 that the Fund would achieve its targets and save over £500 million, NHS England’s Chief Executive said none of the present witnesses had claimed that the Fund would achieve what was now being suggested it should have achieved. NHS England’s Chief Executive also refused to accept responsibly for the performance of the Fund, saying it was “not designed by any of us sitting here”.33 However, as we reported in February 2015, the arrival of NHS England’s new Chief Executive in April 2014 was the stimulus for the pause and redesign of the Fund.34 Managing public money requires accounting officers to take responsibility for their organisation’s business, even if delivery was delegated or if the events in question happened before he or she was appointed.35

Both the Department for Communities and Local Government and the Local Government Association said local authorities were very engaged with their local populations about how they use their local services.36 The Association told us that it was therefore critical that local authorities were involved in the sustainability and transformation plan process.37 However, The National Audit Office’s report warned that so far engagement of local government in sustainability and transformation plans had been variable.38 We also received evidence from London Councils, the UK Homecare Association, NHS Providers, Independent Age, the British Medical Association and the Royal College of Nursing who all expressed concern about the lack of engagement of local authorities in the sustainability and transformation plan process.39

NHS England said local authorities were actively involved in sustainability and transformation plans in many parts of country but conceded that there were tensions in some places.40 The Local Government Association told us social care was being missed off because it was not part of the NHS.41 The Association, the NHS Confederation and National Voices said that because sustainability and transformation plan footprints were not coterminous with council areas it was making it more difficult to engage with local authorities.42

In its recent report on the financial sustainability of the NHS, the National Audit Office reported that some local NHS organisations found the legislative and accountability framework to be a barrier to collaboration under sustainability and transformation planning.43 The Department of Health told us that the fact that local government and the NHS operate under very different legal frameworks and financial bases creates a big challenge.44 NHS England said through sustainability and transformation plans it was trying to operate within the exisiting statutory framework and it could develop workarounds 33 Qq68–71 34 Committee of Public Accounts, Thirty-seventh Report of Session 2014–15, Planning for the Better Care Fund, HC807, para 1 35 HM Treasury, Managing public money, July 2013, para 3.5.3 36 Qq105, 125 37 Q105 38 C&AG’s Report, para 21 39 London Councils (IHS 11) paras 24–25; United Kingdom Homecare Association (IHS 17) para 7; NHS Providers (IHS 14) para 21; Independent Age (IHS 21) para 3.6; British Medical Association (IHS 02) para 13; Royal College of Nursing (IHS 04) para 2.13 40 Qq97, 109 41 Q105 42 Q105; NHS Confederation (IHS 20) para 5.3; National Voices (IHS 01) p. 2 43 C&AG’s Report, Financial sustainability of the NHS, Session 2016–17, HC 785, para 3.15 44 Q78 12 Integrating health and social care to overcome local governance complexities.45 The British Medical Association said that integration could be successfully achieved without large scale structural reorganisations and there was a need for stability to allow greater collaboration between services to develop.46

NHS England acknowledged that sustainability and transformation plans can be jargonistic and therefore not clear and transparent to local people.47 NHS England said that it was right that local people were involved in discussions about how their health and care services were changing and agreed that the NHS had a duty to consult. The British Medical Association told us that many sustainability and transformation plans had not had sufficient public and clinical engagement, and in some areas both local authorities and clinicians have been totally excluded from the process.48 The Local Government Association said that, with the proper engagement of local people, sustainability and transformation plans offer real potential to improve services.49 NHS England said that in accordance with the statutory framework, public consultations would be held for any major service changes.50 45 Q112 46 British Medical Association (IHS 02) para 9 47 Q126 48 British Medical Association (IHS 02) para 13 49 Q105 50 Q106 Integrating health and social care 13