Select committee inquiry
The Interface between health and social care inquiry
Closed
What the inquiry looked at
“Inquiry: Interface between health and adult social care The Public Accounts Committee has regularly explored the relationship between health and social care. We have previously looked at government’s development of the adult social care workforce , and the Committee’s recent Report into local authority financial sustainability found that local governments were facing budgetary pressure because of the growing costs of social care. In a recent report into the interface between health and social care , the National Audit Office found that financial pressure on the NHS and local government made it difficult for them to work together to transform services. Further, as local authorities and the NHS operate in different ways, it can be difficult for them to understand how they each make decisions and coordinate properly. The National Audit Office also published a report looking at NHS vanguards , a programme to delivery savings by devising new care models and piloting them in 50 places. It found that the NHS spent some of the £2.2 billion set aside for vanguards on reducing hospital deficits. Although there are signs that vanguards are helping reduce emergency admissions and that vanguards will make £324 million in savings, the NAO found that it is hard to assess the performance of the programme overall. The Committee will take evidence from the Department of Health and Social Care, NHS England and the Ministry of Housing, Communities and Local Government to explore how to improve the health and social care interface in a way that not only saves money, but gives a better experience for patients and those requiring care.”
The committee's words, from the inquiry page on parliament.uk ↗.
What the government said
No government response is linked to this report.
How the inquiry ran
Each dot is a dated item listed on this page, from the inquiry's opening on 28 June 2018 to 19 October 2018.
- Oral evidence 18 Jul 2018
- Report 19 Oct 2018
- Correspondence 2 letters
What it recommended 3 recommendations · 19 conclusions
1Despite continued efforts for over 20 years to integrate health and social care services, the...
Recommended (the committee's words)
Despite continued efforts for over 20 years to integrate health and social care services, the government is still experimenting with ways to join up care and agree on what local areas should be doing to achieve the government’s aims. The Department and the Ministry of Housing, Communities and Local Government have developed and supported various initiatives to join up health and care services over this period, including introducing new care models through the NHS vanguards. But the Department told us that too many initiatives have not made enough progress and that models have been developed to suit local circumstances, meaning it cannot easily mandate other areas to adopt them. The Department has made limited progress in making integrated health and social care possible. It has set out a high-level vision for what integrated health and social care should look like, secured additional NHS funding and committed to a 10-year plan for the NHS. We have previously reported that the adult social care sector is in a precarious state because of long-term underfunding, yet the government has no similar additional funding or plan in place for social care. Local authorities will have to wait until the 2020 Spending Review to get clarity on future funding, including what will happen to the Better Care Fund, a pooled fund between the NHS and local government. The Government repeatedly tells us that it has increased social care funding but this is largely through council tax increases which produce differential incomes in different areas. Recommendation: The government should, by April 2019, set out a costed 10- year plan for social care to go alongside its 10-year plan for the NHS (expected in November 2018).
2The current legislative framework makes it unnecessarily difficult for local areas to pool funds and...
Concluded (the committee's words)
The current legislative framework makes it unnecessarily difficult for local areas to pool funds and work together, causing additional cost and wasted resources. Legislation currently emphasises the need for individual organisations to balance their books. But this does not support efforts to spend co-operatively. Another barrier is the complex funding system in place for social care, with NHS England describing at least five separate funding streams and four sets of arrangements for means-testing. The Department told us that it has created the right framework to consider simultaneously the legal, accountability and other barriers to integration. The Department is due to publish a green paper on funding social care for older people in November 2018 to align with the NHS 10-year plan. NHS England will then, at the request of the Department, consult on the legislative changes needed to accelerate progress on this 10-year plan. The Department also accepted that there is a set of practical improvements that it can make now without additional significant legislative change. Recommendation: The Department of Health and Social Care and the Ministry of Housing, Communities and Local Government should ensure that their 10- year plans and the social care green paper address the challenges to integration presented by fragmented funding and separate means testing affecting people who receive adult social care, including consideration of any legislative change needed.
3NHS vanguards have shown early promise but they risk becoming yet another short-lived initiative, supported...
Recommended (the committee's words)
NHS vanguards have shown early promise but they risk becoming yet another short-lived initiative, supported at the start but then not adopted as widely as 6 Interface between health and adult social care intended. NHS England told us that vanguards have been successful against two key measures—on slowing down growth in the number of emergency admissions to hospital, and on providing a return on investment. However, by December 2017 vanguards had fully implemented, on average, only one-third of a new care model framework across their respective geographic areas. NHS England has now stopped providing central financial and programme support for the vanguards, although it told us that, alongside NHS Improvement, it is looking at what resources it can redirect to support local areas to adopt new care models. The vanguard programme typically supported local initiatives that were already being developed to some extent rather than being entirely new models. The Department accepted that it could take longer to embed new care models in areas where there are no existing developments to build on. We have previously reported, however, that spending on the vanguards has been less than one tenth of 1% of the NHS budget. Money intended for transforming services has instead been spent on keeping hospitals running day- to-day. The Department told us this meant integration has progressed more slowly than envisaged. It is unclear whether these other areas will get the financial and programme support they need. Recommendation: In its 10-year plan, NHS England should set out how it will support the national rollout of new care models, including how it will accelerate take-up in local areas showing the slowest progress.
4There is a profound lack of transparency and accountability in local health and social care...
Recommended (the committee's words)
There is a profound lack of transparency and accountability in local health and social care systems. In 2016, clinical commissioning groups, trusts and local authorities formed sustainability and transformation partnerships to develop and push forward strategic health and social care planning in local areas. As we noted in March 2018, some of these have now evolved into integrated care systems. The Department told us that it expects these partnerships to provide the structure for integrating health and social care. NHS England similarly told us that the partnerships supplement current mechanisms for overseeing and delivering efforts to join up care. However, we are concerned that they are instead side-lining the current local statutory mechanism, namely health and wellbeing boards. We are also concerned that the public are not yet familiar with what partnership area they live in or what information may be available for them to assess their partnerships’ performance. NHS England publishes performance data for partnerships each July, to go alongside performance measures for individual commissioners and quality ratings for every provider. However, this is a confusing myriad of structures and information for the general public to understand, particularly when not published in the same place. Recommendation: By December 2018, the Department, Ministry and NHS England should set out how accountability will work both locally and nationally under new integrated care system arrangements, and how the public can find out about progress on integration and the performance of the health and social care system in their local area.
5The quality and effectiveness of local health and social care leaders is variable, which makes...
Concluded (the committee's words)
The quality and effectiveness of local health and social care leaders is variable, which makes it difficult for them to drive system-wide improvements in commissioning and service delivery. The Department told us that local leadership is often the biggest factor in determining whether a local area has progressed with Interface between health and adult social care 7 integration. We heard examples of where leadership is effective in driving the NHS and local government to work well together, such as Bradford and Greater Manchester, but these are too few in number. However, in some local areas it can be difficult to identify who is leading the system, and how, and progress can stall due to turnover of staff. Locally the mix and will of personalities is crucial, and there are not sufficient incentives to make leaders work together. The different regulatory regimes mean that these are often perceived to be a barrier to co-working. For the Better Care Fund, the Departments and NHS England mandated local areas to apply a high-impact model and restricted funding until they saw progress in local efforts to tackle delayed transfers of care from hospital. However, the independence that local authorities have through local democratic accountability makes this approach difficult to apply repeatedly without damaging local relationships. The Department acknowledged that it is important that national bodies seek out alternative ways of developing good leadership, particularly aligning incentives to encourage joint working. Recommendation: The Department, Ministry and NHS England should write to the Committee by December 2018 to set out how they will develop and support local leadership consistently.
6There is a wide gap in pay and career structure between people who work in...
Concluded (the committee's words)
There is a wide gap in pay and career structure between people who work in the NHS compared with social care. We have previously reported that the social care workforce suffers from low pay and low esteem. This discourages NHS staff from working in social care and makes integrating the two workforces problematic. We remain concerned that the Department and the Ministry are not doing enough to tackle the difference in pay between the two sectors. Other factors, such as difficulties in transferring pension arrangements across the health and social care sectors, also discourage closer integration. In autumn 2018, the Department and Health Education England will publish a workforce plan that will set out requirements across both the NHS and social care workforces for the first time. We criticised the draft version of this plan, published in December 2017, for lacking detail and suggestions on how issues in the social care workforce could be tackled. We are keen to see how the Department has addressed these failings in the final plan. Recommendation: The Department should ensure its workforce plan addresses the previous criticisms made by the Committee and make sure it tackles the longstanding barriers between health and social care, particularly disparity in pay and conditions and the transfer of pension arrangements. 8 Interface between health and adult social care 1 Delivering government’s plan for integration
7Current legislation covering the accountabilities of local authorities and NHS bodies emphasises the need for...
Concluded (the committee's words)
Current legislation covering the accountabilities of local authorities and NHS bodies emphasises the need for individual organisations to balance their books, which can make it difficult for them to work in an integrated way through pooling budgets, 5 Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 2 6 Qq 91–92 7 Report by the Comptroller and Auditor General, Developing new care models through NHS vanguards, Session 2017–19, HC 1129, 29 June 2018, para 9 8 Q 124 9 Q 7; C&AG’s Report, para 2.5 10 Greater Manchester Health and Social Care Partnership (IBH0008); West Sussex County Council (IBH0005) 11 Committee of Public Accounts, The adult social care workforce in England, Session 2017–19, HC 690, 09 May 2018 12 Qq 34–35, 98; Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, paras 1.11, 2.5 13 Q 78 10 Interface between health and adult social care sharing financial risks and commissioning services jointly.14 For instance, the Greater Manchester Health and Social Care Partnership told us that local areas have used highly complex workarounds to fully pool all their health and care budgets.15 The ways in which the health and social care systems are set up and funded also make it difficult to align funding, commissioning and services. NHS England described the complexity of social care funding, which has at least five different funding streams, including funds raised by local authorities, funds granted by central government, funds transferred from the NHS, and contributions from service users or the benefits system. NHS England also listed four separate means-testing arrangements - for residential care, domiciliary care, NHS continuing healthcare and benefits such as attendance allowance.16
8The Department recognised the legal, accountability and funding issues affecting integration and asserted that it...
Concluded (the committee's words)
The Department recognised the legal, accountability and funding issues affecting integration and asserted that it had created the right framework to consider them simultaneously. The Department told us that it has asked NHS England to confirm the legislative changes it needs to accelerate progress on its 10-year plan. NHS England told us that it plans to consult across the sector between November 2018 and autumn 2019, and then develop options for consideration. The Department accepted that there are practical improvements that it can make now without requiring significant legislative change, but did not specify what these were.17
9The Department told us that it plans to publish a green paper on funding social...
Concluded (the committee's words)
The Department told us that it plans to publish a green paper on funding social care for older people, which was previously expected for July 2018 but has been delayed until November 2018 to align with the NHS 10-year plan. The Department told us that the green paper will also consider wider issues affecting both working-age adults and older people, including social care policy, quality, performance measurement and integration.18 However, the Department said that it does not view the green paper as a “grand panacea for everything”, as significant structural, funding and strategic barriers will remain.19 NHS vanguards
10One way in which the NHS has sought to break down the barriers between health...
Concluded (the committee's words)
One way in which the NHS has sought to break down the barriers between health and social care services, as well as between family doctors and hospitals, is through new care models. In 2015, NHS England selected 50 vanguard sites to develop five new care models - prototypes that could later be replicated quickly across England. NHS England provided a total of £329 million to the vanguards to support them in testing the new care models. It also spent £60 million centrally on supporting and monitoring the progress of vanguards. NHS England ended central financial and programme support for the vanguards in March 2018, by which time it expected individual vanguards to be sustainable without requiring further national funding.20 14 Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 2.8 15 Greater Manchester Health and Social Care Partnership (IBH0008); Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018 16 Q 65 17 Qq 4, 7, 21, 73 18 Qq 10–11 19 Q 175 20 Report by the Comptroller and Auditor General, Developing new care models through NHS vanguards, Session 2017–19, HC 1129, 29 June 2018, paras 3–4 Interface between health and adult social care 11
11Investment in the vanguards by NHS England was lower than initially planned.
Concluded (the committee's words)
Investment in the vanguards by NHS England was lower than initially planned. We reported in March 2018 that spending on the vanguards was less than one tenth of 1% of the NHS budget.21 Furthermore, the NHS has previously spent money initially intended for transforming services on sustainability instead, with £1.8 billion used in both 2016–17 and 2017–18 to help hospitals keep running services day-to-day. The Department said that this diversion of money had meant that integration has progressed slower than planned.22
12NHS England told us that vanguards have been successful in two key ways.
Concluded (the committee's words)
NHS England told us that vanguards have been successful in two key ways. Firstly, the number of emergency admissions to hospital, per capita, rose by 1.6% between 2014–15 and 2017–18 in the areas covered by a vanguard, compared to a 6.3% increase elsewhere. Secondly, on return on investment, based on current rates of return, NHS England predicts a return of £2 for every £1 spent on NHS vanguards.23 While these early signs are promising, the vanguards still have work to do to fully embed these care models in the long term. By December 2017, vanguards had fully implemented, on average, only one-third of a new care model framework across their respective geographic areas. NHS England developed these frameworks for vanguards to test and to inform the development and spread of new care models for the rest of the country.24
13The vanguard programme was largely based on local initiatives that had already been developed to...
Concluded (the committee's words)
The vanguard programme was largely based on local initiatives that had already been developed to some extent. Written evidence from the Health Foundation suggested that vanguards had already been undertaking work to establish new care models for between two and 10 years before the new care models programme started. The Department recognised that different areas will progress at different rates, and that those areas without vanguards might take much longer to adopt and embed new care models. Indeed, the Health Foundation suggested adopting ideas and practices from elsewhere will often need substantial time, resources and creativity to translate the idea into their own setting and make it work. Also, some areas may need more support than others to implement the same types of change.25 NHS England told us that in November its 10-year plan will set out the pace at which it will establish new care models across the rest of England. To support local areas in adopting these new models, NHS England told us that it and NHS Improvement are looking at what resources they can redirect from their other activities, including inspection and monitoring.26 21 Committee of Public Accounts, Sustainability and transformation in the NHS, Session 2017–19, 27 March 2018 22 Q 115; C&AG’s Report, para 2.4 23 Qq 99–105; Report by the Comptroller and Auditor General, Developing new care models through NHS vanguards, Session 2017–19, HC 1129, 29 June 2018, para 16 24 Report by the Comptroller and Auditor General, Developing new care models through NHS vanguards, Session 2017–19, HC 1129, 29 June 2018, para 14 25 Q 121; The Health Foundation (IBH0007) 26 Qq 110–111 12 Interface between health and adult social care 2 Improving integration locally Accountability and transparency
14In 2016, clinical commissioning groups, trusts and local authorities in England formed into 44 sustainability...
Concluded (the committee's words)
In 2016, clinical commissioning groups, trusts and local authorities in England formed into 44 sustainability and transformation partnership areas, to produce area-wide strategic plans covering health and social care for the period 2016–17 to 2020–21. NHS England and NHS Improvement have encouraged partnerships to go further and form integrated care systems, which involves commissioners and trusts taking control of the health budget for the entire population in their area and bringing together the services and care that they offer.27 We examined these partnerships and integrated care systems in March 2018 and raised concerns that NHS England and NHS Improvement could not clearly explain how the new arrangements will sit alongside organisations’ existing responsibilities.28 The Department told us that it expects sustainability and transformation partnerships to provide the structure for integrating health and social care, for instance through systematically promoting and developing new care models.29 NHS England similarly told us that these partnerships and integrated care systems supplement rather than replace existing accountability mechanisms.30
15Health and wellbeing boards are the current statutory mechanism for overseeing and delivering efforts to...
Concluded (the committee's words)
Health and wellbeing boards are the current statutory mechanism for overseeing and delivering efforts to join up care locally. However, the witnesses did not reassure us that new sustainability and transformation partnerships are not side-lining these boards. The Department told us that the 44 sustainability and transformation partnerships were selected to create wide-enough geographical areas that best enable health bodies to work together. NHS England told us that the areas covered by the 152 health and wellbeing boards are too small to use them to plan integrated care services. However, this means that most sustainability and transformation partnerships contain more than one local authority and health and wellbeing board. Sometimes the boundaries of partnerships cut across the boundaries of local authorities and of health and wellbeing boards.31 This makes it difficult for the relevant organisations and their staff to come together to support person-centred care. For instance, we received written evidence from West Sussex County Council which told us that simultaneously working in partnerships covering different geographical areas makes building consensus, planning commissioning and delivery, and developing appropriate governance more challenging.32
16With these additional administrative and planning layers, we asked the witnesses how the public can...
Concluded (the committee's words)
With these additional administrative and planning layers, we asked the witnesses how the public can understand decision-making about local services. NHS England publishes performance data for partnerships each July as well as performance measures for individual clinical commissioning groups. The Care Quality Commission publishes quality ratings for every health and social care provider, including general practitioners. NHS England added that these quality ratings are available on the My NHS and NHS 27 Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 1.11 28 Committee of Public Accounts, Sustainability and transformation in the NHS, Session 2017–19, 27 March 2018 29 Qq 93, 155 30 Q 163 31 Qq 155–157 32 West Sussex County Council (IBH0005) Interface between health and adult social care 13 Choices websites. However, the system, commissioner and provider performance data are not published all in the same place. We were concerned that this makes it difficult for the public to understand local performance.33 Leadership
17The Department recognised that local leadership is important in pushing forward with integration, highlighting it...
Concluded (the committee's words)
The Department recognised that local leadership is important in pushing forward with integration, highlighting it as the single biggest factor determining whether new care models are implemented.34 The Departments highlighted examples from across England where local leadership is working well. For instance, simple but effective joint local governance and decision making is now in place in Bradford. In Greater Manchester, NHS commissioners and local authorities are forming single commissioning functions, and four localities have a single accountable officer in place to cover the clinical commissioning group and local authority. However, in some local areas it can be difficult to identify who is leading the system, and how. In other areas, progress has stalled due to changes in staff.35
18The Department confirmed that the mix and will of personalities is crucial, and that leaders...
Concluded (the committee's words)
The Department confirmed that the mix and will of personalities is crucial, and that leaders can choose not to work together if they do not want to. The Departments and NHS England have limited means of enforcing or encouraging the system leadership needed. For the Better Care Fund, the Departments and NHS England mandated local areas to apply a high-impact model for reducing delayed transfers of care. The Ministry of Housing, Communities and Local Government told us that they challenged areas and restricted funding until they saw progress, which has proved successful. However, the National Audit Office found that this approach has damaged local relationships in some areas.36 Furthermore, the Department and NHS England told us that different political accountabilities and the need for local solutions means they often cannot simply mandate particular models.37 Similarly, the Health Foundation told us that change in the health sector is so complex it cannot be driven centrally, and instead the centre must enable those who work in the system to drive change themselves.38 The Department recognised that it can help support local leadership by creating the right structures and aligning incentives for people to work together, in the form of sustainability and transformation partnerships and integrated care systems.39
19We questioned whether the witnesses were able to monitor the effectiveness of leadership in local...
Concluded (the committee's words)
We questioned whether the witnesses were able to monitor the effectiveness of leadership in local systems. The Department told us that the ratings system for providers used by the Care Quality Commission, and the performance dashboard for sustainability and transformation partnerships published by NHS England, both take local leadership into account. The Ministry of Housing, Communities and Local Government added that it monitors local government closely and intervenes where necessary, including in response to poor leadership. The Care Quality Commission does not currently inspect commissioning arrangements in local government or the NHS, although it has been 33 Q 158–161 34 Q 124 35 Qq 93, 143–147; Greater Manchester Health and Care Partnership (IBH0008); Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 3.8 36 Qq 117, 125–128; Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 2.7 37 Qq 124, 128, 135, 148 38 The Health Foundation (IBH0007) 39 Q 128 14 Interface between health and adult social care carrying out thematic system reviews in 20 local health and social care systems.40 Despite these assurances, we remained concerned that the national bodies do not have sufficient oversight over how well local leaders are working in partnership and exercising system leadership. The Greater Manchester Health and Social Care Partnership said in written evidence that there was benefit in codifying in legislation a system approach to assurance and regulation.41 Integrated Workforce
20We examined the adult social care workforce in England in May 2018 and found that...
Concluded (the committee's words)
We examined the adult social care workforce in England in May 2018 and found that the social care workforce suffers from low pay and low esteem, which leads to recruitment difficulties for providers.42 We were concerned that this also impedes efforts to join up health and social care workforces, as it makes it less appealing for NHS staff to work more flexibly and move into social care. The Department told us that the pay differential between social care and the NHS is well-known. It asserted that pay is not the only factor determining individuals’ decisions about where they want to work and pointed to the fact the vacancy rate for nurses is similar in both social care and the NHS.43 As well as pay, the Greater Manchester Health and Social Care Partnership told us that different ways in which VAT is treated and issues with transferring pensions impede staff moving between local authorities and the NHS.44 In its written evidence, the Health Foundation asserted that a staff turnover rate in social care of 25% adds a further challenge, making integration a near impossibility.45 The Care & Support Alliance said in written evidence that the workforce crisis needs to be gripped with a lot more ambition and determination than it has seen to date.46 The National Audit Office reported that the vanguards regard the workforce—for example, availability of staff with the right clinical or programme management skills—to be the greatest area of risk to the sustainability of the vanguards and to the further development of new care models.47
21Roles in the social care sector suffer from a public perception that they offer fewer...
Concluded (the committee's words)
Roles in the social care sector suffer from a public perception that they offer fewer opportunities for career progression compared with similar roles in the NHS.48 NHS England acknowledged that a career ladder for care assistants in social care should be developed, similar to the apprenticeship and on-the-job type models that enable care assistants in the NHS to become nursing associates or registered nurses. The Department added that this needs to be developed in a way that allows staff to switch between health and social care, rather than as parallel models. The Department highlighted the work being done by Greater Manchester to train the health and social care workforce as a whole and to encourage people to consider both sectors for a career.49 However, the Department said that its primary focus was ensuring it trains the right number of nurses required for both sectors, rather than tackling the low esteem of the social care sector.50 40 Qq 14, 149–151 41 Greater Manchester Health and Social Care Partnership (IBH0008) 42 Committee of Public Accounts, The adult social care workforce in England, Session 2017–19, 9 May 2018 43 Qq 36–43 44 Greater Manchester Health and Social Care Partnership (IBH0008) 45 The Health Foundation (IBH0007) 46 The Health Foundation (IBH0007) 47 Report by the Comptroller and Auditor General, Developing new care models through NHS vanguards, Session 2017–19, HC 1129, 29 June 2018, para 4.9 48 Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 3.14 49 Qq 37–38, 46 50 Q 41 Interface between health and adult social care 15
22In December 2017, the Department and Health Education England published, for consultation, a draft workforce...
Concluded (the committee's words)
In December 2017, the Department and Health Education England published, for consultation, a draft workforce plan for health and social care. The Department told us that this plan, and the consultation supporting it, examined both health and social care workforces together for the first time, in particular professions that exist in both sectors, such as nursing.51 We previously concluded that the plan’s section on social care was short and lacked detail, and did not include suggestions as to how the social care sector could improve.52 In response, the Department commissioned its delivery partner on workforce matters, Skills for Care, to consult with the adult social care sector on how to improve support to care providers and address the workforce issues they are experiencing. The final plan will be published in autumn 2018 to coincide with the NHS 10-year plan and the social care green paper.53 51 Q 36 52 Committee of Public Accounts, The adult social care workforce in England, Session 2017–19, 9 May 2018 53 Q 36; Report by the Comptroller and Auditor General, The health and social care interface, Session 2017–19, HC 950, 4 July 2018, para 3.16 16 Interface between health and adult social care
Evidence
Oral evidence sessions 1
- 18 Jul 2018No witnesses recordedparliament.uk ↗