Conclusions and recommendations
Introduction
1. This
report will highlight several significant issues that the Committee
has identified from the substantial body of evidence received
during our inquiry. Our aim is to paint a picture of how a fully
integrated system could be achieved with more efficient use of
resources and the improved outcomes that it could deliver. The
Committee recommends that the Government respond to the issues
we have raised in its forthcoming White Paper and its proposed
bill as well as in its progress report on funding reform. The
Committee plans to revisit social care in the light of these documents,
with a view to reviewing the progress that has been made. (Paragraph
4)
The consequences of fragmentation
2. Many
older people, people with disabilities and those with long-term
conditions need to access a wide range of services, from the NHS
through to housing services and care and support. Their experience
of these services is often fragmented. The Committee believes
that there is a link between the fact that people experience fragmented
services and the fact that there are multiple funding streams
and multiple commissioners of the services that they use. (Paragraph
11)
Defining social care
3. The
Committee found the evidence provided by the Law Commission instructive.
Faced with the challenge of providing a coherent definition of
social care the Commission clearly felt it was building on sand.
The Committee was not surprised that the Commission found it impossible
to express 80 years of political compromises as a coherent legal
principle. (Paragraph 16)
4. In fact, in the
Committee's view, the Law Commission's attempt to define social
care underlines the central problem. The overarching aim of social
care as defined by them, to "promote or contribute to the
well-being of the individual", could just as easily be applied
to health care or housing services. The conclusion we draw from
this is that attempts to draw a distinction between these services
and social care will fail because such distinctions are artificial
and unhelpful, and because they directly contradict the policy
objective. This objective is the same whether it is seen from
the point of view of service user preference, objective outcome
measurement or cost efficiency. It is to deliver a joined-up,
integrated service that aims to deliver the best outcomes for
the patient and in the most efficient manner possible. If that
is the objective—and the Committee found that it is an objective
shared between users, staff and policy makers—it seems perverse
to attempt to build integrated service delivery on a fragmented
commissioning system. (Paragraph 17)
The case for integration
5. The
Committee is struck that despite repeated attempts to "bridge"
the gap between the NHS and social care, that, aside from a few
notable exceptions, little by way of integration has been achieved
over this 40 year period. (Paragraph 19)
6. Integration between
the NHS and social care systems has been the explicit policy objective
of successive Governments. It is not an end in itself, but can
deliver real benefits to people who use multiple services across
the health and care systems. It is also an essential tool in delivering
quality and efficiency in the public sector. This Government has
recently restated its commitment to integration in its acceptance
of the Future Forum recommendations on this issue. The Committee
welcomes Government support for this objective but is concerned
that progress continues to be disappointing.
(Paragraph 27)
7. Delivery of the
Nicholson Challenge (four per cent efficiency savings in the NHS
over four years) requires a fundamental rethink in how health
and social care services are commissioned and provided. As Sir
David Nicholson told us, NHS organisations that "salami-slice"
services and fail to integrate with housing and social care could
have very serious consequences for standards in both health and
social care. (Paragraph 30)
The case for a single commissioner
8. The
evidence presented to us leads us to the conclusion that when
commissioning responsibilities are divided between different bodies,
the effect is to undermine the ability of the system to deliver
truly integrated services. Each commissioner is inevitably subject
to different pressures and priorities, with the result that it
becomes impossible to focus on the key objective, which must be
to integrate services around the individual. (Paragraph 32)
9. In the Committee's
view the key is that real progress towards integrated care must
begin with a clear commitment to create a fully integrated approach
to commissioning. The precise model will depend on local circumstances.
Integration could take place around a local authority or a clinical
commissioning group. (Paragraph 36)
10. The NHS Future
Forum recommended that Health and Wellbeing Boards should agree
commissioning plans and refer these plans to the NHS Commissioning
Board where they have concerns. Enabling HWBs to develop integrated
commissioning budgets would be a positive first step towards integration
and the Committee recommends that the Government re-examines this
issue. (Paragraph 40)
11. The Committee
does not, however, support the imposition of a single statutory
framework for the achievement of the objective of service integration.
It proposes, instead, that the Government should place a duty
on the existing commissioning structures (including the proposed
new NHS structures) to create a single commissioning process,
with a single accounting officer, for older people's health, care
and housing services in their area. This pooling of resources
will encompass the Government's contribution (in the form of the
budgets and grants it makes to support local health, housing and
care services), the local authority contribution (from national
and local sources) and the contribution of individuals (from charges
for social care services). (Paragraph 41)
12. A single commissioner
will have multiple lines of financial accountability, including
to the NHS Commissioning Board, local authorities and service
users. Central Government, NHS bodies and local authorities will
need to establish robust procedures to ensure effective financial
accountability. (Paragraph 42)
13. The holder of
a single commissioning budget will also need to demonstrate proper
local democratic accountability for its decisions. The Committee
sees the development of the Health and Wellbeing Board, as an
agency of the local authority, as a means of achieving this objective.
(Paragraph 43)
Care Trusts
14. The
Care Trusts that exist in England are, generally speaking, the
most integrated health and social care organisations. Alongside
the provision of services to people, some Care Trusts also combine
parts of the health and social commissioning budgets into one
statutory body. (Paragraph 48)
15. The Committee
notes that the Minister of State for Care Services sees Care Trusts
as "an experiment that […] did not really get out of
the lab" and that he argues it is not the organisational
form of Care Trusts that makes a difference but the behaviours
within the organisation. Nevertheless there is clear evidence
that some Care Trusts have made progress with the integration
of services and the Committee recommends that the Government should
allow communities to have the option of retaining Care Trusts
as commissioners of health, housing and social care. (Paragraph
49)
Integrating outcomes
16. The
new outcomes frameworks for the NHS, public health and social
care systems are crucial as they will become the primary means
through which the Government will establish whether services are
delivering better outcomes for the public. In the context of integrated
service provision and integrated commissioning, the degree of
alignment between these frameworks looks disappointing. We are
particularly concerned that the Government merely "hopes"
that national alignment "will cascade down to local level".
It follows from the recommendations of this report that the Committee
recommends that the Government move quickly to adopt a single
outcomes framework for health and social care for elderly people
and that it will abandon the attempt to create artificial distinctions
between health, social care and social housing. (Paragraph 53)
A social care system in crisis?
17. As
the Committee reported in its recent report on Public Expenditure,
there is clear evidence of resource pressures on social care authorities.
The Committee welcomes the Government's commitment of an additional
£2 billion per annum to social care by 2014-15, but recognises
that even this substantial additional commitment is only sufficient
to meet additional demand if social care authorities are able
to deliver an unprecedented efficiency gain of 3.5 per cent per
annum throughout the spending review period and does not allow
for any progress in responding to unmet need. (Paragraph 66)
18. The weight of
evidence that we have received suggests that social care funding
pressures are causing reductions in service levels which are leading
to diminished quality of life for elderly people, and increased
demand for NHS services. Although the transfer of £2 billion
from health to social care is welcome, it is not sufficient to
maintain adequate levels of service quality and efficiency. (Paragraph
73)
19. As it reported
in its recent report on Public Expenditure, the Committee believes
that the levels of efficiency gain which have been planned by
the Government will not be achieved unless there are fundamental
changes in the way care is delivered. In particular the Committee
believes that successful delivery of the Government's plans requires
a dramatic strengthening of its commitment to deliver more integrated
services. (Paragraph 74)
Rebalancing public sector spending
20. We
noted earlier the Dilnot Commission's conclusion that the social
care system is 'inadequately funded.' Andrew Dilnot was also clear
that the separate funding streams for health, social care and
welfare mean that resources are allocated in an inefficient way.
At a time of scarce resources and rising demand the Committee
believes that this structural inefficiency, which has been recognised
for decades, can no longer be ducked. Too much is spent treating
preventable injuries like falls, which can have a catastrophic
impact on the lives of older people, some of whom may never regain
independence again. If we are to create a sustainable, high quality
support system for older people, commissioners need to rebalance
the entire expenditure on services for older people across the
NHS, social care, housing and welfare. This will be a process,
rather than an event; the purpose of creating integrated commissioners,
is to create agents within the system who have both the ability
and the incentive to drive the necessary process of fundamental
change in service provision.
(Paragraph 76)
Personalisation
21. While
the Committee remains sympathetic to the cause of greater personalisation,
it believes the Government needs to be clear-sighted about the
likely impact of personalisation on total demand for social care
—and therefore on social care budgets. This is an issue
to which the Committee will return. (Paragraph 80)
The Dilnot Commission
22. The
capped cost model proposed by the Dilnot Commission represents
an important element of the total funding model, but it is not
the whole answer. The Committee recommends that in its forthcoming
"progress report on funding", the Government should
accept the principle of capped costs and outline proposals on
where the cap should be set. (Paragraph 88)
23. Dilnot also recommends
that there should be a separate cap on living costs of between
£7,000 and £10,000 per annum. We support this and recommend
that the Government accepts it. (Paragraph 89)
24. The Committee
believes it is important that the future shape of social care
is not dominated by a debate about the technical details of funding.
It is essential that services are shaped by the objective of high
quality and efficient care delivery, and the funding structures
are fitted around that objective, not vice versa. It is, however,
unsurprising that there is a focus on funding issues given the
current financial stress on the care system. (Paragraph 90)
25. Although the Committee
supports the implementation of the main recommendations of Dilnot,
it believes the narrow terms of reference given to the Commission
meant that the more fundamental issues about the need for a more
integrated care model were only addressed in passing by Dilnot.
(Paragraph 91)
Capping care costs
26. It
has been suggested to the Committee that some of the disadvantages
of the cap expressed as a cash sum could be addressed if the cap
was expressed as a period of time. The Committee understands that
the Dilnot Commission considered this approach and rejected it
on the grounds that it would make the actual cost of the individual's
contribution dependent on the acuity of their care needs during
the period involved. (Paragraph 95)
27. The Committee
recommends that the Government should look again at the principle
of expressing the cap on care costs in terms of the length of
time that people fund their social care for themselves in its
progress report on funding, ensuring the equivalence of care standards
before and after the cap is reached. Further work however is required
to address unintended anomalies caused by regional variations
in housing values and the difference between domiciliary and residential
care costs. (Paragraph 96)
Financial products
28. The
Government should clarify the likely market for pre-funded insurance,
equity release, and immediate needs annuities, as well for pension-related
and other products. It should also articulate how it will work
with the industry to stimulate the market for these products.
(Paragraph 101)
Supporting carers
29. The
Committee welcomes the Government's recognition of the importance
of support for informal carers and carers' assessments. The Committee
is however concerned that the effectiveness of the policy is too
often undermined by the failure of GPs, social workers and others
to identify carers. The Committee believes the Government needs
to find new and more effective ways to identify carers in order
to ensure that their needs are properly assessed and met. (Paragraph
112)
30.
The Committee supports the need for reform of the
law governing social care, but is clear that this cannot take
place in isolation from the law governing health, housing and
welfare services. It believes that a new, integrated legal framework
is required which supports integration of care around the needs
of the individual, with a focus on driving forward quality and
improving outcomes. (Paragraph 115)
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