It is estimated that the NHS faces a shortfall of at least £30 billion a year within a decade and possibly a deficit as high as £50 billion. Martin Stevens of King’s and John Woolham of Coventry University report on an event last month where experts debated funding and integration in health and social care.
The Social services research group and the School of Social care Research organised a jointevent on Integration and Funding of Health and Social Care at the London School of Economics, on June 18th. José-Luis Fernandez of the LSE opened with a statistical review of the decline of social care service provision since the 1980s, which had become especially marked since 2008-09 with the contraction in public spending,despite increases in the numbers of older people over this period. While this could in small part be due to better targeting and more effective services, his conclusion was that there was a great deal of unmet need in the community.
Lord Warner and Jack O’Sullivan took this as their starting point for the case for reforming the NHS and for integration with social care. They argued that the level of unmet social care need was creating increased demand in the NHS. This had generated a combined care and cash crisis that threatens to debilitate the wider public sector and economy. On present plans, the NHS faces a shortfall of at least £30 billion a year within a decade and possibly a deficit as high as £50 billion. Lord Warner and O’Sullivan’s report Solving the NHS care and cash crisis proposes a service that would be more affordable without the need for another massive organisational upheaval. It would lead to the emergence of a new National Health and Care Service (NHCS), whose guiding principle would be to “promote and secure the health and wellbeing of the population, and individuals within it, by securing best value from the resources available”.
The NHCS would focus on four key areas:
- New co-production partnership between the NHS and individuals (and their carers)
- Integration of health and social care budgets and services at all levels for personalised whole-person care
- Developing a more community-based health and care service
- Consolidation of hospital specialist services
The report proposes a move to hypothecated taxes, and a focus on using more indirect taxes on alcohol, smoking and potentially unhealthy foods to fund the NHS. In addition, the report proposes a ‘membership’ fee, collected alongside council tax. While this was proposed as a ‘flat tax’, this could also be levied according to ability to pay in some ways.
This would entail an increasing movement of funds towards community based services, with a consolidation of specialist services in fewer hospitals that could offer 24/7 access to consultant expertise.
Another aspect of this proposed reform would be to increase responsibility on individuals for their own health, working in partnership with GPs. This work would be funded by the new membership fee, and would involve annual health MOTs and goal setting for healthy lifestyles. For those with long-term conditions, combined social care and health personal budgets could be used to support the purchase of services that might be needed to meet these goals.
Lord Warner and Jack O’Sullivan’s interesting presentation offered cogent solutions to what are often perceived to be problems facing the NHS, although there is far from a settled consensus within academic and policy communities about the nature and scale of these problems, let alone the solutions. They call for a new partnership between state and individual, and in which individuals not institutions take control. This is clearly fully compatible with the current policy ‘zeitgeist’ of encouraging independence and getting people to take responsibility for their health. However, it might also be argued that it offers only a partial solution to NHS issues, as it places too much faith in what Lord Warner described as ‘disruptive innovators’ (empowered consumers, really). Such an approach ignores the success of collective rather than individual solutions to health scourges of the 20th century. Improvements in sanitation, mass immunisation and housing have eradicated diseases such as smallpox, polio and diphtheria. Though they would be right to say that many contemporary health challenges are self-induced through unhealthy lifestyle choices, collective challenges remain. For example, consider antibiotic resistant bacteria, SARs, Avian Flu and other potentially lethal pathogens, and the failure of the pharmaceutical industry to develop new antibiotics and effective antiviral treatments. These are unlikely to be addressed by ‘disruptive innovation’. Nor is the persistent problem of inequality and the growing gap in life expectancy between wealthy and poor communities addressed.
Lord Warner and Jack O’Sullivan also prescribed the use of personal health budgets in the NHS, praising the efforts of local authorities to introduce personal budgets in social care and claiming that the NHS was some way behind local authorities in this regard. This, though, is to ignore the research evidence, which suggests that though younger adults with social care needs can achieve good outcomes with a personal budget, especially if taken as a direct payment, there is no convincing evidence that they lead to similarly good outcomes for older people—who are the largest consumers of social care services, and also of the NHS.
Following Lord Warner and Jack O’Sullivan, Gerald Wistow, from the Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science, deftly led an ‘expert seminar’ to explore responses to and implications of Warner and O’Sullivan’s ideas. The expert seminar consisted of:
- Mary Backhouse, Chief Clinical Officer at North Somerset CCG, and member of the NHS Clinical Commissioners’ Leadership Group
- Emily Holzhausen, Director of Policy and Public Affairs, Carers UK
- Tony Hunter, Chief Executive, Social Care Institute for Excellence (SCIE)
- Toby Lambert, Director of Policy and Strategy, Monitor
- David Pearson, Incoming President, Association of Directors of Social Services (ADASS)
- Charles Waddicor, National Professional Advisor, Commissioning and Contracting, Care Quality Commission (CQC)
- Rob Webster, Chief Executive, NHS Confederation
Broadly, the panel welcomed the general thrust of the report, although there were some reservations about some of the practical implications. The panel discussed the importance of considering wider factors, including housing and poverty, which are beyond the direct remit of health and care services, although they are a strong determinant of health and well-being. Efforts to bring these aspects into the mix were promoted, although the organisational difficulties were acknowledged. The panel also discussed the funding streams that might become available and how these might be allocated. They stressed the need to move away from tariffs for hospital based treatment, which incentivised particular activity. However, they welcomed the idea of directing more money towards community-based treatment. The importance of changing the interface between primary and secondary health care was also stressed by several members. Emily Holzhausen was keen to promote the work of carers as a resource input to be considered, and to think about the knock-on effects of caring on demand for NHS and other services. She pointed out that the UK was third overall in the proportion of older people being cared for by family, suggesting that calls for families to do more were unjustified.
In the afternoon, Gerald Wistow presented the background and political drivers for the14 Integrated Care Pioneers, which are being evaluated at the moment. NHS Improving Quality is supporting 14 sites to be ‘pioneers’ for integrated care and support. Gerald pondered on the meaning of pioneers (as opposed to pathfinders etc.). The pioneers are showcasing innovative ways of creating and spreading change across health and social care, drawing on expertise from a range of national partners and support organisations. The aim is to make health and social care services work together to provide better, more person-centred support at home and earlier treatment in the community to prevent people losing their independence or needing unplanned hospital care (read more about this).
Gerald discussed the political goals behind these efforts and explored the long history of efforts to make health and social care work better together, suggesting that the goal of making integrated working the norm in five years was somewhat ambitious. The day finished with a description of a small project, linked to the evaluation of the pioneers to come up with an interim framework of indicators of success for integration. There was a final discussion about the pioneers which raised some questions about the importance of maintaining the social model in any integrated service.
Dr John Woolham is Senior Research Fellow in Social Care in the Faculty of Health and Life Sciences at Coventry University. Dr Martin Stevens is Senior Research Fellow at the Social Care Workforce Research Unit, King’s College London. Martin is Chair of the Social Services Research Group.