The Health and Social Care Policy Landscape in England

1. The Health and Social Care Policy Landscapein England Andrew Webster February 2011

2. 2 1. The one minute summary An ageing population with increasing prevalence of long term conditions demands more integrated services for more people Wider policy context demands social action, choice, local leadership and integrated response Social care vision and funding hinges on personalisation and partnership People who use services do not recognise the difference between health and care and expect personal support to retain independence, safety, mobility, confidence, health and social contact The costs of gaps and overlaps are unsustainable and offer potential for better efficiency and lower costs Policy and organisational initiatives to integrate services go back over 30 years and some have been applied in most areas, but only a small number of places have gone for comprehensive integration Case studies show improvements from integration, data shows continuing opportunities for more community based and integrated services Surveys suggest that local cultural factors help integration and national structural initiatives can hinder progress Liberating the NHS provides a major driver for further integration � stronger clinical leadership, more local flexibility, wider choice of services and providers, leadership role for local government on health and well being, personal budgets Resource constraints provide a shared platform for tackling inefficiency and improving quality Co-production is being designed in and underpins new public policy The challenge is about relationships more than policy or structure

3. 3 2. The underlying challenge As average life expectancy at 65 increases to between 85 and 90 over the coming decades, the proportion of the population with three of more long term conditions, needing health services and care support will increase substantially. Most people who require care and support also use secondary health care, but the overwhelming majority of secondary care patients do not need care and support at home � so the system is unbalanced and interactions are complex Health and Well Being is a function of wider determinants including family, community, income, housing, security and other local factors as well as health and care � and is a central corporate concern for local government Total spend across H&SC on common users is over �70bn - nearly �40bn on older people, �20bn on MH, nearly �10bn on LD plus spend on physical disabilities (not collected separately by NHS) LTCs represent nearly 70% of health & social care spend LTCs represent nearly 80% of in patient bed days LTCs represent 55% of GP appointments LTCs represent nearly 70% of outpatient and A&E attendances Proportion with LTCs increases with age (70% over 85 have LTCs)

4. 4 Five strands

5. 5 Big Society - social action, transparency and devolution Liberating the NHS - patient choice, clinical leadership and open provision Public Health - public responsibility, public health England and local delivery Social Care - prevention, partnership and personalisation Local Leadership - joint needs assessment, health and well being strategies, localism and community budgets Overall policy direction

6. 6 Users don�t distinguish between health and care and describe outcomes in terms of independence, safety, mobility, confidence, health and staying in touch with people; Users experience gaps between services when they move in and out of hospital, and confusing overlaps across services at home in the community; Both gaps and overlaps offer opportunities to be more efficient and reduce costs None of this is new � for thirty years there have been regular policy and organisation changes aiming to promote integration of health and social care Most localities in England have used some of the new flexibilities, but only a small proportion have applied them comprehensively; The most common reported means of integrating services is to appoint joint managers and directors The factors that localities say most HELP integration are local and cultural, the factors that localities say most HINDER integration are national and structural Case studies show improved outcomes where services integrate, but performance indicators on speed, outcome and satisfaction with services are more mixed Wide variations in use of expensive residential care and emergency admissions to hospital can�t be explained by need or resources � the patterns are historical. Evidence on integration

7. 7 Demographic changes are increasing demand for long-term care and point towards more integrated services around the individual An ageing population, increasing prevalence of chronic illness and disability increase demand for long-term care including both health and social care The types of services include clinical care, personal care, home help and assistance with life management and involve interaction with different parts of the health and care system. At a high level, all parties share a policy vision for a more integrated service that delivers more affordable, simpler and fairer care. There is a range of partnership models and structures aimed at integrated care.

8. 8 Overlaps between Health, Care and Well Being Services The distinction between health care and social care is in part historic. The NHS was established to tackle disease, while the aims of social care are to enable people to retain independence, control and dignity Evidence indicates that there is now considerable overlap between users of health and social care services � and it could be argued that both are aimed at improving overall health and well being. Health and Well Being, including public health and prevention, is a corporate function for Local Councils Integrating services around users and developing community based prevention could potentially deliver two key objectives: Improve outcomes/experience for users and citizens Improve the efficiency in which services are delivered

9. 9 User experience shows broad consensus on what people want across all care services, although evidence highlights some differences between groups Picker Institute (2007) identifies eight issues that impact on individuals experience of care services: fast access to reliable health advice effective treatment delivered by trusted professionals involvement in decisions and respect for preferences clear, comprehensible information and support for self-care attention to physical and environmental needs emotional support, empathy and respect involvement of, and support for, family and carers continuity of care and smooth transitions

10. 10 Evidence also shows that the current system has gaps and overlaps that could yield efficiency gains and reduced costs Gaps in transitions between health and care settings Recovery from ill heath/hospital care e.g. intermediate care and re-ablement helping return to home Moves from hospitals to settings other than one�s own home e.g. residential care home or nursing home Continuing care, including moving from social care services to NHS nursing services Overlaps in the ongoing health and social care services Service that help individuals to live at home, including with a preventative focus Self-management including community based learning disability care and tele-care to improve Enabling individuals with mental or physical disabilities to live full lives and participate in society Provision of information between care providers e.g. on medicines

11. 11 Lots of policy effort over the last 30 years to reduce the fragmentation between health and social care

12. 12 Health Act (1999) introduced new flexibilities to improve integration of health and social care i.e. pooled budgets, lead commissioning and integrated providers. Evidence of success is variable: In 2004, 98% local authorities had some form of joint working, but only around 16% had joint working around older people The most common was pooled budgets (78%) with integrated provision and lead commissioning used in around 30% of cases. But, formal arrangements make up around 3% of joint Adult Social Care (�13.1bn) and NHS (�86.4bn) budgets [Audit Commission 2009] Even in mental health and community spending integration only amounts to around 10% of budgets. Formal joint arrangements tend to be in learning disability and mental health with little progress on older people � in part reflecting existing arrangements on mental health.

13. 13

14. 14 Survey (December 2009) showed a wide range of models across the country that attempt to improve integration The Integrated Care Networks survey on the State of Integration (which will be presented in the next session) confirms anecdotal evidence that: Many models of integration exist across the country The benefits from integrated care are well-understood but not easy to translate into outcomes Flexibility of models and methods to allow for local variation and complexities are key But more on this laterThe Integrated Care Networks survey on the State of Integration (which will be presented in the next session) confirms anecdotal evidence that: Many models of integration exist across the country The benefits from integrated care are well-understood but not easy to translate into outcomes Flexibility of models and methods to allow for local variation and complexities are key But more on this later

15. 15

16. 16

17. 17 The survey also revealed some factors that helps and hinder integration

18. 18 Evidence on the impact of integration, a number of case studies showing improvements

19. 19 Available performance data shows a mixed picture

20. 20 There remains considerable variation between places on transitions between care settings Proportion of delayed transfers out of acute beds has improved over the last ten years. In part the improvements have been consequence of result of local authority to NHS reimbursement scheme. Still significant variation from 7% of cases to almost none in some authorities Successful transition is a new measure of outcomes, and shows large variation

21. 21 Similarly the variation in the numbers of emergency admissions for over 75s suggests scope for greater prevention � and cost savings

22. 22 Most social care users also use hospital care, but the reverse is not true. Research carried out by Nuffield Trust from five sites shows the overlap between health and social care i.e. nearly 10% of over 75s. The evidence shows that around 70% of social care users over 75 also access hospital services. However, around 15% of over 75s who use hospitals also use social care. On average, social care users are 50% more likely to use hospital services than people who don�t use services, unless they are in residential care, so community infrastructure needs to be stronger.

23. 23 Evidence also shows wide variation in the use of residential care across the country, which does not seem to be related to demand

24. 24 There may be significant institutional barriers to providing integrated services around users � although each has been overcome somewhere System Information � low levels of shared data and little structured comparative information to drive change Geographic variation � evidence of wide variation in practice in, for example, use of residential care and third sector involvement across the country Policy tensions � e.g. between integrated care organisations & choice, between local flexibility and consistency Financial Funding � e.g. social care includes contribution from users while NHS tax-funded, payment mechanism are part contract/part fee for service, tariff includes an element of intermediate care for fractures/replacements Reporting and auditing � Accounting officers required to show value-for-money and ensure contributions are fair, with separate auditing and scrutiny Availability of resources � Evidence indicates that integration may require investment before payback, for example, through changing structures, removing duplication Professional Leadership � absence of leadership at a local level often cited as principal barrier to change at a local level Skills and values � Although users see no distinction staff still remain convinced that services are distinct and must be protected Terms and conditions � differences between employers cited as practical barriers to integration

25. 25 In summary, the evidence shows that integration can improve outcomes, but does not support any particular model Closer working between health and social care has the potential to improve outcomes: Reducing hospitalisation � in particular reducing emergency admissions Reducing lengths of stay in hospital � improving transition to home, residential and intermediate care Reducing use of residential care � improving the standards of home care Reducing duplication � including of assessments and visits by professionals, but also lowering administrative costs Improving management of medicines � improving coordination between prescriptions Improving patient involvement � through self-care, case management and coordination of care Integration will tend to be more successful where: Not focussed on organisations � e.g. formal and informal clinical integration, partnership rather than structural change Supportive local context � history of partnership working and coterminous boundaries provide a strong base Strong leadership and vision � e.g. commitment of managers and clinicians to improving outcomes for individuals, rather than a commitment to integration High quality information systems � information on the individual requiring care and support e.g. risk modelling and case management tools Supported by financial incentives and organisational changes � partnership not enough, but demonstrates commitment and makes it harder to walk away

26. 26 VISION Published in November This vision demonstrates the Government�s values of freedom, fairness and responsibility, shifting power from central to local, from state to citizen, from provider to people who use services.  Based on seven principles - personalisation, prevention, plurality, productivity, partnership, protection and people FUNDING Dilnot review will report in the Summer Examining all options including insurance, partnership and comprehensive systems and committed to a sustainable funding settlement - seeking contributions now. In the current spending review period: �2bn by 2014/15 available within the NHS specifically for measures that support social care & benefit health. Of this, up to �300m per annum will be used for re-ablement to help avoid demand upon social care. In October, the Government announced that an additional �70m would be allocated to PCTs for spending in 2010/11 on services to promote better services for patients upon discharge from hospital In January, the Government allocated an additional �162m to PCTs to invest immediately in vital social care services which benefit the NHS NHS investment in social care will improve people�s outcomes and benefit the NHS by ensuring that people remain independent and active in their communities, whilst at the same time reducing unnecessary hospital admissions.  Expect Councils and the NHS to work together to agree how this funding should be best used to support social care services. Vision and funding of social care

27. 27 Clinicians lead patient engagement and choice in GP Commissioning Consortia and NHS Foundation Trusts by 2014 Local Councils implement personalised services and individual budgets for social care in every locality by 2014 Local Government and Social Care engaged in co-design and implementation of Putting Public and Patients First, NHS Commissioning Development Programme and Pubic Health England by 2013 Local Government leads strategy and integration in each locality by 2013 Partnership Agreement with social care sector on next steps on transformation Supporting programmes: Practical approaches to improving the lives of disabled and older people by building stronger communities Practical approaches to market and provider development Practical approaches to co-production Practical approaches to safeguarding and personalisation Principles of co-production

28. 28 COMPARE Demography Expectation Costs Opportunities Geography Professions CONTRAST Political cycle Market structure Funding streams Scale Speed Compare, contrast and challenge

29. 29