Government risks going backwards on integration, warn MPs

The Commons health committee report on social care, published today, called on the government to amend its health reforms to allow local communities to retain their care trusts, which bring together services offered by health and local government.

The committee said the government’s progress on integration “continues to be disappointing” and warned that the NHS would fail to achieve the £20bn “Nicholson Challenge” without a significant step change.

It stated integration was an “essential tool in delivering quality and efficiency in the public sector” and called for the creation of a single commissioning process for health and social care to address the current failings.

The report said the evidence provided to the committee suggested pressures to make significant efficiency savings were encouraging organisations to adopt a “defensive stance which is undermining delivery of the objective of integration”. For example, it cited evidence from the NHS Confederation’s mental health network that a growing number of councils were withdrawing from integrated services.  

The committee highlighted care trusts as among the “few notable exceptions” in 40 years of failure to integrate services, but said there was a belief that the level of integration achieved by them was threatened by the commissioning reforms, which should be changed.

For example, regarding the example of Torbay in Devon, it stated: “The local authority felt that the effectiveness of the care trust had been diminished by the transfer of NHS commissioning to the PCT cluster.”

The committee said care trusts generally represented the most integrated existing organisations and called on the government to allow local communities to be allowed to retain them.

It recommended that the current approach of encouraging health and social care services to “build bridges” between themselves to further integration had largely failed. 

The report also said the government should “place a duty” on existing and future NHS commissioning structures to “create a single commissioning process, with a single accounting officer, for older people’s health, care and housing services in their area”.

“A single commissioner will have multiple lines of financial accountability, including to the NHS commissioning Board, local authorities and service users,” it added. Health and wellbeing boards would act as a local mechanism for accountability, it suggested. 

The committee also called for ministers to “move quickly” to adopt a single outcomes framework for health and social care for older people and abandon the three overlapping but confusing frameworks being developed.

The committee’s social care document follows last month’s recommendations to drive forward integration from the NHS Future Forum and a government commissioned report by the King’s Fund and the Nuffield Trust.

Responding to the new report, King’s Fund senior fellow Richard Humphries said: “Successive governments have talked about the need to integrate health and social care but have failed to make it happen. The committee is right to stress that a more ambitious approach is needed to achieve this based on co-ordinated commissioning and pooled budgets.”

He added: “Today’s report hits the nail on the head by calling for health and social care services to be organised around the needs of older people and those with complex needs. In our view, this could be achieved by setting an ambitious new goal to improve the experience of patients with complex needs, backed up by enhanced patient guarantees including an entitlement to an agreed care plan and a named case manager responsible for co-ordinating care.”

NHS Confederation deputy policy director Jo Webber said she agreed with the committee on much of what it said about integration. She said: “While promotion of integration is written into the Bill, the creation of new bodies and the division of responsibilities for various services risks fragmenting care more rather than less.

“This is a particular worry for older people who tend to have more than one illness and so require integrated care from different services across health and social care.”

She added: “Integrated health and social care systems are currently the exception rather than the norm. They have been successful in spite of the structural and organisational barriers in place because the relationships between organisations and their leadership has been exceptionally strong.

“Pooled budgets, single commissioners and a single outcomes framework for older people could all help make health and social care work better for patients in more places.”

Royal College of Nursing chief executive and general secretary Peter Carter said: “A single commissioning process is a logical starting point in simplifying the system, addressing gaps and preventing duplication of services for patients and users.”