England’s plans to integrate health and social care systems have been less successful than expected and have not brought in the benefits expected for patients, the NHS or local authorities, warns a report from the National Audit Office (NAO).
The NAO, which is responsible for scrutinising public expenditure, analysed how integration within and between adult social care and health systems has been progressing and concludes that the government’s plan for integrated services across England by 2020 is at “significant risk”.
“Integrating the health and social care sectors is a significant challenge in normal times, let alone times when both sectors are under such severe pressure,” says Amyas Morse, head of the NAO. “So far, benefits have fallen far short of plans, despite much effort. It will be important to learn from the over-optimism of such plans when implementing the much larger NHS sustainability and transformation plans.
“The Departments [for health and communities and local government] do not yet have the evidence to show that they can deliver their commitment to integrated services by 2020, at the same time as meeting existing pressures on the health and social care systems,” she adds.
The NAO analysed the Better Care Fund, which was originally announced in 2013 and requires local health bodies and authorities to pool funding and come up with joint plans for integrating services and reducing pressure on hospitals
But the NAO says the fund has not achieved the expected value for money, in terms of savings, patient outcomes or reduced hospital activity, from the £5.3bn spent through the fund in 2015–2016.
In 2015–2016, the number of emergency admissions increased by 87,000 compared with 2014–2015, costing £311m more than planned. In addition, local areas planned to reduce delayed transfers of care by 293,000 days in total, saving £90m. However, the number of delayed days actually increased by 185,000 compared with 2014–2015, costing £146m more than planned.
“The Departments and partners did not monitor or track the achievement of savings at the local level as they had no mandate to do so,” says the report.
But the NAO does think the Better Care Fund has been successful in incentivising local areas to work together, finding that more than 90% of local areas agreed that delivery of their plan had improved joint working.
Local areas also achieved improvements at the national level in reducing permanent admissions of people aged 65 years and over to residential and nursing care homes, and in increasing the proportion of older people still at home 91 days after discharge from hospital into reablement or rehabilitation services.
Commenting on the NAO report, Alastair Buxton, director of NHS services at the Pharmaceutical Services Negotiating Committee, the government recognised body representing pharmacy contractors, says: “Where community pharmacy has managed to win funding from the Better Care Fund, we have seen that this can have a positive impact and lead to longer term local commissioning of innovative services. Unfortunately, we are aware of very few areas in which this has happened as it seems that, as with all healthcare funding at the moment, community pharmacy is competing with many other priorities and providers for attention.”
He adds: “This is likely to continue and over the next few years community pharmacy must keep adapting and trying to make the most of all new opportunities and funding routes.”
Also commenting on the report, Meg Hillier MP, chair of the committee of public accounts, which has already looked at the Better Care Fund, says: “Unless the Department of Health and NHS England fully engage local government in whatever rehashed targets result from sustainability and transformation plans, then integration by 2020 is nothing but a pipe dream. Meanwhile patients, and older and vulnerable adults, suffer.”
Sandra Gidley, chair of Royal Pharmaceutical Society’s English Pharmacy Board, says the NAO report attempts to quantify and simplify very complex change, which is still in the process of being evaluated.
“My experience of working with NHS England is that there are too few staff trying to deal with complex issues and this situation will only get worse while transformation money is being used to fill financial deficits. What would be really helpful would be detailed analysis of individual care models rather than the broad-brush statistics provided. Pharmacy can be part of solutions but in too many cases it is still an afterthought.”
Gidley has previously called for the establishment of a fully integrated Department of Health and Social Care, with joint budgets and public accountability for the way the budgets are utilised (Pharmaceutical Journal, online 17 January 2017)