NAO weighs in on health and social care integration challenge
Watchdog applauds effort but warns it found “no compelling evidence to show that integration in England leads to sustainable financial savings or reduced acute hospital activity”
A National Audit Office report has warned that progress towards the integration of health and social care is stalling.
It argues that, to date, progress has been “slower and less successful than envisaged” while at the same time not delivering all of the expected benefits for patients, the NHS or local authorities.
It argues that as a result, the government’s plan for integrated health and social care services across England by 2020 is at significant risk.
Significantly, the NAO found “no compelling evidence to show that integration in England leads to sustainable financial savings or reduced acute hospital activity.” It went on, “while there are some good examples of integration at a local level, evaluations have been inhibited by a lack of comparable cost data across different care settings, and difficulty tracking patients through different care settings.”
It said it reiterated its emphasis from its 2014 report on the Better Care Fund that there is a need for robust evidence on how best to improve care and save money through integration and for a co-ordinated approach.
In the face of increased demand for care and constrained finances, while the Better Care Fund, the principal integration initiative, has improved joint working, it has not yet achieved its potential. The Fund has not achieved the expected value for money, in terms of savings, outcomes for patients or reduced hospital activity, from the £5.3 billion spent through the Fund in 2015-16.
However, it said, the fund has been successful in incentivising local areas to work together; more than 90% of local areas agreed or strongly 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 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.
The NAO argues that while there is agreement across the health and social care sectors that place-based planning is the right way to manage scarce resources at a system-wide level, it points out that local government was not involved in the design and development of the NHS-led sustainability and transformation planning programme.
It is critical of both the Department of Health (DH) and the Department for Communities and Local Government (DCLG), saying that while they have identified barriers to integration - misaligned financial incentives, workforce challenges and reticence over information sharing – they are not systematically addressing them. Research commissioned by the government in 2016 concluded that local areas are not on track to achieve the target of integrated health and social care by 2020.
The NAO’s report also found that NHS England's ambition to save £900m through introducing seven new care models “may be optimistic.” It argues that the new care models are as yet unproven and their impact is still being evaluated. According to the NAO, while the departments and their partners have set up an array of initiatives examining different ways to transform care and create a financially sustainable care system, their governance and oversight of the initiatives is poor.
Amyas Morse, head of the National Audit Office, said, “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. 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 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.”
Jos Creese, principal analyst at the Eduserv Executive Briefing Programme which has published two in-depth reports on the challenges of health and social care integration, “Confronting the Challenges” and “The Potential of Digital”, said, “Once again, health and social care integration is in the news, with published research by the NAO and a statement from the Public Accounts Committee this week.
“These are both helpful in raising the profile for the opportunity for joined up care systems, and the huge associated challenges. But they also make rather depressing reading, at least in terms of the continued apparent lack of pace and an absence of truly joined-up thinking about what integrated care should mean.
“Solving the pressure on hospital A&E departments, adult social care capacity, bed blocking and health care demand growth requires two actions. First, a higher level of investment in social care and health, immediately, to help to protect patients and those at risk. This is the penalty from decades of failed policies, under-investment and too many national initiatives not delivering (NHSIT, Connecting for Health, NPfIT, Care.Data, Better Care Fund).
“And secondly, a fundamental rethink into how care services are structured. This is about a total redesign, and that takes time and is not easy. It does not mean a massive government IT project, but it does require some bold thinking and some catalyst projects. It requires the agencies, departments, service leaders and politicians to act and think very differently about priorities and where their intervention and investment can be most effective.”