Feature / Slow progress

27 February 2017 Steve Brown

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There is support for integration and better local working, but progress is slow. Steve Brown reports

GearsIntegration of health and social care has been slower and less successful than envisaged and has not delivered all the expected benefits for patients, the NHS or local authorities. This was the finding of a hard-hitting report from the National Audit Office in February.

The upshot of this slow start is that ‘the government’s plan for integrated health and social care services across England by 2020 is at significant risk’, the report concluded.

The audit body examined three areas:

  • Integrating health and social care
  • The progress of national initiatives including the Better Care Fund
  • Plans for increased integration.

It said rising demand for services, combined with restricted or reduced funding, was putting pressure on local health and social care systems. In particular, rising numbers of delays in hospital discharge were an indication that an ageing population was putting pressure on hospitals and social services. 

Better integration of services – everything from joint care needs assessments to pooled budgets and integrated condition-specific services – is seen as both improving services to patients and service users, as well as being the key to responding to these pressures.

However, the Department of Health and the Department for Communities and Local Government had ‘not yet established a robust evidence base to show that integration leads to better outcomes for patients’, the report said. There had been no tests of integration at scale, and international examples of successful integration had occurred in different statutory, cultural and organisational environments.

It also found ‘no compelling evidence’ to show that integration in England leads to sustainable financial savings or reduced hospital activity – some of the very pressures that integration is seen as addressing. ‘While there are some positive examples of integration at the local level, evaluations of initiatives to date have found no evidence of systematic, sustainable reductions in the cost of care arising from integration,’ it said.

These evaluations had been inhibited by a lack of comparable cost data in different care settings and the difficulty of tracking patients through care settings, the report added.

Looking at national initiatives, it said the Departments’ expectations of the rate of progress of integration were over-optimistic. Embedding new ways of working takes time, especially when working practices and cultures are so different. The Better Care Fund had incentivised local areas to work together, but had failed to meet its financial goal of £511m of savings in 2015/16. Emergency admissions to hospital went up, not down. And the number of delayed days, resulting from delayed transfers of care, also rose.

The NAO said that in 2014 the fund’s saving assumptions were based on optimism rather than evidence. It also said the Departments recognised that performance metrics are affected by factors outside the fund’s influence. The integrated care and support pioneers programme has also not yet demonstrated improvements in patient outcomes or savings.

On integration plans, the auditors acknowledged that the Departments were planning to publish an integration standard describing the core elements of an integrated system. But the watchdog said that governance and oversight across the range of existing integration initiatives had been poor. The lack of comprehensive governance was ‘leading to uncoordinated effort across central bodies’.

Barriers to integration have been identified – misaligned financial incentives, workforce challenges and reticence over information sharing – but are not being systematically addressed.

More positively, the report said there was agreement that place-based planning was the right way to manage scarce resources at a system-wide level. However, local government had not been involved in the design of the sustainability and transformation planning process. While local authority engagement had improved, overall engagement had been variable, especially given the more formal engagement around the Better Care Fund. 

Making its value for money conclusion, auditors said joint working and integration could be vital to the financial sustainability of the NHS and local government. But the Better Care Fund had ‘not achieved the expected value for money in terms of savings, outcomes for patients or reduced hospital activity…in 2015/16’. 

Sustainability and transformation plans could be a vehicle for joint planning – but they aren’t yet. To support more aligned planning, the report said, there was a need for robust evidence on how best to improve care and save money through integration and for a coordinated approach. ‘The Departments do not yet have the evidence to show 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,’ the report said.  

Response to the report

Feature - Chris Hopson

‘It is telling that, despite nearly two decades of initiatives to join up health and social care, the NAO concludes there is still no compelling evidence to show this leads to long-term financial savings or reduced hospital activity.’ Chris Hopson (right), chief executive NHS Providers

‘Integration alone cannot solve the financial challenges facing health and social care. Social care faces a funding gap of at least £2.6bn by 2020. Extra council tax income will fall well short of what is needed to fully protect the services that care for elderly and vulnerable people.’ Izzi Seccombe, chair, Local Government Association Community Wellbeing Board

‘Place-based planning and health and social care integration are the right ambitions for the NHS and local government. If they are to be realised, barriers to integration such as misaligned financial incentives and different planning cycles must be removed.’ Chris Ham, chief executive, King’s Fund

Supporting documents
Slow Progress