21st Century NHS and Social Care – Delivering Integration

Labour Health and Care Policy Commission – UNISON submission, May 2013

Submission produced by the UNISON Policy Unit

Introduction

UNISON has the largest health membership and the largest social care membership of any trade union in the UK, representing around 450,000 healthcare staff and 300,000 social care staff employed in the NHS and local government, and by private contractors, the voluntary sector and GPs. UNISON members include nurses, social workers, occupational therapists, health visitors, midwives, healthcare assistants, care assistants, personal assistants, paramedics, medical secretaries, cleaners, porters, catering staff, and the wider health and social care workforce. With a total membership of 1.3 million members, the union is therefore in a unique position to comment on the workforce and service user implications of the Labour Party’s plans for integrating health and social care.

The union responded to the previous stage of the policy review but did so before Labour had launched its ambitious plans for Whole Person Care. Rather than repeating previous points, this paper adds to the union’s submission in terms of a broad welcome for the idea of Whole Person Care, but also highlights a number of key areas where there is a need for further thinking or where important reassurances will be required to gain the full support of the workforce. The paper closes with some suggestions for interim measures that might be taken in the short-term (and would not require legislative change) while the wider reforms were taking shape.

UNISON is actively engaged in seeking evidence from members working in areas of the UK where integrated services are a reality, and the union hopes to use this learning to inform a further submission to the Independent Commission on Whole Person Care in July 2013.

Whole Person Care

UNISON is broadly supportive of the concept of Whole Person Care. The union’s national conference has called for an integrated health and social care system funded out of general taxation and has previously noted the experience of UNISON members that integrated services can produce better and more efficient services.

This support for the seamless provision of care has, however, come with the qualification that this should only be done if service users, workforce and trade unions are properly involved, and with a warning that integration should not be used as a cover for cuts.

The union particularly welcomes the following elements mentioned so far by Labour as forming part of a potential move to a system of Whole Person Care:

• repeal of the worst aspects of the Health and Social Care Act 2012 (Secretary of State responsibility for the NHS, Part 3 competition regime, private patient income cap);
• greater protection for the NHS through a move back to a “preferred provider” model of service delivery;
• a focus on real lifestyle choices, such as those around maternity or end of life, rather than the illusion of choice offered by the market-driven “patient choice” agenda; and
• the “all-in” approach to social care funding, delivered on a free at the point of need basis.

Big picture issues

There are a number of issues where there are gaps or concerns, or where greater clarification and reassurance is required.

UNISON notes that the terms of reference of the Independent Commission include moving to a system of Whole Person Care “without major structural change and within existing resources”. This looks very challenging. It may well be that by 2015 the current government will have made such a mess of the NHS and social care that it is impossible to avoid a major overhaul, but there needs to be consideration of how best to change the system while avoiding further unnecessary upheaval for staff and service users. In common with other health and social care staff, UNISON members have been subject to a huge number of recent reorganisations, particularly in the past two years with the commissioning changes in the NHS and with public health being transferred back to local government. An onus on changing incentives, powers and cultures rather than structures might be one way of doing this, at least as a first step. If there is a way of moving incrementally towards Whole Person Care this may be one way of smoothing out some of the problems en route. It is worth noting that in the oft-quoted Torbay example, it has taken the best part of a decade for service integration to take shape.[1]

The proposed national citizen entitlement to care would need to be very robust given the proposed lack of ring-fencing for NHS funds that are transferred to local government. The inclusion for the first time of national standards for the delivery of social care within the entitlement would be very welcome. UNISON assumes that repeal of the opening clauses of the Health and Social Care Act is an essential pre-requisite here, as this would return responsibility for delivering a comprehensive (health) service back to the Secretary of State. The Secretary of State would then need powers to intervene in the event of any commissioners attempting to break away from delivering the national entitlement. It is also important to emphasise that ultimate accountability for care services will once again reside with the Secretary of State, particularly as there could be confusion in the short term over whether the NHS or local government is responsible for particular parts of a person’s care package.

Any merging of two models of care with such different funding models is bound to create concerns about bad practices from one seeping into the other. Labour must make sure that no element of means-testing in social care is allowed to creep into the NHS through such a process. This makes it all the more important to move to a free at the point of need model in social care – importing the far preferable system of universal free access to services from the NHS.

There are understandable concerns about the track record of local authorities (including some Labour ones) in contracting out social care services to the cheapest bidders at the expense of quality, and the driving down of fees which has contributed to the downward spiral in employment conditions. This would run contrary to the general anti-market drive of the Whole Person Care approach. The use of the “preferred provider” model is welcome for NHS services, but there should be a double-lock where, for example, a hospital contracted as the preferred provider by a Health and Wellbeing Board was seeking to sub-contract work to other providers. There are big question marks about how a preferred provider NHS would be married to a largely privatised social care sector. UNISON wants to avoid the situation where an NHS preferred provider could continue to contract out social care services to the same cut price providers, perpetuating the downward spiral. A public sector preferred provider approach for social care is also needed as the only way to arrest the alarming decline in quality of care that the current care market has produced. What is Labour proposing to do to halt the flow of care services out of the public sector, and to bring back those that have been privatised?

There may be a need to ensure that foundation trusts remain unambiguously a part of an integrated national system, to minimise the potential for challenges under EU and international competition law. To take this a step further, just before the last general election, the cross-party House of Commons Health Committee (with a then Labour chair) described the purchaser-provider split in the NHS as “twenty years of costly failure”, citing an “increase in transaction costs, notable management and administration costs” and reporting that these had risen to 14% of total NHS costs.[2] The time is right in the wider policy world to look at the split again: the King’s Fund and Nuffield Trust have referred to integrated commissioner-provider organisations as “a potentially important innovation in the organisation of health service planning and delivery”[3]; NHS England and Monitor have begun to look at ways in which Payment by Results might be transformed in the future[4]; and even the current government is set to test current payment systems with its local integration “experiments”.[5]

Labour should use integrated care arrangements as a means for breaking down the market, basing integration on NHS principles and public provision, rather than the government’s approach of market-led integration: Monitor has stated that “effective regulation of choice and competition issues will also be vital in enabling integrated care to flourish” with an onus on encouraging private providers into the system[6], as has already been seen with integrated children’s services in Devon[7] and now with integrated older people’s services in Cambridge.[8]

It is important to note that the government’s belated conversion to integration has come just as their wider market reforms are fragmenting the system, with new competition rules potentially blocking the likes of the Torbay Care Trust from continuing their much-lauded work.[9]

UNISON notes with concern a recent media report that suggested a single personal budget could be used as a means for people to receive their care[10]. As UNISON has noted many times before, personalisation should be focused on person-centred care rather than budget-dependent care – the latter associated with cuts in social care[11] and the potential for inequity in the NHS[12]. The union notes, however, that use of a single personal budget has so far received no formal coverage from the Party and that this may in fact be a misleading reference to the potential application of the Year of Care tariff, as used with diabetes care[13]. There is a need for greater clarity on how far Labour sees the applicability of Year of Care; is this just for long term conditions and particular groups of patients, or something bigger? If the latter, it would need more careful analysis of how (and whether) a specific project of this nature could apply to the wider care system.

For Health and Wellbeing Boards to become the new powerhouses within the system, as envisaged by Whole Person Care, they would need to be strengthened considerably, both in terms of their powers but also in terms of their democratic legitimacy. A greater role for elected councillors is needed than the requirement for them to contain “at least one”, as currently specified in the legislation.

For Whole Person Care to work, the system would need to be properly funded. There are already major concerns about funding problems, particularly in social care where ADASS warned recently that “a bleak outlook is getting bleaker”.[14] So far, there is no particularly convincing evidence about the amounts of money that full integration is expected to save, and in the short term there should be an expectation of increased funding to pay for things such as double-running costs and re-training. Indeed, it has been reported that for integrated care in south London “the total cost of changes to the model of care for older people in Lambeth and Southwark is £6.5m per year for three years” – it is only after this that the prospect of savings begins to emerge.[15] Likewise, the national evaluation of the Department of Health’s integrated care pilots did find improvements but, significantly, not in terms of the most costly emergency hospital admissions.[16]

This lack of evidence is a bigger issue – even some of the key proponents of integration have pointed out that the evidence base is “thin”.[17] The consensus that integration is a good thing is unsurprising and often rooted in “motherhood and apple pie” platitudes. Full structural integration of health and social care exists in Northern Ireland but has not been attempted in a country of comparable size and health demographics to England. The attempts to crowbar in comparisons with the likes of the Veterans’ Health Administration and the health maintenance organization Kaiser Permanente in the USA are not particularly insightful as these represent moves to integrate services within a hugely fragmented insurance-funded system of multiple providers – very different to our NHS.

Finally, thought is required about how to convey the message that extra taxation is necessary to pay for an “all-in” system of social care. UNISON believes the public can be persuaded that this is the right thing to do, but it is important that arguments and statistics are marshalled to highlight the glaring inequity of the current system in which increasingly only those at “crisis-point” are receiving care from cash-strapped councils[18], with many forced to sell their homes or those with any savings seeing them decimated by the cost of care. Given the awkwardness of such a fundamental issue, it is perhaps unsurprising that, at this early stage, the plans for Whole Person Care appear better developed on the NHS side than for social care.

Workforce considerations

UNISON welcomes the fact that the terms of reference of the Independent Commission include a requirement to outline the development needs of the workforce and to test any recommendations with patients, users and practitioners to ensure they are workable and effective. With this in mind, there are a number of workforce specific issues that it is worth raising early on in this process.

The statements about evidence above notwithstanding, it may well be that integration has the potential to save money by changing incentives and cutting back on duplication. But the fear amongst many health and care workers will be that the term “integration” will simply be used as a cover for cuts (much in the way that personalisation has come to be associated with cuts in social care).

There is therefore a need for some reassurance that the positive intentions of Whole Person Care cannot be twisted to justify cuts and dragging down to the lowest common denominator. To this end, it is essential that Whole Person Care aims to bring social care terms and conditions up, rather than pushing NHS terms and conditions down. UNISON notes the helpful call from Andy Burnham for a ban on zero-hours contracts.[19]  This is particularly pertinent in light of the recent ONS estimation that a shocking 200,000 people were on zero-hours contracts at the end of 2012.[20]

Labour would need to guard against the possibility of two-tierism developing in integrated workplaces, with one group of workers on one set of terms and conditions and another on a different set working alongside each other in the same type of work. In UNISON’s experience of current integrated care arrangements where staff have been TUPEd or seconded across, this inequality can be a running sore causing much resentment. There are early signs that this also has the potential to cause resentment in public health following the recent transfer of NHS staff into local government. Such moves may over time be the right thing to do, but the cultural differences will also need to be factored in and a new culture forged with full involvement of the workers. There is a need to avoid the perception of a “takeover” of one sector by the other.

If social care is to be delivered via an NHS preferred provider approach, then the ultimate aim should be to move care workers into the NHS Agenda for Change pay system. This would send out a very strong message that care work was no longer a minimum wage (or worse[21]) occupation, but that those charged with looking after the most vulnerable would now be properly rewarded for the work they did. This would be expensive (and unlikely to happen overnight) but would save the system money in the longer term due to the improvement in the quality of care and the improvement in outcomes for service users that would result, with its knock-on benefits of preventing unnecessary and costly hospital admissions. Proper modelling of this would be something useful for the Independent Commission to carry out. Ideally UNISON would want to see a clear pathway setting out how this could be achieved for all care workers over a given time period, with clear commitments along the way.

In the shorter term, an expectation of national Agenda for Change pay arrangements could be written explicitly into the staff rights section of the NHS Constitution. Any local infringement of this could then fall within the powers of the Secretary of State to intervene in the event of a breach of the national entitlement, which it is assumed the NHS Constitution would form an important part of.

Other quick wins on the way to a fuller version of Whole Person Care would be to address unacceptable local authority commissioning practices by adopting the key components of UNISON’s Ethical Care Charter. This would ensure that local authorities only commission care which meets certain standards, including ending 15-minute visits and the use of zero-hours contracts, payment of travel time to ensure minimum wage compliance, and work to prevent short-changing of client’s allotted visit times.[22]

Similarly, Labour should move quickly to establish safe minimum staffing levels to reduce the potential for harm to patients, as recommended by the Francis report but ignored by the government. Legislation should be used to enshrine minimum staff-to-patient ratios in all healthcare settings, which would also provide peace of mind to families and healthcare staff. There is growing evidence – from the UK and elsewhere[23] – of the positive impact this can have, particularly in terms of lower patient mortality. The US Agency for Healthcare Research and Quality found that hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections.[24] Meanwhile the Safe Staffing Alliance, of which UNISON is a part, has used research from the University of Southampton to state that eight is the maximum number of patients any nurse should look after at one time. Any more than this and a hospital can expect to see more deaths per year than a better staffed institution.[25] The latest UNISON survey of nursing members found that an alarming 45% were looking after eight or more patients on their shift.[26] UNISON would also like to see a commitment to safe minimum staffing levels for all care homes and nursing homes.

UNISON notes that Whole Person Care is designed to work on the assumption that home rather than hospital should be the starting place for care. The union has consistently supported the desire of service users to receive their care in the setting that is most appropriate for them, with care outcomes and overall wellbeing likely to be improved by receiving treatment in one’s own home. For this to become a reality, however, there would need to be some sort of robust mechanism to allow staff currently working in acute hospital or care home settings to be able to operate more flexibly without fear of redundancy, cuts to terms and conditions, or infringements of staff wellbeing. Proper protocols that take note of important staffing issues – such as health and safety, education and training – would need to be drawn up if there is to be an expansion in the amount of home working or lone working undertaken by care staff.

This mirrors the need to engage as early as possible around wider reconfigurations of services, such as those designed to move more care into community settings. It is hardly surprising that attempts to change the delivery of services have met with such opposition from staff and communities, when plans have too often been sprung on local people with inadequate consultation or insufficient explanation of clinical benefits – if indeed these exist at all. Moving care from the hospital and into community settings should not become synonymous with privatisation; there is a need to ensure sufficient public sector capacity is built up in the community before any such moves are attempted.

Further suggestions

Were Labour to win the 2015 election, there are a number of other actions which the Party could take shortly after coming to power, and on which it could signal its intentions now.

With the role of private companies growing within the sector[27], the case for extending Freedom of Information legislation to private providers of health and social care has become overwhelming, and UNISON welcomes moves in this direction by the wider Party.[28] In doing so, Labour should not be swayed by industry calls for an FOI-lite “transparency system”[29]. Even economic regulator Monitor, as part of its “Fair Playing Field Review”, has called for FOI to be extended as a means of providing parity across sectors: “The Government and commissioners should ensure that transparency, including Freedom of Information requirements, is implemented across all types of provider of NHS services on a consistent basis.” [30]

Labour could act decisively to reverse the process of “externalisation” of commissioning support functions, which the government is intending to embark on later in 2013 and which has the potential to remove any accountability from commissioning decisions (in addition to confirming the fallacy that the current system is “clinician-led”). Commissioning Support Units do not exist in law, having been excluded from the Health and Social Care Act, so there would be no need to legislate in this area.

Similarly, Labour should put a halt to the privatisation of hospital management through franchising arrangements of the type in place at Hinchingbrooke and mooted elsewhere, such as the George Eliot in the west midlands and the Weston General in the south west.

There are other existing initiatives that UNISON has noted in previous submissions that Labour should investigate, such as the Listening into Action approach where hospital improvement uses staff engagement as the basis for action.[31] Increasing amounts of academic evidence, from the likes of Aston Business School and the National Nursing Research Unit, point to the link between staff wellbeing and the patient experience of care.[32] There may be something further to look at in terms of worker representation at board level, of the type the TUC have suggested recently[33]. Foundation trusts do have staff governor positions, but to date there is little evidence of staff being able to exercise much meaningful say in the way hospitals or other care organisations are run.

There are also some encouraging signs from parts of the country where privatised services have been brought back in-house. Many of the best performers have opted to bring their cleaning services back in. There are numerous reasons for this, as demonstrated by various UNISON reports that highlight the benefits in terms of cleanliness, team working and fair treatment of NHS staff. [34] A more ambitious project has recently taken place at Colchester Hospital where all of its estates and facilities services have been brought back in-house to improve patient focus, to deliver greater flexibility in future, and to achieve better efficiency.[35]  This project, that engaged staff throughout the process, should be looked at as model for other hospitals.