By the time the NHS celebrates its centenary in 2048, there will be over 100,000 centenarians in the UK. A profound shift is well underway in the age structure of our population. We are becoming an older society.
Our health and care system would still be recognisable to Beveridge and Bevan. Hospital based, treating illnesses, patching people up. It is essentially a healthcare system designed for 1930s needs, when lives were shorter and communicable and childhood diseases dominated.
The healthcare needs of today are different. Non-communicable, often lifestyle related, diseases dominate. Many people have more than one long-term condition or disability. In old age the successful management of long-term health problems can make all the difference, avoiding the need for hospitalisation and reducing the risk of frailty and greater dependency on family and institutional care.
In 2014, NHS England’s chief executive Simon Stevens made the case for change in his Five Year Forward View. The report achieved a remarkable degree of consensus across the party divide and health professionals.
The report laid bare the financial challenge faced by the NHS over the next five years: a funding gap of £30bn by 2020. The government has pledged an extra £8bn funding by 2020, this is on top of the £2bn voted in the March 2015, but in exchange has asked for the NHS to make the £20-£22bn savings.
The efficiency challenge this represents is unprecedented. In his interim report on operational productivity in NHS providers, Lord Carter estimates that “savings of up to £5bn per annum by 2019/20”, could be achieved “provided there is political and managerial commitment to take the necessary steps and funding to achieve these efficiencies.” Carter’s £5bn is a good start but it demonstrates the scale of the task. Where will the rest of the £22bn come from?
Work by Monitor highlighted between £10.6bn and £18bn of potential productivity gains through changes to existing services, delivering the right care at the right place at the right time and implementing new ways of delivering care.
Despite social care spending falling by over 15 per cent between 2010 and 2015, contrary to what was set out in the coalition’s 2010 spending review, social care was crowded out by the NHS ‘debate’ during the 2015 general election. Three-quarters of that reduction in spending was achieved by reducing the amount of care provided.
Directors of Adult Social Services have warned of the fragility of the care marketplace. In 2011 when Southern Cross collapsed, banks and big providers rallied around to avoid a business failure turning into a human tragedy. Since then the Care Quality Commission (CQC) has been given new responsibilities in the event of provider failure. However, will the care sector rally around again if fragility turns to failure?
Health and social care are two sides of the same coin, yet the contrast between them is stark. Health funding has increased from £97.5bn in 2010-11 to £116.4bn in 2015-16, a 19.3 per cent increase. Over the same period, social care funding has decreased from £14.9bn to £13.3bn, a 10.7 per cent reduction, and more in real terms when demography is taken into account. We are heading for a shortfall of £7bn a year by 2020, according to the Nuffield Trust.
The over 65s are the biggest consumers of health and care services, accounting for 43 per cent of all emergency admissions to hospital and 44 per cent of planned admissions. For an older person 10 days in hospital can cost them 10 years of muscle loss. A wait of just two days cancels out the benefits gained from intermediate care. The longer a medically fit person lingers in hospital the frailer they become and the more remote the prospect of a return to the life they led before. Put another way, poorly performing hospitals are frailty factories shunting costs onto social care.
What to do?
There is no single reform, nor amount of money, sufficient to ensure we have an NHS fit for 2048. However, as Lord Rose recently argued in his report on ‘Leadership in the NHS’, a good starting place would be clarity of purpose.
The Care Act 2014 offers some pointers. It establishes a new organising principle for adult social care, namely the promotion of individual wellbeing. For too long, the physical, mental, social and relational dimensions of human health have been kept in discrete professional and institutional silos. The promotion of individual wellbeing should become the unifying purpose of public health, NHS and social work.
The Care Act also charged councils with a new duty to prevent and postpone dependency and frailty. This is essential to bend the demand curve for health and care services and it throws down the gauntlet of reform.
In 2012 the Local Government Association (LGA) embarked on an adult social care efficiency programme to devise and test comprehensive and innovative approaches to help make savings, protect services and deliver the government’s vision for social care. As the LGA’s reports document, a new model of social care is developing which focusses on interventions that enable people to recover, and maintain their independence and social connections.
Councils embracing this model have developed a new frontline for their adult social services. For example, in Shropshire the council has set up a social enterprise, People2People. Led by staff and users, it aims to work with its ‘customers’ to identify what is affecting an individual’s life, calling on this deeper knowledge to devise community-based solutions tapping into networks of local support.
This approach means that the council can offer practical support to far more people. A key marker of success is the proportion of these initial contacts that lead to workable solutions. Results are promising: 75 per cent of enquiries are dealt with at this stage avoiding the need for an assessment or an offer of formal help.
A similar approach has been pioneered by Sutton Council’s adult social services. Community social workers have the task of working with people to foster their own support networks, reducing social isolation.
Other councils have tried and tested a range of preventative measures to assist people in crisis, focussing on recovery, rehabilitation and recuperation. Success depends on a joined-up approach both between social services and the NHS, and within the NHS itself.
As well as overhauling NHS commissioning, the 2012 health reforms established health and wellbeing boards to promote integrated working. These boards have had mixed results so far. Some are fulfilling their potential and becoming system leaders shaping local health and care systems around shared goals, addressing the social determinants of ill health. Others have degenerated into talking shops, while some have failed even to find a common language to start the conversation.
The boards should focus on improving the wellbeing – health status – of the population they serve, challenging unjustifiable variation in performance and outcomes achieved.
It is still early days for the boards: evaluation is needed and investment in developing their capability to realise their potential as system leaders. If a transformation fund of the sort proposed by the King’s Fund were established as part of the 2015 spending settlement it should make such capacity building a requirement.
Getting the relationships right, building trust and systems leadership are prerequisites for the kind of devolution now being worked through in Manchester and Cornwall to succeed. While integration is essential to delivering better outcomes and better use of existing resources, it is not sufficient.
Two critical and often overlooked parts of the health and care jigsaw that have much to contribute are mental health and housing.
The independencies of physical and mental health in the management of long term health conditions and in the treatment of such things as heart disease or cancer has not been widely reflected in models of care. It has been estimated to cost the NHS £13bn a year, quite apart from the wider costs to society and the individual.
Appropriate housing can make a decisive difference to a person’s ability to live independently, as research by Aston University for the ExtraCare Charitable Trust has shown. Models of housing with care offer later life choices that can reduce the call on health and care services. This was recognised in 2014 with an agreement between the NHS, LGA and National Housing Federation, and health and wellbeing boards need to reflect this in the way they operate.
NHS England’s Vanguard programme offers an opportunity to prototype new ways of working that bring mental health, housing and social care into the mix. The Vanguards take forward some of the thinking in the Dalton review into options for providers of NHS care. But they must find ways to ensure that the local debates about organisational reform start with clarity about the shared purpose.
Much has been made of the Better Care Fund (BCF), established in April 2015. The fund is the biggest ever pooling of health and care resources. However, it is still a drop in the ocean and its goals, such as hospital admission avoidance and better discharge co-ordination, are short-termist.
A single budget covering all locally commissioned health and care services must be the goal. The BCF could become the vehicle for this, with health and wellbeing boards the driver. The BCF can help to break down the wall between health and care but that is just the beginning. The promotion of individual wellbeing requires bespoke approaches; what better way to achieve integration than at the level of the individual shaped by their lived experience through a personal budget.
A single budget for health and social care calls into question the ‘middleman’ role of the Department for Communities and Local Government, in distributing the social care spending ‘settlement’ reached by the Department of Health and Treasury. This role should be dispensed with and the Department of Health made responsible for a single settlement for health and care, and the settlement should be ring-fenced.
Until there is one shared purpose – a single spending settlement and a single budget – too many opportunities for transforming services and reducing demand for health and care will be missed.
There is a bigger economic case for investing in prevention and new models of care and health. As the number of people of a working, taxable age shrinks or becomes stagnant, causing gaps in the job market, the need to support longer working lives will grow. For many families the pressures of juggling both caring for frail parents and young children can become overwhelming and trigger a decision to quit work or reduce working hours. UK plc can ill afford to lose these sandwich generation workers.
Wellness and care services are a vital part of our economic infrastructure. Access to reliable and affordable household and personal services, including wellness services, can help families to cope and fulfil the wishes of many to maintain the normal patterns of daily living for as long as possible.
Debates about the ageing society tend to pose the questions in terms of ‘them and us’. Rather, we should talk about what we want for our older selves – a life well lived, opportunities to contribute and a good death.
This was first published by the Fabian Society