What next for health and social care in England?

The King's Fund is today launching a major review of health and social care under the leadership of an independent commission chaired by Kate Barker. The context for the review is a population in which people are living longer but often with long-term conditions, such as diabetes, heart failure and dementia. An increasing number of people have both health and social care needs, and the division between the NHS and social care that was established in 1948 means it is not always possible to meet these needs in an effective way.

We have therefore asked the Commission on the Future of Health and Social Care in England to consider whether the boundary between health and social care should be redrawn by revisiting the post-war settlement and asking fundamental questions about whether it is still fit for purpose. This includes examining how the NHS and social care are funded and organised, and what the alternatives might be to current arrangements. We have also asked the Commission to consider the different entitlements to these services, and whether now is the time for these to be changed. This includes addressing the thorny question of the role of the state and individuals in paying for health and social care.

Recognising the importance of these issues, the Commission will work over a period of 15 months, producing an interim report early in 2014, ahead of its conclusions and recommendations in September 2014. It will be supported by Richard Humphries and Nick Timmins in the Fund and will draw on internal and external expert analyses. The Commission will also be issuing a call for evidence early on in its work and will be engaging with stakeholders to test ideas and options as they emerge.

The decision to establish the Commission grew out of our work on the future of health and social care in our Time to Think Differently programme. In this programme we have argued that new models of care are needed in which there is less emphasis on hospitals and care homes and greater priority is given to supporting people in their own homes and in the community. Care in future also needs to be much more integrated – with boundaries between physical and mental health, primary and secondary care, and health and social care broken down. The Commission will be exploring whether radical changes are needed to make a reality of these new models of care.

The financial and service pressures currently affecting health and social care add urgency to the Commission's work. With the prospect of several years without growth in the NHS budget and further cuts in the funding of adult social care, it is essential that all options for using scarce public resources more effectively are considered. This includes looking beyond health and social care to ask whether other forms of public spending could be drawn on to meet growing needs for support, as well as reviewing the balance between public and private funding of care. The experience of other countries will be used to inform the Commission's thinking on this.

The broad scope of the Commission sets it apart from similar reviews already underway. The commissioners have been given a free rein. They could conclude that radical changes are needed, but equally they may decide that it would be preferable to make the existing system work better. The Commission will succeed if it produces evidence to inform debate ahead of the 2015 General Election and is able to influence the decisions of the next government on what needs to be done to secure health and social care for the future.

Comments

Having been under the treatment of a fantastic teaching hospital in York as an emergency, the referral and incompetence of the NHS hospital where I live in Hampshire was astounding! I am thankful that I am not old so ...., all I can say is that
"whilst there is a need to address the joining up of H&SC, why not tackle the complete bureaucracy, incompetence and duplication of effort in our hospitals, free up the cash and then address the joining up of services!"

I have a great deal of sympathy for Caroline Rutter's comments. My only point of disagreement is with the "most hospices don't want to care for people with dementia" remark. Good end of life care should be age blind and diagnosis blind. If someone is dying and the goal is to give them a dignified death free of pain and distress or trauma to their loved ones, we should be aiming to offer this to all, whether they have cancer, heart failure or dementia and whether they are young or old. Its just a shame we don't have enough hospice places to care for everyone who could benefit. And that many of them are still reliant on charitable funding when they do such great work. Palliative care shouldn't be age discriminatory. And i have never yet found specialist palliative care nurses who treated patients any differnently on grounds of age or diagnosis. They are uniformly excellent

david oliver

The last 40 years has seen a transformation in the role of nurses. Our language has not, however, kept pace with that change. Most nurses do not see their role as caring for patients but managing systems, whether in intensive care, managing dialysis, being nurse practitioners or managing staff on a ward etc. The care assistants far too often see no care to assist with and learn that care is not needed nor valued and do not have enough training, a career path or the motivation for improvement. Even district nurses have changed their own role and aspirations without the NHS and the Care System having recognised that they have stepped back from a lot of what they used to do. There is no-one who has stepped into that breech. This has left families in a position where they are forced into putting loved ones into Care Homes prematurely.
If this Commission could clarify the roles (and training ) of those offering nursing and care with a clarity of language about what care assistants assist with, what live-in carers, family carers and care homes should be able to cope with and what they need help with (possibly from a new specialist group that the current nursing profession does not provide for) it will make a good start. Then we might be able to look at the design of a Home Health Service which understands the challenges it has to meet.
The Commission could also look at the need for specialist training in dementia nursing which does not appear to exist yet. For nurses (or even carers) to be able to to assess the decline in the swallow reflex as stroke and dementia patients near the end of life it would help with the timing of the introduction of thickened diets and the avoidance of aspiration induced pneumonia.
With hospices generally not wanting to be filled with dementia patients, an end of life pathway for them may be an appropriate issue for the Commission to address as well. At its foundation the NHS was designed to treat disease and cottage hospitals as places to die in were regarded as redundant - and therefore closed. In looking at the interface of health and social care the enabling of 'good deaths' must be planned for rather than ensuring 'bad deaths' by default.

Goodness, strong stuff to the casual observer.

To what interest our minority perspective may provide;

For those traditionally left substantially out by both health and social care, the future surely has at least as much potential inclusion as the past has had exclusions.
However, it seems that the time is right now. Groups like ours are working to ensure that, whilst inevitably we are still on the margins, we can perhaps also be at the cutting edge. If whatever change the future holds, in terms of integration and a shift to 'community based' rather than institutionally based care, can be made to work for most traditionally excluded groups at the outset, it will most likely be relatively easy to adjust to for the 'usually included'. But, if the 'usually included' take full control of the cutting edge, they will use it to eat all the pie as, one might say, usual.
Regards all

Dear Andy

i am not sure i buy this. The kings fund has frequently criticised government policy. The review "health policy under the coalition government" or the "never again" book are highly critical, as is my recent blog on "managing expectations in healthcare" (though i am equally critical of management consultants and private healthcare providers). Nick Goodwin before he left the fund clearly shared my impatience with the telecare/telehealth infomercial (see by the way today's latest null trial of WSD in "age and ageing"). With regard to dignified care for older people, the Age UK/NHS confed "delivering dignity" commission or the kings funds own "care of older people with complex needs" report made very clear criticisms of organisational leaders and leaders of professional organisations such as RCGP/BMA etc are often more than happy to be combative and outspoken. I do believe we have a current "great and good" which is a combination of NAPC/NHS Alliance/management consultants/private health providers and their lobbyists/some former ministers who are pushing a "new orthodoxy" around plurality, private provision, care outside hospital, telehealth/telecare which flies in the face of what is actually happening in frontline services and emergency care. But even here, the fund have challenged the prevailing view. So who are "the great and the good"? I am not sure i know

David

I am sceptical about the vehicle of another commission of the great and good - will it really lead to 'different' thinking? One of the requirements of becoming a member of the G&G is that one does not rock the boat and works within the system. This inevitably sets boundaries to what is considered 'thinkable'. I am not sure that the answer will be found inside this perimeter.
I would urge your panel to read the valedictory lecture given by Sir Alan Langlands to the Nuffield Trust reflecting on his time in office: you could substitute 'social care' for 'education'.
Soon it will be time to consider that the NHS is now the greatest impediment to a good future health service for this country whilst recognising that the people struggling within it are our greatest asset?

Given that adult social care spending is being heavily squeezed, and since it is normally a small proportion of NHS adult spending in any locality, isn't this the time to finally grasp the nettle of the split between NHS and Adult Social Care?

Successive Acts and policies over at least the 40 years of my experience have required health and social care to work together. Some places manage to do this really well, most muddle through, a few are desperately bad.

Why not put the total responsibility for all these services into the NHS?

This is the time to ask the impossible questions, what have we got to lose? Failing to ask the impossible questions will just get us more of the same, from a smaller budget - no thank you!

The Mid Staffs enquiries, factors surrounding the Ubani case and Barrow hospital are three cases that seemingly represent the tip of an iceburg when one looks at some of the cultural challenges that pervade the Health and Social care system.

There are pockets of good work and plenty of initiatives, yet there are also strong conservative, resistant, and negative forces which militate against such good work.

Dr. Kadiyali's comments have an intensity that send a chill through the spine of anyone working genuinely in the sector and it seems we are yet to hear further in July as the story unfolds.

Time to Think Differently does capture the imagination and feed the optimism of the likes of me !. The key must be in range of steps that address the huge volume of older people being admitted to acute hospitals with preventable conditions, events and accidents (falls, LTC exacerbations and a general failure of care packages). I am leading work in Devon in developing a Quality Kite Mark for dementia care and we are developing a programme of work that has considerable momentum and that is attracting a lot of external interest from other region wide localities and CCGs, organisations and UK wide programmes - these ideas need to be shared and rolled out based on improvement, collaboration through peer review, best evidence and most crucially - likemindedness in sharing risk and KPOOH / GPOOH - keeping and getting people out of hospital - contact me by all means to find out more

Time to Think Differently, sounds interesting, but do you know the NHS managers will not only harass, bully but also get the coffin ready to burry doctors who suggest changes?

Please do not make statement about healthcare, changes and doctors if you are not a doctor like me who has worked with very sick children in hospitals and community in the last 30 years.

It may be very difficult for you to understand what I am talking about too if you are not a doctor. You will hear about me in July or get to see all the documents I have to help prove my point