The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, I join everyone else in thanking the noble Baroness, Lady Pitkeathley, for introducing the debate, which is very important. It is not easy to respond to, to be honest. I acknowledge that there are great pressures on care providers. We saw queues in A&E on the news last night. There are delays in people getting discharged from hospital. In its recent report on adult social care, the CQC found that the market was approaching “a tipping point”. In addition, as has been mentioned, the Autumn Statement did not make any specific announcements on health and social care. So there is no question but that adult social care is under huge pressure. However, that does not mean that we should become so utterly depressed that we do not see that some good things are being done as well. Many councils have risen to the challenge of achieving significant savings while setting balanced budgets, keeping council tax low and maintaining satisfaction in services. The CQC notes that,
“despite increasingly challenging circumstances, much good care is being delivered”,
and there was encouraging evidence that improvements were taking place. Nearly two-thirds of users of social care services have said that they are satisfied or very satisfied.
It is not all bad—there are some bright lights out there. We all know that there are some wonderful care homes, domiciliary care agencies and social care workers. As the noble Baroness, Lady Wheeler, did, I empathised very much with the words of my noble friend Lady Cavendish, who talked about people being “only a carer”. I agree with the noble Lord, Lord Bichard, that in many ways it is the noblest profession, very much unsung. Over time, the care certificate and the living wage will be able to transform some of those roles and give them greater status, as well as providing them with greater pay. In response to my noble friend Lady Cavendish, I say that we are looking at a single data source for data provided by care homes and others who provide social care. Extending the care certificate to volunteers is an interesting idea.
The noble Lord, Lord Patel, raised the issue of Dilnot. It is still our intention to implement Dilnot at the end of this Parliament, as I said in a debate a week ago. It will be interesting to see the results from the noble Lord’s Select Committee. Its views on insurance will be interesting to read.
I want to spend most of my speech talking about the strategic issues that underline the word “integration”, which has dominated our discussions on the subject for many years; I think that the noble Baroness, Lady Pitkeathley, said that she wrote a book on this in 1978. We had case management in the 1980s, inter-agency working in the 1990s, and integrated care pathways in the 2000s. Successive Governments have tried to bridge the gap. With great blowing of trumpets in 2000, the NHS Plan talked about integrating health and social care. The better care fund, which came out of the coalition Government, was the first national, mandatory integration policy. This year, it has a mandated minimum spend of £3.9 billion. Interestingly, it looks as though it will be up to £6 billion through local authorities voluntarily pooling resources into it. There are some examples around the country—I could give details on Northumberland, North East Lincolnshire and Plymouth—of the better care fund resulting in a change. It is not the bureaucratic change referred to by the noble Lord, Lord Bichard, although that is always a risk if you pool resources. If you pool two enormous bureaucracies, you can end up with an even bigger mess than you started with, but there is evidence on the ground that the better care fund is achieving some results. Of course, the Care Act 2014 placed a statutory duty on local authorities to promote integration. So there is no lack of rhetoric on this matter.
These efforts have not been enough, however, and all Governments—the coalition Government, our Government, the previous Labour Government—have to accept that we have brought in other policy changes that have worked in completely the opposite direction. The creation of foundation trusts, brought in by the party of the noble Baroness, Lady Wheeler, the proliferation of CCGs, brought in by the coalition Government, and, of course, payment by results have all had the effect of making the system less joined up and more fragmented and have diverted resources away from community and primary care—exactly where we want them—into secondary care. Integration is still possible in our fragmented system, but it is incredibly difficult. In practice, it requires exceptional leadership, preferably based on long-standing, trusting relationships, which are rare in many parts of the country.
The Five Year Forward View explicitly recognises this. I shall quote from it because it is worth reminding ourselves of the strategy we are embarked upon:
“The NHS will take decisive steps to break the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally … The traditional divide between primary care, community services, and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need. And just as GPs and hospitals tend to be rigidly demarcated, so too are social care and mental health services even though people increasingly need all three … Increasingly we need to manage systems – networks of care – not just organisations. Out-of-hospital care needs to become a much larger part of what the NHS does”.
I think most of us who have taken part in this debate would say amen to that.
Underpinning all this work on integration is the difficult question of relationships between organisations. As the King’s Fund said last November:
“NHS organisations need to move away from a ‘fortress mentality’”,
with individual organisations protecting their own interests at the expense of the system as a whole. This is the classic “tragedy of the commons” in which individual interest destroys collective and community interest. This separation is not just a legal separation, it is budgetary, it is financial, it is institutional and, most importantly and most difficult, it is cultural. These barriers will not melt away overnight, nor will they be transformed by us passing new legislation: politicians should take note of this.
How do we put this into practice? NHS England’s planning guidance for 2016 states that sustainability and transformation plans,
“will be place-based, multi-year plans built around the needs of local populations. STPs will help drive a genuine and sustainable transformation in health and care outcomes between 2016 and 2021. They will also help build and strengthen local relationships”.
Planning by individual institutions for a year in advance will increasingly be supplemented and replaced by planning by place for local populations for a number of years in advance. For too long, the NHS has emphasised an organisational separation and autonomy that does not make sense to staff, to patients or to the communities they serve. The Government recognise, as NHS England recognises, that the process of developing STPs has been easier in places where there are strong existing relationships. As Sir Bruce Keogh says, different areas are starting in different places and they will finish in different places at different times.
Jim Mackey, the chief executive of NHS Improvement, has said that the STPs are a process, not an event, and we expect local organisations to continue to work closely together to address local health and care needs, but the STPs are bringing together health and social care on the ground. They are not perfect and they will not solve this problem overnight, but they are starting to have an impact. Different organisations are sitting down together for the first time ever and thrashing out some very difficult long-standing problems.
The next theme I want to explore is devolution because that probably has the best chance of driving towards better and more integration across boundaries and more widely across the public sector. We recognise that this process will not be easy but the direction of travel is right. To paraphrase Nye Bevan, when a bedpan is dropped on a hospital floor in Salford, its noise should resonate in Manchester Town Hall, not Westminster. Devolution should be seen as more than a shift from central to local government. It should enable communities to be directly involved in designing responsive and personalised services. Devolution will make care more accountable to local people.
The first and probably the biggest of these devolution arrangements is Greater Manchester, which has already been referred to in the debate, with the Greater Manchester Health and Social Care Partnership now taking responsibility for implementing its five-year strategic plan. The chair, the noble Lord, Lord Smith, said only a month ago that,
“the progress we have made has been revolutionary for the region”.
That progress has been made possible by the unprecedented partnership shown by working with all 37 organisations involved. It works because Manchester has long-established and well-respected leadership.
NHS England has agreed that Greater Manchester’s partners should make their own decisions on how to spend their £450 million transformation fund, which covers more than 2 million people. The new governance structure has both strategic oversight for all matters relating to health and social care services and the accountability to make big, bold decisions that can truly deliver the levels of transformation we are seeking to achieve. We are looking for transformation as well as sustainability. The same is beginning to be true for Birmingham and Solihull STP, for example, which is another STP that is led by a director of social services. The foreword to the STP plan states:
“The STP is an iterative process, and this is the start of a longer transformation journey. It’s not a short term plan—this is for long-term, sustainable change over 5 years and beyond”.
So the STPs, for all the shortcomings that some of them have, are a step in the right direction towards bringing together health and social care at local level. Picking up the point made by the noble Lord, Lord Bichard, I believe that over the next few months we will see a much greater involvement of local users and local people in structuring those STP plans.
There are two important preconditions for the success of this programme. First, too often social care is seen as the poor relation or simply as a means by which we can reduce demand on the NHS. This is to hugely undervalue and undermine the contribution that those working in the service make to the well-being of users, and the importance of social care services in their own right. Any approach to integration that fails to recognise this and instead seeks to draw in social care services just as a means to reduce NHS demand cannot be right. So when we consider how best to bring health and care services together, it is important that local areas fully appreciate the role of social care and the spectrum of services it provides. It would be wholly wrong to see social care solely as a means to reduce A&E admissions or delayed transfers of care from hospital.
Secondly, we need to be careful not to fall into the trap of thinking that better health can be secured just through integrating health and social care services, when in reality the factors that contribute to a person’s health are much more complex and wide-ranging than those within the scope of health and social care alone. The Marmot review and many other commentators since have been clear that health inequalities arise from a complex interaction of many factors—housing, income, education, deprivation, social isolation and disability—all of which are strongly affected by a person’s economic and social status and well-being. Plans to integrate services around people’s needs should consider the wider determinants of poor population health and factor them in.
The five-year forward view sets out a non-partisan strategy for what needs to be done to ensure NHS sustainability and drive improvements in the health and social care system. The STPs are putting that plan into practice. I accept, as I did at the beginning of my speech, that this is taking place against a very tough financial background. Some will argue that it makes it more difficult; I would argue that change will happen only if organisations are forced to change in order to survive. Change is necessary to meet the needs of today’s population in a way that delivers care that is both better and affordable.
I have not given up hope at all on this. The short term does look bleak and I acknowledge the huge pressures on social care—but, for the first time, we have a strategy that is actually being put into practice. It will not deliver all that we need to do in the space of two or three years, or even within the length of the five-year forward view, but if we can show that it works in some parts of the country, we have a much stronger hand to go back to the Treasury and say, “We need some more money to finance these STPs”. But we have to show that it can work at some pace and to some scale.