NHS: Better Care Fund

Baroness Brinton Excerpts

Thursday 3rd July 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I congratulate the noble Lord, Lord Kennedy of Southwark, on securing this debate about the better care fund. This is probably a timely moment to pause and reflect on new routes to integration in the health and social care sectors, but we need to do so with some caution. It is too early to see the implementation of the first round of approved projects to its conclusion, and of course both local council and health budgets are under serious pressure, as all speakers so far have indicated. We also cannot expect full integration without being honest about the cost. It will be interesting to see what emerges in the manifestos of all the parties in the run-up to the next general election.

Still, I am pleased that the coalition Government are determined to see a real start to full integration in health and social care. There has been much lip service paid to it over the years but a marked reluctance by everyone, from politicians in Parliament to local authorities, the NHS and front-line staff, to make it happen. I suspect that this has been for a number of reasons.

First, there is the perception that there is financial competition between the two sectors, each worried about not losing funding to the other. Secondly, financial mechanisms are in place that inadvertently discourage integration. Reports from some areas show that this is a serious issue. Thirdly, which is the most important, the two cultures—social care, whether local government or private providers, versus health—could not be more different. I do not think that the NHS would define itself as naturally entrepreneurial; and it takes a long time to change its ways of working. There have been some major crises recently where we are now seeing wholesale changes in the way we work, as exemplified by the Francis report. The social care sector is a mixed economy, with public service providers working alongside large and small businesses and social enterprises—not just a different model to health but a different model within social care. Therefore it is completely understandable that dialogue at the start of this major project is difficult. But there is progress.

Before turning to that progress, I want to give you one story that absolutely illustrates why we need integration. The aunt of a friend of mine, who lives in Bradford, was receiving both health and social care support at home, which was important because it meant she could live independently. One of her issues was ulcerated legs, with one leg much worse than the other. The bad leg was being treated by the district nurse on daily visits. The better leg was checked and put into support tights by her domiciliary care worker. As a result of cuts made by the Labour-controlled council, all domiciliary care classed as moderate needs was cancelled, including hers. Can noble Lords guess what is coming? Under the local PCT rules the district nurse was not allowed to help with the better leg, so this elderly and vulnerable woman had to rely on a male elderly neighbour to put the special support tights on her leg last thing at night. You see, one leg was NHS and one leg was social care. That was until the better leg deteriorated to the point at which the district nurse was permitted to come in and dress that one too. Honestly, you could not make it up.

That is at the front line; it is not the district nurse but the person in the PCT who is setting down the rules. That sort of behaviour in commissioning makes an absolute mockery of integration. That is what I mean by the clash of two cultures. There are other stories of silo thinking. In some areas there is very little discussion between social services staff and health professionals such as physiotherapists and occupational therapists. Patients are referred by physios and OTs, but there is not a continuing dialogue. One physio recommended an electric wheelchair for a patient, on the basis that this would keep her fully independent, but the wheelchair department’s rules are so strict that the patient did not meet the stringent requirements. As a result, the local authority had to offer a carer to come in to help get her up in the morning, costing both the patient and her council much more money than an electric wheelchair would have cost.

That is enough of the difficult stories. Of course, there are shining examples: not just in Torbay, but in Cambridgeshire and other places. I ceased being a councillor in Cambridgeshire 10 years ago, but even then we had a joint trust between health and social services, as it was in those days, to really start to change the funding. The money was pooled and attitudes really started to change.

We need to hear what these good examples are doing, but also to understand why they work. Unless commissioners and finance directors understand the benefits of integration, there will be a reluctance to move away from the current model. The Bradford case illustrates the point perfectly. Three more minutes of the district nurse’s time would have prevented the better leg from deteriorating and thus costing the NHS more in the long run. Therefore, while there are any cases such as the Bradford one we are nowhere near integration. That is why the extra money from the Government for integration—the £2.7 billion to councils to join up with health and social care providers, as well as local authorities’ extra £100 million this year and an extra £200 million next year—is so vital.

I was delighted to learn from Lib Dem councillors at their annual conference last weekend that the LGA estimates that councils have more than match-funded the total money of £3.8 billion for next year, 2015-16, taking it to £5.4 billion. However, the cost of this means that councils are now spending 35% of their total budgets on social care. Therefore support from central government is essential and I do not believe that we can wait until next year for that to happen.

Personally, I somewhat regret the debate about NHS money being taken by local government. I am sorry to disagree with the noble Lord, Lord Turnberg, but I think that changes in practice will reduce the costs of acute care. Indeed, the noble Lord, Lord Kennedy, referred to amputations for diabetes sufferers in this regard. That is exactly the sort of invest-to-save cost that we should be seeing with the better care fund—for example, spending on preventive care to avoid trips and slips, and in ensuring appropriate support at home for patients being discharged to reduce the “revolving door” syndrome whereby patients return to hospital in a few days. Spending on all those initiatives would help to reduce the crisis in acute care and help to reduce the pressures on its budget.

Where integration is working well, there would not even be an issue about whose money it is, not least because the better care fund plans have been jointly signed off by not just local authorities but clinical commissioning groups and health and well-being boards. Plans have also had to demonstrate how local providers have been engaged. Adult social care services have to be at the heart of the integrated system, supporting health in everything they do by improving hospital discharge and bolstering reablement services.

We have to explode the myth that the better care fund was never intended to solve the financial problems in local government and parts of the NHS. That is one of the reasons why population changes are adding £400 million to council social care budgets every year and why, frankly, budgets must be looked at in this current year. Therefore, will my noble friend the Minister say whether the Government are looking at providing support for the health and social care sector before we even get anywhere near winter problems this year? That is absolutely vital.

I believe that the better care fund is right for the nation’s finances. Investing to save rather than saving to invest is the right thing to do. I believe that in the longer run we need a transformation fund to help the culture change and ease the impact of all the changes that we are talking about, but it must have targets, too, and peer support—something which local government is very good at. The introduction by the Labour Government of the Improvement and Development Agency really helped transform councils that were in trouble and helped with the ground-breaking changes in many council services. It would be good to see that stretched into health and other sectors, too.

In conclusion, I am pleased that the better care fund is now getting well and truly under way but am slightly concerned that NHS England seems to be changing the criteria for targets for the first round and hope that that will not delay the implementation of any of the projects. That must not continue. We will be nowhere near full integration until health and social care for older people in this country are fully funded.