Future of Health and Social Care in England

14 July 2014

The British Geriatrics Society is the professional body of specialists in the health care of older people in the United Kingdom. Membership is drawn from doctors, nurses, allied health professionals, scientists and others with a particular interest in the care of older people and the promotion of better health in old age. It has over 2,800 members worldwide and is the only society in the UK which draws together experts from all the relevant disciplines in the field. We write here to respond to the Interim call for Evidence from the Commission for the Future of Health and Social Care in England.

In compiling this response we also collated and included comments from the OPTIMAL research grouping , a group of leading health and social care researchers who are currently considering optimal models of healthcare commissioning and provisions in care homes as part of a National Health Institute of Health Research-funded study.

The commission set the following questions:

Do you agree with our conclusion that a new settlement in health and social care is needed?

Yes. There is considerable evidence that the existing settlement in health and social care does not meet the needs of care recipients and results in poorer health outcomes, inequity, inefficiency and additional costs, which are to the disadvantage of society as a whole . Older people with frailty, as both the most frequent and intensive users of care services, both health and social, are disproportionately disadvantaged by the current settlement. This represents a form of tacit ageism, which is unacceptable in a progressive society that renders explicit ageism illegal through legislation.

If so, do you support our proposition for a single, ring-fenced budget for health and social care that is singly commissioned, and within which entitlements to health and social care are more closely aligned?

Yes. Older people with frailty make up the majority of users of health and social care and account for the bulk of expenditure in both sectors. The evidence-based model of assessing and caring for this cohort is comprehensive geriatric assessment (CGA), which has been validated in randomized controlled trials and several large systematic-reviews and meta-analyses , . CGA recognises the need to assess all domains of wellbeing (frequently defined in this context as physical, mental, functional, social and environmental) taking advantages of multiple disciplines (a core team of nurse, social worker, occupational therapist, physiotherapist and doctor, with other disciplines included as needed) to establish an individualised, needs-driven, patient-priority focussed, co-ordinated plan of care . This plan is then iterated and case-managed forward. It is one of the models of integrated care. People with frailty who are assessed and managed in this way have better outcomes in terms of being less likely to die, less likely to be disabled, less likely to experience cognitive decline and less likely to be admitted to hospital.

Attempts to establish comprehensive geriatric assessment in clinical practice are confounded by the inability to pay for and commission services that allow those with the appropriate expertise, roles and responsibilities to work together in a co-ordinated fashion. Separate financial and governance infrastructures within health and social care bring competing priorities and counteract the ambition of front-line staff to work as teams to focus their efforts around vulnerable individuals. Bringing health and social care funding and commissioning together would go someway to overcoming these limitations.

The OPTIMAL group highlighted that, whilst integrated budgets are an important foundation to improving the disconnect between health and social care, the research evidence suggests that they are not sufficient to establish integration as a single measure. Taking the example of health care provision to care homes, where there are multiple providers it is unlikely that necessary organisational restructuring could arise from single budgets. More promising would be the development of - and investment in - processes of care that could identify shared priorities, were older people specific and created an expectation that services and practitioners address the patient/user experience of care and measure impact from the perspective of continuity of care, access to services and user/patient/representative involvement in decision making.

Should the aim be to achieve more equal support for equal need, regardless of whether that support is currently considered as health or social care?

Much of this is covered in our response to the preceding question. Models of integrated care – of which comprehensive geriatric assessment is a coherent, well-described and evidence-based example – do not recognise a distinction between “health and social” care priorities. They simply identify care priorities and arbitrary division of these into “health” and “social” adversely influences care planning. Multidisciplinary teams are forced to deliver care along lines driven not by a logical order of priorities, or even a patient preference-driven order of priorities, but by the art of the achievable within the arbitrary framework of health and social care with their discrete, separate, and sometimes competing funding and resource priorities. Given that health and social care are so closely interlinked in this group, break-down in one can result in increased need for the other.

Patients don’t see a care need as “health” or “social” they simply see a care need. The evidence-based models of assessment, similarly, do not distinguish between health and social care. The imposition of a distinction by a system of commissioning and provision of care delivery is therefore inappropriate, arbitrary, inefficient, non-evidence based and unfair.

If so, should social care be more closely aligned with health care (that is, making more social care free at the point of use)? Or should health be aligned more closely with social care (that is, reducing the extent to which health care is free at the point of use)?

The principal of “free at the point of care” is an ideal accepted across the political spectrum and stated as central to the future of health care delivery within England by all major political parties at the last general election.

It is also a pragmatic model of care delivery – particularly in the context of older people with frailty, who comprise both the majority of the users of health and social care resources, and account for the bulk of expenditure. Coping with increasing frailty, morbidity, functional dependency and cognitive impairment is emotionally challenging for patients and their carers. In addition dementia, increasingly the most prevalent cause of disability and dependency in older people , frequently impairs the capacity of vulnerable older people to make decisions about where their care should be delivered, who should deliver it and how they should – and can – pay for it. Necessary legal frameworks in place to protect people who lack mental capacity from abuse – namely the Court of Protection, Lasting Power of Attorney legislation, safeguarding and Deprivation of Liberty safeguards – mean that families of people with dementia often have to negotiate difficult financial and legal frameworks in order to pay for basic care. The imposition of means-testing brings with it an assessment framework – the Continuing Healthcare Needs Assessment – which is superimposed on clinical assessment models and comes with attendant delays and additional physical and emotional burden for vulnerable people and their carers. This leads to delays both in and out of hospital and undoubtedly contributes to inappropriate admissions to, and bed-occupancy within, acute hospitals.

In summation, imposing a large burden of assessment at the point of maximal vulnerability – when a need for social care becomes identified – results in undue stress and suffering at an individual level and delays, inefficiencies and bureaucracy at a whole service level. Taking the burden of financial assessment away from the equation at this time, allowing an appropriate focus on assessment of health and social needs to drive care, rather than the financing of care, would be likely to result in considerable efficiencies as well as being more humane and human.

Do you think that adequate funding for health and social care requires:

  • increased charges in the NHS? If so, for what?
  • increased charges for social care? If so, for what?
  • cuts to funds from other areas of public spending, re-allocating it to health and social care? If so, from what?
  • an increase in taxation? If so, which taxes would you favour increasing?
  • none of the above? If you answer yes to this, is it because you think that funding for health and social care system is adequate, and that extra demands can be met by using existing resources more efficiently? Or is it for some other reason?

The evidence presented by the Commission is compelling. Health care within the UK is adequately, or close to adequately, funded. Social care is underfunded. The care needs of older people with frailty are distributed across health and social care, whilst the care needs of many younger people with acute or long-term conditions are delivered primarily within the footprint of healthcare, this represents a form of tacit ageism. Those with the greatest need have the least adequate funding for care, as a greater proportion of their care need is arbitrarily defined as “social”. If the budgets for health and social care are to be combined into a ring-fenced and singly-commissioned fund predicated for care provision, then total resources allocated to care will have to increase. As already established, charging for care at the point of delivery is an inefficient and, potentially, inhumane way to approach the challenge by asking people less able to make financial decisions to make them at a time when they are already under considerable emotional distress (and often physical stress as a consequence of illness precipitating decline).

The most logical way to pay for care is, therefore at a point in the life-cycle when people are less encumbered by the imposition of disease and disability. This would have to be by either additional taxation or by payment into a predicated health and social care insurance fund, which could be either state-run or operated by private providers.  

Other points

Care homes are the predominant mode of delivering resident long-term care within the UK and are likely to be part of the care spectrum for the foreseeable future as, even under a best-possible case scenario where some compression of morbidity mitigates against the effects of population ageing, there will always be a cohort of older people who, by virtue of medical instability, overwhelming multimorbidity, cognitive dysfunction with behavioural symptoms and/or social isolation can no longer be cared for within their own homes.

Care home residents represent a potent example of how the arbitrary cleavage of health and social care leads to uncertainty regarding roles and responsibilities, to the extent that residents end-up paying for social care driven by medical pathologies, whilst receiving inadequate medical and healthcare support , .

Best practice models , , again suggest that integrated models of working, for example comprehensive geriatric assessment, have a potent role to play in driving up standards by ensuring that care is expert, comprehensive, iterative and focussed on individual needs. A challenge in this setting will be the recognition that “hotel and accommodation” services are integral to care delivery and directly impact upon the health and social care offering. We would suggest they are regarded as part of the “total care package” and that further arbitrary distinctions are not introduced into the debate by seeking separate “care” from “accommodation”.

The OPTIMAL group highlighted the need to develop models of financing and financial management that take account of the prevalent frailty and cognitive impairment present in advanced old-age, rather than to adapt or cross-apply those used in younger, more functionally-independent groups. Taking the example of personal health budgets as a case in hand, whilst these promote autonomy and independence in deciding what care priorities should be, this is likely to be less useful in those people who lack capacity and have nobody to advocate or act as power-of-attorney on behalf. What models of financing can be put in place to provide these patients with a measure of autonomy equivalent to that seen in younger, more independent cohorts?

We are happy to consult further on any of the issues raised in this letter and look forward to the outputs of the Commission both with great interest and considerable hope for a settlement which will more equitably deliver care to our core constituents, the most frail and vulnerable members of society.

[1] The OPTIMAL Group are Prof Claire Goodman, Prof Steve Iliffe, Prof Finbarr Martin, Prof Clive Bowman, Prof Tom Dening, Prof John Gladman, Prof Justine Schneider, Prof Christina Victor, Prof Julienne Meyer, Prof Heather Gage, Dr Adam Gordon, Dr Sue Davies, Dr Maria Zubair, Ms Mel Handley.

[2] Oliver D, Foot C, Humphries R. Making our Health and Care Systems fit for an Ageing Population, available online at http://www.kingsfund.org.uk/publications/making-our-health-and-care-systems-fit-ageing-population

[3] Ellis G, Whitehead Martin A, O’Neill D, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst. Rev. 2011.

[4] Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2008;371:725–35. doi:10.1016/S0140-6736(08)60342-6

[5] Welsh TJ, Gordon AL, Gladman JR. Comprehensive geriatric assessment - a guide for the non-specialist. Int J Clin Pract Published Online First: 7 October 2013.

[6] Living well with dementia: a national dementia strategy : implementation plan. Department of Health 2009

[7] Carter C. Failing the Frail: A Chaotic Approach to Commissioning Healthcare Services for Care Homes. Br Geriatr Soc available online http//www.bgs.org.uk/index.php?option=com_content&view=article&id=1907cqc-report-too-many-failing-hospitals&catid=6prindex&Itemid=99 (last accessed June 18th, 2012).

[8] Robbins I, Gordon A, Dyas J, et al. Explaining the barriers to and tensions in delivering effective healthcare in UK care homes: a qualitative study. BMJ Open 2013;3.

[9] British Geriatrics Society. Quest for Quality: British Geriatrics Society Joint Working Party Inquiry into the Quality of Healthcare Support for Older People in Care Homes:A Call for Leadership, Partnership and Quality Improvement. London: British Geriatrics Society 2011.

[10] BGS Commissioning Guidance - High Quality Health Care for Older Care Home Residents, available online at http://www.bgs.org.uk/campaigns/2013commissioning/Commissioning_2013.pdf (last accessed Jan 20th, 2014).