28 / 02 / 2017
Health and social care integration
National Audit Office, February 2017
This report from the National Audit Office (NAO) assesses progress towards the integration of health and social care. It finds “no compelling evidence to show that integration in England leads to sustainable financial savings or reduced hospital activity”. Looking specifically at the Better Care Fund (BCF) it finds that many of the metrics used to monitor success went in the wrong direction during its first year. The NAO recommends that national bodies should establish a better evidence base for integration, review whether current approaches are the most likely to achieve desired outcomes and put in place national structures to align and oversee integration initiatives.
The report begins by looking at the evidence on the effectiveness of the integration of health and social care. It is found to be lacking, in terms of both the clinical impact and cost-effectiveness of integration initiatives. The NAO observe that international examples of successful integration do exist, but these initiatives exist in the context of very different health and social care systems to our own and may not be replicable in the English NHS.
Looking at specific recent approaches to promoting integration, the report assesses the progress of the BCF. This programme seeks to reduce demand for hospital services through the pooling of health and social care budgets. In its first year the BCF performed poorly against many of its performance metrics:
- Plans aimed for a reduction of 293,000 delayed days, saving £90 million. In fact delayed days increased by 185,000 at a cost of £146 million more than planned.
- Local areas planned to reduce emergency admissions by 106,000 across the year, saving £171 million. In fact emergency admissions increased by 87,000, costing £311 million more than planned.
- There were also some improvements – permanent admissions of older people to residential and nursing homes reduced to 628 per 100,000 population. Also, the proportion of older people still at home 91 days after discharge receiving reablement or rehabilitation services increased to 82.7%. Both were above target.
Moving on to the Integrated care and support pioneers programme, the report quotes an early evaluation which stated that areas were making “slow progress in implementing their plans” and some were scaling back their ambitions, with little evidence found in the pioneers of major services changes or measurable impacts. Significant barriers to integration, including perverse financial incentives, workforce challenges and information sharing challenges, were still in place and required attention at a national level.
The new care models programme, put in place to implement the Five year forward view, also contains ambitious assumptions. It aims to achieve £900 million in savings by 2020 and a reduction in growth of hospital activity from 2.9 per cent per year to 1.3 per cent per year by 2020/21. This programme has not yet been evaluated, so no conclusions can be drawn about either delivery against these assumptions in the vanguard areas, or whether the plans can be replicated in other areas.
Looking to the future, the report notes that the BCF will continue until 2019/20. In parallel, Sustainability and Transformation Plans (STPs) are being refined, although the report notes that much of the money set aside to fund them is being used to meet deficits and sustain current services. Long standing national barriers to integration remain and national bodies have been criticised for their lack of oversight over the range of integration initiatives currently in operation.