Oral evidence: The interface between health and social care, HC 1376
Oral evidence, 18 July 2018.
Witnesses
Sir Chris Wormald, Jonathan Marron, Jo Farrar and Simon Stevens.
Chair
Good afternoon and welcome to the Public Accounts Committee on Wednesday 28 July 2018. We are considering two National Audit Office Reports. One is about the interface between health and social care, which has been a perennial issue for us as a Committee and is now at the heart of Sir Chris’s Department—the Department of Health and Social Care. The other is on NHS vanguards. We have looked at both of them before. We think it is an important time for us to get a flavour and put some markers down about how this is progressing, given that we have now been discussing these issues for a long time—at least my length of time in Parliament, and I think Sir Geoffrey and Caroline Flint would concur from their longer service in Parliament. There are number of structural, cultural and financial barriers to full integration. We have heard from Simon Stevens a number of times before that, whatever money is going into health, it does not work without the social care element. We are hoping to tease out some of these broad challenges and get some candid answers from our witnesses about what the problems and barriers are, and how the team assembled in front of us will help the Government and the country to tackle this. I want to introduce the witnesses from my left to right. Simon Stevens is the chief executive of NHS England. Jonathan Marron is the director general for community and social care at the Department of Health and Social Care. Mr Marron is it your first time in front of us?
Jonathan Marron
It is my third, actually.
Chair
Forgive me. I suppose some people might say that not being remembered by the Chair is not always a bad thing. Clearly, you acquitted yourself well on the last occasion. You are not on our dartboard yet. Sir Chris Wormald is the permanent secretary at the Department of Health and Social Care. Jo Farrar is the director general for local government and public services at the Ministry of Housing, Communities and Local Government, and previously a senior person in local government as a chief executive, so she knows that sector very well. As I say, we are hoping for short and candid answers. We think the country is moving broadly in the same direction on this. You are at the heart of delivering it, so we are keen to hear from you how that will work. In order to get some of those answers, I will ask Anne Marie Morris to kick off.
Anne Marie Morris
Sir Chris, to make this change—this integration—work, do we need new legislation?
Sir Chris Wormald
As the National Audit Office’s excellent Report on the subject sets out, there is a whole range of barriers, some of which, as we have discussed with this Committee before, are rooted in the legislation and accountability system, but an awful lot are not.
Chair
Do you need more legislation? That was Ms Morris’s question.
Sir Chris Wormald
That—this question always comes up in the Committee—is not a matter for me. We work with the legislative structure that we have, and we seek to maximise—
Anne Marie Morris
As I understand it, we’re responsible for reporting on it, but none the less, even as a civil servant, you are responsible for the efficient use of taxpayers’ money to deliver policy.
Sir Chris Wormald
Yes, of course.
Anne Marie Morris
So if it’s not working, it surely is your responsibility to say to the Minister, “Actually, wouldn’t it be more efficient if we had just one regulation rather than three and duplicate reports?”
Sir Chris Wormald
We are obviously not going to talk about what policy advice we give to Ministers. For the purposes of this, we take the legislative structure as it is and ask ourselves the question how we can do best within it. Now, that said, we have made public, as part of the long-term plan for health that we announced, that we would ask our colleagues in the national health service whether there were legislative options they wished to propose for Parliament to consider—
Chair
So the answer is broadly yes, but we could have got to that a bit quicker. It’s a hot day; we all have an interest in whipping through the business as fast as is practical.
Anne Marie Morris
Mr Stevens, what do you think? What would you like to see?
Simon Stevens
I think there would be benefit in making some adjustments to the statutory framework that the health service is operating under, and in response to the invitation from the Prime Minister and indeed from the Health and Social Care Committee, we will use the opportunity presented by the—
Anne Marie Morris
So what might you suggest? Do you agree that we have got a duplication of regulator?
Simon Stevens
Between health and social care, or—?
Anne Marie Morris
Across NHS and social care, and we’re looking to integrate. We’re reporting to a number of different regulators and sometimes the same information is going to different regulators, which is surely duplication.
Simon Stevens
We want to use an inclusive process as we develop the long-term plan to substantively answer the question. I don’t just want to come here today and provide you with the complete list, because that’s going to be a consultative engaging process, probably between November and Easter.
Chair
Between November and Easter, you’re saying?
Simon Stevens
Yes. Our thought is that the long-term plan that the Government have asked the NHS to produce would be produced by the end of November. As part of that, the question will arise, “Are there aspects of the current legislation that, if they were amended”—by yourselves—“would accelerate our progress or enable us to move some of the things that are otherwise harder?” So, between November and Easter is probably the point at which, with colleagues from across the NHS, we will work up options for you to consider.
Anne Marie Morris
Mr Marron, you’ve got responsibility for social care. Don’t you need a 10-year plan as well and shouldn’t you be aligning things?
Jonathan Marron
As you know, we have promised the Government a Green Paper on social care. We have delayed that to the autumn.
Anne Marie Morris
But it’s only adult social care. What about children and those of working age?
Jonathan Marron
Children are the responsibility of the Department for Education. Our Green Paper will cover adult social care as a whole. The Green Paper will set out particularly the approach to funding care for older people, which has been the subject of much debate.
Anne Marie Morris
But that doesn’t include the working age, does it?
Jonathan Marron
And I think we will broadly include, “What do you think the future of social care policy is?” There are lots of things we’d like to do—integration, how we drive quality, how you measure performance—that are applicable to both working-age and older adults. So I think we’ll have a broader theme in our—
Anne Marie Morris
And will you be talking to Mr Stevens, so that you actually look at reducing bureaucracy rather than increasing it?
Jonathan Marron
We have delayed the Green Paper until November, so that we can line up with Mr Stevens on the work of the long-term plan, so we get a joined-up piece of work.
Anne Marie Morris
Presumably you’re talking, because it’s already there; it’s just not been assimilated. Yes? So, are you talking about changes of regulators?
Simon Stevens
In the NHS, you’re talking about—
Anne Marie Morris
I’m talking about both.
Sir Chris Wormald
Just on regulators, that is one of the areas that is integrated. The Care Quality Commission is the inspectorate for both social care and for—
Anne Marie Morris
But only for providers, not for commissioners. The commissioners in local government—
Sir Chris Wormald
At the moment, we don’t inspect commissioners at all. There are lots of issues around health and care integration; I don’t actually think the inspection of regulation is one of them at the moment.
Anne Marie Morris
So you’ll just leave the regulation as it is, because the CQC don’t agree with you?
Simon Stevens
The CQC has done these thematic reviews and it has suggested that there could be changes to its remit which, as Chris and Jonathan imply, will be well worth looking at, but that is not the same as saying that we don’t have a single inspectorate for adult social care and for the NHS, because we do, via the CQC.
Anne Marie Morris
Okay. And what are you going to do about the fact that the two systems are remunerated in different ways?
Sir Chris Wormald
We have discussed this with the Committee on a number of occasions. Under the current law, there are very clearly, as the NAO sets out, systems that are run on different bases. It is eventually a matter for Parliament whether you want to change the boundary between what local government and what national Government does in this space.
Anne Marie Morris
Fundamentally, you are agreeing that we need new regulation, and we need to look at the regulators and at the reporting lines. None of you disagree with that, do you?
Sir Chris Wormald
There has been a debate for quite some time about what changes you would want to make. Can we do things in primary and secondary legislation that will make it easier for the NHS and local government to work together? Undoubtedly, yes. There will be a set of things like that where, subject to parliamentary time—
Anne Marie Morris
I understand that, and I appreciate—
Sir Chris Wormald
To answer your question, there is a separate question that is very frequently asked about whether you should merge the two systems. We are a very long way from having consensus about that. Are there things we can do in legislation? Yes, but that’s not the same as some of the options various people propose.
Chair
Perhaps we will bring in Ms Farrar for a local government point of view. There are obviously bigger challenges for you as a Department and for local government.
Jo Farrar
You are right that there are two separate systems, but we are seeing more and more, through the integration agenda, that the systems are pooling budgets and having joint commissioning—
Anne Marie Morris
No, we’re not. It’s about 20%—
Chair
Let Ms Farrar finish, and then you can come back to that.
Jo Farrar
There is an increase. There is further we can go, but we are seeing very good indications that people are starting to bring together their commissioning arrangements.
Anne Marie Morris
That’s not what the Report says. Neither the NAO Report nor the CQC report backs up what you’re saying.
Jo Farrar
I was also going to say that we have a separate study on working-age adults, which we can talk about at a later stage. That study is going on alongside the Green Paper so we can look specifically at the pressures of work.
Anne Marie Morris
Fine. Well, let’s have that. I understood from Mr Marron that working-age people were going to be included in the Green Paper. Is that wrong?
Jonathan Marron
A Green Paper will look at specific proposals about how we fund future social care.
Anne Marie Morris
So what you are saying is that you have excluded children.
Jonathan Marron
We will look at how we fund social care and at its sustainability. On the specific issue that has been asked about, lots of the political debate is about what additional protections might be put in place to help people who are facing extremely large costs in social care. Changes to caps and questions about floors will be in the Green Paper. We will look at a wider range of proposals, and at how we get high-quality, effective adult social care services. Those elements are, of course, equally applicable to working-age and older people.
Anne Marie Morris
My concern is that it looks like it is adding bureaucracy, rather than looking at the system and trying to reduce bureaucracy to make it work better.
Sir Chris Wormald
We delayed the Green Paper, to the same timetable as we asked the NHS to produce the long-term plan, so we could look at all the issues this Committee has been raising—they are summarised in the NAO Report—at the same time. We have got a structure to look at those things, but as the NAO set out very clearly, a lot of the barriers are exceptionally difficult and have been there for a very long time. We are not trying to suggest that there is a magic moment in the autumn when we can answer all these things, for all the reasons the NAO sets out, but we think we have created the right framework to look at all the issues you are raising simultaneously. How far down this road we want to go will then be a matter for parliamentarians, and then we as public officials—
Chair
We recognise that at some point there will be a policy decision, but you are in a position to be making—
Sir Chris Wormald
We will be making a proposal in the autumn.
Anne Marie Morris
Mr Marron, you said that children are excluded. I understand that they are under a different umbrella, but don’t you think they should be part of this? Aren’t you talking to the Department for Education?
Sir Chris Wormald
As I used to be responsible for this, shall I answer?
Chair
Okay.
Sir Chris Wormald
The interface questions between health and social care are almost all about adult social care. It is not particular about children’s social care, which is mainly about child protection. The grand interface, of course, is with special educational needs. There was already a considerable amount of integration when I was in my previous job. There was the integrated health and care plan for special educational needs children. That is not a part of the children’s social care system in local government, so we don’t have the same sorts of issues. The Government legislated on this recently and is playing through an integration. The issue you raise about how we integrate children’s services with the NHS is extremely important, but it is not specifically about child protection, which is what children’s social services deal with.
Anne Marie Morris
Well, I think it is about a bit more than that, if I can disagree with you, Sir Chris. It seems to me that you’ve also got another regulator involved—Ofsted.
Sir Chris Wormald
As I say, children’s services departments are largely about the protection of children. They take children into care, and intervene there—that sort of classic social work. There are not the kind of interface issues we see between adult social care and the NHS. I’m not saying it’s not important; it’s just a different type of issue.
Chair
Where in your grand plans do the children that Ms Morris is talking about fit in? If you have a child who needs health and social care because of their situation, whose plan are they going to be in?
Sir Chris Wormald
I am sure that the long-term plan that the NHS will develop will include a considerable amount about children’s services, as you would expect, given the proportion of the NHS that they are. We are not particularly looking at the interface with children’s services for the reasons that I have given.
Chair
To be clear—and I think Ms Morris has been clear—you are saying that NHS England will include a strand for children with health needs but many of those children also have quite severe social care needs. If you are a parent of a child with a special educational need and a severe disability, there are a lot of interactions there. What are you saying, just for clarity, about the Department of Health and Social Care: will it be part of your plan to deal with that?
Sir Chris Wormald
What I am saying is that the Government has an existing strategy, which was how we bring together the special educational needs system with the health service that my previous Department is rolling out. The plan is to continue to do so. Clearly, if the NHS felt that changes were needed to that plan, I am sure Simon will tell us, but that was not one of the issues we were particularly focusing on.
Chair
Mr Stevens, can you shed any light? I am a bit nervous, hearing what you are saying, that children will fall through the cracks. A lot of parents will have trouble with this.
Simon Stevens
On that particular point, children are going to be in a cross-cutting focus: children and child health inequalities is going to be part of the long-term NHS plan. Part of that will be looking at the inequality that exists at child birth, maternal and child health, differential neonatal infant mortality rates, the safety agenda. That is one set of things. Then we have two new epidemics affecting our children: childhood obesity and young people’s mental health problems. Both of those have got to be tackled as part of this. The conversation that I and colleagues have initiated with the children’s charities, with the Children’s Commissioner, the Royal College of Paediatrics and Child Health is precisely about scoping out a broad agenda on children’s health and wellbeing.
Chair
In that broad agenda will there be some mechanism, if a child goes into hospital because of their health problem or disability, that they get the care that they need in the community, which might prevent them being hospitalised quite so much, for example? That would save your team money, but it would also give them a better quality of life.
Simon Stevens
We certainly need to look at that and be explicit about what improvements can be brought about. The Nuffield Trust, for example, is doing work right now on inequalities in children’s access to services and the impact that broader inequality has on use of hospital services, so that is in scope.
Sir Chris Wormald
We also, of course, have the Green Paper on children’s mental health, which was done between us and the Department for Education. That is a big chunk of it. If you put those things together, it would be a serious failing if it fell between the cracks.
Chair
We are hearing quite loudly that health can be integrated with everything. I am going to bring in Caroline Flint on one point and then go back to Ms Morris.
Caroline Flint
Could you provide to the Committee your sense of what defines a child and how that will interface with the adult provision? Particularly, as with looked-after children, local authorities have a responsibility that goes way beyond what we would consider a child. I would be interested if you could write to the Committee, breaking down some of those differences of application in what the age of a child should be defined as.
Simon Stevens
That is a really important point. I am sure Jonathan would want to do that. One specific thing we are looking at in the context of young people’s mental health services is the fact that 18 is not a clinically relevant transition point. A lot of young people’s mental health services are organised up to 18 and there is a transition to adult services. There is an argument that is being fuelled and tested in some parts of the country that 16 to 25, or even a little earlier, is more relevant, so that is one of the things that we are discussing with the mental health organisations as well.
Sir Chris Wormald
Indeed, in my previous Department, it was a deliberate act of policy to extend, as you say, responsibility for looked-after children post-18, and also the special educational needs system to look at up to 25, for exactly the reasons you give.
Chair
There is a plethora of ages we could start listing, but if you could write to us, Mr Marron.
Sir Chris Wormald
The important point is that the age cut-offs, for the reasons Simon says, don’t mean very much, so blurred ages are in fact a good thing.
Caroline Flint
It’s the transitioning more than anything else.
Chair
Mr Marron, you could write to us about that. That is certainly, as Ms Flint said, something that needs to be nailed down as part of this wider review.
Anne Marie Morris
Mr Marron, can I be clear? When I asked you whether there is going to be a 10-year plan for social care, you said that there was going to be a Green Paper. Will it be a 10-year plan?
Jonathan Marron
The Government has promised a Green Paper on the sustainable and sound future for social care. That is what we are preparing for.
Anne Marie Morris
So, it is not going to be a 10-year plan.
Jonathan Marron
I think we have got a set of policy proposals about how we put social care on a sustainable footing. The financial element of that will come through in the spending review. We are looking to the spending review to give us a settlement.
Anne Marie Morris
So, it is not a 10-year plan.
Sir Chris Wormald
No, it is not a 10-year plan. Social care works to very different timetables.
Chair
I am going to go Ms Farrar on the funding of social care because, of course, at the moment it is funded through local authorities. In a previous session, you talked about how local authorities can increase their council tax to help fund this. Where are your discussions about the funding of the proposals in the Green Paper? I know we’re not there yet, but if it is going to be sustainable, this year-on-year, hand-to-mouth approach is not going to deliver a long-term sustainable plan.
Jo Farrar
Of course. We had a four-year settlement with local government and it has just over a year to run. Local government have their funding set for that year. We have listened to them where there have been additional pressures, and we have recognised that things will change over the four-year period. That is where the additional funding for social care has come in. Not all of it is through council tax. There was additional funding through the improved Better Care Fund and in the last settlement, for example. We are working with local government now towards the spending review in 2020, where we will bring all the pressures together and talk in the round—
Chair
We know how it works. Are you confident that you are going to have the ability for local councils to build into the sustainable long-term plans we are hearing about?
Jo Farrar
That would be a question for the spending review. We are continuing to work with local government and our partners in the Treasury and across Government to make sure we have a good evidence base to look at local government. We will factor those arguments into the spending review in 2020.
Anne Marie Morris
Mr Wormald, if you are going to look at system change across the two pieces, what are you going to do about training? Are you going to have nurses qualified in both? Are you going to have doctors qualified in both? Are you going to have more flexibility between the systems?
Sir Chris Wormald
The other thing that we brought together in the autumn was the workforce plan—we have also previously discussed that with the Committee. We will be doing that on the same timetable as the other areas. For the first time, in the consultation that went into that workforce plan, we had a look across the two workforces—particularly the two areas you are pointing to, where it is the same professions in both. Co-ordination is extremely difficult, because of course many of the professions on the social care side are employed by private contractors, but we are having a look at it as an entire workforce, particularly in those professions. That is a proposal we will be looking to come forward with. Again, just having a planning system that brings it all together does not make any of the individual barriers go away, as the Committee is well aware, but it does allow us at least to look at the question on the same timetable.
Anne Marie Morris
But, Mr Stevens, you would agree that we need a flexible workforce because people’s needs have changed. What would you like to see, in terms of cross-training between social and NHS? How are you going to deal with the royal colleges, which no doubt rue this change?
Simon Stevens
Three things. First, we have got about 1 million care assistants, compared with about half a million registered nurses, working in health and social care across the country, so the ladder to nursing associate and registered nurse—care assistants can earn and learn through apprenticeship-type models or on the job-type models—is very important, not least for creating career opportunities for people who otherwise might be stuck in pressurised roles in social care and do not see opportunity in the way they sometimes do when working in the NHS. The ladders of opportunity in nursing for care assistants and the bulk of the workforce are hugely important. That is the first thing. The second thing is that a number of nursing homes, and residential homes as well, if they get better support from clinical pharmacists and their local GP, we can substantially reduce the likelihood that people living there are admitted to hospital as emergencies. We are rolling out the direct national funding of NHS pharmacists working in care homes on medication review, polypharmacy and that sort of thing. We are aiming for 240 whole-time equivalents to start with. The NHS contribution to what is happening inside care homes is very important. That is one of the vanguard programmes that we have been funding, and which has succeeded, over the last several years. The third piece is that there is a set of cost pressures. We have seen that from the national minimum wage—there are other pressures around the workforce in the care sector. As part of a sustainable funding solution for care, those are going to have to be factored into the cost of sustaining the more than 400,000 care home beds. For every hospital bed we have, we have four care home beds, so that is a vital part of the system.
Anne Marie Morris
So how, Simon Stevens, are you going to work with Mr Marron to improve the status and standing of social care so that your nurses are prepared to work in the social care sector? At the moment, there is not parity of esteem or of pay.
Simon Stevens
You are right about both points, I think. In terms of workforce planning, it will be very important that HEE, Skills for Care and any augmented arrangements in the future look across the whole care sector, not just at the expected need for nurses in the NHS or in the health sector. I think that point is understood and is going to be acted on.
Jonathan Marron
I agree with Simon. We have good examples of people doing this well today. You can look at Manchester. They are trying very hard to train their workforce as a whole, across health and social care. They are thinking about how they encourage people to view both sectors as a possibility and not just one or the other. The other bit that is really important is how we get people who are trained to work together. Maybe it’s not their primary training, but how do we get a multidisciplinary team and how do we get agreement that people will accept the decisions of each other’s professionals?
Chair
This all sounds great and has been talked about a lot, but the differentials in pay are so large. You have the extra money for the NHS, Simon Stevens, but unless there is some money going into social care, where is the money going to come from to pay the care workers in care homes or to raise the paradigm of that role? I mean in Manchester—it may have worked in one small place, but it’s not working all across the country.
Sir Chris Wormald
It is quite a complicated dynamic.
Chair
This is about money, isn’t it?
Sir Chris Wormald
We have, of course, put more spending power into local government, as we have discussed before; and as Jo said, we will be looking at those issues in the spending review.
Chair
I think the spending power is not going on wages, though, is it?
Sir Chris Wormald
However, when you look at the nurse vacancy rate between social care and the NHS, it is actually not markedly different.
Anne Marie Morris
But you would agree the esteem is markedly different.
Sir Chris Wormald
Well, there is clearly a pay differential, but there is a lot more that goes on in terms of whether people want to work in social care or the NHS than just the pay question, and we of course want to make both attractive. That has to start with whether we train the right number of nurses to service both sectors, as opposed to people making a choice between one or the other. That is the absolutely key bit.
Chair
In 2012, the numbers went down—I’m going to bring in Ms Flint briefly and then go back to Ms Morris.
Caroline Flint
Would you agree that, as we strive for better integration between health and social care, the pay differentials are going to become that much more obvious?
Sir Chris Wormald
Will they become more obvious? They are quite obvious right now.
Caroline Flint
Well, you just said that the vacancy rates in both are pretty okay. I would challenge that. I think there are a lot of people who work in residential care or in people’s homes who are not aware of how much more a healthcare assistant in a hospital is paid over and above your average social care worker.
Sir Chris Wormald
Well, it’s an issue that is campaigned on quite a lot, so I would be surprised. I was not denying there was a differential or that that had an effect. The point I was making was that there are quite a lot of factors in an individual’s decision about where they want to work.
Chair
Yes, but money comes into it, doesn’t it? If you are paying people as little as Ms Flint has highlighted—
Caroline Flint
Answer the question.
Sir Chris Wormald
Sorry, I’m not denying that. I was merely saying it’s quite well known between the NHS and the social care sector, and what causes someone to wish to work in either sector appears to be more complicated than just—
Caroline Flint
Here’s another question. Are you or will you be doing any monitoring of the impact of widening healthcare assistants’ roles, in terms of draining people from social care into those more hospital-based functions?
Sir Chris Wormald
Yes, we do look at those questions.
Caroline Flint
Are you doing or could you do some monitoring of the impact in terms of people who do train in social care? The differential between having got the training and being at the basic level is a disincentive to more training. I have met people when I’ve been knocking on doors who are paid only £1 an hour more, having undertaken substantial training, than the bottom rate of pay in the residential care home that they are working in.
Sir Chris Wormald
Yes, and I think the last time we were here on this subject, Skills for Care described some of the work they were doing to investigate exactly those issues. As I say, although it does not make any of the problems go away, particularly some of the money problems, looking at these issues in the round, across the entire workforce, does allow us to get into those questions. Of course, we want two things. We want the kinds of career ladders that Simon Stevens was describing earlier so that people can move into different professions and up—
Caroline Flint
But they are parallel career ladders—that’s the problem—and you rob Peter to pay Paul.
Sir Chris Wormald
The model Simon was describing tries to get away from that parallel model so that people can see a career that crosses health and social care. Exactly as you said, we need to avoid causing one sector to be much more attractive than the other. That is why we want to look at the two things jointly. I know that does not really answer your question about what we will do about it, but the questions you raise are exactly the ones we are looking at.
Anne Marie Morris
So what are you going to do about pensions? How are you going to—
Sir Chris Wormald
About pensions?
Chair
If you switch between sectors, what happens to your pension? It is not a very big incentive, is it?
Sir Chris Wormald
I am quite happy to write with the exact details, but normally you opt into the pension scheme of where you go.
Chair
Yes, but if you have a career path that zig-zags between sectors, you might be in an NHS pension scheme one minute and then go into a private social care provider’s rubbish pension scheme. If you are lucky, you might then be employed by a local authority and be in a better pension scheme, and then you might go back to health. For small pensions, the administrative costs of that alone are pretty immense.
Sir Chris Wormald
Let me write to you on that issue. It is no different from anywhere else—
Chair
Have you done some work on this?
Sir Chris Wormald
I could not call to mind a specific piece of work on that issue of—
Chair
It is just that despite all the talk about integration—you have painted a nice vision—this is, as Ms Morris has highlighted, a big barrier to it.
Sir Chris Wormald
Just to be absolutely clear, I am not saying that because we have a planning framework that allows us to ask all these questions, that makes all these problems go away. It clearly does not.
Chair
No, but we are just concerned that you understand there is a problem there.
Sir Chris Wormald
Yes.
Chair
You’re saying you understand there is a problem?
Sir Chris Wormald
No, I cannot recall a specific piece of work we have done on the question you have asked. I will go and check and come back to you.
Anne Marie Morris
Sir Chris, do you know how much money you actually need across both health and social care to get it right?
Sir Chris Wormald
We do two types of assessment. Of course, on the NHS, we have just done a long engagement to conclude what we think is an appropriate amount for the NHS that the taxpayer can afford.
Anne Marie Morris
All right, but I asked you what you need, not what you can afford.
Sir Chris Wormald
On the social care side, it is part of the assessment we do of the spending pressures on local government, which is led by MHCLG. For each spending review, we do an analysis of what we think the pressures are.
Anne Marie Morris
With respect, Sir Chris, I am concerned. You are talking about what the Government can afford. That is the second question. The first is what you actually need to keep the system up and running. Bear in mind that a lot of the cost in social care is borne by people who are unpaid—volunteers and third sector—to whom none of you have so far referred.
Sir Chris Wormald
We have not referred to them because you have not asked us that question. In terms of the spending questions, we do it in two chunks. We do an assessment of what we think the pressures are, and then of course there is a Government assessment about what we can afford. You have to come up with a balance between those two.
Chair
But you are talking about the normal planning processes. At the beginning, you talked about a grand vision for integrated health and social care. You are going to do that, and you have a 10-year plan for the NHS. You still need to think about how you are going to fund the equivalent 10-year plan for social care.
Sir Chris Wormald
Yes, and we have said we will set that out.
Chair
If it is spending round by spending round, I do not think most local authorities, which have had 40% cuts in the last eight years, would say, “Great—that solves it. There’s going to be a discussion for the spending review,” unless you are promising a more serious discussion than normal spending reviews.
Sir Chris Wormald
There are various things to say about that. We have never denied at any of the hearings on this subject that local government has been under considerable pressure, for the reasons you mention. Adult social care spending, as you are aware, has been going up, not down, over the last couple of years—
Anne Marie Morris
Funded by the local taxpayer.
Sir Chris Wormald
And we are putting more spending power in the hands of local government on top of that. We made clear as part of the announcement of the long-term plan for the NHS that we will ensure that additional pressure is not put on the NHS by what we do on social care, and we have also made clear that we can settle social care spending powers only as part of the wider spending review that will be done in 2019. We do not have any answers that are different from the ones you have heard before, but that is our model for considering those questions.
Anne Marie Morris
All right, well let me put this to you. I am right, am I not, that in terms of social care the state is only responsible if you are under a certain level of worth financially in terms of your assets and your income, and if your need is great?
Sir Chris Wormald
Yes, there are two tests: a needs test and a financial test.
Anne Marie Morris
So if you do not meet that, which is true for more rather than less of the population of this country, people have to make it up themselves?
Sir Chris Wormald
Yes, they self-fund.
Anne Marie Morris
Have you calculated how much that is?
Sir Chris Wormald
We know that it is approximately £10 billion of self-funding and £18 billion of public funding.
Anne Marie Morris
Could you write to us with the exact figures?
Sir Chris Wormald
Yes.
Anne Marie Morris
Have you costed into that the value of the third sector, who do not charge?
Sir Chris Wormald
Into that particular calculation, no.
Anne Marie Morris
Don’t you think you should? Ultimately, that tells you what the cost of social care is. The fact that somebody can do it voluntarily is very nice, but shouldn’t we know how much it is?
Simon Stevens
It is between £57 billion and £100 billion a year, according to the ONS and Carers UK, as cited by the NAO in the Report that we had on the social care workforce in England.
Anne Marie Morris
Wonderful. We have a figure. I would like, Sir Chris, for you to add all the numbers up and give us a report as to what the actual need is. By the sound of it, from Mr Stevens, the figures are there. What exactly do we actually need for both? Without that information, how will we work out whether the Green Paper meets that need?
Simon Stevens
There are at least three separate questions here. First, what is the expected extra funding overall that will be required? That is the point you are getting at. There are a range of independent estimates of that from the IFS, the Health Foundation, the ADASS directors survey and so forth. I would also draw your attention to the fiscal sustainability report published by OBR yesterday, which lays out a variety of scenarios as to what the cost drivers and pressures in adult social care might be, rather ludicrously out to 2067. That is obviously what they are asked to do, but there is a certain sense of folie de grandeur in that I suspect if we were having this conversation in 1967 we would not be making very good predictions, but anyway, they have said that 1.2% of GDP is being spent on adult social care now. Under their various scenarios that might become 1.9% in 50 years’ time: a pressure, but not an overwhelmingly scary number in the great scheme of things. Anyway, that‘s the first question. The second question is about the mix of funding streams that give rise to that quantum, and the complexity in adult social care is that there are at least five. There are the local authority-raised funds, the central Government funds, self-pay, the NHS transfers, including continuing healthcare, and importantly—we mustn't lose sight of this—there is the benefits system, because for every £1 that is spent on means-tested public social care, the benefits system pays £2. So that is five different funding streams. The third question is: if there is to be a means test, what are the aligned means-testing arrangements? We have four separate means-testing arrangements: one for continuing healthcare, one for domiciliary care, one for residential care and a different one for DWP benefits such as attendance allowance. That, for me, is the meat and drink of the discussion. It is not a question of whether we have a single regulator and we need a change to the law. That is not really the principal issue here.
Anne Marie Morris
I was trying to cut the bureaucracy, but I agree with you: you’ve cut to the chase. Are you looking to your colleagues to align this?
Simon Stevens
That is a matter for Government, obviously.
Jo Farrar
We take all of that data and bring it together. We start alongside all of the other data in terms of local government spending. We look at their financial resilience, as we discussed before. We look at their inflexible spending—
Chair
Are you looking to integrate this?
Jo Farrar
Yes, and then we look at what we think the gap might be in terms of social care and how that matches against—
Chair
Ms Morris’s question is not about whether you are aggregating that money. It’s about how you make it simpler so that there are not multiple, complicated means tests. In the middle of this—I’m sure I don’t need to remind you—is the poor patient or the individual needing the care who has to navigate an incredibly complex system. What are you doing in your Department, Ms Farrar, to try to align the systems that Mr Stevens has helpfully outlined for us that are all out of kilter?
Jo Farrar
Sorry, I was answering a slightly different question from earlier to tell you how we bring all the data together. I was going to the point about whether we are having a 10-year funding plan.
Chair
Can you answer the other point? Are you doing anything in your Department to make sure that these different eligibilities align?
Jo Farrar
We work with DHSC to make sure that we make the funding system as simple as possible for people. That will obviously be covered in the Green Paper and in the other work that we do together to look at people’s eligibility and how they navigate the system. In terms of the long-term funding, we will look at that through the spending review.
Sir Chris Wormald
The honest answer to your question is that those are, of course, all the issues that people have debated about social care over the period that you have said. We are looking at all those issues, but we will not have an answer as to what we propose to do about them until the Green Paper. They are the things that are—
Chair
Are you expecting to cover them in the Green Paper? We do not expect it to be instant.
Sir Chris Wormald
I want to be very clear. The Green Paper will put forward the Government’s proposals. Whether those proposals include any alignment across the things that you are describing is, of course, a matter of policy for the Department, but those are the issues that we will look at.
Chair
We looked at universal credit recently, and we recognise that it is complicated to change those systems and that to do it in a hurry could create more problems and difficulty for the individuals concerned. Attached to or around the Green Paper, will there be any long-term aspiration to smooth over some of the things that make life incredibly complicated for the poor old patient or individual caught in the middle of it?
Sir Chris Wormald
Clearly, if it is doable and avoids some of the problems that you have described, I do not think that anyone would not want a simplified system, but I am not going to promise here a particular set of policies that do that, because that is exactly what the policy development process looks at.
Anne Marie Morris
Mr Stevens has quite a few good ideas. I think you and he ought to share notes, and that you ought to talk to your Minister—
Chair
Mr Stevens is never short of ideas.
Sir Chris Wormald
I can assure the Committee that we do meet outside of Committee hearings and debate exactly these issues. I sound like I am being slightly evasive—I do not mean to be—because the issues that the Committee is raising, and the issues in the NAO Report, are exactly the extremely complicated and difficult questions, in financial, policy and legal terms, that we wrestle with the entire time. I do not want to give you the impression that you are not on the right issues.
Chair
We recognise that there are quick fixes and there is long-term planning. We are in the realms of long-term planning.
Sir Chris Wormald
Clearly, on that point, we will want to do two things. We will want to set out a vision of how the system can be better, because I do not think there is anyone in any political party who does not want the system to be better. We also need to set out some intensely practical steps that are actually doable without enormous legislation, which we do not have parliamentary time for, and without enormous sums of money, which we do not have, and so on. I am not going to promise the earth in terms of what we come forward with, but we will be trying to do those two things.
Anne Marie Morris
This is my last question. Mr Stevens, third-world countries do not have our infrastructure, so they are moving straight to technological solutions for health and social care. In this workforce plan, are you, with Sir Chris, looking at the use of technology? That would make it much more cost-effective. I am thinking big picture plans here; not little bits of communication technology.
Simon Stevens
Yes. There is obviously a whole development around biosensors, home adaptations and ways to give people support that improves the productivity of the care sector. Countries such as Japan have done some important pilots or experiments that we are staying closely in touch with. In addition, the Department has commissioned a guy called Eric Topol, who is one of the world’s leading health technologists, to answer the question about what impact some of those technological advances would have on workforce requirements in the health and social care sector over the next five or 10 years. He will produce his independent report fairly soon. I think the answer is yes. The biggest single shift that does not immediately appear in sight—if it happens, given that more than 99% of pharmaceutical clinical trials on dementia medication have failed over the last decade—would be medical treatment to slow or cure Alzheimer’s and other dementias. If that happened, it would, at a stroke, substitute what is currently social care spending and it would become health spending. There is an interesting question about when on the policy horizon that development might occur.
Sir Chris Wormald
I will add two things. First, my new Secretary of State has a particular interest in technology from his background, and I think you can expect him to want to push exactly the kind of things that you are describing. Secondly, I point you towards the part of the industrial strategy to do with the ageing grand challenge, which is looking specifically at technologies for an ageing population. The one caveat is that although a lot of countries are looking at these things, when we go and look, they have not yet got very far. The Japanese, for example, who have done more than anyone, do not believe for a second that they have cracked this issue via technology. They are doing a lot of interesting things, but it is not as if they have found a transformative technology. It is a very interesting area, but there is a long way to go before you have the right technology.
Caroline Flint
The political question, at the end of the day, which you are not here to answer, is to what extent taxpayers should provide services and to what extent individuals and their families should provide them. Going back to the three points that Simon Stevens raised, Sir Chris, will you be ensuring that, when the Green Paper is published, there will be some analysis in it that looks at issues such as the mix of funding streams and the different means-testing arrangements, to see what costs they are adding on to a system that is not actually providing better social care? To arrive at the end figure, we need to have better confidence that the way in which we are identifying need, and the structures and bureaucracy needed to deliver it, are actually cost-effective. From the sound of it, on those three points, there is work to be done. Will there be stress tests? Will you look at scenarios about how to do that differently? Will that end up in the Green Paper?
Sir Chris Wormald
I will not say what exactly will and will not end up in the text of a Green Paper.
Caroline Flint
Are you considering those three elements?
Sir Chris Wormald
We are certainly looking at those elements as part of the work to develop the Green Paper. The types of analysis that have dominated the debate so far, about who pays what and why, are right at the heart of this.
Caroline Flint
Reducing the fragmentation by looking, in particular, at points two and three that Simon Stevens raised—is that something that is being undergone at the moment?
Sir Chris Wormald
Let me come back to you on the exact work streams, because I do not want to promise something that we have not in fact done.
Sir Geoffrey Clifton-Brown
If we get social care right, does it not have a positive benefit on your NHS budget?
Simon Stevens
Certainly it will reduce the rate of growth in additional demand that hospitals will be managing as frail older people present as emergencies, or it will help to speed up their hospital discharge. So in answer to that question, yes. That is why it was so important that the Prime Minister, as was said, was explicit that sorting out the social care budget will be done in such a way that there are not further pressures placed on the NHS.
Sir Chris Wormald
The ratio is quite complicated, however. The best study, which was done by Kent University—I think I might have quoted it to the Committee before—showed that for every pound spend on residential care, you save 34p in the NHS. It seems to be that sort of ratio.
Sir Geoffrey Clifton-Brown
Mr Stevens, you anticipated my next question. Age UK calculates that delayed discharges are costing the NHS £550 per minute, or £290 million per year. This is surely a problem that needs to be sorted sooner rather than later, is it not?
Simon Stevens
Yes, and we work very closely with Age UK. On that, we have some good news to report. As a result of a vigorous focus on hospital discharge between hospitals, community health services and local council social care services, we have genuinely turned the corner on delayed transfers of care. Around 6,500 hospital beds were in this formal definition of people waiting as a delayed transfer. We are now down to 4,500, so incredible strides have been made across the country as a result of joined-up work between health and social care.
Sir Geoffrey Clifton-Brown
Is that not more or less a stable figure now? You have done the easy bit, as it were, and you are now on the plateau. How are you going to get still further down?
Simon Stevens
This year, we will focus not only on those patients who are formally classified as delayed transfers of care, but on the larger group of patients who are in hospital for more than 21 days. About 19,000 of our 100,000 or so hospital beds are occupied by people who have been there for more than 21 days. For some patients, that is absolutely right, but for many, being stuck in hospital is deleterious to their independent recovery. The goal that has been set is to see whether we can reduce by perhaps a quarter the number of those 21-day-plus stays in hospital. That is a big goal and it will take time, but that is the next phase of the journey.
Sir Geoffrey Clifton-Brown
Ms Farrar, the charities also estimated that the number of those in England with unmet care needs has risen by 19% in the last two years, which translates to 1.4 million over-65s living with unmet care needs. The trend is getting distinctly worse, with people not getting the social care that they need. How and when do you estimate that the trend will be arrested?
Jo Farrar
In terms of unmet care, local government has a statutory responsibility to meet care needs. I think the LGA has different figures for unmet care than that report, so we would probably dispute the figure. However, we do want to make sure that people who need care receive care, and local government has a responsibility to do that. That is why they are working really closely with the CCGs. The example that Simon Stevens gave on delayed transfers of care is an excellent example of how they have worked together to integrate care. The more that local government can help to integrate care at community level, the more people have their needs met.
Sir Geoffrey Clifton-Brown
You might dispute the figure, but the demographics are going in the wrong direction. Not only is the unmet care increasing; the demographics are going in the wrong direction, with the number of people living longer. The two things are going to combine to make it a really difficult problem.
Sir Chris Wormald
Yes, that is exactly right. That is why we have been taking a number of the actions that we have. It is very important to be clear on the definitions here; it is not about disputing numbers—it is about which categories you are talking about. There is care that is a statutory requirement under the Care Act. With the exception of the one local authority that we have quoted before in which we have intervened, we do not have any evidence that any local authority is not meeting the floor that Parliament set. There are any number of different types of number on the need above that floor, which a lot of local authorities used to meet some of—frankly, when they had more resources. It is clearly true that a number of local authorities have taken the view that they meet their statutory obligations and are not looking at the group in which it is discretionary. I expect that is where the figure differential is. We have inevitably focused on our people meeting their statutory duties, which is what the requirements on us are. In terms of the future, yes, that is exactly the position. It is very well described and it needs the numbers that Simon was quoting earlier from the Office for Budget Responsibility report. This is going to be a greater and greater challenge, and there is a percentage of GDP that we will have to put one way or another towards these areas.
Sir Geoffrey Clifton-Brown
Going back to your very helpful answer on the ratio between the savings on spending on social care and health—the £1 to 33p in the health service—does a saving of £600 million in healthcare mean that an approximate cost of £1.8 billion in social care is needed?
Sir Chris Wormald
Clearly, there are various factors that apply to the decision about where you put particular types of investment. Absolutely crucially, we do not fund social care simply because it has a consequence in the national health service; social care is a public service in its own right. As Simon said, we have actually been really rather successful in reducing the number of delayed transfers of care within the existing spending envelope. We want that to continue to go further. That will be one of the investment questions that we have—within our limited resource, where do we want to put further resources into that objective, as opposed to all the other objectives that we expect of our health and care services?
Sir Geoffrey Clifton-Brown
Again, another very helpful answer. Quoting back at you, you are saying that you do not just fund social care to produce a saving in the health service.
Sir Chris Wormald
Exactly.
Sir Geoffrey Clifton-Brown
In answer to my question about £1.8 billion, does that mean that the £1.8 billion is a starter and in fact you are going to need a great deal more than that?
Sir Chris Wormald
As I have said before, we will debate what the right level of spending is for social care in the spending review. When we put money directly into this, which is mainly through the Better Care Fund, we have the three objectives you know about, one of which is delayed transfers of care, but that is not the only one.
Chair
The challenge here is, as we have discussed many times—I will not repeat it all here—that if you get it wrong in social care, the knock-on effect to health is enormous, and vice versa. Local government have been squeezed incredibly, and they are having to rob Peter to pay Paul. You have picked up the nervousness there is here that we are not hearing a very strong commitment. We are hearing bureaucratic answers about how you will measure funding for local government, but that is not really the answer.
Sir Chris Wormald
I am trying to be honest about the position. I do not think there is a difference in analysis between the National Audit Office, the Committee and us. We have put considerably more resource into both social care and health, but—this will come out as we do the long-term planning process—that still—
Chair
When you say “we”, you mean—
Sir Chris Wormald
The Government.
Chair
Well, councils have been able to raise taxes—
Sir Chris Wormald
Okay, the state has put in considerably more resources.
Chair
That is not directly from Government. Let’s be clear.
Simon Stevens
In fairness, Chair, it is a combination. The improved BCF is central Government funding. The transfers from the NHS are central Government funding, as have been the increases in the grant—
Chair
Okay. You are being very good at defending. Robbing Peter to pay Paul is a fair summary.
Simon Stevens
It is a hybrid funding model.
Jo Farrar
There is the £2 billion in the Budget, which was a direct grant.
Sir Chris Wormald
If you prefer “the taxpayer”, then whether it is the national taxpayer or the local taxpayer, the taxpayer has put in considerably more.
Chair
That is more honest.
Sir Chris Wormald
Now, even with that resource—I am sure Mr Stevens will agree—that still leaves us with difficult trade-off decisions, given the level of pressure on both the social care budget and the health budget. So we are not here to say that because there is extra investment in the system every single problem we have discussed today will be made to go away, and we will, as part of these processes, have to take tough decisions about where our marginal pound is best spent. All the issues we are describing are clearly part of that debate, but we could list off the number of other pressures elsewhere in the health service—
Chair
Some of the NAO’s analysis on vanguards is potentially quite helpful in this respect.
Sir Chris Wormald
Yes. But that is why I am giving this answer. I am not trying to give the impression that we have the answer to all these problems. We have a planning framework that deals with every investment and we have some tough decisions to take.
Gillian Keegan
Next year marks the 20th anniversary of setting the objective to ensure better joint working between health and social care. How do you think you are doing?
Sir Chris Wormald
I think it is actually longer than that, but we can take 20 years as—
Gillian Keegan
That was in the Health Act 1999, so that is when it was first set.
Sir Chris Wormald
Yes. The first reference we found was in a White Paper in the 1960s, actually, so longer ago.
Gillian Keegan
How well do you think you are doing?
Sir Chris Wormald
Well, I would agree with what is said in the National Audit Office Report on this. There are a number of very good pieces of progress you can point to, and if you compared the integration of health and care now to 20 years ago, it is a completely different world, but it is not universally where we need it to be. We have some very good examples of parts of the country that have made a lot of progress and other parts of the country are behind. I think we see progress, but a very mixed picture, if I am honest. Do you agree with that, Simon?
Simon Stevens
I agree—it is so much better than it was 20 years ago. I think it was Frank Dobson who as Health Secretary used the phrase the “Berlin wall” between health and social care around 1997 or 1998, leading into the 1999 legislation you talked about. The Berlin wall has, for the most part, collapsed.
Gillian Keegan
We will get to Berlin walls and budget walls in a second. To get us more up to date, figure 4 on page 18 shows the timeline for what has happened since 2012. There are a lot of initiatives. What is working? And why so many?
Simon Stevens
I will orientate myself through this microscopic chart that the NAO—
Gillian Keegan
It has got some legislation, some policy, some funding transfers and mechanisms, which I suppose could loosely be described as initiatives, and some programmes.
Sir Chris Wormald
While Simon finds his diagram, it is beyond doubt that in this area there have been probably too many different initiatives that have not gone where we would have wanted them to.
Gillian Keegan
Which ones haven’t worked?
Sir Chris Wormald
I will leave others with a longer history in this to comment on that. At the moment, we are trying—it is locked in the process with STPs and ICSs—to take all the learning we have created over that period, which is considerable, as the National Audit Office points to, and to create a vehicle where you can do this much more systematically. I think you have had evidence from the Greater Manchester partnership on how to do that and what their successes have been. Our challenge is whether we can do that more systematically. I will leave others with more history in this subject to comment on which they think have worked.
Gillian Keegan
What is working, Mr Stevens?
Jonathan Marron
Can I just pick out some differences? We are lacking some consistency here. A lot of these are the last set of spending review decisions for which we consistently looked at whether we can use the Better Care Fund and pool budgets to bring together the NHS and local government to make shared decisions. The evidence shows that that has had an impact, and local government reports overwhelmingly that it has helped.
Gillian Keegan
How are you measuring the evidence?
Jonathan Marron
We have evaluations of what local government thinks. There are a set of metrics that we track.
Gillian Keegan
They were quite qualitative though, weren’t they?
Jonathan Marron
Indeed.
Gillian Keegan
If I were measuring the impact of spending money on a programme, the first thing I would do would be to set quantitative objectives. You haven’t set any of those, so far as we can see.
Jonathan Marron
We have a set of things around—this programme has always been aimed at both.
Gillian Keegan
That was quite a simple question. Have you set any quantitative targets for any of these initiatives?
Jonathan Marron
We have quantitative evaluation of the BCF—
Gillian Keegan
Against?
Jonathan Marron
Against delayed transfers of care and emergency admissions. The evidence, over time, which has been independently evaluated, shows that we have seen improvements against those measures. There are other measures that we have not seen so much progress against. That is the hard, quantitative bit. The objective was also always to try to bring together the healthcare and the local authority care over the Berlin wall that Simon described, which used to be said to exist. The interesting, hard fact there is that local government and the NHS both put £1.1 billion more than they were required to into these arrangements. They are putting their money behind this way of working. I think that is really strong evidence that CCGs—
Gillian Keegan
It has taken 20 years to get to that. Mr Stevens, what is working, and how can you tell?
Simon Stevens
We have had the opportunity to discuss the Better Care Fund on previous occasions. Without airing all of that debate again, it is what it is, and there will be an opportunity to review it in the context of the long-term plan for social care and to learn from those experiences. More generally, the move towards integrated care is working. We see that with—
Gillian Keegan
Apart from the delayed transfers, how are you measuring it?
Simon Stevens
We are using two measures to track the integrated care through the vanguards. One is whether they are seeing a slower rate of growth in emergency hospitalisations. The second is whether they are producing a return on investment. The answer to both questions is yes. In terms of the return on investment, by the end of this year the gross savings will have paid back the gross costs. Assuming that the trends we have seen continue, we will get a return of about £2 for every £1 spent.
Gillian Keegan
How sustainable is that? When I looked at this, it looked a little bit like there was initiative overlap. In many cases, the same areas have been used as the pilot. Are you just picking the ones that are further along anyway?
Simon Stevens
No. They have grown. For example, we started with a small part of Nottinghamshire as one of the vanguards. That is now expanding to Nottinghamshire as a whole. We started with a small part of Lancashire—the Fylde coast and Blackpool—which is now expanding more widely. We started with a small part of Frimley Health, which is expanding more widely.
Gillian Keegan
Do you think you could go to any area of the country and implement one of these vanguard systems and get the same savings?
Simon Stevens
By definition, it takes a period of time to make a clinical redesign. That is what we will do. The long-term plan is quite clear. There is not a new integration agenda that is different from the one set out here. It is all about accelerating its roll-out across the country as a whole.
Gillian Keegan
Are you just branding what is already happening?
Simon Stevens
No.
Gillian Keegan
Manchester was successful because of the way it has been set up for a long time. It is always used as the same example. I could give you another example in my area of West Sussex where the accountable care organisation did not get anywhere, because all the different organisations could not agree. What do you have in place to unpick the more difficult areas where they do not have something in place that is already working?
Simon Stevens
It is not that it is already working; it is—
Gillian Keegan
It is already working to some extent, or it is designed to work as opposed to designed not to work?
Simon Stevens
Let’s reflect on the fact that the vanguards have succeeded. Here are the differences: here is the rest of England in terms of the per person emergency hospitalisation growth. There is the hospital-led vanguards and there is the GP and community health service vanguards. Combined, the vanguards have seen a per capita increase of 1.6%. At the 95% confidence interval level, anything less than 3.1% is statistically significant. They have succeeded.
Gillian Keegan
How does figure 9 look like success?
Simon Stevens
Longitudinally, that is what that is.
Chair
That is on page 40.
Simon Stevens
I know. I am fully aware. Over the duration of the vanguard’s existence, that is the cumulative effect of the difference. If we can reproduce that across—
Gillian Keegan
I cannot actually see it.
Chair
We cannot deal with documents that we cannot see.
Gillian Keegan
Let us just go to the NAO Report.
Simon Stevens
The NAO has the same figure. The NAO says that the rest of the NHS—
Chair
Can you give us a page number, please?
Gillian Keegan
Page 31 of developing UK—
Simon Stevens
I know. It says that the rest of the NHS outside the vanguard programme has seen a 6.3% increase in per capita emergency hospitalisations. The hospital-led vanguards—the PACs—were 2.6% and the community and primary care ones were 0.9%. That is success.
Gillian Keegan
It is limited success. Now we need to have the very best of that all over the country, hopefully not in another 20 years but by 2021, which I think is the objective. Figure 9 shows progress as basically whether you have an implementable and replicable model. It does not look to me like it is good to go.
Simon Stevens
It is good to go, as judged by their results and their likely return on investment. Through the integrated care—
Gillian Keegan
Is it implementable? Is it replicable?
Simon Stevens
Yes. We now have 12.5 million people covered by shadow integrated care systems across the country, but this is what the plan for the next three years has to be clear about. In part, it loops back to the question we began with, which is are there some statutory adjustments that might speed us up on the way? Possibly there are. That is part of what we will answer as part of this discussion on legislation.
Gillian Keegan
Twenty years to get to where we are today. Three years we have to get this—
Simon Stevens
It is not 20 years. There is nothing magic about starting the clock in 1999.
Gillian Keegan
Three years now we have to get where we found the successes of the various models that were already in place. Where we have that—
Simon Stevens
That is not true; it is not that these were models that were all in place.
Gillian Keegan
Well, many of them.
Simon Stevens
They were explicitly implemented from 2015 onwards.
Gillian Keegan
They were branded from 2015 onwards, but if you look at figure 2, the reason there are five different varieties of them is that you are describing what was often already there.
Simon Stevens
No, that is not true.
Gillian Keegan
I think in many of these cases they were already in place or there was a design already in place, because they have been part of previous pilots.
Simon Stevens
There was an explicit process by which people were able to apply and explain the changes they would bring about, not just a re-description of what they were already doing. They did that and overall they have succeeded.
Gillian Keegan
But in terms of the organisational design and the barriers that stop this being replicable, how much of those have you overcome so that you can take this system anywhere—not just to the places that already had the organisational building blocks in place? That is the question, because that is the only way you will make this—
Chair
There are some deserts: Cornwall, Norfolk—places that do not have much going on.
Simon Stevens
I agree with you on that—that is the question. The Health and Social Care Committee looked at this very carefully and their conclusion was “Bringing local health and social care services together through STPs and ICSs to plan and organise care…is a much better way to manage constrained resources”. So that is what we are doing.
Chair
Mr Stevens, no one is arguing that it is not a much better approach.
Gillian Keegan
Everyone agrees on the approach.
Chair
But there are gaps. To reiterate Ms Keegan’s question, for the avoidance of doubt, how will you make sure that these replicate? We assume that you are not saying one size fits all, so how do you work out which models can be replicated and how quickly can you do it?
Simon Stevens
We will set out the speed of roll-out in the November plan. In order to bring that about there are several things that need to be in place. One is a redesign of the national financial incentives in the NHS. At the moment this has relied on voluntary adoption and effort—particularly moving away from the tariff-based system. Secondly, we will be looking at the notion of an integrated care provider that is capable of delivering a wide range of services and that that might have statutory backing, depending on what Parliament does, or it might be something that has to be delivered as an extension of the integrated care systems. Thirdly, we will be, as part of the join-up between NHS England and NHS Improvement, putting much more of the national resource in the system to help local areas go through this transition that the vanguards and the early ICSs successfully have.
Gillian Keegan
How is that funding working, because I think the funding for the vanguards stopped in March 2018. What is the funding process now?
Simon Stevens
We are looking, with NHS Improvement, at the total resource that has been spent by the national bodies, and how much of that is going on inspection, turnaround support, monitoring and all the rest of it, and whether that can be redeployed. If my colleague Ian Dalton were here, what he would be saying is that NHS Improvement intends to try and effect a shift from being principally a regulator to being more of an improvement agency. As they do that, this is central to the task.
Chair
How will you evaluate the success of it? Let us say you take one of these pilots; you do a similar thing in Norfolk, which has got, currently, nothing going on. How will you know, apart from the structural changes, that you have achieved things; and have you set a savings, or will you be setting cost targets against all of this?
Sir Chris Wormald
If you look at figure 5 of the health and social care interface Report, we do actually have a model that we have worked up from all the various examples of what we think integrated care is—the components of it—and how you go about monitoring it. So it is not that we set off a series of pilots. We have actually tried to distil this into a good practice model that individual local places can begin to use. If you look at the CQC reports on integrated care they also give you—I think the National Audit Office quoted this—some really quite clear things that make it work or not work. Where I completely agree with your questions is of course local places are starting from a very different history of this, and the places like Manchester where you have got a strong tradition of this go ahead much faster. The challenge we will have in the long-term plan, building on all the work on STPs, ICSs, is how do you bring, exactly as you were asking, areas that do not have that tradition, able to deliver this sort of good practice model. That is going to be our challenge.
Gillian Keegan
Going back to the money—because three years is not a long time to get this all done, everywhere, by 2020-21—do you have a clear plan? Which area is next? I think you had 380 applications. You go into the other 350. When will they be implemented? How much will it cost? What do you expect in terms of measurable outputs? Have you got a plan to roll this out?
Simon Stevens
Let us just clarify this 2020 point that you have made several times. It is referenced in the NAO Report. That was a modelling possibility that was discussed as part of the SR15 budget negotiation. It was not a funded roll-out using the original proposition.
Gillian Keegan
How do you get from a modelling possibility to an objective in the world of health and social care?
Simon Stevens
In fairness, the NAO make this point, which is that for very pragmatic reasons we had to use £1.8 billion to support the cost pressures to keep hospitals going day to day. That was money, therefore, not available for what you are just describing.