Public Accounts Committee
Oral evidence: The interface between health and social care, HC 1376
Wednesday 18 July 2018
Ordered by the House of Commons to be published on 18 July 2018.
Members present: Meg Hillier (Chair); Bim Afolami; Sir Geoffrey Clifton-Brown; Caroline Flint; Gillian Keegan; Anne Marie Morris.
Sir Amyas Morse, Comptroller and Auditor General, Adrian Jenner, Director of Parliamentary Relations, National Audit Office, Aileen Murphie, Director, NAO, and Marius Gallaher, Alternate Treasury Officer of Accounts, HM Treasury, were in attendance.
Questions 1-179
Witnesses
I: Sir Chris Wormald, Permanent Secretary, Department of Health and Social Care; Jonathan Marron, Director General, Community and Social Care, Department of Health and Social Care; Jo Farrar, Director General, Local Government, Ministry of Housing, Communities and Local Government; and Simon Stevens, Chief Executive, NHS England.
Reports by the Comptroller and Auditor General:
- The health and social care interface (HC 950)
- Developing new care models through NHS vanguards (HC 1129)
Examination of witnesses
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.
Q1 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.
Q2 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—
Q3 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.
Q4 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.
Q5 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—
Q6 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.
Q7 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.
Q8 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.
Q9 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.
Q10 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—
Q11 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.
Q12 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—
Q13 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.
Q14 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.
Q15 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.
Q16 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.
Q17 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.
Q18 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.
Q19 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.
Q20 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.
Q21 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—
Q22 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.
Q23 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.
Q24 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.
Q25 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.
Q26 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.
Q27 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.
Q28 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.
Q29 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.
Q30 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.
Q31 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.
Q32 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.
Q33 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.
Q34 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—
Q35 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.
Q36 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.
Q37 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.
Q38 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?
Q39 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.
Q40 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.
Q41 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.
Q42 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.
Q43 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—
Q44 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.
Q45 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—
Q46 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.
Q47 Anne Marie Morris: So what are you going to do about pensions? How are you going to—
Sir Chris Wormald: About pensions?
Q48 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.
Q49 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—
Q50 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—
Q51 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.
Q52 Chair: No, but we are just concerned that you understand there is a problem there.
Sir Chris Wormald: Yes.
Q53 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.
Q54 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.
Q55 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.
Q56 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.
Q57 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.
Q58 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.
Q59 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.
Q60 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.
Q61 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.
Q62 Anne Marie Morris: Could you write to us with the exact figures?
Sir Chris Wormald: Yes.
Q63 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.
Q64 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.
Q65 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.
Q66 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—
Q67 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—
Q68 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.
Q69 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—
Q70 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.
Q71 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.
Q72 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.
Q73 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.
Q74 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.
Q75 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.
Q76 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.
Q77 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.
Q78 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.
Q79 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.
Q80 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.
Q81 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.
Q82 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.
Q83 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?
Q84 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.
Q85 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.
Q86 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.
Q87 Chair: Well, councils have been able to raise taxes—
Sir Chris Wormald: Okay, the state has put in considerably more resources.
Q88 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—
Q89 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.
Q90 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.
Q91 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.
Q92 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.
Q93 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.
Q94 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.
Q95 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.
Q96 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.
Q97 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—
Q98 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—
Q99 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.
Q100 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.
Q101 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.
Q102 Gillian Keegan: Are you just branding what is already happening?
Simon Stevens: No.
Q103 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.
Q104 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—
Q105 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.
Q106 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—
Q107 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.
Q108 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.
Q109 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.
Q110 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.
Q111 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.
Q112 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.
Q113 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.
Q114 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.
Q115 Caroline Flint: You have referenced the 2015 decision, which was to integrate by 2020, but if we look further along at figure 4, back in 2013 it was saying there, an “ambition to make joined-up and coordinated health and care the norm by 2018”. So what in your opinion did not work to enable that, that now we have an ambition for 2020 that is going to make a difference?
Sir Chris Wormald: I think it is the answer Simon gave: we have never attempted to deny, in front of this Committee or elsewhere, that money that we had previously proposed to invest in transformation we in fact used for sustainability, for all the reasons that you know. This has undoubtedly gone slower than the original plans. That is one of the reasons for a much longer-term funding settlement, a higher rate of funding settlement, and trying to give some planning certainty, so that we can both have sustainability and the kind of investment in transformation that we want.
One thing—this may be a problem with previous policy—is that I don’t think the concept of, “What date will it be done by?” is actually a useful one in this case.
Chair: We are not asking for a false target. I think that is the point that Ms Flint was making.
Sir Chris Wormald: Exactly, but for some of the reasons that Mr Clifton-Brown was pointing to, this is a situation that evolves every year, and the health and care system will have to evolve every year. But did we go slower than we were supposed to? Yes, we did.
Q116 Caroline Flint: The worry is that where there is money it just gets ploughed into the same areas over and over again. Secondly, where best practice is identified it is not being scaled out. If the best practice that is already available in terms of evidence about what works was expected to be taken on board and started being done by some of the other areas—putting aside all the other initiatives and just focusing on best practice as we know it—what difference would that make?
Sir Chris Wormald: What you have described is what we are trying to do. It is why we—
Q117 Caroline Flint: So what’s the problem with it? What’s stopping it?
Sir Chris Wormald: All the barriers here are exactly as described by the National Audit Office in its report, but we have a model, as I said, and it is set out in figure 5, of what we think integration should look like. Simon is creating a set of vehicles around STPs where we can progress this thing, and we have a long-term plan that will give us a longer term investment framework—
Caroline Flint: Just tell them what works and go out and do it.
Sir Chris Wormald: Yes. I am not disagreeing with you.
Caroline Flint: Stop talking and just do it.
Jo Farrar: That is exactly what we did through the high-impact dashboard, where we gave this to every area. We told them that this works, and we mandated it, and then we have seen some real progress as a consequence. That has led to the progress in delayed transfers of care.
Q118 Chair: Have you done an analysis of what the cost savings are? We keep going back to this issue about money, but if it does not work, then it causes pressure somewhere in the system. It might put NHS costs up, if it gets to the acute end of it. It can lead to more intense social care pressure if things aren’t working properly, so you are preventing, which is presumably where a lot of this has got to go for the long-term health service. Are you doing that financial analysis to prove—given that you were saying, Ms Farrar, that you have mandated people—not just what works, but that you could make some money savings?
Jo Farrar: That is exactly the analysis that we are doing for the next spending review. We are bringing that data together to look at not only what works but what makes a difference financially, because what we want is for local authorities and the NHS to be able to provide the best possible service at the best cost.
Q119 Sir Geoffrey Clifton-Brown: Sir Chris, you came in to rescue Mr Stevens by saying that the £1.8 billion withdrawn from transformation to sustainability was not entirely just slowing down the system, but Simon Stevens did say that because that money was withdrawn the transformation was slower. It went out from 2018 to 2020. Can we have a relatively high expectation that the Green Paper will point to sufficient resources? You have a model that works—Ms Keegan has questioned you very closely about that. Can we be pretty sure that we will have enough resources so that the model that works can be rolled out by 2020?
Sir Chris Wormald: I don’t have anything to say on resources that I have not said.
Q120 Sir Geoffrey Clifton-Brown: No, I am not asking you what the resources are. I am asking you whether there will be enough to make sure that the transformation will be done by 2020. If not, when?
Sir Chris Wormald: The first thing I should say is that I do not think there has ever been any difference between what I and Simon say about how we use transformation money. That was a conscious decision that we have set out before the Committee.
Chair: We have covered that a lot on this Committee.
Sir Chris Wormald: In terms of the investment we have made in health, what we want to see is both the NHS on a sustainable footing that does not require us to do the kinds of things that we have described to the Committee before cap lifts, which is diverting transformation money, and fund the kind of transformation that we have always wanted to see. The test of that—it goes back to the trade-off questions I was describing earlier—will be in the long-term plan process, and as I have said all the way through, this is not a giant silver bullet. There will be tough questions for us about what we pursue. On the local government side of the equation, we will have to wait for the spending review, but of course our intention will be that we can move at a greater pace towards the kind of integrated system that we all want to see. I cannot give you a guarantee, for the reasons that you know, but that is certainly the intention.
Q121 Sir Geoffrey Clifton-Brown: So are we just seeing that figure 9 that Ms Keegan referred to—the easy ones, the 50 pilot ones—are they the easy ones, and are we going to find that the more difficult areas are actually going to take quite significantly longer?
Sir Chris Wormald: Quite possibly. As I have said, undoubtedly it is true that different places round the country start from very different histories, and those that have a strong history of joint working in this area have clearly gone faster and will continue to do so. So will there be variable pace? Yes. I think your view is you can make progress, however, everywhere, recognising that some of the places that do it more will go faster. Is that fair, Simon?
Q122 Sir Geoffrey Clifton-Brown: Leading on to my next question, which is that a lot of this is about personality on the ground.
Sir Chris Wormald: Yes.
Sir Geoffrey Clifton-Brown: So how many of those 152 local authorities have what Gloucestershire has—a properly functioning joint commissioning board at the moment?
Jo Farrar: I do not know how many.
Q123 Gillian Keegan: Is not that a critical thing to measure? It is a critical pillar of success.
Sir Geoffrey Clifton-Brown: It works very well in Gloucestershire, so why do we not know the figure? If you do not, could you write to the Committee and tell us?
Chair: You must know the figure for some of the—
Sir Chris Wormald: I am sure it is known how many do the Gloucestershire model. We will go and have a look. I am sorry; I do not have that number with me.
Q124 Chair: But if it is best practice and you know it is, you must be wanting to roll it out.
Simon Stevens: In fairness, I think that Gloucestershire has got a lot of—
Chair: I am not talking particularly about Gloucestershire.
Simon Stevens: It is by no means the only path to salvation, so—
Chair: No. Sir Geoffrey was not suggesting that, but if you have one model that you know works, and you think it is therefore worth replicating, surely you know how often and where it is being replicated.
Sir Chris Wormald: I suspect how many people do that model is a known number; I do not happen to have it with me. The only other thing I would say is that when you look—I think this came out of the Manchester evidence and the CQC reports—at which areas do this really well, one of the big lessons is that it is really quite intensely local, so Manchester have always been very clear that they have developed a model for Manchester, and it is not the case that you can simply pick up a model and say, “That would now work in Dorset,” or Tower Hamlets or wherever—
Chair: No; no one suggested that.
Sir Chris Wormald: We cannot simply say, “This is the model; please do it everywhere.” There are some common features, which is what the figure 5 model tries to identify, but we do need to see local leaders, and I think CQC makes a big thing of this. Local leadership is the single biggest determinant.
Q125 Sir Geoffrey Clifton-Brown: But my question exactly alluded to that, Sir Chris. It is all about personalities. You have got two different systems. If the two different systems don’t want to work together, they won’t work together. If they want to work together, they will. So what can Government do to actually make sure that the two different systems work together, and that people’s heads get banged together if they don’t work together?
Jo Farrar: This is what we have done with the Better Care Fund—
Chair: You have mandated.
Jo Farrar: Yes, we have mandated; we even challenged, and we have then worked with, or challenged, the areas, brought them directly into a joint panel of the NHS/MHCLG, to not release funding until we can start to see progress. We have had some very difficult discussions, but we have pushed every area forward, and I think—
Q126 Chair: Does it work, though, when you are forcing the pace?
Jo Farrar: Yes, absolutely, because we didn’t have anybody at the end of that process who then were not making progress, so that was great. And we saw a large number who were making progress and didn’t need to come before the panel anyway, and had really strong evidence of how they were integrating—
Q127 Chair: So you are saying that your solution is mandating organisations to—well, banging heads together, as Sir Geoffrey puts it.
Sir Chris Wormald: No; not quite, Chair.
Q128 Chair: Sir Geoffrey is suggesting you want a strong cultural change.
Sir Chris Wormald: Not quite, Chair. I think Sir Geoffrey Clifton-Brown put his finger exactly on what the problems are here, and what we do about it is rather a classic mix of sticks and carrots. We need to create incentives for people to work together from the Better Care Fund and elsewhere. We need to create the right structures so that people can work together, through STPs and ICSs. We need to remove barriers, and then, as you correctly said, we can do all those things and then local leaders have to step up to the mark. So there is a lot we can do to create the conditions for people to work in that way, but—I do not need to tell you this—the very localised nature of the issue means that in the last resort, whether it works or not, us having hopefully created those conditions, it goes down to the issue that Sir Geoffrey Clifton-Brown has identified.
Where there is failure, we go in and we inspect. That is why we had the CQC reviews of areas that were in difficulty. We can intervene if there is a particular problem, as we had, for example, in Northamptonshire, and Simon had in the health system. Those are, of course, last resort things. There is a spectrum of things we can do, none of which get to what will make it work brilliantly, which is what Mr Clifton-Brown is describing.
Q129 Gillian Keegan: I suggest that one of the learnings is that transformation funds will be diverted into day-to-day operations, because that has happened in a lot of the vanguard cases. Are you sure that a stable 3.4% is enough to drive transformation, or is it just enough to keep the existing model working?
Simon Stevens: I think I was asked about this last time I was here. I will repeat what I said at the time, which is that this clearly represents a step change, relative to the funding the NHS has had over the last five years when we have had 2.3% and we now get 3.4%.
Q130 Gillian Keegan: Does it allow you to transform as per the learnings and lessons from your vanguard programme?
Simon Stevens: There are clearly still going to be choices, and improvements are going to be phased. What those choices are and how those improvements are phased will be the content of the long-term plan.
Q131 Gillian Keegan: At the end of it, will we get the best practice that you have got in this Report rolled out across the country?
Simon Stevens: At the end of the 10 years?
Chair: Yes, let’s take the 10 years.
Simon Stevens: The move towards integration is affecting every industrialised country’s healthcare system for patient reasons, clinical reasons and economic reasons.
Q132 Gillian Keegan: It is clear. Everybody agrees with the strategy, just not the implementation.
Simon Stevens: We are going to be doing it. There is not an alternative proposition. This is the plan for the NHS.
Q133 Anne Marie Morris: In the Report, particularly in the foreword, it is pointed out that culture differences and culture change is probably the biggest problem, quite apart from everything else we have talked about. Would you agree?
Sir Chris Wormald: Yes.
Q134 Chair: Jo Farrar, do you agree?
Jo Farrar: It is one of the biggest factors. For a chief executive, culture change and different cultures in different organisations are always a barrier, but local areas have made some really good efforts to come together and create common cultures.
Q135 Chair: So you agree it is a problem. Simon Stevens?
Simon Stevens: “Culture” is one of those words that can be both very salient but also so all-embracing that it disguises some of the underlying factors at play. Yes, there are cultural differences between adult social care and the health service, and the funding pressures in both have sometimes led to a pulling apart, rather than a coming together.
The different political accountabilities mean that it is not the case that the Department of Health and Social Care or MHCLG can just mandate an answer for Lancashire, when Lancashire County Council and the Lancashire NHS bodies are suing each other because they disagree about procurements and the award of services to—I think it was Virgin in that case. You can call that culture, but it is actually—
Chair: A complete breakdown of relations.
Simon Stevens: A political disagreement. It is glib to say that, given the way local democracy works, we will not have some of that in some parts of the country.
Q136 Anne Marie Morris: What we are now doing is getting down to a more granular level on the questioning we started out with. There is big-picture regulation, but there is also the way these different systems work, in terms of the individuals and how they make decisions. The decision making in the NHS is central, whereas in local government it is very local. What can you do about that? If you don’t deal with that, how are you going to deal with this culture issue?
Simon Stevens: Actually, part of what the NAO Report describes, and is almost on the verge of criticising, is that a lot of the vanguard decision making was local. We did not set out at the beginning a mandated routine, because it was harnessing the improvement commitment and energy of clinicians, patients and communities across the country, and then trying to figure out which are the active ingredients and then how we spread it.
For the first year, we did not come up with a top-down proposition, although Sir Amyas implicitly criticised the absence of that. We have got that balance to strike. I think a lot of people in the health service think that a lot of the improvement energy is going to come from the staff of the health service, the patients and our partners, not just from national direction. I would say that there is a double “n” in the NHS. It is a national health service, but, principally, it is a neighbourhood health service. That is how most people work in it and how most patients experience it. That duality is what we have got to get right.
Q137 Anne Marie Morris: Mr Marron, are you sitting down and talking to Mr Stevens about this?
Jonathan Marron: Yes, I am talking to him. The interesting thing that really powerfully comes out of the vanguards is—we spend a lot of time talking about the organisations and the structures in the centre, which are clearly important and can get in the way or help to drive it forward—the actual changes in the way clinical staff and care staff are working together to give a better service to patients. It is not just a question of whether we have the will to do those things, but whether we understand what the changes are. How do you align a GP individually with a care home and reduce admissions?
Q138 Anne Marie Morris: With respect, Mr Marron, that is a good answer, but these vanguards are only in very small areas where you have been given time to do that. Sir Chris, love him as I do, his answer was to bang their heads together.
Chair: High praise. Love is breaking out!
Jonathan Marron: There are two things: what are the service changes and do we understand which ones work? Obviously, the more evidence you build through the vanguards and programmes that doing it this way—that the enhanced care in care homes practice worked—that makes it much easier for the next person to come and do it.
Q139 Anne Marie Morris: But you have to make that happen across the country, and that is a culture change. How will you do that? I hope you will not follow Sir Chris’—
Sir Chris Wormald: I did not actually say that my answer was banging heads together, but okay. It may be useful to think about this at three levels. There are the big national barriers, such as legislation, accountability and so on, and we could wait around for them to be solved and not do anything—so park those. There is a second layer that Sir Geoffrey pointed out of whether there is great local leadership, and there is no getting away from that.
Then there is a set of things that Jonathan is pointing to, which there is no politics in, such as whether there is a compatible data system between the health service and the local authority in a particular area, and is there a proper way to do a joint assessment between a social worker and a hospital in an individual hospital in which two people do a single assessment. There is no politics in that; there is no accountability; there is not even very much money.
Q140 Anne Marie Morris: There is huge politics—information is power.
Sir Chris Wormald: But in having two systems that can talk to each other, as it were. Nobody objects to the practicalities of actually doing that. In terms of—
Q141 Chair: But there is money attached to that, isn’t there, because whoever is doing the commissioning for that—
Sir Chris Wormald: Exactly. These are the things where we need to invest more, and we have been under-invested in previously for the reasons that we have been describing. If we think of it at those sorts of levels, what are the things we need to tackle in local areas to allow people to work together? On Sir Geoffrey’s point, how do you build the local leadership that wants to do that? Are there big structural changes you want to make at a national level that will necessarily happen only at a particular time?
Q142 Anne Marie Morris: Sir Chris, you make an incredibly good point, which is that leadership and getting that right is key. How will you get that to work across all those different political organisations—because they are political with a big or a small p?
Sir Chris Wormald: Yes, and that is where we see STPs working really well with local government and the voluntary sector integrated into them to create that shared leadership—that is the point of that—
Q143 Anne Marie Morris: Have you seen them working well?
Simon Stevens: For example, if I take Devon as a case in point—
Anne Marie Morris: We have had a big resignation. Working well is—
Simon Stevens: I’m looking at the Devon County Council cabinet paper from 14 March, which says, “With NHS and Local Authorities now working more closely together than ever, this should give our doctors, nurses and social care staff the best chance of success” and it goes on to describe how they are doing that.
It goes on to say that the integrated care system that is being developed in Devon is “not about changing organisational accountability or privatisation of NHS or council services and the local authority will remain responsible for all its existing statutory obligations,” but it has the potential to “result in services that are far more joined up, less confusing and better coordinated especially for primary, secondary and social care”, and it will “reduce the administration involved in managing these services.” That is Devon County Council—just one example.
Q144 Anne Marie Morris: Mr Stevens, I love you too, but you can write whatever you like in a statement from a council, and it does not make it true. You know that we have had a resignation of our chief executive of our STP. You know that we have had challenges in appointing somebody to take over. You know that the voluntary sector is pissed off—forgive me—for not being involved in all this, as they should be. Love the report, love you, but that does not reflect the facts.
Simon Stevens: I am just referencing the county council—
Q145 Anne Marie Morris: That is kind of you, but it doesn’t—
Chair: I think we get Ms Morris’s scepticism.
Jo Farrar: But local government does have local leadership and it can choose to join up with the NHS. That is where we are seeing—
Q146 Anne Marie Morris: But there is good leadership and there is bad leadership. How are we going to make sure we get good leadership? Where is the incentive? Where is the motivation?
Jo Farrar: For local government there is a big incentive, because to provide independent care for people in their own homes, which is what local government really drives towards, it needs to have local leadership with the NHS. That is not only affordable for local government but provides so much better—
Q147 Anne Marie Morris: That is logical, but where is the personal win? Saying someone has to do something because it is their objective is not the same thing as a motivating factor.
Jo Farrar: We are seeing so many more examples of this, where local leadership is working alongside the local leadership in the NHS, which, as Simon said, does have quite a lot of freedom, particularly around community care, and we are seeing joined-up services. The recent CQC report about Bradford, which actually set out to look for good practice, was a really good example. It talked about really simple joint local governance and decision making, and the ability to make a difference.
Q148 Anne Marie Morris: I understand what you say, but the challenge is that you cannot mandate somebody to be a good leader, just like you cannot make everybody good by passing a law saying something is a crime. Actually, in Teignbridge—my area—it is brilliant, but that has absolutely nothing to do with the STP. It works because there are leaders who are prepared to work together. That is all about character, personality, leadership and a willingness to go the extra mile. But you can’t mandate that.
Sir Chris Wormald: No, of course you can’t. I completely agree with that. What I was trying to describe earlier is that there are undoubtedly things you can do at national Government level to create the right incentives, the right framework and the right good practice. We cannot mandate great local leadership. If we are going to have a system in which there is a strong local voice and councillors get a say, that puts a limit on the amount of mandating we will do, because obviously if you do that you lose the power of local democracy in this world. I completely agree with you: there are things we can do to promote good leadership, but we cannot create great leaders locally and just put them into place.
Q149 Anne Marie Morris: But one of the challenges is that we do not actually recognise that in this area. When Ofsted go in to report on a school, leadership is one of their key measures. I am not convinced that when I have looked at how—
Sir Chris Wormald: The CQC rating system—this is my specialist subject now—is of course heavily based on the Ofsted one and does look at local leadership.
Q150 Anne Marie Morris: But they do not evaluate the commissioning by local government.
Sir Chris Wormald: No, that is true.
Anne Marie Morris: Yes, it is true, and it is quite a big piece.
Simon Stevens: But we have an STP ranking system as well, which has a leadership assessment in it.
Q151 Anne Marie Morris: How are you going to take that down to local government? We have been talking about Devon County Council. Local government is not regulated.
Sir Chris Wormald: Here we do get into a number of ideological and political questions, on which I am not really going to comment. The question of whether national Government’s job is to inspect local government or whether it is a matter for local electors to inspect local government is much debated, and I am not going to enter into it. We do it differently in different places. We do inspect children’s services departments via Ofsted. We do not inspect other aspects of local government. Of course, different Governments have taken different political choices.
Anne Marie Morris: I totally get what you say.
Jo Farrar: However, we do monitor local government closely and look at all the factors that make local government successful. We do have powers to intervene, and we have intervened in local government. Often, one of the main factors for our intervention would be their leadership.
Q152 Chair: Ms Farrar, your permanent secretary was in front of us not that long ago, and she was unable to tell us the measures that would indicate to your Department when a local authority was becoming unsustainable.
Jo Farrar: Yes, and I think we wrote to you about that and set out how we assess the risk of a local authority.
Q153 Chair: But here in the room she could not give us a clear explanation of when you can see a local authority is becoming unsustainable.
Jo Farrar: We did write to you about how we risk-assess local government. We do risk-assess local authorities, and where we see there are significant failings, sometimes that is in leadership. As the Max Caller report pointed out in Northamptonshire—
Anne Marie Morris: But I think—
Sir Chris Wormald: Your question is undoubtedly true. We inspect and regulate the NHS centrally in a way that we do not local government. That is in the end a political choice, and you know the debate about that.
Q154 Anne Marie Morris: In which case, Sir Chris, let me ask you to take back from the Committee a request that they look at the whole practice of commissioning and governance of local government in its commissioning.
Sir Chris Wormald: I am happy to take that away as a request. As I say, you know the debates around this question.
Chair: Yes, take that as an offline conversation.
Q155 Anne Marie Morris: Let me ask you about health and wellbeing boards, Mr Marron. Those are supposed to be examples of how we all work well together, yet the NAO Report says they are a bit here and there, and a bit iffy. I do not see any way that you have been looking at that to see whether they work or do not work. Is this well led? Where is your challenge about whether or not this is going to be the vehicle for the future? I am stumped.
Jonathan Marron: We are sort of drifting back into the inspection of health and wellbeing boards, but over the past couple of years, we have looked really hard at the STP structure being the structure that we will look to in bringing together the integration of health and, working with local government, health and social care. It is slightly bigger than individual councils and individual health and wellbeing boards.
Q156 Anne Marie Morris: So are you going to get rid of the health and wellbeing boards?
Jonathan Marron: No, we have been looking at trying to get a geography that allows us to have a wide enough span that allows us to look at how the health service works together. Those 44 areas selected are local areas choosing the geography that they feel makes sense for their—
Chair: Sorry, it is the geography that the health people thought made sense. It did not actually connect with local government at all.
Anne Marie Morris: Yes, and it does not work for local government, because they are completely different boundaries.
Q157 Chair: If anything shows the lack of integration, it is that these 44 areas appeared like spaceships out of nowhere. They have no overlap with any logical area, even in places like London, where you have got enough boroughs close together that you could configure it in lots of ways. It made no logical sense.
Simon Stevens: I think you are overstating it a tad, in that for the most part they were self-generated by different parts of the country. There were some difficult judgments around some parts of Essex, Humberside and Hull. We are open to adjusting those but, just to be clear, we cannot plan integrated health service on an N=152 basis. We are going to need councils sometimes to work together with their neighbouring councils for the kind of joint endeavour that joined-up care services will require. That is so obvious in London; you cannot actually have an integrated national health service cut into 32 borough slices.
Chair: The PCCs did not do too bad a job.
Q158 Anne Marie Morris: How are you two, Mr Marron and Mr Stevens, going to actually make that work? Are you going to be transparent about this? Are you going to publish who is doing what so that we the public can at least see what is going on?
Jonathan Marron: We are. On the STP performance, we have a performance scorecard that we publish each July that sets out clearly how each STP is doing, based on a range of performance metrics, including—
Q159 Chair: That is fine if you are a citizen who knows you live in STP area 1 to 44—whatever the number is—but I do not think anyone in my constituency knows which STP area they are in. They think they live in Hackney, Homerton or Hoxton; they do not get that they are part of this bigger area. How will the average patient know whether they are getting good health services, or does that not matter in the grand scheme of things?
Jonathan Marron: If people are looking at whether they get good health services, we have a whole range of things. The CQC inspects each individual provider. If you are thinking about your hospital, you could look at that.
Q160 Chair: We know that there are a lot of places where people can go and do this. If you are an average patient who just wants to know quickly and easily, how do you propose in this system that people can see what is happening? Will they know if they are in a vanguard area, where this is the best service being offered, or whether they live somewhere where they are not yet getting vanguard services, such as Norfolk? How can an individual patient see that?
Jonathan Marron: If I am an individual patient, it depends on the question I am asking. If I am asking whether my care or my provider is good, I would look at the CQC reports on either the GP, the hospital or the provider I want to look at. That is the clearest way to look at that. If you are saying, “Is my CCG an effective area?”, Simon and NHS England publish a scorecard against each CCG and their performance. Against very similar measures, we also publish an STP. If the question is, “Is my local service one that I should feel confident about?”, go to the CQC. If it is, “Are my local commissioners doing a good job?”, you would look at the CCG. I realise it is getting complicated.
Chair: This is already getting a little beyond your average patient.
Jonathan Marron: The integration challenge is a bigger challenge—
Q161 Chair: There is no dashboard, is there? There is no simple way.
Simon Stevens: There is. If you go to the NHS Choices website or My NHS, you will find these data laid out by provider and by GP.
Q162 Chair: Certainly for GPs. It is understandable for people—
Simon Stevens: The point I wanted to make is that I know this hearing is about health and social care, but a lot of the join-up of services that has to happen is within the national health service. It is not just for the subset of our patients—in particular, it is frail older people, but also adults with learning disabilities or children with autism—who require a strong interface between health and social care. A lot of this is about GP services joining up with community nursing services and redesigning what happens in outpatients as a way of looking after people with specialist support over a long period of time. That is redesign and integration within the health service that really has little to do with the discussion around adult social care per se.
Chair: Absolutely. From my recent experience as a mystery shopper in the NHS, I have ample examples of that. We can come back to that.
Q163 Anne Marie Morris: That, in a sense, says it all, doesn’t it? These issues around leadership and trust—with leadership comes trust—will only be got right if you can sort out the overall governance piece so that there is some clarity. It is still not clear, other than telling me it is difficult and you cannot have 152—which I accept—how you are going to do that.
Simon Stevens: Well, we are doing it, as the Health and Social Care Committee said, in a pragmatic way through the development of the STPs and the integrated care systems. Some people characterise this as a workaround to some of the arrangements; I regard it as a supplementation of the mechanisms that are in place. Nye Bevan said that the way legislation should work when it comes to the health service is that there should be local experimentation which then, at the right point in time, Parliament can make universal across the country. It may well be that that will be an opportunity for Parliament as part of the development of the long-term plan.
Chair: We were wondering when we would get to some point like that.
Q164 Anne Marie Morris: The only problem I have with that, Mr Stevens, is time. Time is not on our side. Waiting for Nye Bevan’s—
Simon Stevens: Agreed. We are going as fast as we can, given the constraints we are operating under. There are two possibly contradictory thoughts emerging from this hearing, one of which is that making this work is heavily dependent on local relationships and the particularities of place and people. The other is the critique that says, “Why don’t you just mandate it across the country as a whole, in one fell swoop, and get on with it?” Those cannot both be true at the same time.
Chair: I don’t think we are suggesting that.
Q165 Anne Marie Morris: One is about structure and one is about culture.
Simon Stevens: Sure, but you cannot issue a memo on culture—
Anne Marie Morris: You are going to issue a memo on culture? I look forward to that.
Simon Stevens: No, I meant you can’t—double negative. No, single negative, as President Trump might say.
Q166 Anne Marie Morris: Right, culture. I am still, Mr Stevens, lost—as I am, Mr Marron—as to how you going to address this. Is there any one thing you could tell me that is going to give me the comfort I do not yet have about how you are going to deal with it? You have told how you cannot deal with it, and I understand you cannot mandate it, but what are you going to do, having acknowledged it is one of your biggest problems?
Simon Stevens: Earlier in the conversation we discussed a number of things that will make a difference and that we are going to be doing. One of them is redeploying the support available to spread the learning from the places where it has worked—from NHS England and NHS Improvement. The second is to redesign the financial flows and incentives to move people in this direction. The third is looking at the workforce changes, because a lot of this is actually about a redesign of the way clinical teams operate across some of the boundaries that have been kind of hard-wired between primary care, secondary care and community health services, so that is the third piece. The fourth piece is obviously what we have spent a lot of time doing, which is making sure that we, to the greatest extent possible, get the relationship right with local government, while recognising that it takes two to tango.
Q167 Anne Marie Morris: Great answer, Mr Stevens—I love you even more. Mr Marron, have you got a better answer?
Jonathan Marron: No, I have a supplement to Simon’s. One thing that is not really talked about in the report on integration is the work that originally started out by the National Association of Primary Care on how to build what they called primary care home, but essentially it is GPs working together for a 30,000 to 50,000 population, but bringing in a much wider range of staff to support people in those local activities. It is kind of a locality that makes sense for local government as well. It is not a council, but a neighbourhood.
The progress made there—about 15% of GPs are now part of that movement. We are very keen, as we look at the GP contract going forward, to make that networking into groups of that size a major part of how we integrate healthcare. That could take us a long way to having locally recognisable units that could take on some of this challenge of how we can—
Chair: We are going to get into constituency size.
Q168 Sir Geoffrey Clifton-Brown: Mr Stevens, can I take you to page 37, in the integration of care Report, and the extraordinary figure 8, quoting the Ipsos-MORI survey result of what the public think they can expect from our health service and our social care services. They are asked two questions in that Ipsos-MORI survey. The first one was, “The NHS provides social care services for elderly people”, and 63% answered “True”, and 34% answered “False”. The second question they were asked was, “Social care services are free at the point of need”, and 49% answered “True”, and 47% “False”. The answer is, of course, “False” in both cases. Clearly, almost half the population have no idea that they need to pay for social care—or that it is means-tested, shall we say. That leads you into problems, because they leave hospital needing social care and expect to get it for free, but find they have to pay for it. They then launch proceedings against the national health service because they think they ought to get it for free. What is the answer to that?
Chair: That is a big question to finish on.
Simon Stevens: I think answering this question is the precursor to Parliament being able to do anything that might emerge out of Green Paper proposals and all the rest of it. Unless people understand the status quo, they will not appreciate what the improvements are. Be it “death taxes” or “dementia taxes” and so forth, if people do not understand the fact that already your assets will be run down with the means test to £23,250 and that that is the status quo against which to judge alternative propositions, then it will be very hard for our elected representatives—yourselves—to construct a durable consensus that the public buy into. That seems to me to underpin everything.
Having said that, there are at least three criteria that a good policy answer, from the NHS’s point of view at least, would want to take into account. First, any additional public funding should be buying additional services rather than substituting other strands of funding. If public spending on social care is going to go up, then it would obviously be beneficial if that were buying extra packages of care or extra support for people, rather than substituting between funding streams.
The second conundrum to get right is that obviously there needs to be fairness between retirees. There is a sense that, at the moment, the contingency of what illness strikes has an impact on whether you are on the hook for costs through social care. The third is the intergenerational question: how much of the funding should be redistributed between retirees versus paid for by working-age adults? The latter two questions are obviously political and policy questions for Government and Parliament, not for the national health service.
Q169 Sir Geoffrey Clifton-Brown: I have two quick questions, a wider point and a narrower point, to follow up, because this is a very big subject. The wider point is that, as the demographics lead to an older population and sophistication of treatment means that people live longer but become more expensive, presumably that is true not only in the health service but will be increasingly true in social care. They will need increasingly sophisticated care packages at home if they are not to stay in your hospitals longer than they need clinically to do.
Simon Stevens: That is probably right, although there is a debate about—if you will excuse a bit of jargon—the so-called compression of morbidity hypothesis, which suggests that as people live longer, it may be that the period of time that you are nevertheless unwell or unable to look after yourself might expand proportionally with the increase in life expectancy, or it might remain the same fixed period and you have extra years of healthy life preceding that. The data points in opposite directions on that. That is really the question you are getting at, I think.
Related to that is the fact that, all of this said, we have actually done a very good job as a country in enabling people to live independently and to live healthy, longer lives. Even over the last five years, your chances of being hospitalised as an emergency have gone down by 12% on a like-for-like basis, because of the support that the community, GPs and social care—despite all the pressures—have been able to put in place.
Sir Chris Wormald: Very roughly, since the second world war I think it is right that for every two years of life we have added, we have added one year of healthy life. Both have been going up, which is a huge tribute to the health service and wider public health initiatives, but what leads to the effect that Sir Geoffrey is describing is the gap between those two lines. The future challenge is that obviously we want to see life expectancy go up and up, but almost as—possibly more—important is to see that “years of healthy life” line go up at the same sort of speed.
There are a couple of things in that. The inequality grows by decile of the economy, so the gap is at its widest at the lowest decile. The preventive work that we have to do—what we have been doing on obesity, smoking and so on—has to work so that those years of healthy life go up, hopefully, even faster than years of total life. The key point is that it is the gap between those lines, rather than the total age, that drives our cost pressure.
Q170 Sir Geoffrey Clifton-Brown: So the narrow point, which comes back to my delayed discharge point, is that people are reluctant to leave hospitals—or their relatives are reluctant for them to leave hospital; we all see that, as Members of Parliament—if their home care package is not in place, particularly if they are worried about paying for it. How do we educate the general public about this matter? It is much better for them, on the whole, to be out of hospital, but on the other hand they don’t want to leave because they are worried about paying for their care.
Jo Farrar: We very rarely see people not wanting to leave because they are worried about paying for their care. It is more often because the provision isn’t available for them. People generally tend to want to come home.
Q171 Sir Geoffrey Clifton-Brown: That’s the same point, isn’t it?
Jo Farrar: It is more about making sure that the right provision is there locally, and that is what we have been working on through the integration agenda and through helping people to live independently in their homes for longer. We now put joint discharge teams in a number of hospitals, so that people can really understand the implications of leaving hospital and to help them to make a smooth transition back into, hopefully, their family home.
Sir Chris Wormald: I think we need to be blunter about a number of these things. The medical director of NHS England made a lot of news by pointing out just how bad it is for someone to be in hospital for a week or more, which is not well known enough. It is not a happy message, but being in hospital for a prolonged period—
Simon Stevens: When you don’t need to be.
Sir Chris Wormald: When you don’t need to be, yes—is very bad for your health. That is an exceptionally important caveat to what I was saying.
Sir Geoffrey Clifton-Brown: He has now rescued you, Mr Wormald.
Sir Chris Wormald: Thank you, Simon. However, I don’t think that message is widely known enough. You want to go to hospital, get better as fast as you can and get out again. We can’t really say that often enough.
Jonathan Marron: One thing I might add is on the question about how we organise ourselves. Quite a lot of areas now try to discharge people from hospital into an intermediate care setting or into a residential care home and then assess their future package. That has shown to generally require a lower level of support and gives people more independence. Doing it in a hospital is the worst possible time to make decisions about your long-term future. There is something about the public being better organised—or educated, maybe—and there is something about how we run our system to give them the best possible chance of making sensible, long-term decisions.
Q172 Chair: All of this depends on the certainty. You can have all the promises in place, but people need to hear and experienced the certainty. That brings me partly back to funding. Jo Farrar, you kept talking about how you are analysing what local government needs and so on. If this all works out and people are in their homes for longer, independently, it is local government that bears the brunt of the cost, through social services. Mr Stevens’s organisation will have less to pay—maybe not less to pay; I am sure there will be other demands. That is the problem, isn’t it? The cost shunting is still in place. Where the money is spent is sometimes not where the saving is made.
Jo Farrar: If you look at integration, the savings will be across the community care.
Q173 Chair: Yes, that is all very well, but if you are the accounting officer for a budget and you are providing good social care—say you are one of the best local authorities in the country for keeping people at home and independent—that is fantastic, but it costs you a lot more than the council that does a rubbish job and all the patients have to go into hospital for longer.
Jo Farrar: Yes, but if I have joint commissioning and pooled budgets across community services, we are managing that burden together. We tend to see people coming out of hospital into some kind of community care. That might be an expensive care home, intermediate care or in their own home. Their own home tends to be the best option for most people, and it tends to be very cost-effective.
Q174 Chair: My point is that local government ends up paying for a lot of this—quite rightly on one level, because it is what is supposed to do.
Jo Farrar: Well, some of it, because there is also healthcare. If people are independent in their own homes, some of that is local government spending and some of it health spending, and that is why you would want to have some kind of integrated commissioning or pooled budget. It is not all a cost on a local authority, but you are right, and they are exactly the types of arguments that we need to bring together for the spending review, so we can start looking at what the longer term funding solution is for local government.
Q175 Chair: It is not just the spending review. I think you are getting a loud message from the Committee that there is a lot of hope riding on the Green Paper. The danger of the Green Paper is that you all sit here and say, “It’s all right, the Green Paper is coming, and it covers all of these things.” There is a will in this Committee Room and outside to get this to work, but there has got to be a certain honesty about it and an honesty about the funding—if there is this much funding, we can only do this much; if there is that much funding, we can do more. That would have to be an honest discussion. I am hoping—although I am not sure, Sir Chris, whether we have got the comfort from you yet—that the Green Paper and the visions around it will be open and candid.
Sir Chris Wormald: As I say, I hope I am being very clear that I am not seeing the Green Paper as a grand panacea for everything, for exactly the reasons that you say and for exactly the reasons that the National Audit Office points out are all the problems. They don’t go away because you have a Green Paper on the subject. These are all the issues that we and our partners discuss and struggle with, and they are not easy, for all the reasons that the Committee has pointed out.
It has been said that an awful lot of this rests on culture change, and I am sure that there are a number of people around this table who have run culture change programmes. At the last resort, it is all about a set of incentives, a set of sticks and talking a lot. You actually get culture change by facing up to these challenges, debating them in every hospital and in every local authority and in the public. That is really the only way we are going to get progress. There are things—I hope we described them—that we can do to create the right conditions, but it is only going to happen if the kind of debate we have been having is replicated in every local place and we do face up to all those tough challenges.
I do not want to give you the slightest impression that I think a Green Paper as such is going to change the world. It will be changed by lots of people in individual places sitting down in rooms we haven't heard of and never see and having a really great conversation about how they can do it better locally, and all the examples we have are really about that.
Q176 Chair: And an honesty about the funding, and analysing what needs to be spent and what the benefits are.
Sir Chris Wormald: Exactly, and that is what we have sought to do in this hearing. We are not sitting here saying that there is a huge pot of money coming that will solve every problem; we are saying that there is what we hope to be a sustainable funding package that will allow us to make progress on transformation, but there will still be tough decisions to take about which priorities—
Q177 Chair: We know that. I think you have got that caveat in a number of times.
Sir Chris Wormald: Yes, but that is what we came to say to you.
Q178 Sir Geoffrey Clifton-Brown: I have one last question for you, Sir Chris, which I do not expect you to have the answer to, but I would like you to write to the Committee. How many change management specialists does the NHS employ to deal with this matter?
Sir Chris Wormald: You are correct that I do not have the answer to that, and I do not know if it is—
Chair: For each organisation? You probably won’t know that off the top of your head.
Sir Chris Wormald: I am not even sure that is a knowable number, because it depends on what people are called.
Chair: Go and look and see what you can provide us with.
Sir Chris Wormald: I will go and look at what we know on that question.
Q179 Sir Geoffrey Clifton-Brown: That would be really helpful, Sir Chris. Perhaps we could ask local government for the same statistics. How many change management specialists have the 152 authorities got working on this problem? That would be really helpful.
Sir Chris Wormald: We will look at what is known. I will not promise you a number.
Chair: Thank you for your time on this hot, sticky day. The transcript will be up on the website in the next couple of days, uncorrected as ever, and our report will be out in the autumn as we are shortly to go into recess. Thank you very much indeed.