Better Care Fund and improving care
This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government
Secretary of State for Health talks about preparing the NHS and social care system for the challenges of an ageing population at NCAS.
Let me start with a thank you.
All of you have been talking about delivering integrated, joined-up care for a very long time and I know sometimes it has felt like banging your head against a brick wall. And now it is happening, for real. Instead of people just talking about it, you are actually delivering it. And without your vision, your determination, and your passion to do better for some of our most vulnerable citizens it wouldn’t be happening.
I am also pleased to be saying these words in Manchester which has been at the forefront of joining up health and social care and proved beyond doubt that integrated care, driven not from Whitehall but by local enterprise and initiative, can support the transfer of hospital services to out-of-hospital settings by truly focussing on the needs of patients and service-users.
And the fact that this kind of project is not peripheral but now central to the change we want to see in our NHS and social care system was demonstrated last week with NHS England’s visionary Five Year Forward View. It talked about inspiring new models of out-of-hospital care, exactly the change that people here have been arguing for. That plan and your ambition is completely consistent with the government’s own view about the future of health and social care.
We all agree that change needs to happen. But to work it has to be locally led, tailored to local needs and designed by those who know those needs best. So the role for government is clear: no grand blueprints, no structural shake-ups, no one-size-fits all. But our role will be to enable, champion - and yes fund - your endeavor.
So I want today, as my first response to the NHS England Five Year Forward View, to outline the four pillars of our plan to prepare the NHS and social care system for the challenges of an ageing population. And as social service directors your role will be absolutely central to every element of that plan.
Funding backed by a strong economy
The first pillar of our plan concerns funding. A strong NHS and social care system needs a strong economy to support it. The last four years have been the most challenging ever for both the NHS and social care system - and they started because of an economic crisis. It is in all of our interests to make sure the economy continues to grow, create jobs and generate the tax revenues that allow sustained ongoing financial support for health and social care. In Portugal, Spain and Greece we have seen services cut as the price of economic failure - and we don’t want that to happen here.
And when we did have to tackle the deficit, we prioritised the NHS by protecting its budget - which meant tougher settlements for other departments including local government. But the interconnected relationship between the services we both offer to vulnerable people means that we in the NHS have a responsibility - as we move to fully integrated services - to help you deal with a tough financial settlement. If we operate in financial silos the costs will be higher for both of us - hence there is no sustainable NHS without the tremendous strategic importance of the Better Care Fund which we are celebrating today.
Transformed out-of-hospital care
But it isn’t just about money: it’s also about the way we deliver care.
The NHS was set up in 1948 in a very different world. The model was essentially if you were a little bit ill you went to your GP; if you were very ill you went to hospital. You were then patched up and sent home.
With an ageing population our challenges are profoundly different. By the time of the election we will have nearly one million more over 65s than at the start of the last parliament. Within the next two years, we will have three million people with three or more long term conditions. A few years after that we’ll have one million people with dementia. And a few years after that - by 2030 - the number of over 80s will double to 5 million people, 10% of the entire population.
Older people with complex conditions need a different type of care, one that is usually best delivered out of hospital settings. They’ll be frequent users of the health and social care system so they need one person taking responsibility for their healthcare. And they need to know that wherever they go they will be dealing with someone who knows about them and their family, knows their medication history, and knows about their other interactions in the system.
So if getting a strong economy is the first pillar of our plans for the NHS and social care system, getting this new model of care right for an ageing population is the second.
Better Care Fund
And on that front I am pleased to report today some remarkable progress with the Better Care Fund, which for the first time anywhere in the world is integrating health and social care across an entire health economy.
Building on the excellent work by Norman Lamb on the Integration Pioneers that many of you were involved in, local authorities and local NHS commissioners have joined together and painstakingly planned commissioning for adult health and social care with pooled budgets. Budgets from the local authority side are for the first time helping to reduce emergency hospital admissions and budgets from the NHS side are for the first time helping to reduce permanent admissions to care homes.
I want to thank my colleague Eric Pickles for making this happen, and thank the Better Care Fund Team and Andrew Ridley.
Sceptics said this wouldn’t happen. Critics said there wasn’t the appetite among local councils or the NHS. The papers criticised it and opposition politicians called for it to be halted and when they were proved wrong said it didn’t do enough.
Well they were all wrong. Because today I am delighted to announce the total amount of pooled budget for next year is even higher than the government’s original £3.8 billion. It has risen to a staggering £5.3 bn.
I can announce that 97% of the 151 plans have been approved.
And that as a result of these plans NHS England estimate that the Better Care Fund will be supporting at least 18,000 individuals in new roles delivering care in the community. This will be a range of social workers, occupational therapists, care navigators, doctors and nurses, deployed based on local needs and delivering outside hospitals care to some of our most vulnerable citizens.
Taken together, these plans will mean savings [to the NHS] of £500m in the first year alone. More importantly in terms of patient care, they will mean 163,000 fewer hospital stays or 447 fewer hospital admissions every single day; and 100,000 fewer unnecessary days spent in hospital in total through organising better delayed discharges
This is a great start and everyone here should feel very proud. But based on the same principles that we’ve learnt in the last year I want to ask why should we not go further?
Accountable care organisations
For me GPs, whose services are commissioned by NHS England, sit at the heart of NHS community care. We need them to be part of this change too. So this year, for the first time, CCGs have been offered for the chance not just to commission social care jointly with local authority colleagues, but also co-commission primary care with NHS England. I hope the result will be in many areas a single integrated approach to commissioning all out of hospital care, whether through community care, GP practices or social care, often using personal budgets to integrate care even better around the person.
I think we can go even further than that.
Should we not adopt the same partnership approach we have so successfully pioneered with the Better Care Fund for public health responsibilities as well? You have made a great start with your new public health responsibilities - alcohol recovery rates up, smoking down, teenage pregnancy down and health checks at an all time high. It would surely make more sense for local authorities to plan their smoking, alcohol, drugs and obesity strategies alongside NHS colleagues who have a direct financial interest in making them successful. In doing this we can turn CCGs, working alongside local government colleagues in accountable care organisations, responsible for commissioning end-to-end integrated care for their entire populations - including both care closer to home and proactive prevention programmes.
And in the same vein, should we not also consider joint commissioning of children’s services, building on our review of Children and Adolescent Mental Health services? That review highlighted the importance of different organisations working together - so as we move to integrated care we should consider what the benefits could be for this very important patient group.
A strong economy and integrated community care are the first two pillars of our plan. The third pillar involves being much better at embracing innovation and efficiency.
The technology revolution means that now half of us bank online, nearly two thirds of us have a smart phone and three quarters of us access the internet every day. Yet still in the NHS we employ people whose main job is to input the contents of faxes from hospitals onto electronic health records in GP surgeries.
IT investment has had a chequered history in the NHS but in the last two years we have made some good progress. By the end of this year a third of A & E departments will be able to access summary care records, as will one third of 111 call centres and one third of ambulance services. This will then be rolled out to everyone.
I know electronic record sharing is a key part of the Better Care programme you have been working on - so let me give you one example of where I think it could make a huge difference. Shouldn’t residential care homes be able, with a patient’s consent, to update someone’s condition onto their GP record on a daily basis? We’ve introduced named GPs for all over 75s this year, rolling out to everyone next year. But we could make this much more meaningful if the responsible GP was able to check on someone’s condition on a daily basis just by looking at their record on a computer.
But innovation is not just about electronic medical records.
One of the most common criticisms of the NHS is that it is a slow adopter of technology, even when adopting such technology earlier would save overall costs. This tends to be because we look at costs in financial silos so people are reluctant to invest in costs upstream that benefit another part of the system downstream.
We therefore need CCGs and local authorities to collect full real time total NHS and social care cost information by patient and service-user. Only when we can see that will commissioners invest properly in the preventative innovations that both improve health and contain cost.
Innovation and efficiency is the third pillar of our plan. And then final pillar is the most difficult of all, because it is not financial, it’s not operational it’s cultural.
We need to change the culture of a system that has too often failed to put patients at the heart of its priorities.
Almost two years ago, after less than two months as Health Secretary, I made one of my most difficult speeches I’ve ever made when - in the wake of Mid Staffs - I talked about the normalisation of cruelty in the NHS. And we have sadly also seen at Winterbourne View the criminal abuse of vulnerable adults.
Since that time, thanks to the huge efforts of people across the health and care system, we have made great strides in improving quality and safety in hospitals. We have 5,000 more nurses in our hospitals, every patient being asked whether they would recommend the care they receive to friends or a member of their family and with the new Chief Inspectors of Hospitals, General Practice and Adult Social Care we probably have the most robust independent inspection regime of anywhere in the world. And we are doing more as well to help adults and older people live independently, with the appropriate support, rather than in residential care.
And these things are all important - but unless the culture changes as well they will be for nothing.
And the heart of the problem is that for too long in the NHS, perhaps less true in the social care system, but in the NHS we have relied on top-down targets as the main way to raise standards. Whilst there will always be a role for some targets in any large organisation, the danger with too many targets people focus their energy away from the vulnerable person sitting right in front of them - as we saw at Mid Staffs with tragic consequences.
We need to recognise that transparency of outcomes and peer review is a far more powerful way to improve care than yet more targets.
Transparency of outcomes was pioneered by Bruce Keogh and our heart surgeons a decade ago: since they had the courage to assemble and publish, surgeon by surgeon, mortality rates we have moved from having some of the highest heart surgery mortality rates in Europe to some of the lowest.
The MyNHS website now displays comparative performance by hospitals and local authorities on a wide range of indicators, from food to efficiency to safety and public health. I want this to be the engine that turns our NHS and social care systems into truly learning organisations.
And as part of that cultural change we need to see, which is to make sure the primary accountability of doctors and nurses is not to system goals but to the patient standing in front of them.
From next year every NHS patient will have a GP who is personally responsible for their care, with the GP’s name at the top of their electronic health record. Named, accountable doctors so that both patient and NHS know where the buck stops. And GPs supported to discharge that responsibility with more capacity in primary care, whether through additional GPs, practice nurses, district nurses or administrative support.
So I wanted to spend some time explaining the four pillars of our plan to transform our health and social care systems over the next parliament: increased funding backed by a strong economy; integrated, joined up out of hospital care; innovation and efficiency; and a culture where patients and service users always come first.
If it sounds ambitious, I think it is.
But we have a few trump cards to play.
A social care system that has succeeded in weathering perhaps the toughest financial challenge in its history.
We have an NHS that was rated this year by the independent Commonwealth Fund as the top-performing healthcare system in the world - ahead of America, ahead of France, ahead of Germany, ahead of France, ahead of Spain.
The commitment and values of not just NHS staff, but also colleagues in the social care system who have given their lives to the most noble cause of all, giving dignity and respect for our mosy vulnerable and disadvantaged citizens.
And we have a growing economy. But the litmus test for us as societu is what we do with the fruits of economic success.
Today shows that with hard work, imagination and commitment we can pass that litmus test and rise to the challenge of an ageing population by making Britain the best country in the world to grow old in.
There’s a long way to go, but today the journey has started.