I was due to chair a session at the Beyond Dilnot conference for the Kings Fund in London today, due to my train breaking down and signal problems I remained stuck in Leeds and have been unable to attend. I wanted to put together my thoughts on the report as I unfortunately missed the opportunity today.
Lawrence Tomlinson
The Dilnot Report: Integrating Health and Social Care
Please note that some of the information contained below has come directly from the Dilnot Report. This is my (Lawrence Tomlinson) view and summary of the report.
Summary
- Government spends £140 billion in England on older people in England (social care represents around 6%; the NHS, 35%; and social security benefits 59%).
- Many commentators on social care and NHS funding believe the cause of much inefficiency, and poor service, results from the artificial divide between funding for health and social care needs.
- The Dilnot Commission’s objective was to ascertain how a fair and affordable system of social care can be achieved. They found that one of the major barriers to fair funding was the lack of integration between health and social care. One of its key recommendations is that the government consider how this can be achieved and that the Law Commissions report is accepted.
- The Commission broadly supported the findings of the independent Palliative Care Funding Review, which is looking into end-of-life care funding.
- The report is strongly supportive of pooled budgets, with a single budget holder. Some clarity is needed, but current best practice for budget ownership is on a case by case basis.
- The report calls for improved prevention schemes and early intervention activities, encouraging local bodies to work together to develop strategies and joint commissioning.
- The Dilnot Commission also suggested that the government should consider whether those on NHS Continuing Care should make contributions to their living costs.
Background
The government currently spends £14.5bn p/a on adult social care.
The integration of health and social care funding has been under the political radar for many years. It is commonly felt that one of the major barriers to the improvement of adult social care is the structure of funding, rather than simply the levels of funding. The change in demographics, exemplifying much higher levels of dementia, immobility and clinical reasons for residency, means that the emphasis on integration is more significant than ever. Residents’ needs are often complex, covering a range of social and health needs. It is believed by many that funding mechanisms currently ‘get in the way’ of the delivery of appropriate care and support.
Most people entering the social care system require some level of healthcare treatment. There are currently grey areas surrounding the distinction between continuing health care needs and social care needs. This leads to cost shunting between local authorities and the NHS thus increasingly causing inefficiency, discontent of patients and unfair cost burdens. The care the patient receives then rests upon which services heading they fall under instead of their actual needs. This leads to the accusation that the current system is not reflective of patients needs leading to poor quality care and vast inefficiencies due to unnecessary hospital admissions, deficient utilisation of resources nad substandard commissioning decisions.
This is especially the case for NHS Continuing Care (NHS CC), whereby the NHS picks up the full bill for the residents care. Many people who are eligible for NHS CC also have serious social care needs- including their living costs. Those people who, possibly marginally, do not meet the strict criteria for NHS CC still have serious needs and have to pay high costs for their care. The Law Commission has published a report suggesting NHS Continuing Care be put on a firmer statutory footing.
At present, the lack of integration has the following negative impacts:
- It creates a postcode lottery
- Assessment lacks transparency
- Care responds to services, rather than individual need- poor service quality
- Major inefficiency
Many commentators on social care funding believe that removing some of the barriers that the distinction prevails would facilitate more innovative commissioning and combined services, increasing patient choice and sidestepping the current ‘cost shunting’ between social and healthcare commissioners.
Dilnot Findings
The main objective of the Report was to consider how best the costs of care and support can be met through reform of the role of the individual and the state in funding. The review aimed to find a fairer solution to the question of funding social care.
One of the key findings of the report was that assessment criteria/processes are complex and opaque leading to poor information for service users and disjointed services. This causes unfair funding decisions and creates an unaffordable system for the future.
The commission acknowledged and emphasised on numerous occasions in their report that social care funding cannot be considered in isolation when considered questions of fairness of funding. The report said, “Social care is part of a wider care and support system, which includes social care, the NHS, the social security system housing support and public health services...The Commission believes it is important to look at care and support in the round- firstly, because we know that people want to receive a coherent package of support that is shaped around them, not funding streams, and secondly because aligned and integrated services offer better value for money.”
They said that care and support needs lie on a spectrum and cannot easily be divided into assessment criteria, therefore any attempt to define the roles and responsibilities of separate part of the system is artificial as in reality they naturally overlap.
They were therefore strongly in support of pooled budgets as they believe that a single budget holder should lead to more strategic decisions on service delivery and reduce the number of disputes between professionals which currently plague the system.
The Dilnot Commission recommended that the government consider, “how the whole care and support system can be reformed and better integrated to deliver better quality services and improved choice its forthcoming White Paper.” They continued to urge the government to review the scope of improving integration between social care and other services in the care/support system.
To assist with the problems associated with NHS CC the Commission not only support the findings of the Law Commission, but also recommend a new national eligibility framework for social care with greater transparency and consistency- they urge the government to consider how this will work alongside the assessment process for the NHS CC, “clarity in this area could be beneficial to many”.
The Dilnot Commission also called for improved prevention schemes and early intervention activities, encouraging local bodies to work together to develop strategies and joint commissioning.
Law Commission Report
The underlying objective of the Law Commission’s suggested reforms is to create a more unified social care system through a single statute and code of practice. The recommended scheme would consist of a single adult social care statute (separately in both England and Wales) which would set out the core duties and powers of local social services authorities that would not be subject to further directions or approvals. At a secondary level regulations would be made by the Secretary of State to provide more detail and allow for future policy development. The government would then create a code of practice for local authorities in line with the recommendations.
Some key points to note are that the recommendations have a single purpose for adult social of promoting/contributing to ‘individual well-being’ and that the low threshold for assessment will remain in place. The regulations must require that, as a minimum, assessors:
- Adopt a proportionate approach to assessment
- Carry out a specialist assessment in specified circumstances
- Consider all needs, irrespective of whether they can/are being met by a third party
Once an assessment has been undertaken by a local authority, they must make sure that any needs that call for the provision of services are met.
The Commission’s scheme also aims to provide a legal framework to enable the expansion and development of personal budgets. One aspect of this is that although existing legal provisions regulating direct payments would stay the same, the current restrictions on the use of direct payments to purchase long-term residential care would be removed- allowing service users to use direct payments to buy residential care.
In relation to the divide between health and social care, the commission recommends that existing statutory prohibitions remain, but that certain aspects should be further clarified. They recommend that the quantity and quality test should be included in the statute rather than being part of case law.
Also, they suggest that the government establishes an eligibility framework within regulations for the provision of NHS continuing healthcare and specify what combination of needs establish a primary health need whereby the person would be eligible for NHS Continuing Care.
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