Matthew Taylor CBE: Chief Executive, NHS Confederation

Today, however, chronic under-funding, and the scaling back of governments’ commitment to reform, means that the challenges for social care are greater than ever. Social care capacity has been depleted by market changes, workforce constraints and continued cuts to local authority budgets. Investment has been inconsistent and insufficient to meet rising costs and increase service provision. The direct consequence: fewer people are being supported by the state-funded social care so crucial to maintaining independence and dignity. And, of course, gaps in social care provision have direct impacts on the health service both in terms of overall demand and the flow of people through the health system.

Of course, the NHS - social care's key integration partner - similarly faces an environment of ever-increasing pressures. Persistent underfunding particularly in relation to staff and capital investment combined with a pandemic and rising acuity and complexity of demand from an ageing population have created a ‘perfect storm’. In recent years, difficult winters, financial challenges, and more recently the impact of industrial action, have put even more strain on systems and staff - affecting the provision of care, lowering morale and threatening working relationships between professional groups.

The Care Act paved the way for health-led initiatives to support integration."

Chief among these is the Better Care Fund, launched shortly after the Care Act. The Fund has had some success in encouraging local councils and the NHS to collaboratively deliver integrated health and social care through pooled budget arrangements. In Warwickshire, health and social care partners are jointly delivering a Community Recovery Service which provides therapeutic intermediate care services for up to six weeks following discharge from hospital. 

This has resulted in a significant reduction in the number of people waiting for a package of care, thus reducing length of stay in acute settings and maximising the home first approach. While successes like this are currently only seen in pockets, the Fund’s focus on person-centred care, improving sustainability and creating better outcomes for people and carers - in lockstep with the vision of the NHS Long Term Plan - remains in place.

This is particularly true of the Better Care Fund’s latest revision, which offers greater scope for much needed longer-term planning. But there is a risk that it continues to be used as a means of plugging winter pressure gaps, rather than delivering more forward-thinking integration initiatives. This is symptomatic of a widespread affliction of both health and social care: short-termism. 

Health and care leaders trying to work together to plan longer-term transformation are working within different funding cycles and are constantly hitting the brick wall of small, penny packet funding pots. Disparities between health and social care (cultures, ways of working, image and perception, and funding), and the short term, reactive firefighting approach has not only made it difficult to identify joint issues and consider ways of working together, but now risks pushing partners further apart.

Realising the ambitions though integrated working

Fundamental changes in the way care is delivered are needed to realise the ambitions of the Care Act and ultimately to ensure the future sustainability of our health and care system - not to mention the future prosperity of our nation. These are precisely the shifts that integrated care systems (ICSs) were put on a statutory basis to deliver.

The first change is moving from a sickness service to a preventative model of care, with better community-based care and support. This aligns with the Care Act’s vision for the care and support system to actively promote wellbeing and independence, rather than waiting for people to reach crisis point. To keep up with levels of demand - largely in the acute sector - NHS expenditure has risen from 8 per cent to around 11 per cent of GDP. 

Shifting resources upstream towards primary and community care and earlier preventative interventions across the NHS and social care is a more efficient approach to improving health outcomes and limiting demand than more expensive downstream services. As Chief Medical Officer Chris Whitty argued in his 2023 annual report, the medium-term sustainability of health and care demands we proportionately shift focus and resource from hospital-based care of sick people in the last stages of life to a wider variety of interventions that can help people stay healthier and more independent for longer.

The second shift is towards more personalised care, focusing on giving people the support they need to manage multiple chronic conditions and supporting people to lead as good, independent lives as close to home as possible. There is much the NHS can learn from the social care sector in this regard. Only by working together can we guarantee that care is personalised and person-centred and offers people choice and agency in their lives. There are some great examples of this across the country. Dorset ICS improved anticipatory, preventative care by integrating community, primary and social care teams at neighbourhood level. They have halved the number of A&E and emergency admissions among its oldest residents and promoted self-care through a fall prevention service.

ICSs also represent our best opportunity to shift from focusing on activity to outcomes, act on the wider determinants of health and tackle the widening inequalities that exist in society. There are some important enablers for this shift to occur. The most obvious of these is social care reform. The sector needs a fair settlement and enough staff to deliver crucial support to our increasingly ageing and sick population. There is still around a 35 per cent disparity between the pay of a support worker in the NHS and a support worker in social care.

A truly integrated social care system is one in which system leaders are given scope to focus on future thinking while firefighting the current crises. The Hewitt Review of ICSs autonomy and accountability highlighted the impact of command-and-control approaches and target-setting on system’s scope to deliver integration and transformation. Health and care leaders must be given the headspace to understand local need, capacity and demand. Funding cycles across health and care must also be aligned and take place over a longer horizon to enable longer-term planning.

With these shifts, health and social care have an opportunity to work together to deliver care more efficiently and to prove that there is scope to safeguard the future of the sector through integrated care.