Commons health committee’s social care report fails to make its case

The committee’s approach raises as many questions as it answers, often presenting a muddled and superficial treatment

The latest report from the House of Commons health select committee has argued for greater integration of NHS and social care, and particularly for a single commissioner for older people’s health, care and housing services.

The integration message is a familiar one from the health committee, as much as it is in recurrent government policy aspirations. The mantra of “only connect” has an appeal, but the reality is rarely that simple. Unfortunately, in exploring the way forward, the committee’s approach raises as many questions as it answers.

The report is titled Social Care and the very breadth of that focus is perhaps the greatest weakness of the analysis.

Perhaps the inquiry should have been focused specifically on social care reform and funding, but as it is the report skips around multiple themes but fails to explore any of them in depth. In consequence it presents a muddled and superficial treatment of some vital issues including support for carers, and developing the social care workforce.

Discussion of the personalisation agenda (which is core to the government’s vision for adult social care), for example, is limited to just four paragraphs. While signalling that this is “an issue to which the committee will return”, and declaring itself “sympathetic to the cause of greater personalisation”, the committee portrays this as if it was a new idea of some marginal interest.

The committee also demonstrates confusion in describing personal budgets as something “more akin to social security than social care” and assuming that the allocation of a budget “creates a scenario in which people’s needs could be assessed less personally.”

To draw parallels with the uncapped social security budgets that fuelled residential care growth in the 1970s and 1980s, is both ill-informed and curiously out of touch with the direction of travel.

If the major concern of the committee was with the integration of service commissioning, it is especially surprising that personalisation was not explored from this perspective. Increasingly, commissioning is taking place not through the direct actions of local authorities, but through micro-commissioning at the level of the individual user of personal budgets, or through consortia.

Instead, the committee focuses on commissioning being integrated “around a local authority or a clinical commissioning group.”

Just last year the committee was unsupportive of the development of health and wellbeing boards, but has since undergone a damascene conversion and now not only believes they have a role in commissioning, but that the HWB should become the holder of the local integrated budget.

Given the immense weight of expectation that is being attached to HWBs, and the practical challenges which HWBs are already facing in understanding their role and how to engage with the requirements of undertaking joint strategic needs assessment and the development of joint health and wellbeing strategies, the demands of also developing integrated commissioning budgets could prove extremely over ambitious.

The committee says it does not want to impose a single statutory framework for integration, but does wish to see a single commissioning process. The ongoing criticism of the health and social care bill surely underlines the folly of centrally driven reform introducing multiple new structures and complexities.

The committee itself has previously joined the chorus of complaint but now advocates a system that would introduce further “multiple lines of financial accountability” and necessitate the establishment of (yet more) “robust procedures” to ensure this would operate as intended. Moreover, whilst the discourse around HWBs is increasingly about “health and wellbeing”, and about the wider determinants of these within the community, the committee continues to view the world through the old lens of service boundaries.

There are many factors that impact on people’s wellbeing which are nothing to do with either health or social care, but may involve wider local commissioning (including leisure services, libraries etc) – should all these also come under the banner of the single commissioning budget? On closer inspection the complexity of such a model rapidly overshadows the initial appeal of the apparent simplicity of the integration message.

Why the committee decided to address social care only in relation to older people is bizarre. While there is much populist and political alarm over the increasing older population, it would have been refreshing to see the committee putting this negative demographic despair into some perspective; to recognise that not all older people need social care, and by no means all users of social care services are older people (consider people with mental health needs; with learning disabilities; physical disabilities and long term conditions; substance misuse issues and so on).

While the committee is especially exercised over the “artificial distinctions between health, social care and social housing”, it is disappointing that it fails to address the equally artificial schism between older people and others who use social care and support.

In arguing for an integrated approach to outcomes, the committee similarly argues that the three national outcomes frameworks (for the NHS, public health and social care) should instead become a “single outcomes framework for health and social care for elderly people”. There are already attempts at integrating the outcome frameworks, and work is ongoing in developing shared and complementary indicators. It seems likely that this is a more fruitful – if imperfect – model than one which follows a client group model which would introduce further fissures around definition and transition.

The committee’s desire to see greater integration as a route to better outcomes is commendable and well intentioned. But the report fails to fully make the case and there is a profound sense of unfinished business.

Melanie Henwood OBE is a health and social care consultant who has advised organisations including the Joseph Rowntree Foundation, and was a vice-chair of the General Social Care Council