On 1 April, hundreds of NHS organisations were abolished at a stroke, while hundreds of others were created and existing bodies gained responsibilities, transforming the provision, commissioning and regulation of healthcare in the process.
While this is a huge change for the NHS’s 1.35m staff in England, it will also affect significantly social care professionals, who will not only have to learn a whole new set of acronyms, abbreviations and jargon but get to grips with how the reforms will impact on them and their clients.
Out with the old, in with the new
The Health and Social Care Act 2012 has abolished the 153 primary care trusts, responsible for health commissioning, and the nine strategic health authorities, responsible for performance managing the NHS in their regions. It also signals the abolition of remaining acute, mental health and community NHS trusts; they are all expected to become or be merged with more independent foundation trusts, or be dissolved over coming years.
In comes 211 clinical commissioning groups (CCGs), led by GPs, to take over responsibility for most healthcare commissioning with a combined budget of £65bn. They are overseen and held to account by NHS England, a new super-quango that will commission specialist services and primary care and operate regionally through 27 local area teams. CCGs are supported by 19 commissioning support units, whose functions will include contract management of providers, procurement and service redesign.
It is arguably a more complex NHS for the social care sector to engage with. Most of the 152 councils in England shared the same boundaries with their local PCTs, meaning they only had one commissioning partner in the NHS; but many will now have to engage with more than one CCG and all councils will have to forge strong relationships with commissioning support units and NHS England local area teams. For instance, NHS England is responsible for disbursing £859m of funding for councils to spend on social care services that benefit the NHS in 2013-14, a function previously carried out by PCTs.
Why are the reforms happening?
The reforms are designed to help ensure the long-term sustainability of the NHS at a time of rising drugs costs and demand from an ageing population, by achieving much better value for money and shifting care out of hospital into the community.
CCGs are expected to use their clinical knowledge to purchase more efficient services than more remote PCT managers. In addition, they will be encouraged - some would say obliged – to tender out services to any provider that meets required standards, so that competition can be used to drive up standards.
The legislation is also designed to deliver closer integration between health, social care and other related services, on the grounds that this will deliver better value for money and improved care. PCTs’ public health responsibilities, and almost 3,500 staff, have been transferred to councils, on the assumption that councils’ responsibility over related areas, including housing, leisure and social care, will lead to more effective public health practice and reduce strain on the NHS. As part of this, councils will take responsibility for commissioning substance misuse.
Another plank of the reforms is improving the ability of patients and the public to hold the NHS to account through the creation of new patient representative organisations, Healthwatch England and local Healthwatch groups. Like their predecessors, the local involvement networks (Links), local Healthwatch groups will focus on social care as well as health.
Improving joint working
The Health and Social Care Act 2012 explicitly promotes joint working between health and social care, principally through the creation of health and well-being boards (HWBs) to oversee services in each area. These are committees within every council with social services responsibility, including representation from CCGs, the local Healthwatch and the directors of children’s and adults’ services.
HWBs will prepare joint strategic needs assessments (JSNA) and councils and CCGs will both be under a duty to produce strategies that respond to the JSNA but also to have regard to each other’s strategies. CCGs and HWBs will also be under a duty to promote integration of health and social care.
What this means for joint working at the front line, or social care commissioning, remains to be seen. It is unclear how far it will lead to greater use of formal partnership agreements, under section 75 of the NHS Act 2006, to pool budgets, integrate commissioning or set up joint teams across councils and the NHS. Several of these existed between councils and PCTs, particularly in learning disabilities and mental health, and CCGs will have inherited many of them.
The legislation should also in theory make it easier to set up care trusts – individual organisations responsible for health and social care commissioning or provision – as it removes the requirement for these to be approved by the secretary of state for health. However, so far among CCGs, it appears only the group in North East Lincolnshire, where there was previously a care trust, has taken on responsibility for commissioning adult social care.
One barrier to this happening more widely is that elected councillors are barred from sitting on the boards of CCGs, restricting councils’ ability to exercise direct oversight over adult social care. North East Linolncshire has got round this by setting up a sub-committee with councillor representation to take crucial decisions on adult care.
The risks of competition
One of the chief concerns of critics of the reforms is that their promotion of competition among providers of all hues for NHS business will lead to the fragmentation of care, to the detriment of quality and integration with social care. When the legislation was originally published in 2011, the Royal College of Psychiatrists warned this could happen to mental health, with the potential break-up of community mental health services. The college had wanted the bill amended to ensure that competition should only be employed if it were shown to benefit patients.
However, this did not happen, and regulations under clause 75 of the Health and Social Care Act 2012, published last month, said CCGs could only award a contract without competition, if it was satisfied that the provider was the only one capable of providing the service – seen as a high threshold by critics. The regulations prevent CCGs from acting in an “anti-competitive manner” unless this is in the interests of patients, including to improve the integration of care. It remains to be seen whether this clause ensures that competition does not lead to fragmentation of care.
Safeguarding adults and children
CCGs have inherited PCTs’ responsibilities for safeguarding children. Like PCTs, they must appoint a designated doctor and nurse with responsibility for safeguarding children and looked-after children, to provide advice and leadership to NHS bodies and professionals in their area; CCGs and NHS England also sit on every local safeguarding children board.
Every CCG must also have a designated adult safeguarding lead, to oversee inter-agency working with councils and the police and ensure systems are in place for responding to abuse or neglect in NHS-funded services. When the Care and Support Bill – currently in draft form – becomes law in 2015 or 2016 - CCGs will become mandatory members of safeguarding adults boards, but they will also now join existing non-statutory boards.
Each NHS England local area team has a director of nursing with overall responsibility for safeguarding adults and children in their NHS region; this will include commissioning any enquiries or reviews of services provided by independent contractors.
Mental Capacity Act and Mental Health Act: new responsibilities for councils
CCGs must also have a Mental Capacity Act lead, whose responsibilities will include that the care commissioned by the group is compliant with the MCA and the Deprivation of Liberty Safeguards (Dols).
However, councils are now responsible for authorising deprivations of liberty in hospitals, a role previously carried out by PCTs. Councils are also now responsible for commissioning independent mental health advocate (IMHA) services for people detained under the Mental Health Act or subject to community treatment orders.
NHS continuing health and nursing-funded care
Clinical commissioning groups have inherited PCTs’ responsibilities for NHS continuing healthcare and nursing care for people in residential care, and must comply with the national framework for these services, revised last November. This role involves commissioning assessments by a multi-disciplinary team of people most likely to be eligible for continuing care – often following an initial screening assessment – with eligibility determined using a prescribed decision support tool. The CCG is also responsible for commissioning places and care management for those deemed eligible.
CCGs are expected to involve local authorities in this process. There is an expectation that CCGs may delegate some of their continuing healthcare functions to commissioning support units; however their statutory duty to determine eligibility cannot be delegated.
As well as handling current cases, CCGs will have to review cases of people who feel they should have been assessed for NHS continuing care from 2004-12 but were not. Controversially, the Department of Health imposed deadlines for families to apply for a review so that no applications made after 31 March 2013 will be considered for reviews relating to unassessed periods of care from April 2011-March 2012; an earlier deadline of 30 September 2012 was imposed for unassessed care from 2004-11.
The full impact of the NHS reforms on social care will become clear over the coming months. The immediate challenges for social care professionals, managers and providers is understanding how the pieces of the new NHS jigsaw fit together, who they should be doing business with locally and how they can influence the new health landscape in a way that most benefits social care service users.