Dr Sarah Wollaston MP
Chair of the Parliamentary Health Select Committee

I am afraid notice of your emergency review of English Accident and Emergency services only reached me yesterday, so please accept my apologies for writing this letter comparatively late in the day.

I do appreciate, too, the urgent and important nature of your review. The issue with which it is going to deal are pressing, immediate and urgent, affecting as they do the security, health, safety and wellbeing of thousands of older and vulnerable people.

There has been increasing interest and speculation about the role of social care in assessing for, and arranging, services in the community to enable the transfer of care. With that in mind and the fact that your Committee does not, as yet, appear to be taking evidence about this, I thought it would be helpful if I wrote to you, to set out our understanding of the causes of the current challenges and some of the solutions.

Why are A and E pressures rising? The truth is; there are a variety of reasons. The visits have been increasing year on year for ten years since the primary care-out-of-hours were changed ten years ago. The College of Emergency Medicine has concluded that 15 per cent of people who visit A and E could be treated elsewhere – a figure which matches the increase in the number of people who are living with long term conditions - particularly older people. We expect to have three million people living with three or more long term conditions by 2018 and the number will continue to rise.

Correspondingly there is also the question as to whether delays make a contribution to the lengthening of the waits in Accident and Emergency Departments. It is our analysis (and we believe this is supported by the excellent work of the College of Emergency Medicine) that the issues are multi-causal.

There can be no doubt that one of the major factors bearing on the current situation is the increasing number of older people who have an increasing number of long term conditions such as strokes, arthritis, dementia and heart disease. In these circumstances, as we know, illnesses such as influenza can become life threatening and require emergency treatment and admission. Put simply, as it was by an older man on Independent Television News yesterday evening, there are more older people now than ever before. And if we offer the same service to them - let alone one that has reduced by 26% or £3.5 billion in the past four years - it will not have the capacity to provide the additional services that are required to meet the increasing needs.

Despite those funding reductions local authority councillors have done their best to protect social care as it has moved from 30% to 35% of local authority expenditure. At the same time delays in transfers from hospital to community attributable to social care have reduced from 33% to 26.5% of all delays. There are some that are attributable to both the health and social care, while the remaining two thirds are the responsibility of the health service.

Properly funded social care is an essential part of the solution not only in helping to ensure that hospital pressures are eased but also in the most important task of ensuring that people’s needs are met in the right time and place with the dignity they deserve.

So what do we need to do?

The Better Care Fund objective is to join local planning to integrate care albeit that the money, £5.3 billion, is already being spent on priority care elsewhere. It is a good initiative but does not go anywhere near far enough to redress the very deep cuts that have been made to social care budgets in recent years.

In the short term we are working with government and the NHS to help to improve the current position through ensuring seven day working across the country; working with care providers in care homes and the independent and voluntary sector to increase capacity and ensuring that assessments for making arrangements for care happen as quickly as possible.

There is no doubt that urgent additional funding support directly to social care is essential. I do not yet have the full picture as to how much of the recent allocation of £700m came to social care, but we do know that it was a very small proportion and nothing like the 26.5% that would be a reflection of the attributable delays.

And in the longer term we should:

* Develop multidisciplinary care in primary care settings,
* Identify those most needing a proactive approach,
* Provide crisis intervention services
* Involve the voluntary sector in community-based schemes
* Share information efficiently
* Develop more supported living schemes such as extra care
* Develop more schemes to support people at the end of life to stay in their own homes
* Give better treatment and services to support people to live well with dementia, and
* Make sure informal carers are supported appropriately.  

I hope it is not too late to bring these issues before your committee, albeit in absentia.

We really do need investment in a range of provision in the community. Social care does have a big part to play, but we need an aligned funding settlement within social care and health. 

We know that there is a shortfall of £8 billion from the Five Year Forward View. Well, there is also a similar problem in social care. The LGA/ADASS report on the state of social care finances predicts a gap of £4.3 billion. This needs to be addressed alongside the gap in the health budget in the next spending round. We must use this period as a wake-up call for the need to plan and prepare for the changing needs and requirements of our population.

I would be very happy to provide more evidence or answer any questions on this subject if it would be helpful to your Committee.

David Pearson
Association of Directors of Adult Social Services