In summer 2014, the NHS and the LGA contacted all councils and clinical commissioning groups to warn that the better care fund - a pot of money pooled to help councils, hospitals, GPs and others to bring care and health services closer together - was changing.
Now councils and health and wellbeing boards must make sure they have enough money left from the fund to compensate hospitals if, despite their best efforts, hospital emergency admissions do not fall as a result of their prevention efforts.
The latest NHS England figures show that £2bn of the fund is earmarked for social care while £1.66bn is already going to the NHS. So far 64 health and wellbeing boards have contributed more financially towards the fundthan required, indicating a huge appetite among local health leaders to make change
The soft stuff is the hard stuff. It’s the relationships and how well people get on. You can’t mandate that from the centre
Richard Humphries, King’s Fund
But is the better care fund really necessary? Or does the constant stream of initiatives from central government over integration of health and care services paradoxically prevent those working at the coalface from improving and joining up the services they provide by themselves? That was the issue under debate at a recent LGC roundtable debate hosted with Capsticks at the King’s Fund headquarters in central London.
Sarah Baker, group manager, children, education and adults group, Surrey CC
Chris Brophy, partner, Capsticks
Miriam Deakin, head of policy, Foundation Trust Network
Lance Gardner, chief executive, Care Plus Group North East Lincolnshire
Nick Golding, editor, LGC (chair)
Frances Hasler, director, Healthwatch Camden
Alison Holbourn, primary care programme lead, Warrington CCG
Richard Humphries, senior fellow, social care, The King’s Fund
Simon Kenton, assistant director, integrated commissioning, Warrington CCG
Jean Nunn-Price, chair, Healthwatch Oxfordshire
Alison Richards, senior lawyer, Capsticks
Paul Thomas, GP, and editor of the London Journal of Primary Care
Patrick Vernon, health partnership coordinator, National Housing Federation
However much energy and enthusiasm there is for a government scheme, realism is the key determinant in any policy achieving its aims.
When the Foundation Trust Network surveyed its members it found just 11% agreed that the 3.5% target cut in emergency admissions was a realistic goal for their own areas, and just 16% thought the better care fund would make savings for them and their organisation. The network’s head of policy Miriam Deakin said the pressure under which they were working had fuelled scepticism over this latest effort at better integration.
Despite this, many areas are getting on with the job of working together very nicely indeed - and without assistance from Whitehall.
Lance Gardner, chief executive of the Care Plus Group in North East Lincolnshire, described how the county had designed a shared system of health and social care years ago. It merged the primary care trust as it was then and council services in 2007, with all adult social care funding managed by the local NHS and public health and paediatrics controlled by the local authority.
“Because of our geography we’ve created an integrated system,” he said. “We’re actually looking at joint venture arrangements across all the providers. We are known by the chief medical officer and that’s because we’re the only place in the country that says the hospital is there to support the community rather than the other way around.”
Oxfordshire is also making good progress, despite its challenges. Jean Nunn-Price, chair of Healthwatch Oxfordshire, said: “It’s a very rural county; it’s the least wellfunded of all counties in England per capita and it’s also got some of the worst challenges because of that.
“The requirement to save money in A&E for Oxfordshire should be 3.5% less costly than last year but because last year [there] was a greater demand on the services that actually means something like a 10% reduction in real life. It’s an increasing battle to know how you can save anything there.”
However, Oxfordshire already has pooled budgets and joint appointments. “Pooled budgets have been working for a long time. There is a huge amount that goes on together,” Ms Nunn-Price said.
Further integration will ideally concentrate reallocated resources on where they are needed most, she added.
“Any readjustment from one part of our services to another, which is what the better care fund does, will be concentrated as far as possible on the frail elderly. Anything we can do to make sure they stay healthy, any preventative means we can provide to make sure they don’t fall, will mean they will have a happier life and we’ll have a less expensive one.”
These important local decisions are among the goals of the better care fund but local leaders have been working towards identical goals anyway.
As Capsticks senior lawyer Alison Richards put it: “Many of you have been working in an integrated way for many years, but it’s not been called the better care fund. It’s just been given a label and a bit more guidance to support it.”
The journey towards integration between health and social care services has been a slow one. Richard Humphries, senior fellow for social care at the King’s Fund, said: “We’re in the fourth decade of initiatives on integration. That we’re still talking about it ought to tell us something. If it was easy and straightforward it would have been done years ago. Virtually everywhere is doing something, but nowhere is doing everything. It’s very often small scale; it’s local and the big challenge is how we scale it up.”
Mr Humphries has observed that obstacles to joint working are best overcome where there is a history of strong local relationships, such as in Torbay and Sheffield, and “have tended to be places that have been working at it for a long time”.
Continuity and stability of leadership in core positions can also contribute to success. Mr Humphries wryly observed: “These are not characteristics we [have] associated with our health service in recent years.”
He added: “The soft stuff is the hard stuff. It’s the relationships and how well people get on. You can’t mandate that from the centre.”
All of these questions feed into the reasons why many working in local government and health now believe the better care fund is already on its way out. Mr Gardner described the scheme as “doomed”. He criticised the way it prioritised costs over quality of care and dehumanised a process which should be about one thing: improving the experience for users of hospitals, health services and care providers.
“Most of [the people around] this table are targeting frail elderly [people] because they are expensive but they are also important and valuable members of our communities. There are one million of them and they’re not getting the services they need,” he said.
“It’s a race to the bottom around domiciliary care. There is no chance of changing health inequalities [through the fund].”
Meanwhile Frances Hasler, director of Healthwatch Camden, said the fund had been a “distraction” away from more important work on understanding wider health economies. She said every element of the health and care service got excited about what the better care fund might mean for them, particularly if it could lead to an increase in funding available for their service, but overall it had very little impact.
“It’s really quite small,” Ms Hasler concluded.
The fund is nevertheless in place, whatever the objections, and local areas must demonstrate they are making use of it. They are required to submit updated
plans to show how the money is being targeted to achieve the desired (if ambitious) cut in emergency hospital admissions. It may not be the vehicle that will solve the care funding crisis but it will start conversations that may have otherwise been difficult to get off the ground.
It will also help focus minds on what it is that is holding those conversations back. The big common problem is risk.
“An agreement is only a relationship on paper, so if you can’t get that agreement the relationship isn’t going to come very easily,” said Sarah Baker, group manager of children, adults and education at Surrey CC. “It’s really worth trying to work on that first. The relationship issues explain why in our area we
have problems with risksharing.
“The big fear is they won’t have enough funding left for the acute services, and I’m sure I’d have the same fears if I was managing those services.”
Another core problem is community groups and other service providers, such as housing associations, feeling pushed out of the conversation. Social landlords provide a route into tackling the costs associated with frail, elderly and disabled community members. They often also have the ability to raise money through the stock market and yet to date have not been directly involved in the strategic planning of health and care services. Some housing providers which had ffered their own frontline care provision have walked away from that market due to the pressure placed upon them by commissioners refusing to be flexible in their plans.
Patrick Vernon, health partnership coordinator at the National Housing Federation, said: “What we’ve been trying to do is break the silos and perceptions about housing. It’s not just about fuel poverty and damp.
“We have some of our professionals who have been successful in building those relationships. We all know the home, whether you’re being discharged from hospital, or just living in decent housing, is very important.
“We are trying to work in this marketplace and the better care fund is just the tip of the iceberg. It’s taken 40 years for health and social care to get their act together. Now it’s time to give housing a chance.”
For Capsticks partner Chris Brophy, the best way to find a route through this mire is to just get going and see where it leads. “You may need to start with four providers just to kick it off and get it going, and people could then adhere to those agreements. People have got to be able to agree and get round the table, so maybe the better care fund has kickstarted that.”
Simon Kenton, assistant director of integrated commissioning at Warrington CCG, described how the better care fund seemed to grant staff “more licence” to commission services innovatively.
Others set out a more prosaic route to success. “We’ve got to think of integrated care as less of a noun and more of a verb,” said west London GP Dr Paul Thomas.
“Think of it not so much as a machine that you can control and more of an organic body: how do you get those cells to integrate with each other like the human body?”
He warned that the pressures placed on GPs, resulting in early retirement, burnout and exhaustion, created “a very serious problem” for the progress and success of better care fund agreements, many of which may be drawn up by advisors and commissioners who are not working at the coalface themselves.
“If we say the solution is inside general practice we have to be careful how we act on that idea,” Dr Thomas warned.
He said if GPs were given responsibility for identifying and controlling local health communities, on top of their day-to-day work, “it will push everything off a cliff”.
Warrington CCG had, however, observed more enthusiasm from family doctors. Its primary care programme lead Alison Holbourn said: “In our neck of the woods GPs have stepped up to want to change the system. They want to actually make it sustainable for the future, they want to redesign it and recreate it.”
If GPs can’t bridge the gap between all the parties fighting to integrate, then surely it’s the service user or citizen who can fill that void.
Mr Brophy said many organisations in the health sector were still struggling to understand how to involve their citizens more closely in designing, commissioning and delivering services.
“You get really quite thinly ‘social’ enterprises who are struggling to connect with patients. It’s a surprise [to them] when people don’t turn up [to meetings], but there’s no history of real connection, people don’t know what’s in it for them. Maybe direct payments will give a boost to that. If [citizens] all get the money and it doesn’t go the classic commissioners then it all changes.”
There is reason for optimism, however. The group agreed this was a unique era of dedication to the cause of integration and to bringing services together to make them easier to access and more cost-effective to fund.
Mr Humphries said: “In my career I have never known or experienced more commitment locally to make this work. Whatever governments do, that’s the building block. In the past we have over-relied on the government to do things. I never thought I would agree with Ann Widdecombe but she said we expect more of government sometimes than of God.
“If this happens it will happen because of what we do locally, not because of some edict.”
What is needed to make this happen is a pioneering spirit: something which, Dr Thomas feared, quickly raises red flags within government.
“Pioneers make things happen and then get axed at precisely the moment they make a difference. That’s fear, isn’t it?” he said.
Ms Hasler, however, said service users could become the pioneers themselves, in a time of scarce resources in the health and care sectors. She said: “You’ve got to go back on your own resources and your own creativity, so despite the pain there are some really interesting things coming out of it.”
It’s a future Mr Gardner, a pioneer of integration himself, would heartily welcome. “The customer is king for me and the customer is not the commissioner,” he said.
“The sooner they manage their own budgets are better. The system is in chaos and chaos brings absolute opportunity for the pioneers. Bring it on.”