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DTOC discord is latest backward step in the integration drive

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Commentary on the latest developments in health and social care integration

Integration between council and NHS services has at best been categorised as two steps forward, one step back.

But the forward/backward steps ratio has always been open to question and some within local government would suggest backwards steps are currently in the ascendency.

One could have made a case for forward step primacy quite frequently in recent years. NHS England chief executive Simon Stevens’ 2015 launch of sustainability and transformation plans was one such moment: the health service was to receive an extra £8bn but only on the condition of it developing a longer term approach to planning. Councils were to be given a major role in this planning across the health and social care system, with senior local government figures heading STP plans in five of the 44 areas.

More recently, in Philip Hammond’s March Budget, there was a step forward when it was announced councils were to get extra £2bn over three years to fund social care. While this was less than the Local Government Association’s estimate of the care budget shortfall, it nevertheless constituted a really significant sum money to help facilitate joint working across the health/social care divide (and prevent the care system collapsing).

However, councils have become increasingly disillusioned by the number of strings applied to this better care fund cash.

In July the Local Government Association withdrew its support from the better care fund planning guidance after councils were told the £2bn had to be used to reduce delayed transfers of care (DTOCs) from hospitals to the care system. The priority was on freeing up to 3,000 hospital beds, rather than future-proofing the care system to cope with an ageing population.

LGA community wellbeing board chair Izzi Seccombe (Con) said at the time: “[The NHS] wanted more money and thought [the £2bn] should have gone to them. There was resentment that it came to us and they want to control how it is spent.” A clear backward step.

The extent of this backward step became apparent today when LGC disclosed the letter from earlier this month that gives each council a target for reducing DTOCs. Forty-seven of the 152 top-tier councils are being told to reduce DTOCs by 50% or more by September, based on their performance in February this year.

A letter from Jo Farrar, director general for local government at the Department for Communities & Local Government, and Department of Health director general for community care Jonathan Marron said they would “take stock of progress in November” and “consider a review” of allocations of the 2018-19 portion of money. Poor performers – often those councils with the most entrenched problems – could lose out.

“Entirely counterproductive”, “arbitrary” and “tough” were some of the terms council chief executives used to describe their area’s target.

Northamptonshire CC chief executive Paul Blantern said: “If a fake undeliverable target is put onto the system that threatens the improved BCF funding in 2018-19 then of course those planned improvements would have to be withdrawn as soon as it was clear the false target was not going to be met, given our statutory duty to deliver a balanced budget.”

Meanwhile, in a column today, the independent social care and health specialist Andrew Cozens lists a whole series of other priorities for the care system, including services not meeting minimum standards and addressing the impact of out-of-area placements, which should not be neglected by a prioritisation of DTOCs.

“We must listen and respond to the experience of those unnecessarily delayed leaving hospital. But this must not be to the exclusion of those struggling to cope at home or the need for humanity in our response to those who care for them,” he writes.

Chief executives’ reaction to DTOC targets is not the first indication of integration woe disclosed by LGC this week.

In a column for LGC, Leicestershire CC chief executive John Sinnott declared on Monday: “From a local government perspective it looks as if NHS England now regards STPs as being all about NHS bodies and financial control, with local authorities a sort of optional add on.” He added: “All that was good about the original STP idea is in danger of being lost up an NHS pathway of process.”

The integration of health and social care, like so many other areas of councils’ work, is continually alternatively buffeted by centralism and drives to provide the resources to help local organisations address deep-rooted problems.

It is hard to believe this pattern will end anytime soon. There will be more forward and backwards steps than a Riverdance show.

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