Wednesday, 9 July 2014

Better Care Fund, better read the small print?

Better Care Fund, better read the small print? Although earlier rumours of the demise of the Better Care Fund – the government’s flagship £3.8 billion pooled fund to promote integrated care – have turned out to be greatly exaggerated, the significance of the government’s latest announcement about the fund should not be. Although this has been fed by mounting political anxieties about the state of hospital finances ahead of next year’s general election, the writing has always been on the wall.

While sharing resources across the NHS and local government is a step in the right direction, expectations of what the Better Care Fund could achieve, and how quickly, seemed heroic. The £3.8 billion fund is not new money, the national conditions for its use were stringent and plans had to be assembled very quickly, with insufficient time to engage properly with acute providers whose buy-in is essential for the plans to work. It is surprising that anyone was surprised that many of the local plans submitted on 4 April didn’t pass muster. What began as a well-intentioned agreement between the Department of Health, NHS England and the Local Government Association is fast becoming a Faustian pact – the devil truly will be in the detail of the revised guidance that we haven’t yet had sight of.

The key change is that £1 billon of next year’s fund will be allocated through a local ‘performance pot’ for each health and wellbeing board – and the money each board receives will depend on its performance in reducing hospital admissions. The remaining money will be used to commission NHS services. This will offer some small cheer to hard-pressed acute trusts – it means the NHS will avoid paying twice for emergency admissions (once through the fund, and again for the admission that wasn’t avoided). But the price of this very modest amelioration for the NHS is a substantial shift of risk back to local authorities that can’t be sure they will receive the grant for services that have to be funded up-front.

There are three obvious and immediate consequences of the rethink. First, most plans will need to be rewritten within weeks and will then be subject to a further central assurance process and ministerial sign-off. This represents a huge amount of time and scrutiny of less than 3 per cent of total NHS and social care spending – a distraction from addressing the much bigger challenges of how best to plan with 100 per cent over a more realistic time frame.

Second, reaching local agreement on the new performance rules – especially the key metric of reductions in emergency hospital admissions – and how they will work in practice seem a recipe for conflict and local disagreement at a time when the NHS and local authority partners need to be collaborating like never before. Rises or falls in emergency admissions are influenced by a wide range of factors and attributing changes to short-term Better Care Fund investment will be tricky to say the least.

Third, it creates new uncertainty for local authorities in planning their budgets for next year, with the prospect of at least £600 million to be spent on NHS services and not available to protect social care. This will only add to the woes of the social care system where the cracks are beginning to show as last week’s Association of Directors of Adult Social Services budget surveydemonstrated.

Reducing hospital admissions by providing care closer to home depends in part on investing in alternative services in primary, community and social care. This takes time, and a good understanding of what types of intervention are best suited for local needs and circumstances – we have summarised the evidence in our evidence-based guide, Making best use of the Better Care Fund. Crucially there will need to be additional money for new or additional services before resources can be released from hospitals. The Better Care Fund in its current guise does not do this.

As Simon Stevens, Chief Executive of NHS England, pointed out recently, merging two leaky buckets does not create a watertight solution. What is needed is a genuine health and social care transformation fund with new money to meet the double-running and transition costs of changing how and where care is provided. Finding extra money in the current fiscal climate is a big ask but one that will become increasingly urgent as the financial crisis facing both the NHS and social care gathers pace. The consequences of not acting are serious – sticking plaster solutions will not deal with the significant challenges facing social care, nor will they address the growing funding pressures facing the NHS. The King's Fund

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