After NHS restructuring, the Better Care Fund is a real step change – or is it a leap in the dark?

Written by Tony Millett.

First year report on the coalition government’s major NHS shake-up – part two

The NHS is about to begin yet another major change in direction.  April 2014 sees the inauguration of the coalition government’s Better Care Fund (BCF) which will put NHS money into social care in a bid to reduce the NHS’ fast rising costs – largely fuelled by the ever increasing age of the population and the complexity of long-term illnesses.

The size of the problem is best seen in numbers: in Wiltshire the over 65s make up 21.8 per cent of the population.  But, Wiltshire Clinical Commissioning Group (CCG) reckon they use 47.4 per cent of the health services the CCG commissions.

Or, to put it another way, the CCG’s annual spend per head of Wiltshire’s 479,992 population is £1,023.  This increases to £1,600 for those between 65 and 74, to £2,917 for those between 75 and 84, and to £4,913 for those over 85 years old.

Wiltshire's Better Care Fund planWiltshire's Better Care Fund planThe BCF aims to reduce these costs by providing better social care for the ‘frail elderly’ in their own homes, treating them locally and avoiding inappropriate admissions to hospital.  And if they do have to be admitted it wants to make their length of stay shorter.

The basic means to those ends is the close integration of social care (the responsibility of the Council) and health care (the responsibility of the CCG.)  

The Fund was originally given the descriptive title of ‘Integration Transformation Fund’, then political spinners re-christened it with an aspirational title: ‘Better Care Fund’ – more like an election manifesto headline.  Will it deliver what it aspires to deliver?

In 2014-2015 the BCF will start with modest pots of money – Wiltshire’s will be £22.37 million some of which will come from the CCG’s budget.  In the first year, this money will be used “as a catalyst for stimulating integration of health and social services.”

For 2015-2016 Wiltshire’s BCF pot will rise to £29.51 million.  The money will only be available once each local authority-and-CCG has a jointly agreed plan that is approved (by ministers) detailing how the fund will be used.

The BCF will rely on projects and commissioned services agreed, planned and run jointly by the CCG and the Council acting under the Wiltshire Health and Wellbeing Board (HWB) which was set-up under the Lansley reorganisation.

There is one somewhat grey area: some of the fund will be allowed to fund mandatory changes brought in soon by the Care Bill (now before Parliament.)  And at least one CCG has agreed that it should fund existing social services on the grounds that they come under ‘preventative health measures’.

The BCF’s budget will not be new money.  So where is it coming from?  The BCF will largely be funded by ‘top-slicing the CCG’s annual budget’.
In Wiltshire it will mean the CCG surrendering – or ‘top-slicing’ – £15.52 million from its budget for 2015-2016.  This will go into the pooled budget together with existing council social care funds.

While this sounds eminently sensible and laudable, there are four main risks around the BCF.  

The first is that the CCG top-slicing will in fact come totally from the budgets of the foundation trust hospitals like the Great Western Hospital which would further destabilise this vital part of the NHS’ cradle to grave treatment regime.

When a Wiltshire Council committee examined the Council’s budget for 2014-2015, they delivered this analysis of the BCF: “The funding …will be drawn from the acute hospitals in the form of top slicing three per cent from their budgets to streamline services and form a centralised system aimed at providing more community care.”

If that becomes the norm England’s already struggling hospitals could become endangered species.  And when frail elderly people – not to mention other patients – are too ill or their condition too complex to be treated ‘close to home’, will there be beds and expertise left in the acute hospitals to treat them?

De-stabilising the acute hospitals is something that Wiltshire CCG’s finance director, Simon Truelove, has been warning against during the past year.  All the BCF money is going to social care and community health care – there is no money in the fund to bring about the necessary changes in our hospitals.

At the March board meeting of NHS England (NHSE), its chairman, Sir Malcolm Grant, gave a stark warning about the BCF: “I think this is one of the most challenging and daunting things that lies ahead of us…I think it carries very high risks.”

NHS England's Jane CummingsNHS England's Jane CummingsNHSE’s Chief Nursing Officer, Jane Cummings explained the BCF’s inherent risks: “We anticipate that emergency activity [in hospitals] will need to reduce by about 15 per cent.  There will be a massive risk if we continue to have the same system of patients in hospital and try and create this fund…there is quite a lot of risk associated with this.”

Where the BCF will show bright red on NHS risk registers is over the inevitable time lag between the steady build-up of relevant social services resulting in the promised “better care”, and the withdrawal of funds from acute hospitals leading to a swift reduction in their capacity.

The Wiltshire BCF plan lists seven areas of risk and they are all rated as ‘high’. The risk of destabilising hospitals is not among those risks – that is somebody else’s risk.

Outgoing NHS chief Sir David Nicholson warned the board meeting about the consequences of missing that 15 per cent reduction target:  “We’ve never quite done it in that way.  If we can’t do that we have to get hospitals to provide not [the existing] four per cent efficiency, but eight per cent – which I think is simply impossible.”

Or as one commentator put it: “Top slicing CCGs is fine, but there is the risk that the benefits of community oriented integrated care conforms to a longer timetable than that of the loss of funding created locally.”

Julie Jordan of the law firm Mills and Reeve, who specialises in health matters both NHS and independent, calls the BCF an “effective cut in the acute care budget” and she identifies another hurdle in the process of setting up the BCF.

This second risk stems from the change in CCG’s spending which will have to take place:  “The mechanics of extracting such a large amount from acute service contracts must demand a degree of service reconfiguration, so we should expect to see a raft of public consultations on proposed service changes in the months leading up to April 2015.”

“Won’t that be jolly when it coincides with the final months of the current parliament, as we head for a general election on 7 May 2015?”  (The Secretary of State’s new powers in Clause 119 of the Care Bill [see the third article in this series] may pre-empt any consultation.)

The third risk is that the money transferred from the CCG and from other NHS budgets will not be ring-fenced when it reaches the new pooled pot and may not be used only for its agreed purposes.

Ms Jordan, writing in the Health Service Journal, believes new legislation will be necessary to ensure ring-fencing is robust. And NHS England’s deputy chairman, Ed Smith, warned against “the diversion of money into other activities.”

And this brings us to the BCF’s final risk factor:  it is being overseen locally by the HWBs which are committees of local authorities and very new, untried institutions.

Wiltshire’s HWB is chaired by the Council’s leader, Jane Scott, with the Chair of the CCG, Dr Steve Rowlands, as her deputy.  It now meets in public and is responsible for the broad strategy for health and social care provision within the county.

But the CCG retains legal responsibility for the services it commissions.  If it sees money from its allocated budget going into social care services it does not rate or which are non-health social care services, sparks may fly.

Julie Jordan again: “Some CCGs have already expressed concerns that the pooling of budgets will in effect result in the NHS subsidising non-health social care services.  Not exactly the health and social care ‘happy families’ the government intended.”

MPs have called for HWBs to have a greater role in the move to integrated care.   The Commons health committee’s chairman, Stephen Dorrell, said HWBs should become “commissioners of joined up health and care services.”

But the committee also said that without ring fencing of social care funds, “…there is a serious risk to both the quality and availability of care services to vulnerable people in years ahead.”

Ed Smith again: “We are reliant on the HWBs.  I think the jury is out at the moment on whether they are sufficiently robust to be able to provide the assurances we need.”  

It should be noted that at the March meeting of the Wiltshire HWB Jane Scott said: “I don’t think it’s going to be easy – it’s going to be quite challenging for all of us.”  And she added that she was disappointed the BCF was restricted to the frail elderly.  She wanted to include disabled adults and children and mental health patients.

The outline plan for Wiltshire’s BCF had to be drawn up in a great hurry to meet government deadlines.  It already carries a list of seven risks rated ‘High’ with an outline of measures needed to mitigate those risks.

According to an NHSE executive the Wiltshire BCF plan has been “very well received – as being people centred.”

In its section on ‘Integration Aims and Objectives’ the glossy covered plan includes 17 principles for the integrated plan.  They include principles of very great interest to everyone in the county:

•    “Our principle: we will shift our services from being paternalistic to ensuring that services are designed for and with the people who use them.
•    Our objectives for integration: People will be involved in the redesign of integrated services.
•    Our measures: patients and service users will be involved in pathway reviews, service specifications and tendering.”

Whether it is ‘people’ or ‘patients’ or ‘service users’, Wiltshire Council and Wiltshire CCG are now committed to listen to and consult a very large proportion of the county’s population. We will see over the coming year how they intend to do that.

Marlborough News Online will be reporting on the specific projects the BCF is providing for Wiltshire.