Better Care Fund for Wiltshire: the costs, the rewards and the risks

Written by Tony Millett.

Having just successfully sorted out the change from Primary Care Trust to Clinical Commissioning Group – or for that matter from Lansley to Hunt – there’s a new health service name claiming its place in the headlines:  Better Care Fund.

It has not yet been reduced to a generally accepted acronym (which it surely must if it is to be fully accepted in the NHS) because they cannot make their minds up whether it should be known generically as a Fund or a Plan.  Some term the whole scheme ‘the Better Care Fund plan’. That’s a bit confusing.

We will stick with Better Care Fund and for now ‘BCF’.  But then, in Wiltshire the BCF has already given birth to a fully-fledged plan – a joint venture by the Clinical Commissioning Group (CCG) and Wiltshire Council.  What’s more it has become one of the first five in England to be officially signed off by the government.

The idea of the BCF is to concentrate more treatment in the community so as to keep people out of acute hospitals – the average bed in an acute hospital costs £1,785 per week before you count in treatment costs.  And hospital is certainly not always the best place to be, especially for the elderly.

Most of the money for the BCF is not new but comes from funds re-assigned to a pooled budget for use in integrated care by the CCG and Council working together.

Wiltshire’s Health and Wellbeing Board (HWB - set up under the Lansley reorganisation) is the body responsible for the BCF.  Jane Scott, leader of Wiltshire Council and chair of the HWB, wanted the fund to cover patients from cradle to grave.  But the government decreed that in its first full year (2015-2016) it must be restricted to the ‘frail elderly’.

Jane Scott was at the Marlborough Area Board on Tuesday (September 30) to explain the BCF.  Also there were Maggie Rae (Wiltshire’s public health chief), Simon Truelove (the CCG’s head of finance), Dr Jonathan Rayner (Ramsbury GP and a leader of our area’s locality group of the CCG), Dr Abi Griffiths (from the Marlborough Medical Practice) and two frontline representatives from GWH’s community health service.

Wiltshire’s scheme is being piloted this year in three areas – Calne, Salisbury and Bradford on Avon – with brand new integrated teams of social care and health professionals.  

It will only get its full budget of £27million next year to develop integrated community based service teams across the county which should reduce the need for hospital care and protect the existing level of social care services.  The aim is to provide teams for each community of 20,000 centred on GP practices. (Our area’s size will be larger - over 30,000.)

Of the BCF’s £27 million, £15.5 million will be top-sliced off the CCG’s budget – that’s three per cent of the CCG’s total funding for 2015-2016.

Official government guidance states that the ‘expected minimum target’ for BCF plans (there we go again) is a 3.5 per cent reduction in emergency admissions to hospital.  But four of the first five plans have set reductions below that figure.

Wiltshire’s plan is aiming for a 3.75 per cent reduction, but only after the expected annual rise of 2 per cent in non-elective hospital admissions is taken into account.  This equates to a reduction of just under two per cent or, over the next two years, 37,000 bed days.

In financial terms this should save Wiltshire CCG in the Fund’s first full year £3.6 million of its ‘purchase’ of beds in the main three acute hospitals that serve the county.

If it worries readers that the CCG is foregoing £15.5 million of its budget in order to save £3.6 million – the Better Care Fund is not just about money.  It is aiming, as it says on the tin, to provide ‘better care’ – better care before hospital admission becomes essential.

Wiltshire’s Better Care Plan originally envisaged a reduction in hospital admissions of 4.75 per cent, but the government became anxious about the effects on the finances of hospitals and ordered a reduction in the ‘admission avoidance ambition’ to a more realistic level.

The continuing year-on-year rise in hospital admissions has been worrying many acute hospitals.  The Great Western Hospital believes the BCF will allow it to keep operating safely with its existing number of beds.  

Indeed they had expected a shortfall of 55 beds by the end of 2016 if there had not been a change in the care system such as the BCF should provide.

The basic tenet behind the BCF was spelled out by Jane Scott: “We want care in our home…the last place we want to be, unless we have to, is in an acute hospital or care home for the rest of our lives.”  Not everyone, it should be said, agrees with that – among them people who have had experience of services to the frail elderly in their own homes.

There is recognition in Whitehall that the BCF may cause problems – notably that reduced income – for acute hospitals.  So it has been made mandatory to have a “Risk Share agreement with Acute hospitals in the event that acute activity does not reduce in line with plans.”  

But Simon Truelove told the meeting that the BCF was not at all about destabilising the acute hospitals – like the GWH, Salisbury Hospital and RUH Bath: “We absolutely need our three acute hospitals with their specialist care.”

Apart from the risk that there are bound to be cases where people are not admitted to hospital soon enough, there are other risks as responsibilities blur between CCG and Council.

When the BCF plan went before Wiltshire Council’s cabinet, Cllr Ron Hubbard questioned why it stated there were no direct safeguarding implications – his question was brushed away on the grounds that “Officers would of course continue to work closely with the Safeguarding team.”

As Jane Scott told the Area Board: “Funding is going to be a huge challenge – on top of the funding challenges that the Council has, which are huge.”  One risk for the BCF is the looming cost of the new Care Act, which may, from April 2016, set the Council back an extra £15 million.

And there is always the risk of friction between the Council and the CCG.  Already there was talk about this at the Health Fair in the Town Hall before the Area Board met.  

The Council feel they are helping through their efforts on the social care side of the partnership to make savings on treatment costs, which accrue solely to the CCG.  This they feel is not fair.

This quite overlooks the fact that even before the BCF hove into view, the CCG was helping with social care costs. They were, for example, funding quicker exits of patients from hospital – reducing the dreaded ‘delayed transfers of care’ or ‘bed blocking’.  

As we have seen, most of the BCF for Wiltshire comes directly from the CCG’s budget.  And from the pooled BCF budget there is £9.18 million set aside both this year and next to support such Council social care responsibilities as care home admissions, the Council’s Help to Live at Home Service and hospital social work services.

What was that about robbing Peter to pay Paul?