Will the Better Care Fund produce better care? Or is it more of a slogan putting a little shine on depleted and struggling social care systems?
While the NHS in England has been surrounded by electioneering headlines, promises and slogans, an unseen revolution has begun in earnest this month. The Better Care Fund came into full operation at the beginning of April after a trial period last year.
The coalition government's Better Care Fund has given birth to Better Care Plans (BCPs) that are using a great deal of NHS money to integrate health (NHS) and social care (local authorities) and try to keep the frail elderly out of hospital - treating them at home or nearer to their homes.
This quiet revolution, which is creating pooled health and social care budgets under the joint oversight of councils and clinical commissioning groups (CCGs), has had no new money. Its funds are, as one health service expert has put it, "As recycled as tap water".
Across the NHS in England several billion pounds of NHS funding is being allocated to this scheme. In Wiltshire the CCG is spending £27.1million in this financial year on the BCP - with much of that money going from the CCG to Wiltshire Council.
This expensive and as yet largely unnoticed revolution has suddenly become an important part of the General Election. Health Secretary Jeremy Hunt has told the Health Service Journal that £8billion extra promised by the Prime Minister for the NHS "...is very significant for the social care system as well as the health system". It will, he hinted, be spent through an "accelerated and extended" Better Care Fund scheme.
The Conservatives have not said how this £8billion will be funded or when it will be available. Jeremy Hunt: "We're saying we're going to spend £8billion a year extra on the NHS by the end of the Parliament, when it is legitimate to fund it through the proceeds of economic growth, which we're confident of delivering."
Part of the cost of the current BCP is to be met by savings made by commissioners when frail and elderly patients are not admitted to hospital. Many people have questioned whether these savings will materialise - judgments have stated the BCP is based on "optimism rather than evidence" and that projected in-year savings are "wildly unrealistic." And the risks of destabilising the struggling acute hospitals are being kept very quiet.
It is not only cynics who are saying that the whole BCF scheme was dreamt up so that NHS money could replace some of the savage cuts councils have had to make to social care. Good, reliable and sustainable social care is vital to help keep older people out of hospital and get them home safely if they have had to go into hospital for treatment.
Wiltshire's BCP is a joint undertaking between the Wiltshire Clinical Commissioning Group and Wiltshire Council - and their detailed plan has won plaudits in Whitehall. Integration of health and social care runs right through the BCF's stick of rock - both nationally and locally.
However, the plan relies on one part of Wiltshire Council's adult social care provision - their Help to Live at Home (HTLAH) scheme. And like many similar schemes across the country, it is doubted on the NHS side of the integration equation that Wiltshire's much-vaunted HTLAH scheme is resilient and well staffed enough to support the county's BCP.
In February the Daily Telegraph headlined its report on 'home help services': "Revealed - more than 500,000 home care visits last less than five minutes." Marlborough News Online has heard evidence that some of those 500,000 short-change visits have happened in the Marlborough area.
We have been told of home calls that are so peremptory they involve nothing more than a head round the front door and a shouted "You all right then? See you next week." And we have been told about old people who are suddenly told that their visits will change from once a week to once a month - with no agreed change to their care plan. (The provider denied that this was due to any change of policy.)
And that on top of late visits, visits by people not known to the old people and visits by people not wearing uniform - who therefore might be feared as possible fraudsters or thieves - some vulnerable older people decide they do not want the care visits they are offered.
HTLAH was set up by Wiltshire Council as part of their effort to consolidate care into the hands of fewer providers. There were 120 home care organisations in the county and this was cut to four main organising or 'strategic providers'.
The Council divided the county into four areas each under an umbrella contract with one company. Marlborough is in the East Area and the contract is with the London based charity and company Leonard Cheshire Disability (LCD).
(In West Wiltshire the contract is with Mihomecare - in the North & West with Somerset Care at Home - and in the South with Mears Care Ltd - more of whom later.)
It has to be said that Wiltshire's HTLAH scheme comes with a plethora of fine words and has impressed other councils and nationally got a good 'peer review' report. But all has not been well with the scheme - and problems persist.
The scheme was launched in 2011. Within a year one provider - Enara Complete Care - had, after complaints about their service, handed its contract back. In 2012 LCD sub-contracted the housing support part of the required service to GreenSquare, but 18 months later LCD ended that contract.
Since 2011 some of the HTLAH staff in the Marlborough area have had to switch employer three times.
In the summer of 2013 changes were made to the service. Wiltshire Council told Marlborough News Online: "The new service means that instead of every person getting a visit whether they need it or not, we are able to focus staff and resources on those who need it most." The changes were made to bring 'transformational savings'.
Lo and behold, in May 2014, the Care Quality Commission (CQC) were critical of the service in the LCD area because they were meeting 'outcomes' and so visits 'were not necessarily time of duration specific' to the individual's needs.
Then in September 2014 came the bombshell CQC judgment on Mears' Help to Live at Home service in the south of the county. Mears had taken over the contract in something of a rush in August 2013 (from Careline) and managers seem to have been concentrating more on absorbing smaller providers than on the quality of care.
Mears' service was not meeting standards in five areas of their contract. Things had got so serious that the CQC stopped Mears taking new referrals. And Mears was soon featuring on the CCG's 'High Level Risk Register': "This is impacting on delayed transfers of care [getting patients out of hospital quickly and safely] at [Salisbury Hospital] and management of placements at home."
Part of the problem was a shortage of staff and at one point Wiltshire Council was offering to help find housing for Mears recruits. During a meeting of Wiltshire's Health Select Committee, it was made clear that the Council was "...looking to move away from zero-hours contracts and towards encouraging small to medium sized suppliers..."
After implementing an agreed action plan, Mears have been cleared by the CQC and are taking new referrals again.
In 2014 Wiltshire Council and the CCG ran a "Hundred Day Challenge" to test the resilience and check the ambitions of the Better Care Plan against reality. A report on this exercise included these words: "The major challenge moving forward is building capacity for care at home, through the development of Help to Live at Home...further work is underway to build capacity in Help to Live at Home providers to deliver urgent and intermediate care at home."
In December 2014 Mears put out a publicity leaflet to attract care contracts from other local authorities. Controversially it quoted one of Wiltshire Council's officers responsible for HTLAH, James Cawley, (Wiltshire Council’s Associate Director for Adult Care Commissioning, Safeguarding and Housing): “It’s not a popular opinion, but the reality is we’ll only get good quality care if we work with the private sector and recognise that they need to make a profit, that is reasonable, transparent and affordable for customers and local government.”
“We set out to develop services that moved away from zero-hours contracts and 15-minute visits to outcomes. By setting out our stall, service providers can understand the market and spot niches – and ultimately provide a good quality care service and make a profit for themselves.”
“It does take a long time for these changes to happen, but we’re at the stage now where we have invested in care partnerships and as a result, have better, stronger relationships. Now, instead of falling out with service providers, we can agree to disagree – and move on towards a better solution.”
With that sort of lead time, it remains to be seen whether HTLAH can get its staffing right and pay them enough (and still give providers that 'profit for themselves'), in time to ensure the Better Care Plan works well enough to make a real difference and not simply be a drain on the financial resources of NHS services in the county.
At the CCG's Board Meeting in March, there was a welcome for the first 'green shoots' of success in their pre-BCP plans to treat people away from major hospitals. But Dr Toby Davies (Chair of the CCG's Sarum division) told his colleagues that social care was the key: "Until we start solving that the green shoots are going to be frosted - and wither." And he added: "The Council say we have to use Mears."
The questions keep coming: this week concerns have been raised that banks are no longer lending money to care providers. As the commentator who reported this put it: "Why should they? Staff are difficult to recruit, tariffs are coming down, margins don't exist and the CQC are all over everyone like a rash. It's not a business anymore - it's a way of throwing your money down the drain."
It should always be remembered that this multi-billion pound scheme began life as the 'Integration Transformation Fund' - use of the phrase 'Better Care' came from political spin doctors rather than NHS doctors.