Can Wiltshire's Better Care Fund bring better waiting times as winter pressures hit the NHS?
Winter is coming. The older amongst us are queuing up for flu jabs and just about everyone you meet who works in health and social care is terrified that this will be the winter when the NHS and council care services are finally - and dangerously - overwhelmed.
There are staff shortages at almost every level of the NHS. Wiltshire is short of GPs - Swindon needs even more GPs. And Swindon's GP shortfall is affecting Great Western Hospital as it struggles to meet the A&E 4-hour treatment target: more people go straight to A&E if they cannot see a GP.
Primary care is in crisis: when Wiltshire Clinical Commissioning Group (WCCG) began in 2012 it had 58 member GP surgeries. Now - after closures and mergers - there are 49 surgeries across the county.
All around England people asking for appointments at GPs' surgeries are finding longer delays, hospitals are struggling with the ever-increasing demand son staff, beds and especially on A&E. At the heart of the problem is the continuing rise in delayed transfers of care (they appear in the column marked DTOCs.)
They are patients who have been successfully treated and are ready to leave hospital, but need care at home or need further NHS care or a care home place. They occupy beds needed by people coming to A&E who then require a hospital bed.
With winter and flu in mind, the government is so concerned about DTOCs that they are giving targets to local authorities - they have even threatened to fine them for not reaching the magic figure of 3.5 per cent of their beds filled with DTOCs. Across England the figure in March stood at 5.6 per cent.
The government want to make sure the extra £2billion they handed out to local authorities in the Spring budget to relieve pressures from cuts to social services is used to reduce pressures on acute hospitals and the level of DTOCs. In July Wiltshire bed days lost to DTOCs stood at 2,260 (considerably above the BCF target) - or 72.9 days lost to DTOCs in a day, which is well above NHS England's target for Wiltshire of 42.9.
In Wiltshire there has been great reliance in solving the DTOCs problem on the Better Care Fund (BCF) and its Plans for the frail and elderly. In three years, the BCF's success has been limited and it is a very expensive policy, which may not always be giving value for money.
The main aim of Wiltshire's BCF is to keep people out of hospital treating them at home for as long as possible. The success of this is measured mainly by what is known as 'Admission Avoidance' - a somewhat loose way to judge matters. If someone is kept out of hospital on Monday, does it still count if they have to be admitted on Wednesday?
The BCF has been running a series of programmes for three years as a joint Wiltshire Council and WCCG venture. It has a new Director.
It is now admitted that the BCF way of working may be causing problems for patients when they do eventually have to go into hospital with more complex conditions - so causing problems for hospitals when these patients need high levels of nursing, complex treatments and they are more difficult to place in appropriate after care so they can be discharged.
As a recent report to the Wiltshire Health & Wellbeing Board puts it: "...admission avoidance activity in the community is supporting patients before admission becomes necessary and causing increased acuity of admission in hospital. This resonates with the messages from the three acuter hospitals in [sic] Wiltshire who [sic] have all experienced an increase in complexity and acuity of admissions through A&E."
This is substantiated by figures showing that Wiltshire has a low level of admissions but high levels of 'length of stay'. The BCF is an expensive tool. This year its budget is just over £44million.
Most of this money comes from a £19.7million 'contribution' transferred from the CCG to Wiltshire Council, £11.5million paid directly by the CCG for BCF schemes, Wiltshire Council's 'contribution' of £4.25million and the Council have added in the £5.8million received in the Spring Budget money for social care.
At a CCG meeting in July, Dr Richard Stanford-Hill (who has since been elected as Chair of the CCG) asked whether the BCF was 'value for money'. And the Joint Commissioning Board has agreed to take a close look at the BCF and evaluate its impact - especially so it can focus on parts of the plan that will help meet winter pressures.
What is clear from the recent Health & Wellbeing Board paper is the determination to link the BCF (and its money) to the integration of health care and social care (aka the integration of local authority - Wiltshire Council - and the NHS - the WCCG). This integration is a key policy for Baroness Scott and the new BCF Director, Sue Shelbourne-Barrow is a joint Council-CCG appointment and is called Director of Integration and Transformation.
It is not clear how the £5.8million of extra social care funding added to the BCF is being spent. The recent BCF paper merely says the aim is to "create and develop a market economy that is sustainable and has its focus on community resilience and market capacity to meet demographic demands placed upon it."
It then lists - in NHS-speak shorthand - seven aims which end with "National Living Wage pressures." So it may be that some of this extra money will simply be used to increase the pay of the Council's social care staff.
Perhaps when the BCF is next debated, we shall find out precisely how this £5.8million is being spent - we are, after all, half way through the financial year.