Unresolved disputes over funds between Wiltshire Council and Wiltshire's NHS commissioners could end with legal challenges
What appears to be a fairly bitter row has developed between cash-strapped Wiltshire Council and cash-challenged Wiltshire Clinical Commissioning group (CCG) over funding that was supposed to promote integration of health and social care through the government's Better Care Fund (BCF) scheme.
The dispute is a tussle over 'ownership' of some of the money - much of it transferred from Wiltshire's NHS budget to Wiltshire Council - earmarked to support social care and flagged under the BCF.
In September the CCG's Finance Director, Simon Truelove told the meeting of its Finance and Performance Committee: "Wiltshire Council recognised the Payment for Performance (P4P) position and would ring-fence and release the £1.2million, however the CCG should be mindful of the severe financial position of the Council and the political sensibilities around this."
At this meeting it was minuted that: "The CCG was confident in the leadership of Deborah Fielding (Accountable Officer) and Simon Truelove" on the grounds that "the biggest hospital deficits lined up with the CCG's deficit, so this position was not to do with leadership."
By October's meeting of this committee things were not looking so rosy: Simon Truelove reported a "...difficult meeting with Wiltshire Council" regarding P4P and the underspend on the BCF.
"Currently," he reported, "the Council are assuming 100 per cent of the underspend to their bottom line which the CCG will not agree to. Also Wiltshire Council does not recognise the P4P criteria, but this is essential for the CCG and must be secured."
Responding to the Council's adamant position, Simon Truelove had ordered "holding back the P4P element (£2.3million) from Wiltshire Council in line with national guidance." And he had stopped "payments relating to the BCF completely until the dispute has been resolved."
He also told the committee that the CCG's internal auditors had failed to find any evidence that "the £2.3 million provided for additional adult social care (aligned to the care Act) has been used for that purpose." He added: "A legal challenge by Wiltshire Council is possible."
This is not the only dispute between the Council and the CCG over funds. There is also an on-going spat over the continuing care of learning disability patients who, after NHS treatment, become the responsibility of Wiltshire Council. The CCG has been invoiced by Wiltshire Council for these patients - £634,000 for 2013-2014, £435,000 for 2014-2015 and £500,000 for the current year: "This issue may require arbitration."
The P4P money is seen as an incentive to complete schemes under the BCF, but can also be viewed as a contingency against the schemes not realising their intended savings or advantages. In an effort to understand P4P a lot further, Marlborough News Online consulted the NHS England guidelines for the administration of the BCF. Faced with incredibly complex rigmaroles written in NHS-ese, we failed to get any further enlightenment.
But we were left wondering whether in some respects the government's claim to have cut the number of managers and to have stripped out the much-touted bureaucracy is in the latter case somewhat bogus, and in the former counter-productive as the chase to make every pound work for patients gets more and more complex with each of the government's new schemes for the NHS and for social care.
As far as Marlborough News Online can discover, there has been no public airing of these disputes by Wiltshire Council. The CCG committee was advised that they would be discussed at the Council's October Cabinet meeting. If they were then there is no mention of them in the agenda or minutes for that meeting.
There is some anxiety that as the Better Care Fund proceeds with further money from the NHS budget moved to local authorities and social care budgets continue to shrink, disputes like these will become part of the landscape. The government may need to find an independent body to regulate or adjudicate them.
The full minutes of the two meetings of the Finance and Performance Committee referred to above can be found here. This dispute - critical to the future of the current NHS structure and to local authorities' ambitions for devolution and their take over of health service commissioning - has come to light now because minutes of the CCG's committees are only published with board meetings which are held every two months.