The changing NHS: Wiltshire Council's role in the county's health servicesAfter the 2017 elections for Wiltshire Councillors, the Council Leader, Baroness Scott told local reporters that it was not sustainable to keep health and social services separate - it was vital for the council and the NHS to work together.
Progress on this integration has been slow and patchy - especially when NHSEngland had other priorities. At times, it has even caused some friction between the Council and the Wiltshire Clinical Commissioning Group (CCG).
The Council and the CCG do co-operate over joint procurement and commissioning of services. Now, as change comes to the county's NHS services, we can look at the two main ways Wiltshire Council has been involved in providing health services.
Under the Health and Social Care Act of 2012, Wiltshire Council has a say in health policy through the Health and Wellbeing Board and, from 2014, it has played the central role in the Better Care Fund programmes.
The Better Care Fund (BCF) was originally known as 'The Integration and Transformation Fund'. The more ambitious and politically spun title came when it was announced in the 2013 spending review with funding of £5.3bn. Has it brought 'better' care?
The BCF "...was intended to help the NHS and social care work more closely together, by creating a shared budget and a joint planning process for services that help people leave hospital in a timely way, and to prevent people going into hospital in the first place when it could be avoided."
It began by concentrating on the elderly and aimed to save money by reducing emergency admissions to hospitals and reducing the number of days people remain in hospital unnecessarily - the wrongly termed 'bed-blockers' who are now called 'delayed transfers of care' (DTOCs).
In 2017 the House of Commons' Public Accounts Committee had an alternative view on some the BCF's purpose: "In practice, the Fund was little more than a complicated ruse to transfer money from health to local government to paper over the funding pressures on adult social care."
They were pretty cross and criticised the 'appallingly casual attitude' they had heard towards the targets set to reduce hospital admissions and DTOCs. The BCF was soon given a re-boot and became the Improved Better Care Fund (iBCF).
The trajectory of the BCF in Wiltshire has been erratic - not helped by staff changes at the Council. In March the Council advertised for a BCF Programme Manager on a three month contract, 37-hour week at £250 a day.
While most of the money comes through the CCG, the Council manage the fund and its programmes. Some improvements have been made, but targets have not been hit.
Last year the Care Quality Commission's review of the governance of health and social care in Wiltshire was uncertain the BCF was being successful enough: "The BCF was being used to pump prime the Adult Social Care transformation agenda, including for example, the funding of a post that supported transformational change across adult social care and finance.
“The BCF plan had been very late in its development with no clear ownership until shortly before our review."
"At the time of our review there were over 50 work streams aligned to the BCF. The focus of the board was on reducing [DTOCs] which was a significant priority for Wiltshire, but there needed to be wider work on system flow." And the CQC added pointedly that in a neighbouring authority DTOCs had 'decreased significantly'.
Was the BCF simply a sly way to plug the swingeing cuts in government funding of local government's social care budget? In March the Wiltshire CCG heard from Council staff that its adult social care budget received 44 per cent of BCF funding.
Though Council staff did add "...it was acknowledged that schemes had an impact across the whole system" - a somewhat defensive and unproven assertion.
The BCF in Wiltshire is overseen by the Health and Wellbeing Board (HWB). Setting up these non-executive committees was compulsory under the Coalition's 2012 Act - one of the Lansley 'reforms'.
In Wiltshire it is treated as a committee of the Council and was led by Baroness Scott. It meets every other month and some meetings are fairly perfunctory. It does similar work to Wiltshire Council's Health Select Committee - but has even fewer teeth.
The Board listens to providers presenting their plans or reviewing their services and asks a few questions - it cannot really even be called a 'talking shop'.
Wiltshire's HWB currently has ten voting members - four from the CCG, three Conservative councillors and one representing the Council's 'Opposition Group', the Police and Crime Commissioner (also Conservative) and a representative from NHSEngland. There are thirteen other members.
The CQC review of Wiltshire services mentioned above, also looked into the effectiveness of the HWB: "The [HWB] was well-established with the majority of key partners involved. However the HWB was operating very much as a formal council committee with public meetings taking place on a bi-monthly basis."
"We were told that the Health and Wellbeing Board was committed to continuous improvement and had participated in peer challenges. However, they did not demonstrate how learning from the peer challenges was disseminated and acted upon and there was not a culture of appreciative enquiry."
After the CQC's verdict, Baroness Scott brought in the Chair of Wiltshire CCG, Dr Richard Sandford-Hill to be Co-Chair. As we shall see in the final article in this series, there are consultations afoot about how the Lansley Act should be altered by Parliament - once Brexit is out of the way.
It would be strange indeed if the HWBs survived changes to the legislation under which they were established. It is also unclear how integration of health and social care - CCG and Council - will fair once there is, on one hand, a more centralised regime under the geographically broader Sustainability & Transformation Partnership covering Wiltshire, Swindon and Bath and North-East Somerset, and, on the other hand, smaller primary care business units across Wiltshire known as Primary Care Networks.
However, when Wiltshire Council's cabinet member for health and social care, Jerry Wickham, stood down due to ill health, Linda Prosser, Wiltshire CCG's interim head, responded: "We have come the closest yet to effective health and social care integration because of your guidance. We won't stop,"
This is the sixth in our series of articles on the new shape of the local NHS - following our introductory report of 28 March 2019. Next - and finally: What does the future hold for the NHS generally and in Wiltshire?