After a rocky start, the government’s ambitious plan to integrate health and social care is ready for launch. But is the challenge simply too big? Mark Rowe asks the experts
Winston Churchill once described Russia as “a riddle wrapped in a mystery inside an enigma”. Yet even that epithet doesn’t really capture the complexity of putting together the Better Care Fund (BCF), the latest attempt by government to join up health and social care.
One diagram seen by this writer sought to explain how the fund might work: it depicted a patient wrapped, like a Russian doll, in a series of colour-coded protective layers that represented 49 elements of medical care, from outpatient care to community geriatricians. And that particular diagram was drawn up by an NHS/local government coalition singled out by the Department of Health for its clear vision on the issue.
The BCF has a pooled £3.8bn budget designed to integrate local health and social care services, improve care in the community and lessen pressure on health services. It is a cross-cutting venture, taking in the Department for Communities and Local Government, the Department of Health, the Local Government Association, the Cabinet Office and the Treasury. NHS England and the LGA are responsible for its delivery and implementation.
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Various governments have tried – and failed – to marry up health and social care in a meaningful way. Richard Humphries, assistant director of policy at The King’s Fund, says the policy aspiration is at least 40 years old. The reasoning was there for all to see this winter when several hospitals declared major incidents and were closed to non-emergencies.
The BCF launches next month but – and perhaps a medical reference is appropriate – its gestation has proved eventful. All 150 local health and wellbeing boards (introduced by the Health and Social Care Act 2012 to encourage integrated working between health and social care commissioners) submitted spending plans in April 2014 for 2015-16. The idea was that these local boards would develop plans with minimal central prescription: this would, in theory, realise the benefits of local knowledge and drive innovation.
It’s hard to find anyone who does not think that this concept of sharing and pooling services, creating a more joined-up and integrated scheme, is anything other than laudable. The National Audit Office said the BCF was “an innovative idea”.
Yet the NAO’s assessment of the initial groundwork was scathing. In a report last November, Planning for the Better Care Fund, it concluded that “the quality of early preparation and planning did not match the scale of the ambition”.
The NAO report found that “there was no central programme team, no programme director, limited risk management and no analysis of local planning capacity, capability, or where local areas would need additional support”. Nor was the scale of expected savings ever spelt out.
“The key issue was the lack of financial target,” says Ashley McDougall, director of Value for Money at the NAO. “It wasn’t that the local planners necessarily did a bad job. They didn’t get the necessary guidance. They were planning in good faith, but this has involved lots of people coming together from different areas.”
Early planning assumptions from the DH and NHS England put savings at around £1 billion but, by May 2014, NHS England had stress-tested the plans and concluded the proposals from the wellbeing boards would collectively save just £55m, and noted dryly that the fund plans were “biased towards over-optimism”.
Planning for the fund paused between April and July 2014 and, under revised conditions, local areas were asked to aim for at least a 3.07% reduction in their total emergency admissions over 2014 levels. “When the target was finally introduced it was something concrete for them to work to,” says McDougall.
“There’s no doubt that the BCF has galvanised councils and NHS partners to have essential conversations,” says Humphries. “There is nothing like money to concentrate the mind and there is some excellent work going on. But the government expects councils and NHS partners to achieve way too much, with too little, too soon.”
A care worker employed with children’s health in the south west says the intentions behind the fund have been broadly welcomed. “No-one quibbles with the intention,” she says. “From the patient’s point of view, it doesn’t matter whether their care is delivered by the NHS or the local authority. The problem is everyone suspects the fund is designed to save money first, and that joining up care is an expected bonus, rather than the other way round. These new merged services are being created from services that have already had enormous cuts. There’s no capacity for it to really happen.”
And there, McDougall acknowledges, lies a knot that will prove tricky to unpick: “Schemes such as the Better Care Fund are inherently quite difficult,” he says. “They are trying to reduce A&E admissions but the evidence base for that happening is not great. There is no great guidance to tell people what works, so they are planning ideas that don’t have peer reviewed evidence.”
The risk, says McDougall, is that ideas that show promise – or those that work in a localised context – become mainstream, drop-in templates, without being rigorously tested. “A lot of decisions have been based on something that appears to work well somewhere else but hasn’t actually been tested, or on things that some GPs have spoken highly of.
“What needed to happen was planning, in a dull, bureaucratic way with spreadsheets to demonstrate whether the ideas were going to be good.”
In that respect, McDougall says, the revised proposals from local boards last autumn were more coherent and plausible. “They said things like, ‘if we have an extra six nurses doing Y then we can keep X people out of hospital’.”
Sunderland was highlighted by the DH for putting together a coherent plan for delivering the fund. Commissioning is based around five localities in the city, rather than specific services. These focus on five groups of GP practices, each covering a population of around 250,000. Key aims include reducing unnecessary admissions to hospital and subsequent readmissions within 30 days of discharge, and investment in what are called Time to Think services, which support people to recuperate after a hospital stay, enabling a more joined-up assessment of needs in an environment outside hospital.
Neil Revely, Sunderland’s executive director of people services, who works with the local health and wellbeing board, cites a scenario where a GP might historically prescribe a patient medication for depression, but the fund may instead enable links with the council housing department to move the patient to more suitable accommodation.
Revely is confident the fund model will work where other attempts have failed. “We have a Clinical Commissioning Group led by GPs who absolutely understand how the system isn’t joined up,” he says. More colourfully, he points to a second, pressing reason: “We have a burning platform that is getting hotter – diminishing resources and increasing demand. It’s becoming tangible, we’re seeing it with hospitals declaring major incidents in what has been a benign winter.”
Sunderland’s problems typify those across the country. “We recognise the world has changed from when the NHS was built,” says Revely. “The NHS was designed for episodic interventions. You got ill, you were treated and went home. But with an ageing population people have long-term needs. We have to get people flowing through the system.”
Strikingly, Revely found that the exacting demands of the revised plans, stressed as a necessity by the NAO, did not always seem to be relevant. “The fund got more complicated as it went along. Suddenly we went through a lot of bureaucracy and hoops that we didn’t find particularly helpful. We had a lot of staff tied up with the information we had to send through, with the level of detail, metrics and risk logs,” he says. “On other the hand, there may be other local authorities where such a level of detail was a necessary catalyst for getting people together.”
The NAO has also identified key areas where more joined-up action is still required, including a need to clarify with local government the balance between local areas’ freedom to set fund objectives and centrally mandated objectives, and to develop indicators to measure the extent and effectiveness of local service changes and integration.
Those involved in the Better Care Fund believe lessons have been learnt. “This has built bridges across departments,” says Ed Scully, DH deputy director on the BCF taskforce. “It can still be tricky, you can’t say everything is perfect, but the four partners have learnt to listen to others. We needed difficult conversations to happen. You need to build a team, trust, that doesn’t happen overnight.”
According to Terry Willows, DCLG deputy director on the taskforce, you must present issues and points in a consistent way to all partners, including your own organisation, rather than summarising to some parties what you think you said to others. “You can feel conflicted,” he says. “You are looking after your own organisation’s interests, but the pitfall is that you can do that too robustly. You need to be prepared to compromise.”
“Everyone has their own interests,” adds John Wardell, deputy BCF programme director. “But the biggest pitfall is someone who refuses to compromise. You have to be able to walk in other people’s shoes.”
The NAO has identified other lessons that can be more widely applied across government. These include a need to agree financial and service expectations with HM Treasury, and reflect these explicitly in programme objectives and guidance; establish programme governance, management, resources, risk management and timescales appropriate to the programme’s scale and ambition; clarify the separation of responsibilities between departments and arms-length bodies; and prepare evidence at an early stage on the costs and benefits of different types of proposals to integrate services.
“The biggest pitfall is over-promising,” says McDougall. “There has to be a recognition that this particular issue is difficult; it hasn’t been cracked. The risks of organisational interests don’t go away. Both the NHS and local authorities are under a lot of pressure.”
Pooled budgets are another lesson that Whitehall might more widely heed. “Structurally, it’s a good idea,” says McDougall. “Local government and the NHS have to agree to share. Before, if people were less keen on a given idea it impeded joint working. Now we have a situation where the official in Whitehall is not telling people what to do; if you plan together then there is money in it for you.”
That old fashioned concept, people skills, applies, he suggests. “The longer people work together on joint planning, the more they understand what others are thinking and feeling. You realise what you are doing is not too far away from the other side. You are both looking to keep people at home, in the community and out of hospital.”
With this aim in mind, Sunderland has encouraged different sectors of health and social care to be based in the same office. “Organisations don’t have relationships, people do,” says Revely. “You can have the best systems in place but if the people don’t get on, it’s no use.”
At the time of writing, 147 of the 150 health and wellbeing boards had been signed off, while three still required support. Is there a danger that once the project is launched, there’s a collective sigh of relief and people forget what they are supposed to be doing to see things through? Wardell is emphatic that this will not happen. “What is driving this is the nature of health and social care, the immense pressure. Partnership working will be even more important as part of the bigger transformation and the wider agenda of integrated care plans. There’s been a bit of a Berlin Wall between them, but the wall’s being knocked down.”
Case study: Wiltshire
In Wiltshire, the Better Care Fund will focus upon frail older people. People over 65 make up 20% of the county’s population, and account for 47% of Wiltshire’s NHS resources. Wiltshire describes its care and support as fragmented.
In response, Wiltshire is integrating care around clusters of GP practices that cover 20,000 people. Wiltshire has developed a concept of “wrap around” care that involves co-ordinated care by, among others, community nursing teams. Every patient will have one person who co-ordinates all their care.
Several steps were necessary, says Jane Scott, chair of Wiltshire’s Health and Wellbeing Board, to make the fund work. “We wanted the acute hospitals on our board. You have everyone who is part of the system around the table, even if they don’t all get on.
“The meeting of two different cultures, the local authority and the NHS, has been the biggest issue. Health is very much controlled by regulations so can’t be as flexible. It’s not all sweetness and light, there are difficult conversations, but with good relations you can get through them.”
The fund has been trialled for 100 days in three areas of the county, a policy that is now allowing Scott and colleagues to improve co-ordination ahead of the launch.
“The key thing is to know your area, talk to your staff, your patients, so that you have a really clear idea of what services you need,” says Scott.