The £5.3bn Better Care Fund was launched as a one-year programme for 2015/16. It aims to kick-start integration between health and social care and to make investments that will yield savings. Halfway through the year, it made sense to assess how it was going, the more so after July when the government confirmed there would be a second year of the fund.
It also made sense, in the spirit of integration, for CIPFA to collaborate with the Healthcare Financial Management Association (HFMA) to ask health and social service authorities for their views. One obvious question, given the long-term nature of most of the potential benefits, was whether the BCF should carry on long term. Respondents thought it should, so it was pleasing that the 25 November Spending Review included a commitment to carry on with the fund throughout the current Parliament. That not only facilitates forward planning, it also gives ongoing relevance to the lessons to be learned from early experiences if the BCF is to be the cornerstone of the journey to full integration of health and social care by 2020.
In our survey of NHS bodies and local authorities, representing almost a third of Better Care Funds, HFMA and CIPFA found that, although positives are emerging after six months of the programme, the particular mechanics of the BCF have led to at least as many negatives.
The main findings were:
Health and social care communities have typically embraced the new arrangements keenly. Around half of them pooling more money through the BCF than the minimum required (see graph)
Local implementation arrangements differ considerably in structure as well as in the detail of plans. For example:
- Governance is often complicated, with numerous clinical commissioning groups and local authorities formally required to take part many other stakeholders, notably providers, needing to be involved. Arrangements in areas with unitary authorities tend to be much simpler
- No one method of setting up and accounting for the flow of funds involved has emerged as preferred practice
- It was assumed that local authorities would most commonly host the BCF and this assumption has proved to be the correct. Having said that, a diverse range of approaches has emerged based on financial, geographical, historical, practical and political factors.
- Respondents made positive and negative points about the BCF. Positive implications mostly related to the improvement in working relationships between organisations, the breaking down of organisational boundaries, better collaboration and improved understanding of each other’s pressures. The impact on services was also acknowledged, with wider consideration being given to the links between social care and acute activity, and some examples of new and innovative investments.
The main negatives were:
- Bureaucracy: the BCF is seen as unwieldy, consumes a disproportionate amount of management time and comes with demanding metrics and oppressive reporting requirements
- Unrealistic expectations fuel disputes between partners and are, in the words of one respondent, ‘giving integration a bad name’. Eighty per cent of respondents did not expect the BCF to meet its targets.
- The pressure it added to already-stretched health finances, essentially because the BCF merely reuses existing funding while assuming it creates additional investment.
Not surprisingly, then, respondents called for improved clarity, simplification, and a recognition that implementing joint working arrangements is difficult and takes time: “relationships begin to get tested when the money dries up,” said one CCG. However, they also recognised the benefits of integration, especially where a common purpose can be built, joint posts set up, and alignment achieved with other major change programmes in the local health and social care economy. No one argued with the need to focus the whole system on the key activity of developing alternatives to hospital admission.
Given that context, CIPFA and the HFMA are calling on the government to:
- Review the administrative and monitoring arrangements prior to the start of 2016/17 with a view to simplifying and streamlining them; and consult as early as possible on proposals so as to facilitate effective planning
- Continue to modify and liberalise the arrangements going forward so there is maximum synergy with the emerging devolution programme, which is likely to prove the most sustainable model for taking forward integration at scale
- Use the lessons learnt from the BCF so far when finalising the arrangements for the development of plans for full integration of health and social care by 2017, to be implemented by 2020
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