Feature / Caring and sharing

CCGs and local authorities are finalising their better care fund plans for 2015/16. Seamus Ward looks at how the joint arrangements will work

Pooled funding arrangements between the NHS and local authorities have been around for several years, but the sums involved have tended to be small. In England, this is being turned on its head with a national requirement to bring significant amounts of local funding together to integrate the commissioning of health and social care under the better care fund from 2015/16.

There are a number of ways of pooling funds currently. The so-called health act flexibilities are based on the Health Act 2006. Section 75 of the act allows NHS bodies to partner local authorities and transfer funding to cover costs incurred in the exercise of health service or local authority health-related services. These often involve services to older people or community mental health services. One party, usually the local authority, acts as the lead commissioner with the other delegating specific duties.

Section 76 allows local authorities to make payments (service, revenue or capital contributions) to NHS bodies to support specific additional NHS services, where this ensures a more efficient use of resources.

And section 256 of the act allows for less formal arrangements with commissioners transferring funds to local authorities to support or enhance specific council services that affect individuals’ health.

Government increase

Until now, the use of these mechanisms have been left up to local discretion, but the government has not only decided to make the sharing of funding mandatory but also to increase the amount of pooled monies. A total of almost £2bn will be transferred from the NHS to social care in 2013/14 and 2014/15 under section 256, while at least £3.8bn will be pooled through the better care fund from 2015/16 (under section 75 agreements). All CCGs and their partners were required to submit a draft better care fund plan by mid February, with final plans expected by 4 April.

Half of the better care fund will be based on existing pooling arrangements – the £1.1bn to be transferred from health to social care in 2014/15 will also be passed to social services in 2015/16; £354m in capital funding, including the disabled facilities grant; £300m in clinical commissioning group reablement funding; and £130m in carers’ break funding.

However, with the other £1.9bn coming from CCG funding (around 2% of their budgets), there is some concern that the fund could destabilise the system, as it pools existing money. None of this is new money – the hope is that integrated commissioning will improve quality, give patients and clients a better experience and drive out inefficiencies. For example, single assessments of clients/patients could avoid duplication.

Despite this, many areas are embracing the better care fund, seeing it as an opportunity to integrate and transform the services offered locally. In Wakefield, for example, a significant chunk of the district council adult social care funding will be added to funds from Wakefield Clinical Commissioning Group.

Helen Childs, the CCG interim programme manager for care closer to home, says the local fund was expected to stand at around £26m. But when the CCG and local authority reviewed the adult health and social care service lines they commission, they realised that many of them fell within the scope of the better care fund. With these additional services, the better care budget will rise to around £42m. And although not required by NHS England guidance, the council and CCG are keen to have better care fund-style plans for children and family services.

The services included in plans will be largely dictated by six national conditions set down for access to the fund. These are:

• Plans to be agreed jointly CCGs, councils and health and wellbeing boards should sign off the plans, and providers likely to be affected should be involved to develop a shared view of the future shape of services.
• Protection of social care services NHS England guidance says this does not mean protection of social care spending.
• Seven-day services Local areas must confirm how plans will support discharge and prevent unnecessary admissions at weekends.
• Better data sharing Data should be shared between health and social services, based on the NHS number.
• A joint approach to assessments and care planning This is necessary to ensure there is an accountable professional where funding is used for integrated packages of care. This is particularly important for dementia services.
• Agreement on the consequential impact of changes in the acute sector Assurance will be sought on engagement of the public, patients and service users, as well as plans for political buy-in.

As in many areas, services in the Wakefield plan include general community nursing and specialist nursing services, such as the geriatric service. It differs from most by including public health funding in its better care plan. ‘We are doing that to promote proactive care and prevention, so people are able to look after themselves for longer. We can’t do that without public health services,’ Ms Childs says.

As a result, much of the council’s adult social care budget is included. The principal exclusion is spending on residential care home services. The CCG was unable to unpick all of the community element of the adult mental health services block contract prior to the initial submission. However, Ms Childs hopes it will do so before the final plan is submitted in April – increasing the local better care fund to more than its current £42m.

‘It’s a moving feast,’ she says. ‘The national guidance said that it would be an iterative process, but it’s also something we would want to do anyway.’

London collaboration

In north west London, three CCGs (Central London; Hammersmith and Fulham; and West London) have collaborated with their corresponding local authorities (the City of Westminster and the London boroughs of Hammersmith and Fulham and Kensington and Chelsea) to create a better care fund plan. Cath Attlee is whole systems lead for the

tri-borough adult social care and says the bodies had close working relationships before entering the better care fund process together.

Several section 75 and 76 agreements are in place for 2013/14 to a value of £113m, covering learning disabilities, mental health and older people’s services. A further £11m has been transferred from the NHS under the section 256 social care to benefit health initiative.

Much of this funding and service is likely to be included in the better care fund, including the social care health benefit money and funding for services such as helping people live independently, joint nursing and care home commissioning and psychiatric liaison. 

With integration across the boroughs well advanced, the partners expect to increase their 2015/16 better care fund budget beyond the mandated value of £47m. According to their draft plan, the local authorities and CCGs are exploring expanding the shared fund to include joint commissioning of all residential and nursing homes, domiciliary care, community healthcare and the emergency patient pathway. If they make this move, the fund value would be £442m and the partners believe this step would allow them to manage the shift to care based in the community and domiciliary care settings.

The ultimate prize is transforming services being commissioned. For example, Wakefield is looking to involve voluntary and third sector organisations in providing some types of care.

Ms Childs says: ‘Sometimes statutory providers are not being used in the right way. In low-level social care support, the voluntary sector could be used to keep people healthy and offer a variety of support.’

She points to a local scheme with Age UK Wakefield as an example of a voluntary organisation better placed to perform straightforward but necessary work. The scheme places volunteers in A&E to support patients who are not medically unwell but who may be vulnerable if sent home on their own. The volunteers accompany the patient home to make sure they have everything they need, such as ensuring their heating is on and there is food in the cupboard.

As part of the better care fund development, Wakefield CCG is working with local trusts to ensure that all parties understand the consequences of moving money away from hospital-based care.

‘This has been an enabler for us, not only to explore the principles around joint commissioning but also to see how we are going to work with our providers,’ Ms Childs says.

‘We know we want to reduce acute activity and the bed base within acute providers to release funds for community and primary care services. But we also need a risk and reward mechanism in place so that everyone knows what’s happening, can prepare and work together on the plan.’

Performance issues

There are concerns over the performance element of the better care fund. Initially, NHS England was due to hold back £1bn in 2015/16. This would be paid out in two equal amounts, with £500m released in April 2015 and the balance in October 2015, based on performance against national and local objectives. The funding would not be released if the performance targets were not met.

Ministers decided in January to postpone the implementation of the sanctions for the first year. However, local authorities and CCGs that fail to meet the objectives may be required to rethink their plans or NHS England could step in and direct how the money should be spent.

Although happy about the ministerial rethink, there is some confusion among CCGs and councils about how the penalties will be applied and what would happen if they had already spent the money. They are hoping that NHS England’s reply to their initial better care fund plans this month will shed more light on the subject.

There are other concerns about the initiative. King’s Fund assistant director of policy Richard Humphries believes the initiative offers an opportunity to push ahead with integrated care, but benefits to patients will vary by area.

‘The downside is that it is not new money and a lot of it has already been transferred from the NHS to social care,’ he says. ‘From 2015, £1.9bn will come straight out of CCG allocations, so a lot will depend on the financial position of each CCG. Where the local acute providers are already struggling to balance their books, there is a risk that the better care fund could be part of the problem rather than the solution.’

Ms Attlee says she can see why NHS commissioners in areas with less well developed partnerships could see the transfer of funds to social care as a major risk. ‘But I don't think it is seen as such a high risk here because it sits within a health and social care economy where we are saying: “Let’s make better use of public sector money by putting it together”,’ she says.

North-west London has an advantage in that it is undergoing a substantial reconfiguration of local acute hospitals under the Shaping a healthier future initiative, she adds. The tri-borough better care fund plan was not developed in isolation from the changes in the acute sector.

‘It puts us in a better position to understand the impact on acute services as we have already done some work on the reconfiguration of hospital services,’ says Ms Attlee. ‘We have looked at what we need to do in the community to make that work.’

While it will not be a magic bullet, there are high hopes that the better care fund will represent a significant step in the integration of services that facilitates the movement of care out of hospitals. One thing is certain: with plans being finalised this month and 2014/15 seen as a preparatory year, CCGs and local authorities will have to act fast.