More details called for on plans to expand pooled budgets

The government published its integration white paper – Joining up care for people, places and populations – in February. The paper set out the intention to have a single person accountable for shared outcomes at place level within systems and also called for the expansion of pooled or aligned budgets. And it set out a series of questions for engagement with stakeholders.

In its response to the questions, NHS Providers acknowledged that pooled budgets could be helpful to enable joint decision-making, but said they would not be appropriate for all places. While it welcomed the flexibility in the white paper for local areas to decide the level of budget pooling, it called for more details about the government’s call for place-level pooled budgets eventually to cover a ‘significant proportion of health and care spend’.

Successful integration depended on relationships, behaviours and joint working, and was not about who held the funding. Formal budget pooling along with an accountable person at place level could risk recreating sub-integrated care system planning footprints. ‘This risks cutting across integrated care boards’ responsibilities, making it more difficult to streamline bureaucracy, and undermining the benefits of reunifying NHS budgets at system level,’ the representative body said.

It also called for the government to consult with the HFMA and accountancy body CIPFA about the harmonising of reporting standards and how to overcome ‘frictions between accounting systems’.

NHS Providers also highlighted local government funding shortfalls as the biggest barrier to expanding pooled or aligned budgets. ‘An adequately funded social care system is needed before pooled budgets can be a reality,’ it said. And it cited some trusts reporting significant budget reductions in local authority funding leading to money being diverted away from NHS services where a section 75 agreement had been implemented. Some agreements also failed over the inability to agree meaningful risk sharing arrangements.

The response paper also questioned the ability of a single leader to be accountable for shared outcomes across the NHS and local authorities when statutory accountabilities for both systems would remain in place. It also raised concerns about the lack of flexibility in the proposal. ‘Places should have the freedom to decide their leadership and governance arrangements,’ it said. The arrangement could in fact blur accountability structures and may not add value, particularly in smaller systems.

The HFMA, which published a summary of the integration white paper proposals in February, has been engaging with NHS England and NHS Improvement over the finance and governance implications of the move to integrated care systems. ‘The introduction of statutory integrated care boards comes with both a number of opportunities and challenges,’ said HFMA policy and research manager Lisa Robertson (pictured). ‘Ongoing conversations and co-design will be the key to the success of the move to greater integration.’

She added that the ICB finance role would be different from that in current clinical commissioning groups and support may be needed to help teams develop these changed roles. The move to a more permissive and less rules-based system would also require changes in the approach to regulating systems, she said.