The latest effort is the £3.8 billion Integration Transformation Fund (ITF) (now known as the Better Care Fund) announced in the June spending review, to be spent locally on health and care to drive closer integration and improve outcomes for patients and people with care and support needs. As further details emerge, it's becoming clear that most of it will come from existing NHS budgets – it is not new money. As John Appleby has shown, this is equivalent to an average reduction in allocations to clinical commissioning groups (CCGs) of around £17 million, with potential knock-on consequences for acute and community health services.
So, as the financial pressure on the NHS and local government intensifies, the stakes are high and there are fears that some health systems could be tipped over the edge. The latest guidance is clear that the ITF does not address the financial pressures faced by local authorities and CCGs which remain 'very challenging'. It is a joint fund, not a transfer to social care, so it will be a big ask for CCGs and local authorities to agree how the money will be spent to achieve better outcomes for patients and also satisfy local needs and the national conditions attached to the grant. These include protecting social care services, ensuring seven-day working to support hospital discharge and relieving pressures on urgent and emergency care. Expectations are great but can they be achieved?
The ITF does offer a major opportunity to drive forward integrated care – there is nothing like money to focus the mind – and there are three broad approaches that could guide thinking about how money is used.
The first is adopting an evidence-based approach to what different kinds of service investment (how much, in what kinds of intervention, for how long) will offer commissioners the biggest bang for their buck in both providing a better model of care for users and relieving pressure on the system. We have begun to synthesise our own work and other research about what works in integrated care to assist local discussions about how the grant could be used to achieve maximum impact. These discussions will be testing, as they will involve considering the opportunity costs of a range of choices. In many cases this will require organisations to reduce or disinvest in some activity.
The second approach is about the role of health and wellbeing boards in bringing together local partners. Relationships, especially between CCGs and local authorities, will be key in developing an agreed, costed and deliverable plan – by March 2014 – that offers a win-win for both the NHS and social care. The ramifications for providers could be very significant – which means their engagement in the process will be essential. But our latest health and wellbeing board survey suggests that, as yet, few boards have begun to get a grip on some of the tough strategic challenges facing their local health and care services, with most prioritising public health and health inequalities. The requirement that boards sign off local plans will be a big test of their readiness to offer effective system leadership, rather than rubber-stamping decisions made elsewhere.
The final approach is about using the ITF as a stepping stone to the longer term transformation of services. The requirement that local plans should be part of a five-year strategy for local health and care services from 2015 will be a helpful spur to look beyond the immediate short-term pressures and develop a shared vision of what future local services should look like. The ambition surely should be to plan with 100 per cent of NHS and social care resources in mind, not just the 3 per cent the ITF represents.
With apologies to Pink Floyd, will the ITF be part of the foundations of a genuinely integrated system or just another brick in the wall?
Read the related paper: Health and wellbeing boards: one year on