The Better Care Fund: what’s love got to do with it?

Valentine’s Day is known for expressions of romantic affection, when the love-struck hope that Cupid will work his magic. But this year Cupid’s arrows will be sharing airspace with the first cut of 152 local Better Care Fund templates winging their way towards NHS England to meet the 14 February deadline. The success of the £3.8 billion Better Care Fund – designed to promote integrated care and help shift care closer to home – depends on a different kind of chemistry between local NHS organisations and their local authority partners.

The King’s Fund’s latest quarterly monitoring report (QMR) indicates that it is money, not love, that colours the outlook of health and social care leaders. Although service performance has generally held up well, this quarter’s survey found rising levels of pessimism about the financial prospects for local health and care economies – 86 per cent of NHS trust directors were fairly or very pessimistic about the next year financially, as were 66 per cent of clinical commissioning group (CCG) finance leads and 63 per cent of directors of adult social services. Nearly a third of trust finance directors said they were very pessimistic – the highest proportion since we began monitoring in 2011.

So will the Better Care Fund help disperse the gloom? In the latest QMR survey, opinions about whether the Better Care Fund would help or hinder organisations to maintain performance in key priority areas, such as delayed transfers of care, were mixed. Directors of adult social services were the most optimistic – slightly more than half of those surveyed thought it would help. This view was shared by only 12 per cent of NHS trust finance directors, nearly half of whom thought it would be a hindrance. CCG finance leads were somewhere in the middle, with 38 per cent seeing the Better Care Fund as helpful.

These findings reflect some of the challenges and risks, as well as the opportunities, offered by the Better Care Fund and it is entirely unsurprising that these are perceived in different ways by different parts of the system. That our recent Better Care Fund learning event was packed to the rafters spoke volumes about the significance of this fund in reshaping local health and care systems. The joined-up clarion call from both the health and local government ministers, to be ambitious in pooling a much bigger share of NHS and local authority commissioning budgets, met no resistance. Instead the mood of the event was about the ‘how’ questions. Material from the event is now available on The King’s Fund website but I was struck by four particular themes:

The first was that so few acute providers attended the event. Our QMR survey suggested that most acute trusts see the Better Care Fund as a problem, not an opportunity. Yet the most effective local Better Care Fund plans will be those that arise from collaboration across the whole system of health, care and support, engaging fully with all NHS, local authority and third sector partners – especially with acute and community health partners. If used successfully, the Better Care Fund will see a reduction in hospital activity and income. This is potentially big, risky and hard to do. It’s difficult to get a sense of whether many places have really got to grips with the tough choices that are the inevitable consequence of the fact that the Better Care Fund is not new money. We’ve published an evidence summary to help partners assess what kinds of investment will offer the maximum impact on needs and outcomes. 

A common refrain at the learning event was that the tight submission deadlines made it almost impossible to secure engagement and buy-in to Better Care Fund plans, not only from the acute sector but from many other stakeholders, not to mention the general public. This underlines the importance of anchoring the two-year Better Care Fund plans within a five-year strategy for transforming local services.

A third theme was whether health and wellbeing boards are far enough along in their own developmental journey to secure local agreement to their local Better Care Fund plan. Will boards bring real system leadership in developing a shared vision about future services, with the Better Care Fund plan as a stepping stone? Or will their role be confined to rubber-stamping plans that have already been decided elsewhere – two of the scenarios identified in our recent research on health and wellbeing boards? The picture is mixed, but our afternoon workshop heard some heartening examples from boards – such as Southwark, Leeds and Enfield – that were making imaginative efforts to engage and consult on their plans and priorities.

Finally there was much discussion about metrics; information governance and data-sharing were seen by many as continuing obstacles to integration, despite the Caldicott Review. And there were worries about how progress would be measured – especially the performance element of the Better Care Fund. Older readers can share valuable lessons from the joint finance programme – a big idea applied to a small slice of total spend and suffocated by process.

A final thought is that the world of politics and policy-making tends to over-estimate what can be achieved in the short term and under-estimate what can be achieved in the long term. Some of the best examples of integration took years to achieve. As 14 February draws nearer, it will be the strength of long-term relationships – not short-term plans – that will bring us closer to the prize of integrated care.

This blog is also featured on the Public Finance website.