Better Care Fund, better read the small print?

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Although earlier rumours of the demise of the Better Care Fund – the government’s flagship £3.8 billion pooled fund to promote integrated care – have turned out to be greatly exaggerated, the significance of the government’s latest announcement about the fund should not be. Although this has been fed by mounting political anxieties about the state of hospital finances ahead of next year’s general election, the writing has always been on the wall.

While sharing resources across the NHS and local government is a step in the right direction, expectations of what the Better Care Fund could achieve, and how quickly, seemed heroic. The £3.8 billion fund is not new money, the national conditions for its use were stringent and plans had to be assembled very quickly, with insufficient time to engage properly with acute providers whose buy-in is essential for the plans to work. It is surprising that anyone was surprised that many of the local plans submitted on 4 April didn’t pass muster. What began as a well-intentioned agreement between the Department of Health, NHS England and the Local Government Association is fast becoming a Faustian pact – the devil truly will be in the detail of the revised guidance that we haven’t yet had sight of.

The key change is that £1 billon of next year’s fund will be allocated through a local ‘performance pot’ for each health and wellbeing board – and the money each board receives will depend on its performance in reducing hospital admissions. The remaining money will be used to commission NHS services. This will offer some small cheer to hard-pressed acute trusts – it means the NHS will avoid paying twice for emergency admissions (once through the fund, and again for the admission that wasn’t avoided). But the price of this very modest amelioration for the NHS is a substantial shift of risk back to local authorities that can’t be sure they will receive the grant for services that have to be funded up-front.

There are three obvious and immediate consequences of the rethink. First, most plans will need to be rewritten within weeks and will then be subject to a further central assurance process and ministerial sign-off. This represents a huge amount of time and scrutiny of less than 3 per cent of total NHS and social care spending – a distraction from addressing the much bigger challenges of how best to plan with 100 per cent over a more realistic time frame.

Second, reaching local agreement on the new performance rules – especially the key metric of reductions in emergency hospital admissions – and how they will work in practice seem a recipe for conflict and local disagreement at a time when the NHS and local authority partners need to be collaborating like never before. Rises or falls in emergency admissions are influenced by a wide range of factors and attributing changes to short-term Better Care Fund investment will be tricky to say the least.

Third, it creates new uncertainty for local authorities in planning their budgets for next year, with the prospect of at least £600 million to be spent on NHS services and not available to protect social care. This will only add to the woes of the social care system where the cracks are beginning to show as last week’s Association of Directors of Adult Social Services budget survey demonstrated.

Reducing hospital admissions by providing care closer to home depends in part on investing in alternative services in primary, community and social care. This takes time, and a good understanding of what types of intervention are best suited for local needs and circumstances – we have summarised the evidence in our evidence-based guide, Making best use of the Better Care Fund. Crucially there will need to be additional money for new or additional services before resources can be released from hospitals. The Better Care Fund in its current guise does not do this.

As Simon Stevens, Chief Executive of NHS England, pointed out recently, merging two leaky buckets does not create a watertight solution. What is needed is a genuine health and social care transformation fund with new money to meet the double-running and transition costs of changing how and where care is provided. Finding extra money in the current fiscal climate is a big ask but one that will become increasingly urgent as the financial crisis facing both the NHS and social care gathers pace. The consequences of not acting are serious – sticking plaster solutions will not deal with the significant challenges facing social care, nor will they address the growing funding pressures facing the NHS.

This blog is also featured on the Public Finance website.


Kevan Keegan

Managing Director,
Eldercare Business Solutions
Comment date
11 July 2014
Why not simply have the hospital recharge its costs for any admission of a client of the Joint Fund?

The Fund then has control and accountability for its performance. And if it can avoid higher costs by investing more smartly in its own capability then it is motivated to do so. And if it cannot, then either it is incompetent...or the model is flawed and the intellectual conceit is false.

Or is that too simple?!

Geoffrey Cox

These challenging times - In such times of chronic austerity; post the bank collapse, the structural defect and a globalised downturn,it seems that the short termism of our 5 yr political cycle / system is bringing out the worst in our leaders; presentiMD,
Southern Healthcare
Comment date
11 July 2014
These challenging times - In these times of chronic austerity; post the bank collapse, the structural defect and a globalised downturn, it seems that the short termism of our 5 year political cycle / system is bringing out the worst in our leaders; presenting attention grabbing headlines, setting unrealistic challenges, impossible timeframes and a lack of any engagement with those who have to meet them.

Are we all deemed naive? - In a recent response to a question in Parliament about the crisis in social care, Mr. Cameron responded with an attack on the previous government as usual, and then went on to say 'that's why we have increased funding to the NHS'. In other words, the issue was ducked, and I am not sure about that answer either.

This pretty much sums up the paradox in health and social care in this melee and it surprises me that we are expected not to notice. I would hang on to politicians words for some shred of clarity, commitment or innovation, but I see none. Far from it.

We have an ageing population, living longer with more complex conditions, and are still reeling post Mid Staffs, Winterbourne View, Ash Court etc., yet health and social care continues to be cut particularly in terms of residential care and even more dramatically with care at home over the last 3 years despite the rhetoric to the contrary. It just gets worse and worse and the gap between statement and reality grows ever wider.

The paradox - There are claims that we are responding, learning, and are supporting more people, better at home. In truth, we are failing on every count. Particularly, the reality is the steady withdrawal from state supported health care, social care and elderly care in particular, which started in the 90's, and is now being accelerated.

Decades ago we saw the withdrawal of NHS geriatric facilities, and rightly so, but now the decline in private residential care is simply resulting in NHS general facilities increasingly serving the elderly, leading to a furore over 'avoidable admissions’ in this blame culture. Are they really 'avoidable admissions' in the current situation, whilst we find someone or something to blame, and have brought this on ourselves through successive policy failures. Perhaps we should take our lead from the Australians who have better solutions and do not seem to indulge in the politics of avoidance, disaster and blame to the same extent.

Richard Humphries puts in words what we all suspected or knew but we were perhaps being naively hopeful.

The Care Act too is a mystery. The government's main drive has been to cut the deficit. So, how will cash strapped local authorities, dependant on central government funding, fund more and more of the existing (albeit declining) residential care placements? The £18bn residential care sector depends on the self pay market for roughly half its revenue, (cynically called 'the catastrophic costs') which the government now expects local authorities to pay the bulk of. Or does it? If so, how can they? They can't cope now. Oh, it must be someone's fault.

It seems to be a paradox of modern times that the more difficult things become, and the more we need to work increasingly closely together, the more likely it is that we are being set up to fail. That includes Local Authorities, the NHS, its Managers, Consultants & Doctors, as well as Social Care Providers, all Nurses and Healthcare assistants, all of whom seemingly take it in turn for public or more likely political vilification.

What I hope is that one day we might see some honesty, a long term vision and some determination to back plans with resources, financial and otherwise so that they have a chance. However, I won't hold my breath.

Geoffrey Cox MSc. LLb.

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