Last week’s announcement about the Better Care Fund plans coincided with the annual gathering of social care leaders in Manchester, the publication of a grim ‘state of the nation’ assessment of social care funding by the Local Government Association and Association of Directors of Adult Social Services, and further evidence of deteriorating NHS performance as shown in our latest NHS quarterly monitoring survey.
Local government secretary Eric Pickles declared in a parliamentary written statement that health and social care services were being integrated ‘for the first time’ under these plans, a historically curious assertion to which Health Secretary Jeremy Hunt added ‘the time for talk is over – our plans will make this vision a reality’. Past veterans of a policy aspiration that is at least 40 years old may find here an equivalent muse to Philip Larkin’s memorable lines:
‘Sexual intercourse began
In nineteen sixty-three
(which was rather late for me)
Between the end of the "Chatterley" ban
And the Beatles' first LP.’
It is true, of course, that past efforts have not gone far or fast enough in ensuring consistent, joined-up care. The claims made for what these plans will achieve, if anything, have become bolder and more confident – seven-day working, named professionals, shared information, joint assessment and, crucially, savings of £523 million and a 3.07 per cent reduction in hospital admissions. So much for speculation earlier this year about the imminent demise of the fund; the BCF plans are now described as ‘the centrepiece of the coalition government’s commitment to joining up the health and care system’. But will the BCF work?
There’s no doubt that the BCF has galvanised councils and NHS partners to have essential conversations. There is nothing like money to concentrate the mind and there is some excellent work going on, for example in Greenwich and Wiltshire, as we heard at our recent integrated care summit. But much of this work pre-dates the BCF and accords with the evidence that the benefits of joined-up care take years to achieve. The BCF may well have put ‘a bit more fuel in the tank’, as one presenter put it, but so far it has not been a game-changer. And it has added a further layer of process and reporting requirements that cause some to see it as part of the problem not the solution.
The fundamental limitations of the BCF have not changed – it is not new money, amounting to less than 5 per cent of total NHS and social care spend – though Norman Lamb has talked of ‘total pooling at local level by 2018’. It does not address the cost of the service changes needed to reduce hospital admissions by shifting care closer to home. The central proposition – that the BCF will reduce hospital admissions by a surprisingly precise figure of 3.07 per cent – is the shakiest. As John Appleby explained in his latest blog, since 2008 the trend increase in total referrals to hospitals has been 4.2 per cent a year – elective admissions have risen by 2.8 per cent a year, non-elective by 1.6 per cent. Evidence that these rises can be stabilised let alone reversed is flimsy. Defying gravity would be easier. The government expects councils and NHS partners to achieve way too much, with too little, too soon.
Meanwhile the financial and service pressures on the NHS and care system are simultaneously intensifying as our latest quarterly monitoring report and last week’s LGA/ADASS report testify. Although I have never known a time in my own career when local government’s commitment to working with the NHS has been greater, the mood among local authority delegates in Manchester last week was sombre. The BCF rule changes this summer have soured relationships with the NHS, with a barely concealed feeling that NHS England had reneged on the initial deal. The shift of financial risk back towards councils will come back to bite the NHS when the consequences of next year’s local authority budgets become clear.
There’s a further question about the fit between the BCF and the government’s plans to announce 10 further pioneer sites – areas with ambitious plans to integrate at pace and scale. But surely the BCF should ensure that all areas are at the forefront of local innovation without needing the benediction of pioneer status – all must be pioneers now.
So, as the NHS and local government edge closer to the financial precipice, the BCF is well-intentioned but no substitute for a proper transformation fund to meet the double-running costs of shifting care closer to home and short-term action to address the gathering financial storm. In the longer-term we need a new settlement to place health and care on a sustainable footing.