This article originally appeared in The MJ
If we’re being honest the Better Care Fund hit a bump in the road a few weeks ago. DCLG and others did an excellent job of rapidly briefing out that its imminent demise was wide of the mark; the result of Whitehall whispers. But nevertheless, confidence does seem dented. In his keynote speech on integration at NHS Confederation conference last week (5th June), the better care champion and Care and Support Minister Norman Lamb didn’t even mention better care until the last couple of minutes, and then almost as an aside.
The reality is concerns remain about the make up of many of the plans submitted. At the heart of this problem is a fundamental tension between national and local about the complexity of the integration challenge and the time required to bring it to life. Last November the iMPOWER report A Question of Behaviours argued that whilst the funding available for integration went as far as 2015/16 the integration efforts would extend well into 2020 and likely beyond. Thankfully many others are now also supporting this thinking. At the start of May King’s Fund Chief Executive Chris Ham wrote an excellent article arguing for the creation of a separate transformation fund that runs separately to Better Care but is focused on the post 15/16 period to help sustain integration momentum. Added to this in the last few weeks the LGA has now co-opted this idea by arguing both for a similar transformation fund to be created but also a five year commitment from both health and social care to join up funding. In short, integration is a decade long journey and there appears to be a consensus building behind this thinking. The drawback is that this is inconvenient for the political cycle and government appears unwilling to commit beyond what has already been agreed (which is understandable given the election in 2015 being so uncertain).
This tension has been borne out in the Better Care plans submitted. Local partners have acknowledged the time frames to make this work sustainably and as such have focused their efforts on short to medium term developmental work for the first two years of this decade long process. By prioritising the building and strengthening of the relationships between NHS and local authority they are creating a foundation that can take the stresses of more complex and radical measures to integrate health and social care. Unfortunately, government doesn’t appear to see it in the same way and instead has approached the Better Care Fund pot and the time frames laid out as the period in which integration will happen.
In fairness to central government, its core concern, the under representation of acute trusts in the development of the plans, is legitimate.Irrespective of how long you believe it will take to create an operational integrated health and social care model the whole endeavour will fail if the hospitals aren’t intimately involved. The financial rationale for integrated health and social care is predicated on a reduction in activity within the acute setting. As this is also a direct challenge to the traditional acute business model then government is entirely right to put this front and centre when pushing back.
Looking from the other side, Councils and CCGs were asked to do two incredibly hard things in a mere couple of months:
- Be clear on hospital reconfiguration (something we have ducked nationally and locally for a generation)
- Overcome entrenched disagreements and misaligned incentives and include hospitals in this discussion
The fact that most plans haven’t managed to achieve either of these should not be surprising.
The answers to both ‘how do we resolve this local vs national tension?’ and ‘how do we make integrated care actually work?’ are in fact the same. A radically new conversation about the shape and pace of change involving the hospitals.
Integrated care’s biggest threat is the fragmentation of the partners involved who are meant to be making it happen. (Again, a paradox issue we raised in our A Question of Behaviours report) If partners retrench and focus on protecting their own turf at the expense of more difficult (and more rewarding) endeavours then the game is lost. Local government is aware of the national political power the NHS has over ministers and the wider political debate.
So what is the answer?
It’s not inconceivable twelve months before an election that the government decides to ‘bail out’ the NHS. How do you solve its short term financial problems without simultaneously removing its greatest motivation to be engaged in the integration debate meaningfully. One of the sessions at the NHS Confederation asked four different clinical discipline representatives to argue for what they could do with an extra £1bn. All started by saying it wasn’t enough!
Does the weakness of the better care planning process mean that £3.8bn is too big a bet? We believe there is no going back, this isn’t an each way proposition. Sustainable health and care is the big challenge for public services and will take a unified focus over many years. We’ve collectively backed it, now we need to make it work.
Jeremy Cooper, iMPOWER, Director