Better care fund doesn't match Sheffield's ambition

The recent coverage in HSJ about Sheffield’s plans for integrated commissioning of health and social care led us to think that we should say more about our plans and how we aim to realise them.

‘Our move towards a single budget is already leading to positive changes in behaviour’

Our ambition was prompted around 18 months ago by discussion in the emerging clincial commissioning group and at the Sheffield Executive Board about how we make best use of the resources available to the city, leading to shared recognition that a single budget for health and social care could create major opportunities for transformation.

We developed this thought with our health and wellbeing board, which is a broadly equal partnership of councillors, GPs and officers from the council and CCG. There was a real shared understanding of the opportunities that a single budget presents and a commitment to turning that into a reality.

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There are two drivers for us: first, having a single budget will enable us to go further and faster with our work with providers to integrate services, so that people have a better, joined up experience of our services. Second, we will be more likely to find lasting solutions to the problem of meeting increasing demand with decreasing resources if we really work together. 

Our move towards a single budget is already leading to positive changes in behaviour. Our commissioning teams are increasingly working together, focusing on how we make best use of the “Sheffield pound” to deliver improved outcomes for people. Much less energy is being spent on protecting organisational positions and budgets. These changes are as important to us as the harder system changes that will result from integrated working.

Ahead of the game

Our discussions predated the publication of better care fund. Our ambition is entirely consistent with political thinking, but goes much further than the fund.  Our first step towards a single budget is the planned establishment of a pooled budget of around £280m, with shared responsibility for whole areas of care.

‘We are clear that our ambitions need to be shared and owned if they are to be delivered’

While we could have just created a set of projects within the £41m better care fund, that would not have led to us each really owning the collective challenges of shrinking resources and increasing demand.  A single budget for whole areas of care means these are joint problems to solve, with the consequences of failing felt by both of us.

There are a number of things we need to focus on, as well as the specific commissioning projects we have agreed, to make sure that we can run a single budget and realise the benefits of it.

Our decision making and risk and gain sharing arrangements will need to be clear and fair in practice, and need to reflect the statutory responsibilities of both organisations, while avoiding issues being batted between us in search of agreement. We plan to establish a single decision making body with delegated authority from both organisations. This will inevitably require some changes for the CCG governing body and the council cabinet and we are working through the challenges this presents.

Local approach for local ambitions

Having first focused on developing a strong co-commissioning relationship in developing our plans, we are now concentrating on the partnership with our providers. We are building on a strong foundation of longstanding partnerships in adult care (Right First Time) and children’s care (Future Shape Children’s Health) and are working on extending those partnerships to include a wider range of health and social care providers, and on clarifying how contractual relationships support our partnerships. We are clear that our ambitions need to be shared and owned if they are to be delivered.

‘The scale of our ambition sits uneasily within a prescriptive better care fund framework’

In addition, we need to work with NHS England to ensure that there is alignment of national and local commissioning intentions and resources, that the strength of our ambition is fully explained through the assurance process, and that we adopt the right measures to provide assurance both nationally and locally that we are delivering on the changes that need to be made. Real integrated commissioning will require stronger co-commissioning with NHS England.

We know that our ambition is in line with national thinking on integrated care. But the scale of our ambition sits uneasily within a prescriptive better care fund framework. We can’t squeeze, without compromise, our vision led programme of change into detailed project templates at this stage. Nor can we measure the delivery of our ambitions with ill fitting performance measures.

We hope that future changes to the better care fund do not create constraints or unintended perverse incentives that distract us from our ambition. We hope the revised rules will recognise that the ambition of places like Sheffield requires a different approach to managing risk than the national rules suggested in recent reports.

Tim Furness is director of business planning and partnerships at Sheffield CCG and Joe Fowler is director of commissioning at Sheffield City Council