Better care fund: good policy needs great execution

The need for greater synergy between health and social care, to ensure both sustainable services and better outcomes for people, has been emphasised in countless speeches and policy papers. Achieving this requires cultural revolution rather than structural reorganisation.

‘The success of the fund will largely be determined by the alignment of three things: professional, public and political will’

The government’s “better care fund” (renamed from the integration transformation fund) will combine £3.8 billion of existing funding into one health and social care pot aimed at improving outcomes for people up and down the country.

So far the debate around the fund has been about money and structural arrangements. These are important. But we need to keep our sights firmly fixed on what it’s all for if it is to achieve its full potential. Real success means better outcomes for the people we care for, not just moving money to a different place in the system.

So if the fund is quite clearly the right thing to do, what are the conditions for success?

Enablers and barriers

Surveys show the main enablers of integration are cultural and not structural. They include leadership, commitment from the top and collaboration between commissioners and providers. Conversely, the main barriers to integration include organisational complexity and changing leadership.

Furthermore, the success of the fund will largely be determined by the alignment of three things: professional, public and political will; outcome measures with the desired success; and risk management across the whole health and care system − all three of which require cultural revolution.

‘The fund is supposed to achieve improved patient experience; greater emphasis on quality of life and wellness’

Relationships need building to facilitate constructive discussion. Many health and wellbeing boards are charging ahead and forging excellent working relationships. But others need support as they develop.

Compounding this challenge, clinical commissioning group leaders have indicated that NHS England’s support to them could improve. The NHS Confederation believes it would be helpful to identify and offer support - especially peer support - to those areas finding it hardest to implement the better care fund.

We need to engage the public, professionals and politicians differently, explaining the benefits of change rather than simply selling our solutions in a traditional consultation exercise. However, the tight (and non-negotiable) timetable for the fund planning risks some places having insufficient time to do this.

A plan for success

The fund is supposed to achieve improved patient experience; greater emphasis on quality of life and wellness; and more service provision in the community with less reliance on hospitals.

Measures for these three things do exist − albeit not perfect ones. We must use measures as close as possible to these meaningful outcomes, rather than just relying on the more traditional proxy measures that can result in perverse incentives and structural over cultural change.

‘Politicians have a “duty of candour” in explaining that the fund is not “new” money but a pooling of existing resources’

Some trusts already face significant financial challenges and the integration fund will make their situation even tougher. NHS Confederation members across different regions have made it clear that the fund must not have the unintended consequence of removing acute capacity without reducing demand for hospital beds for good.

To address this risk, the whole system will need to work in greater partnership to get maximum value from limited, shared resources and it will be vital to include providers in discussions from the outset.

To increase the chances of the fund’s success, the NHS Confederation is therefore calling for the following:

Discussions focusing on the fact that delivering good care with limited resources will require tough choices. These same conversations need to take place at Westminster, the town hall, and local consultation events.

• Peer support to be offered to those areas that need it most.
• Success measures matched closely to intended outcomes − patient experience, wellness and bed days
• Payment mechanisms that align across the care system, to incentivise coordinated care from all providers
• Investment to support some double running, including longer term financial settlements to allow up-front investment in change.
• Local arrangements on risk sharing that encompass reputational, political and financial risk.

Finally, as Foundation Trust Network chief executive Chris Hopson and others have emphasised, politicians must be completely honest about the scale of the challenge. Politicians have a “duty of candour” in explaining that the fund is not “new” money but a pooling of existing resources.

If, at the end of this, all we have done is move the money around without securing better outcomes for patients we will not only have generated additional financial risk for the NHS, but safety risks for patients − and we will be even less prepared for future challenges facing the NHS.

Dr Johnny Marshall is director of policy at the NHS Confederation