How the government is screwing up its best idea

“Great to see, absolutely fantastic news, thank you for listening, at last some sense, I am absolutely delighted, the best news to come out of Whitehall in years.”

That was how HSJ readers greeted the announcement in November 2012 that government was planning a series of significant integration “experiments”. HSJ’s editorial noted the reaction and asked if this was “a turning point in health policy”.

‘Reducing hospital demand should be a welcome by-product of integrated care, not the reason to pursue it’

The idea developed rapidly. It snowballed into the integration transformation fund, soon renamed the better care fund. The government stipulated a shared pot between local authorities and the NHS of £3.8bn for 2015-16. Local partners, according to HSJ research, added another £1.4bn.

Suddenly the integration ball was rolling after years of stasis.

The correct model

But that momentum has stalled, with the centre requiring more assurance local plans will produce the effect they desire.

This is the nub of the problem. In the eyes of too many the better care fund has become the answer to the financial and performance issues afflicting the hospital sector. This is reflected in the Department of Health guidance that overtly links the fund to reducing hospital activity.

‘The government is strongly attached to a policy that plays to the interests of both coalition partners’

Better integrated care should mean fewer people ending up in hospital in the medium to long term, though not necessarily fewer seriously ill patients whose care is the most costly. But reducing hospital demand should be a welcome by-product of integrated care, not the reason to pursue it.

Integrated care is the correct model because it responds to the needs of patients: enhancing outcomes and experience. Efficiency gains will come, but only after a teething period in which the kinks are ironed out, the cul de sacs explored and the redundant parts of the outdated pathways phased out.

This awareness is being lost in what is beginning to look like something close to panic over England’s hospitals.

Provider woe

There is, of course, plenty to be concerned about. HSJ reveals this week the impact growing financial strain is having on provider trusts – with some suppliers in uproar over late payments and equipment having to be mothballed as maintenance budgets disappear.

Meanwhile the Trust Development Authority reports a £241m deficit for the NHS trust sector and Monitor has warned foundation trusts about overly optimistic financial plans.

NHS England, reacting to increasing nervousness at the centre over the hospital sector’s ability to deal with a “bad winter”, has issued a rallying cry to clear the backlog of elective operations as fast as possible.

Running through this tale of provider woe is the theme that things would be so much more manageable if it were not for effective requirement of the better care fund to divert money from the acute sector.

Vanished optimism

However, the government is loath to climb down. It knows any change to the fund would require a renegotiation of the comprehensive spending review. It is also strongly attached to a policy that plays to the interests of both coalition partners. As a result it is forced to demand an emphasis on reducing hospital activity.

‘Better some tricky policy making than discrediting this crucial, long overdue initiative’

This is how policies develop a bad name – something strongly reflected in the comments accompanying the announcement of the fund’s new assurance regime. The optimism of 2012 is long gone.

The answer? Recognise the hospital sector needs a long term plan to ease it through the pain of transition to a more community based system and find some cash to support its delivery. The spending review makes slowing the ambition on the better care fund to raise the required finances complicated and there are no attractive alternatives.

But better some tricky policy making than discrediting this crucial, long overdue initiative for short term – and largely illusory – gain.