Transcript Document

Integrated care: national policy
and local experience
Bobby Pratap
National joint integrated care team (DH / DCLG / NHSE / LGA)
Tuesday 14 July 2014
This presentation
• Overview of national policy – why integrated
care and why now?
• Focus on the Better Care Fund – drivers and
challenges
• Local experience of integrated health and care
• Personal view
DH-DCLG policy
Better Care
Fund
Integrated care
pioneers
Removing the barriers to integrated health and social care
Better Care Fund Overview
•
•
•
Announced in June 2013 as part of the Spending Round
The NHS and Social Care will share £3.8bn in 2015/16
Every CCG + LA has to jointly agree a spending plan for integrated care
DH – Leading the nation’s
health and care
Drivers for integrated care
• “A lack of joined up care is one of the biggest frustrations for patients,
service users and carers.”
• “Getting it right will make a huge difference to quality, safety and
people’s experience of care.” (Jeremy Taylor, CEO National Voices)
Nuffield Trust: are health and care services changing to meet the needs of ‘Mrs Smith’?
Source: A narrative for person-centred coordinated (‘integrated’) care, National Voices
http://www.nationalvoices.org.uk/sites/www.nationalvoices.org.uk/files/narrative-coordinated-care.pdf
Drivers for integrated care
•
Concern that Fractures in systems and delivery allow individuals to ‘fall
through the gaps’ leading to poor experience and avoidable costs.
•
Optimism that integration can improve quality while saving money
(evidence from Torbay says ‘yes’ but benefits accrue over many years)
•
Financial Imperative: need for health and care to work together more
efficiently in the context of a challenging Spending Review
•
Political Imperative: joined up care is a political issue with Labour
proposals for fully integrated health and social care, Oldham Review etc.
•
Frustration about lack of progress and perceived failure of voluntary
initiatives (pooled budget, care trusts etc.) to enter the mainstream
Drivers for integrated care
Social care transfer – 2010 Spending Round:
•
Social Care funding is not protected or ring-fenced (unlike NHS)
•
Funding requirement was expected to increase from c£16bn (2010) to £17bn by
2014
•
Overall local government “spending power” was set to fall by 14% in real terms over
four years.
•
Additional funding for social care – enough to allow authorities to protect adult
social care if they choose to (still not ring fenced)
•
Includes NHS funding averaging ≈ £1bn per annum (with larger amounts each year)
•
DH / NHS spending on social care is still viewed as ‘health spend’ because care can
benefit health. Giving health money to social care should also improve integration
and partnership working
Drivers for integrated care
Integration transformation fund SR2013:
• Faced with overall budget pressures authorities have still chosen to cut social
care by broadly the same amount as other services.
• Ultimately this means restrictions in services, increased care charges, and
lower quality
• Limited evidence of NHS funding being used on integration or prevention
• Simple transfer of money is not enough to protect social care services (and
therefore also protect health)
• Need to go further to incentivise integration of services to secure sustainable
improvements and efficiencies
The Better Care Fund: NHS and Councils will share
£3.8bn of funding for integrated health and social care:
Better Care Fund
£3.8bn
Shared between NHS and Local Government
“Health Spending”
DH DEL of £115bn
BCF ≈ 3%
Social Care spend of £17bn
BCF ≈ 25%
LG Spending Power of £50bn
BCF ≈ 7.5%
How the BCF is funded (detail)
The June 2013 SR increased NHS funding to social care over two years:
2014/15
2015/16
£1.1bn transfer from NHS to social care
(£200m more than originally planned for
14/15)
£3.8bn pooled budget to be deployed
locally on health and social care through
pooled budget arrangements
In 2015/16 the £3.8bn BCF will be created from the following:
£1.9bn additional NHS funding
£1.9bn based on existing funding in 2014/15 that is allocated across the health
and wider care system. Composed of:
• £130m Carers’ Breaks funding
• £300m CCG reablement funding
• £354m capital funding (including c.£220m of DCLG money)
• £1.1bn existing transfer from health to social care
The DH / NHS contributes £3.5bn of the BCF total – £1.9bn more than it is
contributing to social care in 2014.
Integration Transformation
Fund
Every LA and CCG must agree a BCF spending plan
National
Conditions
Plans will be locally determined, but with some nationally mandated elements:
 plans to be jointly agreed between the LA and CCG
 protection for social care services (not spending);
 7 day working in health and social care to support patients being discharged
and prevent unnecessary admissions at weekends, aligned to;
 better data sharing between health and social care, based on the NHS number
to ensure a joint approach to assessments and care planning;
 a lead accountable professional for integrated care packages
 agreement on the consequential impact of changes in the acute sector.
£1bn of the
funding is
available to be
linked to
outcomes
Payment for performance
Payment pot will be locally agreed and based on reducing emergency admissions.
If ambition is high enough the whole of a local area’s share of the £1bn will form
the performance payment. If a lower level is set (soft threshold of 3.5%) then the
performance payment will be lower .
The remaining portion of the £1bn will be spent on health services (that benefit
health and social care) Local areas will decide on the balance between the two, and
must achieve their target to secure the performance money.
Areas can pool
Local Flexibility to go further
additional
funding Each area has a mandated amount (totalling £3.8bn) it must pool – but local areas
Integration Transformation
can choose to include additional CCG or LA funding and many have done so.
Fund
Reactions to the Better Care Fund…
“The largest ever financial incentive for the NHS and Local
Government to work together”
Jeremy Hunt, Secretary of State for Health
“Integrating £3.8 billion of a total NHS and social care
budget of £120bn is depressingly unambitious”
Liz Kendall, Shadow Minister for Older People
“There is a fear the labels will be taken off the money and
it will be used for filling in potholes”
Sir Bruce Keogh, Medical Director at NHS England
“It is robbing Peter to pay Paul […and could be…] either a
catastrophe or a catalyst”
Chris Hopson, Foundation Trust Network
DH – Leading the nation’s
health and care
Implementing the BCF – Policy Issues
What a ‘pooled fund’
means in practice
Pay-for-performance
Legal framework
How can the money be
genuinely shared between
health and care?
£1bn of the £3.8bn is to be
paid on the basis of
performance. How will this
work?
Primary legislation is
required to a create a
pooled fund – late
amendment to the Care Bill.
Allocating funding
Ministerial assurance
Relationships
At a national level there will
be at least £3.8bn in pooled
budgets but how is this
determined locally?
The SR agreed that
ministers would sign-off
local plans to ensure they
were robust
Getting the key
stakeholders onside to help
deliver the BCF
Integration Transformation
Fund
What a pooled fund means in practice
Funding is shared between the LA and CCG in each area using a ‘Pooled
Budget Agreement’ (legal flexibility under S75 of the NHS Act 2006)
Pooled
Budgets
• Pooled Budgets are an equal partnership between the CCG and LA –
both decide jointly how the budget is used.
• CCGs can shape how the money is spent, so that:
• It does not get spent on parks and bins and potholes
• It goes on the ‘right’ kind of social care (preventive etc.)
• Some funding may go on health services
• LAs can also influence direction of health spending, e.g. on reablement, discharge and other services that reduce pressures on care
homes.
• The outcome depends on local negotiation and relationships
• We don’t know yet how much will spent on health and how much on
social care (and if services are integrated the distinction may matter
less)
• Either way money is likely to leave acute to fund community health or
care services.
Integration Transformation
Fund
Pay for performance
Objective:
To design a pay-for-performance scheme to cover £1bn of the BCF
funding that creates incentives to improve integration and outcomes
Issues
Areas will be performance managed against basket of indicators including
linking payments to reducing emergency admissions – but how to penalise
poor performance?
SR Starting Point
• Areas who under perform will lose some of their funding
• Believed to drive good practice and ultimately savings
Problems
• Taking money away from less successful health economies could be
counterproductive
• Mixed evidence on efficacy of P4P arrangements
• Risk of breaking health spending commitments
Outcome:
• Areas that fail will need to reallocate P4P money to pay for unplanned
activity but money will stay in the area
• No
Integration Transformation
Fund
loss of monies in 15/16
The legal framework for the Fund
Objective:
To create a legal framework that delivers the SR agreement
Issues
• NHS England has autonomy over its finances and spending choices – but
the SR requires it to share £3.8bn with local government for integration…
• Legislation is needed to enable Ministers to:
1. Require the creation of pooled budgets
2. Route the BCF money through CCGs
3. Create the pay for performance element
• Key challenge was doing this without undermining NHS autonomies or
creating rival accountability mechanisms to the NHS Mandate.
Outcome
• Late Care Bill amendment agreed in December that strikes a balance.
• NHS Mandate will contain (first ever) requirements to ring-fence BCF
monies / allocations and consult with local government
• NHS England will move the money around and retains a degree or
autonomy BUT will be under legal duty to operate BCF in interests of
health and social care.
Integration Transformation
Fund
BCF local plans: developing and improving
Headlines:
• All areas have submitted a BCF plan, signed off by HWB
• Anecdotally the BCF has acted as a catalyst for strengthening local relationships
• Around a third of areas are choosing to pool more than the minimum - some
may pool the entire adult social care and community health budget
• Total pooled spend will be £5bn - £6bn (not £3.8bn)
• We need to do more to identify financial benefits and Ministers wish to see
these linked more closely to reducing emergency admissions
Challenges:
• Limited evidence of engagement with providers
• Need for more robust approach to managing risks on both sides – local areas must
rapidly agree this in coming months
• Primary care cannot yet be included in the Fund
• Lack of evidence on what works for integrated care
• Some areas have gone further, faster than others - a minority may need more
support
Milestones and challenges for the next year
INTEGRATION
TRANSFORMATION
Ministers
sign off on
plans
Communications
effort to support
service change?
Election
Local, regional
and national
assurance of
plans
Local Areas
agreeing
their plans
Support to
improve
plans
DH – Leading the nation’s health and care
Support to
areas struggling
with P4P
metrics
DIFFICULT
RECONFIGURATIONS
Milestones and challenges for the next year
INTEGRATION
TRANSFORMATION
Ministers
sign off on
plans
Communications
effort to support
service change?
Election
Local, regional
and national
assurance of
plans
Local Areas
agreeing
their plans
Support to
improve
plans
DH – Leading the nation’s health and care
Support to
areas who
fail P4P
metrics
DIFFICULT
RECONFIGURATIONS
The next
Spending
Review
?