Integrated care: national policy and local experience Bobby Pratap National joint integrated care team (DH / DCLG / NHSE / LGA) Tuesday 14 July 2014.

Integrated care: national policy and local experience

Bobby Pratap National joint integrated care team (DH / DCLG / NHSE / LGA)Tuesday 14 July 2014

• 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

This presentation

Better Care Fund

Integrated care pioneers

Removing the barriers to integrated health and social careRemoving the barriers to integrated health and social care

DH-DCLG policy

• 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

Better Care Fund Overview

• “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’?

Drivers for integrated care

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

• 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

Drivers for integrated careIntegration 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:

LG Spending Power of £50bnBCF ≈ 7.5%

Social Care spend of £17bnBCF ≈ 25%

“Health Spending”DH DEL of £115bn

BCF ≈ 3%

Better Care Fund£3.8bn

Shared between NHS and Local Government

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

Integration Transformation Fund

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.

Every LA and CCG must agree a BCF spending plan

Integration Transformation Fund

National Conditions

Plans will be locally determined, but with some nationally mandated elements:plans to be jointly agreed between the LA and CCGprotection 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 packagesagreement on the consequential impact of changes in the acute sector.

£1bn of the funding is available to be linked to outcomes

Payment for performancePayment 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 additional funding

Local Flexibility to go furtherEach area has a mandated amount (totalling £3.8bn) it must pool – but local areas can choose to include additional CCG or LA funding and many have done so.

Reactions to the Better Care Fund…

DH – Leading the nation’s health and care

“The largest ever financial incentive for the NHS and Local Government to work together”

Jeremy Hunt, Secretary of State for Health

“It is robbing Peter to pay Paul […and could be…] either a catastrophe or a catalyst”

Chris Hopson, Foundation Trust Network

“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

“Integrating £3.8 billion of a total NHS and social care budget of £120bn is depressingly unambitious”Liz Kendall, Shadow Minister for Older People

Implementing the BCF – Policy Issues

Integration Transformation Fund

Ministerial assuranceThe SR agreed that ministers would sign-off local plans to ensure they were robust

Pay-for-performance£1bn of the £3.8bn is to be paid on the basis of performance. How will this work?

Legal frameworkPrimary legislation is required to a create a pooled fund – late amendment to the Care Bill.

What a ‘pooled fund’ means in practice How can the money be genuinely shared between health and care?

RelationshipsGetting the key stakeholders onside to help deliver the BCF

Allocating fundingAt a national level there will be at least £3.8bn in pooled budgets but how is this determined locally?

What a pooled fund means in practice

Integration Transformation Fund

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 re-ablement, 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.

Pay for performance

Integration Transformation Fund

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 loss of monies in 15/16

The legal framework for the Fund

Integration Transformation 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.

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

DH – Leading the nation’s health and care

Local Areas agreeing

their plans

INTEGRATION TRANSFORMATION

DIFFICULT RECONFIGURATIONS

Local, regional and national assurance of

plans

Support to improve

plans

Ministers sign off on

plans

Support to areas struggling

with P4P metrics

Communications effort to support service change?

Election

Milestones and challenges for the next year

DH – Leading the nation’s health and care

Local Areas agreeing

their plans

INTEGRATION TRANSFORMATION

DIFFICULT RECONFIGURATIONS

Local, regional and national assurance of

plans

Support to improve

plans

Ministers sign off on

plans

Support to areas who

fail P4P metrics

Communications effort to support service change?

Election ?

The next Spending Review