The Better Care Fund was in many ways the centrepiece of the 2013 Spending Round. The £3.8 billion pooled budget was designed to deliver better outcomes and value for money through coordinating health and care services. Few could question the ambition of Ministers. Delivering this kind of “integration” between health and care had been on the agenda for years. With an ageing society and the growing prevalence of chronic illness patients the mission of the health and care system had changed. Rather than treating people through short stays in hospitals the NHS now needs to support people with ongoing healthcare needs live independent and healthy lives. Therefore for many linking up health and care is essential.
Having placed their faith in the Better Care Fund to deliver integration at “pace and scale”, Ministers will find the report by the National Audit Office on the policy sober reading. Despite recognising the pooled budget is an “innovative idea” the NAO concluded the “quality of early preparation and planning did not match the scale of ambition”. Current plans aim to deliver savings of £314 million; a long way short of the £1 billion target. The auditors point out that initially there was “no central programme team, no programme director and limited risk management and no analysis of local planning capacity, capability, or where local areas would need additional support”.
The implicit plea from the NAO is for the Department of Health and other agencies to do better; although, with Ministers themselves signing off individual local plans, it is hard to see how the Department can take much more of a firm hand. As much as the NAO’s report highlights weaknesses in national planning and support, the experience of the Better Care Fund reveals – at times – unhelpful interventions from the centre. In some respects the objectives of the initiative were confused, in one instance permissive of local innovation and in the next a reversion to central planning. Was the core idea to promote integration of health services, ease pressure on A&E, tackle delayed discharges or simply shift resources from the NHS to cash strapped local councils that already felt the brunt of the Chancellor’s axe?
More worrying was the impact the Better Care Fund had on local relationships between different services. While it was obvious to many that for “integration” to succeed it had to be based on local trust and cooperation between local services and professionals, in some places the Better Care Fund created a wedge and not a bridge between health and care. Rather than becoming the “glue” that held the system together the top down attempt to shift resources bred suspicion and envy, reinforcing silos.
While “integration” is an ambition of many health systems around the world, the debate in England is preoccupied with integrating health and social care. For most joining up these two distinct existing services is at the heart of what integration is. Certainly it was at the heart of what the Better Care Fund sought to achieve. However many of the global exemplars of integrated care do not work in this way. Take Kaiser Permanente in the United States or the Alzira model in Spain, both examined in Policy Exchange’s report All Together Now. These systems are based on the integration of primary and secondary health and coordinating the patient pathway between GPs and hospitals. The curious fascination with integrated health and care has meant that too often the fragmentation with the NHS is overlooked.
Given the glacial pace of change in the NHS and the gathering storm of funding pressure and rising demand it is more than understandable the Ministers want to accelerate change. But Ministers’ desire to have “ownership” of reform and have a national approach may have frustrated local initiative. Certainly the Better Care Fund has potentially detracted from the Pioneer programme. Announced before the Better Care Fund, these 14 large scale and ambitious projects in integrated care sought to “draw out, disseminate and promote lessons for adoption across the rest of the system”. Although of course this meant that some parts of the country would “achieve” integrated care first. The Better Care Fund created the opportunity for the rest of the NHS to keep up with the Pioneers.
Ministers and policymakers have accepted that “one size fits all” is no longer suitable in today’s NHS. The command and control era where if a bedpan dropped in a hospital corridor the reverberations should echo in Whitehall, has long since past. In a system based on local innovation, and local leadership and ownership of change, we also need to lay the notion of “one speed for all” to rest.