Everyone agrees that integrating health and social care is a good idea – it would improve patient outcomes and reduce inefficiencies, such as bed blocking. But whether the Government’s new health and social care Integration Transformation Fund is the correct way of approaching this is much less clear.
Michael Schofield – chair of ACCA’s Health Service Network Panel and Chief Financial Officer of the Brighton and Hove CCG and of High Weald Lewes Havens CCG – fears that it is introducing an additional financial squeeze for the health sector that represents “a QIPP on top of a QIPP”. Without new funds, the Integration Transformation Fund (ITF) is merely moving money about, hoping that in doing so it will amazingly reveal new efficiency savings.
“It’s a mixture of existing funding in the system, plus a massive amount of further savings,” argues Schofield. “I don’t know how we will deliver it.”
The headlines look good – there is to be £3.8bn of funding to ensure closer integration between health and social care. But peek beneath the surface and it is less positive. Financial contributions come from the Carers’ Break funding, £130m; reablement funding, £300m; and Disabled Facilities Grant, £220m. Those activities will either continue, paid for from the ITF, or will be lost and so represent new service cuts.
More significant, though, is £1.1bn to be transferred from health to social care that was already committed, plus an additional £1.9bn to be transferred from NHS allocations. The funds will be ringfenced for social care, with joint control of budgets and joint planning between CCGs and local authorities. But how will NHS services that are under pressure from QIPP efficiency savings generate these £3bn of transfers?
Theoretically, better social care provision will reduce demands on acute services. But will these translate pound for pound? What happens if they do not? Where are the risk strategies in case the process goes wrong? And what role will acute services have in the planning for the integration with social care that they will contribute perhaps half towards? None of these questions has, as yet, an obvious answer.
Another problem is the move towards full seven day working for health and social care. While this will improve patient services and make more efficient use of capital resources, how will the costs be met? Much of the detail of the integration proposals come down to ‘invest to save’ – which typically means short term costs to generate longer term savings, while creating further pressures on near term budgets.
“We know all this must be self-financing,” points out Schofield. He calculates that, in rough terms, the cost contributions from the NHS for ITF added to the existing QIPP obligations equate to around a 3% to 3.5% reduction in NHS funds over the 2014/15 and 2015/16 years. “This is health money being used for social care,” he stresses. “The plans for this have to be in place by the 1st April – and that is also going to be a big challenge.”
The implication is that ITF will generate a genuine transformation of health and social care. “If this fund is not going to spend on things that are different, then what is the point?,” asks Schofield. “We are talking about a major change in the way that health and social care is going to be delivered.”
ITF will come into play in the 2015/16 year, just when many local authorities say they cannot see how they will they cope. In effect, ITF could bail-out councils, while protecting social care from the financial pressures on other local government services. But in doing so it will increase pressure on CCGs – half of which are already struggling to get to a sustainable financial position in Schofield’s view – and acute trusts. These latest pressures together with the Keogh review could lead to significant service reconfigurations, suggests Schofield.
Chris Ham, Chief Executive of The King’s Fund, shares the concern that the arrangements for ITF will worsen the financial problems of the NHS. ‘While the NHS budget remains protected, it is under intense pressure,” he says. While ITF will assist local government find the money to deliver social services, this is at the expense of the NHS, he argues.
“We welcome the significant increase in funding transferred from the NHS to promote joint working between health and social care,” he explains. “Alongside the recent announcement that new pioneer areas will develop integrated care at scale and pace, this signals a much more ambitious approach to delivering integrated care and a real opportunity to improve the co-ordination of services for patients and service-users.
“The flip side is that this will increase the strain on the NHS at a time when many hospitals are already struggling to reduce costs and absorb reductions in the prices paid for their services. It will also add to pressures to reorganise hospital services – essential in any case to improve quality and increase financial sustainability.
”Looking to the future, there is a limit to how long a sticking plaster can be applied to a growing wound. It is time to ask whether the post-war settlement, which established separate systems for health and social care, remains fit for purpose. This is why we have set up a new commission [the Commission on the Future of Health and Social Care in England] to explore whether the current settlement should be re-shaped, including the scope for developing a single funding system for the NHS and social care.”
Unsurprisingly, councils are more relaxed about ITF. Sir Merrick Cockell, Chairman of the Local Government Association, says: “The Spending Round was extremely challenging for local government, reducing council budgets at a time of significant demand pressures. In this context, the announcement of a £3.8bn pooled budget for integration in the Spending Round is therefore a positive, practical move and can contribute to delivering our goal of using the money in the health and social care system to best effect.
“The fund is an important catalyst for change, and moving more towards preventative, community-based care will help to keep people out of hospital and in community settings for longer. That’s in the interest of the individual and the public purse.”
The big question, though, is about the cost of achieving this – not just financially, but also the impact of acute and other NHS services.