As CCGs will be aware from the letter from NHS England and the Local Government Association about the Better Care Fund (BCF) formally Integration Transformation Fund (ITF) this is now a matter needing prompt action to get the initial building blocks in place to support the preliminary year arrangements for 2014/15. The letter makes it clear that NHS England is expecting local agreements on a five year strategy and a two year operational plan in order to implement the fund at a local level.

This is not as simple a task as the letter might imply. By 15 February 2014 Health and Wellbeing Boards have to submit the template setting out their proposals. Working backwards this means that not only do you have to have a project plan for the scheme and documented evidence showing how the scheme will relate to the six national conditions for BCF schemes (see National Conditions below) but also to demonstrate patient service user and public engagement and service provider engagement. Clearly the former reflects the obligations on CCGs under section 14Z1 of the 2006 Act to involve public and patients in thinking about services and indeed the obligations under the regulations governing section 75 pooled fund schemes, but since the Fund is essentially recycling money already in health budgets in one form or another the explicit expectation is that this will have an impact on existing services and hence the need for provider engagement. Indeed where the effect is the reduction or removal of existing services this itself will require consultation.

CCGs need to be working closely with their local authority colleagues through the Health and Wellbeing Boards to ensure that there are sensible and realistic plans for this. They need to take into account the requirement to meet outcomes and as the NHS England documents indicate the measures against which BCF schemes will be assessed and the conditional elements of the BCF released are likely to include:

  • Delayed transfers of care
  • Emergency admissions
  • Effective re-ablement
  • Admissions to residential and nursing care
  • Patient and service user experience.

If there are other local measures that you would like to put forward you will need to ensure that there is adequate data now to be able to measure the impact of the change.

Agreements must also meet national criteria

National conditions:

  • Plans must be jointly agreed
  • Protection for social care services (not spending)
  • Supporting 7 day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends
  • Better data sharing between health and social care based on the NHS number
  • Ensure a joint approach to assessments and care planning and ensure that where funding is used for integration packages of care there will be an accountable professional
  • Agreement on the consequential impact of changes in the acute sector.

Whilst NHS England intends to provide some support, these are challenging objectives and the ability to devise scheme within the timescale and to then implement them over the next two years is of itself likely to stretch the capabilities of some CCGs. 

Implementing integration successfully is likely to give rise to a number of commercial issues:

  • Use of social investment (through social impact bonds - SIBs) to help fund transformation. We have closed two SIBs and are already working on 7 others, including the pathfinder in health (end of life care with Marie Curie, Sandwell and the NHS Confed, funded by the DoH Social Enterprise Investment Fund)
  • Pooling budgets. From more traditional S75 arrangements to the use of a Local Integrated Services Trust (LIST)
  • Governance and the role of the HWBB, including the need for community engagement in co-production whilst at the same time ensuring proper accountability for delivery
  • Consultation, where service transformation is more radical – which in some cases also gives rise to the need to consider competition and EU procurement issues
  • Links to Transforming Community Services (TCS) refresh in community health services and, potentially in tandem, the retender of the public health services that transferred to Local Authorities such as sexual health
  • Use of COBIC (Capitated Outcome Based Incentivised Contracts) such as the one we are working on for the frail elderly services in Cambridgeshire

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