What NHS England isn’t telling you, and more indispensable insight for commissioners. This week by HSJ commissioning correspondent Sharon Brennan.

State of uncertainty

Commissioners could find themselves struggling to keep people out of hospital if the government doesn’t resolve how it wants the Better Care Fund to operate in 2019-20.

The fund, which was set up in 2015, is in a state of uncertainty.

The next financial year could be the last in which it exists in its current form, as Whitehall officials are currently reviewing how the fund will work from April 2020 and beyond.

But with the government focusing on the fund’s long term future (and the social care green paper), and NHS England embroiled in writing the NHS 10 year plan, the BCF scheme for 2019-20 has been pushed to the sidelines.

Social care organisations are alarmed that the policy framework for how the fund will operate next year is yet to be published, and may appear as late as December 2018.

This means that local councils are now in the throes of planning for the next financial year without any indication of how much each area may receive from the fund, or how they will be directed to spend it.

With councils needing to give three months’ notice on most contracts, some are already beginning to decommission BCF funded services as a result. These includes schemes vital to NHS commissioners such as social prescribing programmes and admission avoidance schemes.

The fund was successful in driving down delayed transfers of care numbers in 2017-18, and decommissioning could affect how quickly patients can be released from hospital, and have a knock on effect on how well the system can cope with rising volumes of elective operations.

Sources have told me that without any plan forthcoming, decommissioning could become more widespread. This is because extremely tight council budgets mean there is little financial reserve to allow councils to commit money without a confirmed income guarantee.

It is likely that the 2018-19 policy will roll over a year, but without funding being signed off there is reticence to plan for that.

This is partly due to the way DTOC targets were introduced in 2017-18. These targets were seen as a significant shift in how the BCF operated, especially as the guidance surrounding them wasn’t published until July 2018 – six months after spending plans had been finalised. Councils and clinical commissioning groups had to do their best to repurpose programmes to get the outcomes desired.

That experience has made the planning process for 2019-20 even harder, as both parties are to some extent distrustful about what outcomes will be expected by the centre in exchange for the funding. This is especially the case as there is a suggestion that length of inpatient stay may be introduced as a target alongside DTOC measures.

And what of the future?

While the BCF has been in operation since 2015, some form of NHS funding transfer to social care has been around for decades. While the funding is highly likely to remain, the BCF itself could be on the way out.

The government has confirmed that the structure and function of the BCF will be reviewed as part of the long term plan to ensure it supports care integration even more.

Councils want the funding pot to be refocused back onto preventing people needing to be admitted to hospital, and have become increasingly frustrated that NHS England is able to tinker with the plans and targets.

Richard Humphries, senior policy fellow at the King’s Fund, suggests the government could go further and increase the percentage of money both sides are told to put in the BCF funding pot to really drive the integration of care.

Indeed, many areas are already investing more than the statutory minimum. In 2017-18, spend in England overall was approximately 30 per cent higher than the mandated minimum of £5.1bn.

The fledging “integrated care systems” are also showing the limits of BCF. The reporting mechanisms behind the BCF can be onerous and frustrating to more advanced health and care systems.

For example, Greater Manchester is effectively moving to single health and social care budgets, and the now irrelevant BCF boxes still have to be ticked.

To some extent, the “Improved Better Care Fund”, in which good systems could graduate from some of the reporting restrictions, was meant to help with this, but three years after the policy was launched the latest BCF guidance said that no system has yet achieved this.

In the long term, the system needs greater flexibility if it is to work for both the least and most advanced integrated systems.

But in the immediate term, it must sort out funding for 2019-20 or risk unintentionally reversing some of the gains the fund has made in improving patient care.