Executive Summary: The BCF big freeze

Integration on ice?

On Wednesday, we revealed that one of NHS England’s requests to the government’s spending review is for the minimum the NHS must put into the better care fund – designed to support social care services struggling amid severe budget cuts in local government – to be frozen at £3.8bn next year.

The Treasury will have to decide whether to resist the temptation to expand the mechanism that allowed them to effectively “double count” the same funding for both the NHS and local government, and to provide superficial relief to social care from within the NHS “ringfence”.

If it does listen, it will ease the health service’s immediate financial headache in 2016-17, and be a victory over the messy fiscal trick of the better care fund, which Simon Stevens has regularly disparaged since rejoining the NHS last year.

Given the significance of the overall spending review decisions for the NHS, it would be a limited victory, though - also up for negotiation are the overall pot for the Department of Health and NHS during this Parliament, when it will arrive and whether there will be extra transformation money.

Freezing the better care fund for a year also provides no answer to fundamental, pressing questions for health and care: how will social care be sustainably funded in the future, and what is the NHS’s role in this picture?

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Take VAT

Two clinical commissioning groups have committed to spending £9m on support services, without being completely clear on whether VAT would be charged on top of the contract value.

VAT is charged at 20 per cent, but is not applied to contracts between two NHS organisations. South Lincolnshire and South West Lincolnshire CCGs have brought in Optum as their new commissioning support services provider, having previously used an NHS commissioning support unit, raising the question of whether VAT will now be applied.

When HSJ spoke to one of the chief officers responsible on Tuesday, he told us they were “awaiting clarification” on VAT from NHS England – a strange state of affairs given they were expecting to sign the contract that day – and that they did not expect they would have to pay VAT.

This set off a lively debate among readers on the story’s comment thread on whether the CCGs would be able to reclaim any tax charged.

We have since received a belated response from NHS England. VAT “has always been chargeable for some commissioning support services provided outside the NHS” is the line – which might be news to the CCGs.

Local commissioners will be able to recover the majority of this VAT, NHS England claims, “but the exact amount will depend on the services included within the scope of the procurement”. The national body estimates that VAT costs are likely to add 5-9 per cent to the cost of full scale commissioning support procurements.

An unusual case

In a rare case, a High Court judge this week ruled a mentally ill man with type 2 diabetes should not be forced to undergo a life saving amputation against his wishes, despite the fact the patient lacks capacity to make treatment decisions about his own medical care.

The case involved an application by Wye Valley Trust to allow doctors to amputate the foot of patient, known as Mr B, who has paranoid schizophrenia and hears voices which he believes are from angels. Due to complications caused by his diabetes, Mr B’s foot is severely infected. Without the operation he is expected to die very soon.

Judge Peter Jackson ruled that despite his lack of capacity and mental illness, it would be wrong to force the amputation on Mr B, saying: “A conclusion that a person lacks decision making capacity is not an ‘off switch’ for his rights and freedoms. To state the obvious, the wishes and feelings, beliefs and values of people with a mental disability are as important to them as they are to anyone else, and may even be more important.”