The NHS tariff funding system and the way money flows between local organisations is hampering efforts to integrate care, the Care Quality Commission has warned.
The regulator today published its final report from 20 local system inspections examining how well organisations are working together to deliver health and social care for older people.
Difficulty with funding flows was identified as a barrier to joint working “at all levels” and although every system had an ambition to integrate care, the separate funding streams and payments caused divisions between organisations, the report found.
It recommended moving from an activity based funding model to a more population based approach.
Sir David Behan, outgoing chief executive of the CQC, told HSJ: “Undoubtedly the tariff has encouraged trusts in the health service to behave in a particular way. The challenge is, can we think creatively in the 10 year plan about how funding flows can incentivise people to work much collaboratively together to deliver better care for older people?
“This is not a challenge of policy but a challenge of delivery.”
Sir David, who will step down from the CQC this month, said “competitive rivalries” at a national and local level needed to be set aside so that realistic local plans could be developed about how best to improve care for older people.
He said: “We are not saying the Five Year Forward View has failed but what we are saying is there are some key ingredients that need to be in place locally if we are going to deliver improved outcomes.
“Too often what we have seen in the past is one bit of the system, one agency, developing a plan and giving it to the other agencies and expecting people to come along and what we are arguing here is that it needs to stop. They need to be truly joint plans designed to meet the needs of local people.
“We deliberately chose the phrase that organisations should be involved as ‘equal partners’; those words were chosen with care because we wanted to make a statement.”
There has been widespread criticism of NHS England’s handling of the sustainability and transformation partnerships process with a number of local councils and organisations protesting at their lack of involvement.
Sir David denied the criticism that was aimed at NHS England, saying it went “both ways”.
“The NHS and local authorities need to come together and some of the things that have historically got in the way, competitive rivalries, need to be put to one side. This is far too important an issue to be lost in professional rivalries or small town politics with a small p,” he said.
While the report does not recommend increasing funding for social care, Sir David said he personally wanted to see a multiyear funding settlement for adult social care alongside the NHS long term plan.
He told HSJ: ”In 1948 the creation of the NHS, in the face of opposition by many, was an act of courage and political bravery. I would like to see the same courage and political bravery in bringing forward a long term plan for adult social care.
“We continue to see unmet need increase, the number of nursing home beds decrease, contracts being handed back by providers because they can’t deliver at the price and quality that is needed and all this is happening while there is an increase in older people.
”Personally, I believe its possible for politicians to make decisions that could actually see an investment in adult social care. These are the choices that face politicians.”
The report identified a failure of planning by local organisations hampered by performance management systems which were focused on how individual institutions delivered as well as poor workforce planning which made it difficult for services to recruit sufficient staff.
The CQC inspections found examples of commissioners adopting what it called a “reactive approach” to funding pressures and cutting support services.
In another example, one system allocated just 0.1 per cent of spend on primary prevention and early intervention while another region allocated 16.5 per cent of their total Better Care Fund spend.
It said nationally spending on prevention and early intervention was being reduced. In 2017-18 the total was 2.73 per cent but spending plans for 2018-19 were cut to 2.61 per cent.
The report warned: “Current funding flows, and short term funding cycles, as they currently exist in most systems, can make it very difficult for commissioners to move money across organisational boundaries and invest in services outside of core commissioning responsibilities.”
Recommendations made by the CQC today include:
- Funding reforms to move from activity based tariffs to population health budgets
- New legislation to grant the CQC powers to rate local systems
- Joint local plans with local authorities, independent sector and voluntary organisations as “equal partners”.
- A single, nationally agreed framework for performance management of how services collectively deliver care to older people
- New joint workforce plans for health and social care
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- Care Quality Commission (CQC)
- Department of Health and Social Care (DHSC)
- Finance and efficiency
- Local government
- NHS England (Commissioning Board)
- Older people’s services
- Patient experience
- Policy and regulation
- Social care
- STPs NHS England
- Sustainability and transformation plans (STPs)