Tracking everything that’s new in care models and progress of the Five Year Forward View, by integration reporter David Williams.

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The week in new care models

Readers’ comments

A reader’s comment from last week’s briefing on the integration paradox toots a note of caution in the direction of anyone who thinks that the system would be much more integrated if you just do away with the purchaser-provider split in the NHS.

The anonymous correspondent writes: “Where I work in Scotland, already we are seeing the integration paradox in operation. To put it crudely, in my local example, finances are not flowing from the council’s social care budget (which is in the black) to community health (which is in the red) to balance the integrated areas of need.

“Instead the council is planning to reduce its funding of social care, leaving health to make additional cuts to its already impoverished community services. Unless money can flow freely across the divide, integration will not be able to balance the complementary health and social care services.”

The idea of the NHS needing a bailout from well-heeled councils looks novel from this side of the border, too.

Taking stock of the better care fund

NHS England has finally published performance data for the better care fund covering the first half of 2015-16.

The figures are obviously a bit out of date, but I’ve spent some time looking at them for two reasons: They do tell us some useful things about this important, if unloved, integration policy; and, I’ve grumbled previously about the authority’s sluggishness in putting them out so it would be a bit odd to ignore them when they do finally arrive.

The data is extensive, and covers whether national conditions have been met, how health and wellbeing boards are performing against the key metrics of delayed transfers and emergency admissions, how much money has been put into local BCF pots, and how the “payment for performance” element of the fund has been used.

Here’s what we now know:

Accident and emergency activity

The BCF was failing to deliver the planned reduction in accident and emergency admissions. In fact, it was failing to deliver any year-on-year reduction in A&E admissions. This should surprise no-one – indeed NHS England instructed clinical commissioning groups to assume activity would increase by 2 to 3 per cent – but it is worth pointing out because ministers told us in 2014 how their brilliant new policy would relieve pressure on the acute sector by cutting A&E activity by 3 per cent in 2015-16.

Other data published last week by NHS England confirms A&E admissions were up by about 2 per cent in 2015-16 on 2014-15.

More positively, however, the BCF data reveals about a third of areas were managing to cut admissions at the midpoint of the year. I’m not going to name the top performers because the data isn’t adjusted for population size. But some places with vanguards and integration pioneers do seem to be bucking the national trend – among them Hampshire, Bradford, Nottinghamshire, Torbay, Derbyshire, Wirral, Greenwich, and Sutton.

Delayed transfers 

The BCF has also failed to deliver the planned overall fall in delayed transfers of care. Again, BCF data lags behind last week’s national data which demonstrates that, a year into the BCF, this measure of dis-integration is at its highest ever level.

NHS England’s press briefing note on DTOCs last week emphasised the fact that over the past year (ie since the BCF kicked in) much of the rise can be attributed to social care. This message looked a bit partisan, given the whole point of DTOCs is that it’s a problem with mutual causes and mutual consequences. But it also pointed to another malfunction in the BCF: one of the national conditions of the BCF was to ensure there was seven day discharge support. If that was working, you wouldn’t expect to see DTOCs rising in one sector and not another.

Maybe part of the problem was that, as another element of the BCF data demonstrates, halfway into the year over a third of areas had still not put their discharge support teams in place.

One more area of concern: 82 out of 150 health and wellbeing board patches could not tell whether patient experience was improving because they didn’t have the data. I’ve written enough times already about the difficulty of coming up with meaningful metrics for integrated care. This just reiterates the point.

Reasons to be cheerful

The new BCF data demonstrates, on a seven-month delay, that the BCF was on a national level a widely-predicted failure in terms of substantially lessening the NHS’s operational pressures.

But it does give some cause for hope on the social care side (a cynic might suggest this is the very least that could be expected for ploughing about £2bn of NHS cash into social care).

Halfway through the year, more than half HWBs were on track to hit their targets to cut permanent admissions to residential care, and over two thirds were likely to finish the year with some improvement.

Meanwhile reablement care on the whole also looked like it got better during the start of 2015-16: More than two-thirds of places reported more people were still at home 91 days after discharge from hospital.

The great acute sector clawback

The BCF data also shows how much of the integrated fund was clawed back into the NHS. In 2015-16 there was a “payment of performance” fund. Notionally it was worth £1bn, but actually only about £200m was related to BCF performance – the rest had to go into non acute NHS services.

Under the “p4p” element, if A&E activity didn’t fall as planned, some BCF cash would have to be spent on acute care to pay for the admissions that were not supposed to have happened.

At the midpoint of 2015-16, £132m of the £200m-odd was in play. About £48m had gone into the BCF, mainly in places which were hitting the A&E reductions targets. That leaves £85m held back. More than half of it - £46m – had been spent on acute care, although the actual amount reaching hospital trusts could have been more, as another £27m had been coded as “not applicable” or “other”.

If those proportions followed through for the rest of 2015-16, that suggests between £70m and £110m of BCF money ended up going into acute care to pay for A&E admissions that, within the strange alternate reality of the BCF, were unanticipated. It’s not a huge sum in the context of a £110bn service, or even a £5.3bn pooled integration fund. Still, given the pressure on acute budgets last year, the small gain for the sector will have been marginally useful.

Which, as the BCF goes, is one of the more positive things that can be said about it.