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06.07.17

NHS and council bosses at odds over divisive Better Care Fund targets

Two influential leaders from the NHS and local government are firmly at odds with the government’s decision to outline ‘expectations’ – in other words, targets – of how much areas will have to reduce the amount of delayed transfers of care (DTOCs) that occur in their interface between health and social care.

Simon Stevens, the chief executive of NHS England, and Sarah Pickup, the deputy leader of the Local Government Association (LGA), debated the issue at yesterday’s LGA Conference, where they revealed starkly different views on the merits of the government’s approach.

Earlier this week, the Department of Health published the long-awaited Better Care Fund (BCF) guidance, which explains how the policy will be implemented on the ground, alongside a dashboard and metrics. These form part of the £2bn deal struck in the Spring Budget to ensure there is more thorough measurement of how councils and NHS bodies are performing at the boundary between health and social care.

The guidance spreadsheet also included ‘expectations’ across areas about to what extent DTOCs would have to be reduced, divided between CCGs and the local council – an approach that has been staunchly rejected by local government representatives.

“We have been opposing that because we think that the financial situation councils have been in mean that expecting a reduction as compared to the previous year, specifically council by council, without any reference to circumstances or volume of activity, is not something we can support,” argued Pickup.

We do support continuing to work together, we do support people getting together on the ground, and we’ll work together nationally. But we felt we couldn’t do what we did with the framework – we put our badge on that with government and with NHS England – on the guidance, because we didn’t support the inclusion of specific targets.

“We particularly didn’t support a statement [in the guidance] that said [the government] would assess how good progress is, and that there may be some changes to allocations in 2018-19 for poorly-performing areas.”

The guidance document had said that while the BCF plans would be agreed for a two-year period for the first time, arrangements will be set out in a separate guidance later this year “for refreshing or updating plans for 2018-19, for instance to take account of progress against metrics”. Allocations for the next financial year are set out as ‘indicative’ for the time being.

“We cannot support proposed sections of that sort or targets,” continued the LGA leader. “It’s not about not working together, it’s about saying: here’s some guidance, is this really joint guidance that we all agreed? And we didn’t feel that, at that point, it was. So we haven’t badged that guidance.

“It may seem a very small thing, but I do think it’s important that we represent your views on how tough it is out there to deliver, and I know that councils are doing everything they can to help get people out of hospital. There’s so much effort that goes into this. If they can get the delays down they will, but without knowing the volume of activity that’s coming your way or the whole volume of discharges you have to deal with, saying ‘you must get to this level’ was unsustainable.”

Conflicting views

Stevens, however, laid out three reasons as to why he disagreed with Pickup’s perspective and why it’s “worth paying attention to the health/social care interface issues going into this coming winter, particularly related to delayed discharges in hospitals”.

The first reason was that both councils and the NHS care about the quality of services that acutely sick people access countrywide, and while some of the difficulties faced last winter can be linked to community health services or insufficient care home places, the proportion of DTOCs has doubled over the past couple of years. As a result, both local government and the health system have a “shared interest in trying to do something about that”.

“It’s not the only pressure that adult social care is facing, it’s certainly not the only pressure that local authority finances are facing, but that is one that really matters to your folks and to our patients,” said the NHS England boss.

The second reason, which he argued is perhaps less compelling, is that they are being required to do this whether they agree with the approach or not as part of a mandate – and then proceed to show the extra money is producing value in both sectors.

And lastly, he argued: “The third reason that I think we actually shouldn’t take the stance that Sarah [Pickup] was describing is because we all want, I want, you to win an argument with the public and the politicians about the importance of a well-funded social care service, and that is going to require more than what is currently on the table.

“There’s a Canadian fellow called Bob Evans who says that the difference in most countries between the public and private sectors is that the private sectors try and get their customers to stump up more by explaining how brilliantly they’re doing, and the public sectors attempt to get taxpayers to put their hands into their pockets by explaining how it’s all getting worse. I believe we need a little more of the former and a little less of the latter, and therefore the argument we have to win is that when you do put incremental funds into social care, we get results in visible ways.

“The fact is, part of what has stood in the way of us compellingly winning that argument with the public and the politicians is that we have not been able to demonstrate so clearly the connection between incremental spending and incremental outcomes. And so, not just for the here and now, but for the future argument we need to win, getting this right on this most salient and visible public objective is all about shared interests.”

This is not the first time in recent days that the NHS and the LGA have clashed when it comes to DTOCs. In late June, NHS Providers released a piece of research that suggested the extra social care money announced in March was intended to free up capacity in the health service. But Cllr Izzi Seccombe, chair of the LGA’s Community Wellbeing Board, argued this stance was “misleading” and that the NHS needed to do much more itself before criticising councils.

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