interviews

Ambitions far beyond the better care fund

The number of Integrated Care Pioneers has expanded to 25. Among the new wave just announced is Sheffield, which has created an ambitious pooled health and social care budget of £270m. NHE spoke to Sheffield CCG director of partnerships and planning, Tim Furness.

The various Integrated Care Pioneers (ICPs) across England share some common goals, but are using different methods to achieve those goals. 

Tim Furness of Sheffield clinical commissioning group (CCG) said: “We applied for Pioneer status because of the scale of our ambition and the size of our pooled budget – £270m – and what that means for how we’re approaching commissioning health and social care in Sheffield. 

“The Pioneers are pioneering in slightly different directions. We’re different because of the scale of our ambition, but some of them are different because they’re doing something specific that’s ahead of other people. 

“We’re trying to do something people haven’t done before, so getting support and advice from other experts is helpful.” 

The two main aims are, firstly, improving the experience of service users across health and social care, making everything more joined-up and seamless; and secondly, managing pressured resources more effectively. 

Reducing non-elective admissions helps with both of these aims, and so is an important element of the new partnership working. 

Delivery 

Governance of the pooled budget is handled via the city’s health and wellbeing board, and is led by a ‘joint commissioning executive’, co-chaired by the accountable officer of the CCG and the chief executive of the council. This group guides the work of delivery teams responsible for the development of integrated care plans, specifications and contracting arrangements. There are not many joint posts so far, but instead a bigger focus on joint working in the delivery teams. 

The four initial priorities are:

• Keeping People Well in their Community
• Independent Living Solutions
• Active Support and Recovery
• Long Term High Support 

The pooled budget includes current spending in all four areas, including CCG expenditure, community equipment, intermediate care services, community nursing and NHS Continuing Healthcare, as well as expenditure on non-elective admissions, other than surgical admissions. An internal report notes that this was included because “our plans should result in movement of money – and savings – from this area”. 

Progress 

Earlier in 2015, the first annual report was released into the progress made by the first wave of ICPs nationally since their creation at the end of 2013.

The foreword, written by care minister Norman Lamb MP with Pioneer Support Group co-chairs Ian Dodge of NHS England and Worcestershire’s integrated commissioning director Frances Martin, says: “The diversity of their ambitions and context has been one of the programme’s strengths, enabling different approaches to produce different results, and so increasing our knowledge of what works. They are already starting to make a real difference for their communities, with examples of older people being kept out of hospital, people with chronic poor health helped to maximise their health and wellbeing, and communities empowered to be healthier. 

“As well as making progress locally, the pioneers are working together to identify the problems and issues holding them back. We have learnt that addressing these barriers is difficult work, with few quick fixes.” 

Despite plenty of individual examples of good news from around the country, Furness said his overall view of the report was of a lot of “work in progress”. He said: “Whilst in lots of places there are encouraging signs, in terms of really evaluating the impact of the work and showing that it is actually reducing admissions and therefore helping manage the resources, to me it’s not quite proven.” 

Reductions in admissions achieved among small and specific cohorts are good, Furness said, but if overall admissions are still going up, ways have to be found to scale up that work. “The [positive] results were sometimes the products of very specific pieces of work; you cannot lose sight of the overall picture.” 

Enablers and barriers 

The annual report identified leadership, relationships, information governance and data-sharing as key areas. These are all enablers of integration when done well, but can act as a barrier when done badly. 

Furness said: “Evidence on the interventions that make a difference, and how you evaluate those interventions, is one of the things we really want to learn from the Pioneer network.” 

“Pioneer status gives us access to support and expertise from both the national team, and also – more importantly – from colleagues across the country who are forging ahead.” 

Discussing the national support on offer, the annual report notes: “It has been a key learning point from the first year that progress is quicker and more widespread when the support offered to Pioneers is more structured and targeted. The initial model of providing programme management support equally across sites did not adequately reflect and respond to the targeted of the Pioneers’ challenges and context.” 

It admits that there will be “challenges in maintaining momentum and building on early successes”. 

Scaling up 

Working at scale, rather than on individual integration projects, is an important factor in Sheffield’s planning. 

Furness explained: “Given the scale of what we’re doing, the pooled budget includes virtually all the commissioning budget for adult social care – the only major spend that’s not included is the actual assessment and care management costs of directly employed social workers. 

“The council expects cuts in funding to continue to happen, which will need to translate into cuts in funding for social care. That will manifest in a reduced pooled budget – and so one of our objectives is to make changes to make sure we can continue to support people with less money. 

“The reduction in non-elective admissions is considered nationally to be the place to go to make savings and reduce spend, so that we can recycle that money and support people – which probably involves supporting social care specifically.”

Better Care Fund 

The £270m is essentially a massive extension of Sheffield’s £43m share of the Better Care Fund (BCF), with the BCF itself just one of five areas of work within the wider pooled budget. 

Furness explained: “The need to comply with the national rule set about the size of our pooled budget has been a bit of a challenge, I think it’s fair to say. 

“It’s harder to apply that rule set to [our] size of budget than it is to a set of more specific projects. But going through the process of approval for the BCF was really helpful in terms of prompting us to make sure that we had business cases lined up and that we’d talked about the metrics. 

“We received the letter of approval for setting up our BCF back in January, so we ‘passed the test’. The real test, of course, is being able to live within our means and contain our spend within the pooled budget, while ensuring there aren’t any differences in patient outcomes, and that we improve patient care.” 

One of the first pieces of work was negotiating a new outcomes-based specification for intermediate care services, bringing together more than 20 previously separate services handled by a range of providers. 

Working with providers 

Cllr Mary Lea, Sheffield City Council’s cabinet member for health, care and independent living, said: “We’re working more closely than ever with health services and focusing more on prevention; to help people stay well and healthy at home, before they reach a crisis point. The strength of our partnership working with the CCG was recognised last year when we won an additional £1m funding for Sheffield. We’re pleased to be recognised as a Pioneer in bringing health and social care services   together.” 

Although the pooled budget arrangements are between the council and CCG as commissioners – £165m from the CCG and £105m from the council – they are not ignoring the vital role of providers in the integration agenda. 

Furness said: “We in Sheffield started this particular round of conversations about integration – it’s not like we’d never talked about it before! – very much as a conversation between the CCG and the local authority. We were a new CCG at the time, building a relationship with the local authority. We had continuity in terms of senior management and so on, so it wasn’t like we were going from a standing start. We were building on a partnership in Sheffield called Right First Time, which the providers and commissioners were all involved in. 

“One reflection on that partnership was that one thing that got in the way of true integration was the fact that commissioners weren’t as joined up as we might be, because we were still holding separate contracts with the same organisation. How can you integrate services when you’ve got two paymasters and two sets of contracts and terms and conditions? 

“Developing the co-commissioning relationship meant looking to our providers. We can change the way we contract, set the outcomes we want to achieve and so on, but it’s only the providers who can design services and change the way their staff work, and recruit a different workforce if they need to. I don’t think it can be done ‘commissioner-only’ or ‘provider-only’. We can only achieve real change if everybody’s on board and trying to achieve the same thing.”

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