NHS: Better Care Fund

Lord Hunt of Kings Heath Excerpts

Thursday 3rd July 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am indebted to my noble friend Lord Kennedy for raising some real concerns about the way in which the better care fund will impact on the NHS. I thought that his questions went to the heart of the problem. I am grateful also to my noble friend Lord Turnberg for setting the very challenging context in which the fund is to work.

As we have heard, this is a straight transfer of money from the National Health Service to local government. The theory is that this will lead to more community provision, and therefore fewer people will need to go into hospital and it will be easier to discharge patients who have been admitted. The result will be that we need less acute capacity, and therefore the NHS can live on less money. That is the theory. However, there are five or six problems with the way in which this will work out in practice. The first problem is that local authority social care funds have been slashed so much that it is almost inevitable that a substantial portion of this money will be used to shore up their mainstream services. Only yesterday we had a report from the Association of Directors of Adult Social Services saying that these directors have had to cut their care budgets by 26% in the past four years. The budgets are very, very stretched indeed.

The second problem was identified this morning by the Health Select Committee. It described, in particular, managing the care of people with long-term conditions, who are the people we are largely talking about in this debate. It said that moving care for those with long-term conditions to primary community care and self-management—which I am sure we all support—is,

“intended to reduce unplanned admissions to the acute sector”.

That is absolutely right. However, it says:

“Reducing the activity of acute hospitals … and their income from such activity, is bound to have a consequential impact”,

on NHS hospital acute services.

One has to understand, as my noble friend Lord Turnberg said, that although one can certainly find problems with the way in which the health and social care system works at the moment, those who say that the NHS should become more efficient—and of course there are areas where it needs to become more efficient—also have to come back and respond to the point that this country has the lowest bed numbers and the shortest length of stay of any developed country in the world. That is why I certainly have some concern. Obviously, having just given up chairing the board of an acute trust, I come from that angle. But I am concerned whether this will be able to happen in practice.

One of my concerns is the absence of large NHS providers from these discussions. This is a consistent theme in the way in which local authorities, health and well-being boards and clinical commissioning groups have worked over the past years. I think that the reason for this is that they are scared of the acute trusts. They think that they will not be able to withstand the robust argument put forward, and therefore they prefer to exclude them from many of the discussions.

As the King’s Fund said, that is a big mistake. These decisions impact on providers’ existing activity and funding, and the risks arising from that need to be assessed and managed. We have seen it before. Let us take, for example, the four-hour A&E target. Although CCGs and local authorities make decisions that impact on that target, they do not bear the responsibility for it. That is the big problem with the fund that we are talking about. The local authority and the clinical commissioning groups may well make decisions about the fund that will impact on the ability of NHS acute services to do an effective job, but they do not bear the responsibility for it.

I think that the only way to do this would be to give acute trusts a lock on the plans. Unless there is shared ownership, we will not get uniformity in terms of accepting the risk and making sure that the use of this money will indeed drive down the use of acute hospitals. That is where we run into trouble. I am sure that the noble Earl will have seen the recent Nuffield Trust work by Nigel Edwards, who I think everyone agrees is an expert commentator. He says, and I agree absolutely, that,

“nobody can argue with the … sound principle of bringing health and social care closer together”,

as the Labour Party wants to do in its whole person care. However, he says that there is a fatal flaw in that:

“The Fund assumes that hospitals can quickly achieve a 15 per cent reduction in emergency admissions and that these reductions will result in savings in the same year, at full cost”.

The noble Baroness is absolutely right about the need for some kind of transformation fund. Unless you have some kind of double running, you run the terrible risk of money certainly being spent on community provision but acute hospital admissions not reducing, and then the system falling over. That is why we would be very grateful to hear the noble Earl, Lord Howe, respond not only to the questions put to him by my noble friend but also on how the Government will make sure that this community fund is absolutely spent on measures that will actually reduce acute hospital admissions. I hope that he will say—because I believe that this is right—that they should be signed off by the acute hospital providers. This is not an issue where you can simply say, “The commissioners will decide”, because the commissioners do not bear the responsibility. That is often a fatal flaw in the current arrangements. The Government should take a further look to make sure that this system will work effectively.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, I join other noble Lords in thanking the noble Lord, Lord Kennedy of Southwark, for enabling us to consider a topic of considerable significance for patients and service users.

In every area of the country, CCGs and local authorities are now planning together to use the better care fund to transform local health and care, to improve outcomes for people and to secure the best possible value for money by pooling resources. This is one part of a wider picture of change for health and social care. We must move away from traditional models if we are to provide responsive, effective services to a changing population.

Noble Lords will remember that the need for greater integration of health and social care has long been a recognised issue. The NHS and the social care system provide some fantastic care for people when they are already experiencing acute poor health and high care needs. We must, however, get better at providing care for those with long-term, chronic conditions by keeping people as healthy and independent as possible, living in their own homes and communities for longer, and going to hospital only when they really need to for specialist medical treatment. People will be supported to return to their homes, and to independence, as soon as possible.

We are living longer now than ever before, which is obviously good news, but we do not live all our lives in good health. As people live longer, we are seeing a corresponding rise in long-term conditions that require regular treatment. A lot of this treatment currently occurs in hospitals when it does not have to. It happens because the NHS was founded to treat episodic cases of sickness in hospitals, but the needs of the people are changing and we as the Government must work with the health and social care sector to adapt.

The noble Lord, Lord Turnberg, gave us some of the statistics. ONS projections show that between 2010 and 2030 the number of people aged 85 and over will increase by 95%. This increase is equivalent to more than 1.1 million people or a local authority the size of Birmingham. By 2030, there will be more than 3 million more people than today with three or more serious, long-term conditions.

Much long-term care can be undertaken in a way that promotes independence, sometimes with family members and carers, or with the support of professionals in people’s own homes and communities. People have told us this is what they want and, yes, it is a more efficient use of resources. As I said, these truths have been recognised for some time, and this Government are the first to address it head on. There is broad consensus that greater co-ordination of health and social care services to enable this kind of home and community-based care for the majority is the right direction in which to go. The better care fund presents a real opportunity for radical change at scale and pace for people to receive the right care in the right place at the right time. Local authorities and CCGs are working together to plan and deliver this shift to a more integrated system, with resources used to best effect where they are needed most. As the noble Lord, Lord Hunt, pointed out, acute trusts should indeed be part of that work.

As my noble friend Lord Bridgeman mentioned, for the first year of the BCF, it will include £1.9 billion of the real cash increase in the NHS budget. This represents 2% of the 2013-14 NHS budget, and it is being redistributed to help fund care in non-NHS parts of the system, which will in turn help to make acute care more efficient.

The noble Lord, Lord Kennedy, asked about funding for the longer term. I cannot yet commit to a five-year plan because we have said that it is for the incoming Government to look at their priorities next year. The 2013 Autumn Statement, however, made it clear that pooled budgets would be an enduring part of the framework for health and social care past 2015-16. While the structure of the fund and the pay-for-performance elements may change as progress is made, the principle is very much here to stay.

The noble Lord, Lord Turnberg, asked a similar question about funding for health and social care generally. We will set out the funding levels for social care from 2015-16 in the future spending review but the Government have already set out their plans for changes in how social care will be funded in the future through the Dilnot reforms.

On the specific issue of winter funding, which my noble friend Lady Brinton put to me, the Department of Health is constantly looking to the future, as she may well be aware. Possible pressures on the NHS and social care are very much part of that thinking. We have considered what pressures there will be in the coming winter and I can assure her we are planning appropriately.

Leading care professionals—hospital staff, care workers, GPs and researchers—all agree on the need for resource to be put into integrating our health and social care services, so that a better service can be provided at the same cost. This will certainly involve changing the way things are currently done. The NHS model is geared toward treating people as they get ill. We must shift our approach to focus increasingly on keeping people well and providing acute care in hospitals for those who unavoidably get sick. Keeping people well and out of hospital for as long as possible, and reducing their length of stay by co-ordinating with social care, will reduce the strain on NHS acute services. It will also improve people’s experience and improve health and well-being. An integrated service would allow this to happen, and that is what the BCF has been formed to do.

The noble Lord, Lord Kennedy, asked me whether dementia will be prioritised in the BCF. Guidance on the better care fund sets out that dementia services provision can be a part of the better care fund. Many area plans already contain good examples of health and social care working better together to provide dementia services. He also asked me what seven-day social working means. It is imperative to see social care working over seven days. Too often people have to stay in hospital because they are unable to leave at the weekend. Seven-day working, which will see social care operate at the weekend, as it already does in many areas, will see people return home at the earliest opportunity.

The noble Lord, Lord Turnberg suggested that all this was about robbing Peter to pay Paul. With respect, I do not see it like that at all. This is not about taking money from one part of the system and giving it to another. The better care fund will be held jointly by CCGs and local authorities for them to decide between them how best to spend it. They will decide how to make best use of the money available across the whole care system. This provides a real opportunity to join up services and transform people’s lives, particularly vulnerable people.

As I have explained, one of the aims of the BCF is to reduce the burden on acute services caused by avoidable admissions to hospitals. The way that funding for acute services works means that hospitals receive a marginal level of funding for unplanned admissions. Using the available budget to fund better-integrated, more proactive services will help hospitals to balance their budgets by reducing the operational and financial burden created by avoidable admissions. I am sure the noble Lord will be familiar with the 30% tariff for emergency admissions above a certain threshold. All this will allow hospitals to focus on providing specialist and trauma services, for which they receive full funding so it will make them more financially viable than they would be if the current system was retained. I say to the noble Lord, Lord Hunt, that evidence suggests around a fifth of all emergency admissions are avoidable in some way. If we get it right, transforming hospital care could therefore prevent these unnecessary admissions, which can be distressing for patients, quite obviously, and are costly to the NHS.

The noble Lord, Lord Turnberg, asked me whether the Government have plans to recruit more doctors into general practice. I am sure he will know from statistics that the number of GPs has increased since 2010, but our mandate to Health Education England requires them to increase the proportion of trainee doctors going into general practice from 40% to 50%. We have also set out our ambition to increase the primary care workforce as a whole—not just doctors, but nurses and other primary care professionals—by 10,000 by 2020.

Using resources to keep people out of hospital, by improving other methods of care—social care and home care—will lead to better use of NHS services, ensuring that services are focused on people who cannot be treated at home or in the community.

That brings me to the issue raised by the noble Lord, Lord Turnberg, of the impact of the BCF on acute care. All areas need to show that they have assessed the impact of their BCF plans on the acute sector—that is, hospitals. No plan will be approved without this. They will need to show that they have considered both the operational and financial implications and how these will be—

[Lord Hunt of Kings Heath]

My Lords, I realise that the noble Earl does not have much time but can he just answer this point? Why not give the acute trusts the ability to sign up to it, or not, to prove that it will reduce capacity?

[Earl Howe]

My Lords, we are looking at ways to assure these plans, and to assure them in a way that is satisfactory to the acute sector. At the moment, I cannot tell the noble Lord precisely how that mechanism will work but his central point is well made. I hope that in due course we will be able to share some of our thinking with him. However, the key point is that acute providers must have been consulted in this process.

This sort of approach is being pursued around the country. We know that it can work. For example, a network of 14 pioneer areas around the country are currently working with central government and health sector and third sector organisations to demonstrate the logic of integration and to disseminate what they have learnt to the rest of the country. That includes data-sharing—a point raised by the noble Lord, Lord Kennedy. Areas that have made significant progress in that respect are Southend, Leeds and South Tyneside.

There are other examples, too. In Greenwich, more than £1 million has been saved from the social care budget. In addition, 64% of people who went through their new integrated care pathway required no further services upon completion of the pathway. That has helped to lead to a 50% reduction in the number of people entering full social care.

My noble friend Lord Bridgeman asked whether admissions had been taken into account in the pilot scheme. Greenwich is a good case in point. More than 2,000 patient admissions were avoided there due to immediate intervention from the joint emergency team.

In Northamptonshire, £3.5 million has been saved through prevented admissions, exceeding the target by 14%. In Leeds, children and families now experience one service supporting their health, social care and early educational needs, championing the importance of early intervention. Since the service has been in operation, the increase in face-to-face antenatal contacts has risen from 46% to 94%.

Those examples, along with many others, should demonstrate to noble Lords that the integration of our health and social services can, and indeed has been, achieved in several areas. Integration will not only preserve our ability to provide services but improve them. The better care fund exists to enable all the local areas in England to do what the pioneers and others are doing to move towards a more responsive, effective and sustainable system that makes much better use of the resources available.