Five Year Forward View and Distinctive, Valued, Personal
The Five Year Forward View (5YFV) was produced by NHS England in October 2014 as a strategy and planning document and has subsequently been supported by government. Integration is a central feature in the document. ‘When people do need health services, patients will gain far greater control of their own care – including the option of shared budgets combining health and social care’.
Distinctive, Valued, Personal (DVP) is ADASS’s vision for social care. It sets out why social care matters and presents a five-year vision for a social care system which is protected, aligned and re-designed. It sits alongside the Care Act 2014 which was enacted on the 1st April 2015.
There is cross-party consensus within local government that integration of social care and health is the right approach, particularly to improve outcomes for citizens, but also because some believe it may improve value for money in the long-term. We are not sure that there is any consensus, however, as to what integration means. We believe that integration is not an end in itself but a means to better co-ordinated care and that is thus has the potential for better outcomes for people. We are not convinced of evidence of financial savings
The central planks of both the 5YFV and DVP are ones of sustainability and transformation. Both reflect the challenges of an ageing population with higher expectations of health and social care and both are responses to the financial challenges of responding to this. The pace of change suggested in the 5YFV will be very difficult to achieve.
Devolution is one of the Government’s flagship policies; as set out in the recently passed Cities and Local Government Act. Devolution cuts across the whole of Government and the UK. Recent care and health reforms, the 5YFV and ADASS’ DVP further recognise the need for care and health systems to be locally led, with a stronger emphasis on prevention and more personalised services. In February 2015, it was announced that Greater Manchester would become the first region in England to get full control of health spending. Since then, a number of other local authorities have submitted successful devolution bids, these include: Birmingham, Liverpool, Cornwall, Sheffield, Cumbria. Following the Budget is March new deals were announced for East Anglia (£1 billion funding), West of England (£1billion funding), Greater Lincolnshire.
Locally led transformation of health and social care delivery has the potential to improve services for patients and unlock efficiencies.
There are a number of issues which need to be considered for social care in relation to integration:
- There is a risk that timescales or behaviours mean that systems change does not involve the individuals and communities it intends to serve.
- There is a risk that integration becomes an end in itself rather than a means to an end. There have been many forms of ‘integration’ over the last 20-30 years. There have also been many splits of joint services.
- There is a risk that the social model is subjugated to the medical model, that social care becomes ancillary health care and that social work reverts to case management. Social care and social work require more confidence and a stronger identity in integrated models. We need to work to ensure that while we support the implementation of the 5YFV we also engage our NHS partners in implementing DVP.
The Better Care Fund (BCF) was intended to set the foundation, but arguably has been addressing the challenges of now and in many places has contributed to the system just holding up rather than supporting transformation. The government wants further and faster joined up care. The Spending Review sets out an ambitious plan so that by 2020 health and social care are integrated across the country. Every part of the country must have a plan for this by 2017, implemented by 2020.
Five years of continued funding reductions for social care have had a significant impact on the numbers getting support, the level of that support, on the sustainability of provider and labour markets and on the NHS. The Spending Review and subsequent LGFS offer some alleviation to this if every council is able to increase its council tax by 3.99% every year until 2020. Even so, the next two years will be extremely difficult for both adult social care and for the other local government functions that contribute to people’s health and wellbeing due to the backloading of social care funding. Equally, whilst the NHS’s settlement is front loaded, addressing deficits in the acute sector now will inevitably mean that the balance of funding to transform the system in line with the FYFV will be limited.
The next key financial statement is the Budget on 16th March 2016. Whilst this is unlikely to have a huge impact on health and care budgets, there could be some policy announcements.
The BCF was announced by the Government in the June 2013 spending round, to ensure a transformation in integrated health and social care. It has been a top down process that aims to create a local single pooled budget to incentivise the NHS and local government to work closer around people, placing their well-being as the focus of health and care services. Both rounds of BCF nationally have proved extremely difficult and it could be argued that the jury is out in terms of the extent to which overall the process has helped or hindered better co-ordinated care and better outcomes for people.
From 2017, the Spending Review makes available social care funds for local government, rising to £1.5 billion by 2019-20, as an improved BCF. Areas will be able to graduate from the existing BCF programme management once they can demonstrate that they have moved beyond its requirements, meeting the government’s key criteria for devolution. However, this additional funding will not be available to all councils as it is being used to counter the differential ability of councils to raise council tax and business rates.
A number of concerns have been raised about the BCF: the late publication of the BCF planning guidance hasn’t help local areas with developing their plans, the bureaucratic nature of the assurance process and payment for performance.
The BCF and 5YFV have triggered a range of new initiatives which are set out as Appendix 1 of this paper.
The government Integration Implementation Task Group’s focus largely on the enablers to integration. The challenges for us now are to support our members and NHS staff to address more significant transformation, to better co-ordinated care and better outcomes.
New Models of Care
All new models of care and vanguard sites are rethinking and redesigning the way care is delivered. The new models of care will show what the future NHS could look like: what integration can really mean in practice, for different communities, patient groups and staff; and across home and community based services, urgent and emergency care, elective care and specialised services.
Through the New Models of Care Programme, individual organisations and partnerships were invited to apply to be Vanguard sites. These organisations worked with national partners to co-design and establish new care models, tackling national challenges in the process. The establishment of Vanguard sites signalled one of the first steps in the implementation of the new care models that are described within the 5YFV. The aim of initiating these new models of working is to organise services that focus on the needs of patients and look to dismantle the traditional boundaries as to where, when and how care is delivered.
29 areas were selected to pilot new models for localised healthcare in March 2015. On 23rd July, NHS England launched eight new Vanguards relating to urgent and emergency care which are tasked with changing the way in which all organisations work together to provide care in a more joined up way for patients. On 25th September, a further 13 hospital Vanguards were announced which allows some of the best-known and best-run hospitals in Britain, to extend their geographical reach, and to step up to the challenge of driving efficiency and improvement across the country. The Vanguard sites have now really superseded the Integrated Care Pioneers.
Integrated Care Pioneers
The aim is to make health and social care services work together to provide better support at home and earlier treatment in the community to prevent people needing emergency care in hospital or care homes.
Integrated Care and Support: Our Shared Commitment
In 2013, Integrated Care and Support: Our Shared Commitment was published by the National Collaboration for Integrated Care and Support. One of the shared commitments was for integrated care and support to become the norm by 2018. In the Spending Review the Government wants health and social care to be integrated by 2020.
Integrated Personal Commissioning Programme
Integrated Personal Commissioning (IPC) programme has blended comprehensive health and social care funding for individuals, and allow them to direct how it is used.
Successful demonstrator sites are: Stockton on Tees, Barnsley, Cheshire West & Chester, Lincolnshire, Luton, Tower Hamlets, Hampshire, Portsmouth and South West Consortium.
Integration Implementation Taskforce
Following the general election, a new ministerial Integration Implementation Taskforce was formed to deliver an integrated health and social care system. The Taskforce will monitor and drive delivery, as well as consider the options for future health and social care integration policy. Its focus to date has been on metrics, workforce and information governance.
On 1 July, the Secretary of State for Health announced a new set of unified metrics for the integration of health and social care. The Scorecard has recently been renamed as the Dashboard. Currently there are six metrics proposed around outputs, technology and patients’ experiences. All areas should be baselined and benchmarked by April 2016.
Sustainability and Transformation Plans (STPs)
STPs will be place-based, multi-year plans built around the needs of local populations. They will help ensure that the investment secured in the Spending Review does not just prop up individual institutions for another year, but is used to drive a genuine and sustainable transformation in patient experience and health outcomes over the longer-term. STPs will be delivered by local health and care systems, known as footprints. Local organisations will work together to deliver transformation and sustainability. There are 44 footprints.
There have been concerns raised about the size of the proposed footprints (about 44 areas areas), short time scales and the need for earlier involvement in the planning process of local government. The deadline for completion of local STPs is the end of June 2016. There is an STP Oversight Group co-ordinating the work. ADASS is part of the Group.
By 2020 councils will retain 100% of business rates, giving councils the power to cut business rates to boost growth, and empowering elected city-wide mayors. The Budget announced that the Greater London Authority will have 100% of its business rates devolved by 2017. As part of these reforms, the main local government grant will be phased out and additional responsibilities devolved to local authorities, empowering them to drive local economic growth and support their local community. The government will be consulting over the finer details of the proposals.
Local integration plan
By 2020 health and social care are to be integrated. Every part of the country must have a plan for this in 2017, implemented by 2020. Areas will be able to graduate from the existing Better Care Fund programme management once they can demonstrate that they have moved beyond its requirements, meeting the government’s key criteria for devolution.