To approve the better care fund quarter one return.

The better care fund joint commissioning manager presented a report on the performance of the better care fund against the plan for the first quarter of 2016/17.  The return for quarter one had already been approved under delegated authority by the director for adults and wellbeing, in consultation with the CCG accountable officer, in order to meet the timescale for submission to NHS England.    

The following key points were highlighted:

• non-elective admissions were on track. Rapid access to discharge was redesigned on block contract arrangements through the CCG. There were some ongoing issues in relation to delayed transfers of care (DToC) with no indication of immediate improvement and an uplift of £55k had been made available to support improvements in performance
• performance in relation to the number of placements in residential care homes remained the same and the target was reduced from last year in line with regional trends
• a unified contract for residential nursing had been developed and over 100 care homes had submitted bids following extensive engagement and consultation. The benefit to providers is that the council pays the gross amount for care so providers are not affected financially if an individual does not pay their top-up contribution, which would be collected by the council.  It was not considered that the risk and cost to the council of this arrangement was significant.  For individuals, the impact was that the potential was removed for providers to act unethically in attempting to increase fees charged to service users, although it was noted that this had not been a particular issue locally.  Providers were now being assessed using the quality assessment framework. 
• the section 75 agreements that supported the BCF legal framework had been combined to make a single agreement across children’s and adults’ services with effect from 1 October 2016, as agreed by Cabinet.
• in terms of financial implications, there was a 40% increase in the unit price paid for NHS funded nursing care, putting pressure on the budget for the CCG. This was as a result of national policy change and not a local issue.
• it had been possible to cap the risk share for each BCF partner by reducing the client cohort. The risk is set at 13% of the contribution to that cohort for each partner and reviews of clients were picking up. The situation was to be monitored on a monthly basis.

The chair observed that although performance had not reduced, there were no significant improvements and asked how this could be addressed, and what the health and wellbeing board could do to help.

The director for adults and wellbeing explained that the BCF formed only 10% of the directorate’s budget, and much less of the CCG budget, which was not of sufficient scale to change behaviour.   He suggested that one solution might be to count the protection of adult social care element of the BCF budget in with business rates, such that it was received direct by the council rather than as a transfer from the CCG, but there were tensions associated with this. Where the BCF had made a difference in other areas, it was where it formed a larger proportion of the adult social care budget. To do this would require closer working and this was the direction of travel for joint commissioning work.  There was a whole system approach but with a small fund. The alternative would be to produce plans for full integration, and this may be the way forward.  The national context was that the NHS was looking at 2-year plans, with guidance for this becoming available in the next few days, and although ministers were engaged with integration, there was a knowledge gap within DH around social care. 

The vice-chairman commented that the rate of change for the NHS made it hard to plan over two years.

Referring to the section 75 agreement, the director for adults and wellbeing explained that it presented some difficulties in governance such as differing rules for delegation of decisions between the council and the CCG. A way forward was being developed to address this which would be shared with cabinet members.  The chair emphasised the need to ensure this work happened in order to remove barriers to the effective management of the BCF.   

Discussion took place regarding the help to live at home project which updated the arrangements for domiciliary care. Therapy led interventions were being considered for initial reablement rather than using the domiciliary care market through commissioning and use of rapid access to assessment and care (RAAC) beds.  It was recognised that this formed part of the frailty pathway, which included long term conditions and children, and supported integration.  

The director of public health asked about the key areas to focus on for improvement and how to overcome slower performance.   The BCF joint commissioning manager explained that cultural change played a big part in improved performance and there needed to be a shift for services to be considering discharge as soon as someone started to receive care. Greater focus on DToC and RAAC beds would help release funds for community-based care so that people could go home sooner. 

The director of public health commented on closer inspection of any evidence of links between causative factors for particular conditions and whether prevention work would assist the situation. 

Healthwatch commented on the need for more proactive contingency planning with carers to prevent admissions. It was important to make best use of resources and evaluate the effectiveness of provision.   It was observed that patients from Wales used Herefordshire services and there were disconnects between English and Welsh social care systems.  It was noted that Powys had a significant impact on DToC and this needed investigating as there was no specific reference to Powys in the BCF, although charges were made back to Powys to cover cost of care.   However, an action plan was needed to address this so that out of county assessments could be made to enable care closer to home. It was suggested that the additional funding for DToC could be used in improving performance in this area as a matter of priority.

In considering BCF performance and making the link to the wider context of understanding the integration agenda and the sustainability and transformation plan (STP), Healthwatch commented on public engagement and awareness and that it was not helpful for the NHS to expect consultation on the STP within a very small timescale.  Healthwatch was supporting engagement on this and developments were happening both in terms of social media and face to face work. The health and wellbeing board had an oversight role on the development of the STP and there was more that could be done to contribute to the local plans, including closer working with the Worcestershire health and wellbeing board. 

The director of children’s wellbeing reminded the board that it had a statutory role in ensuring plans were in line with the health and wellbeing strategy. The director for adults and wellbeing commented that NHS England seemed unclear about the role of health and wellbeing boards and whilst they intended them to sign off the STPs, in practice they were expected to take a less directive role. A meeting of the board before submission of the STP on 21 October would ensure that the board fulfilled its governance role against the health and wellbeing strategy. 

RESOLVED

That, in light of the information within the better care fund (BCF) 2016-17 quarter one return, as reviewed, and in the context of the wider integration and STP agenda, the board meet to review and comment on the STP prior to its submission on 21 October.