Will the Better Care Fund benefit general practice?

The Better Care Fund will pool £5bn in health and social care funding to boost integration of care. But are GPs outside CCG boardrooms aware of how it will work? Graham Clews reports.

If the government is to be believed, the Better Care Fund (BCF) is already a roaring success, before it has even started work.

Due to kick in from April 2015, the BCF was intended to cut emergency hospital admissions by pooling £3.8bn of health and social care funding to improve integrated care.

In November, health secretary Jeremy Hunt announced that additional voluntary pooling of budgets locally had boosted the BCF figure to £5.3bn.

Mr Hunt said 97% of the 151 plans drawn up across England had been approved, which will result in 447 fewer hospital admissions every day and 100,000 fewer days spent in hospital by patients because of smoother discharge arrangements.

A report by the National Audit Office, published in November, criticised the BCF's evolution, but from a chiefly financial viewpoint.

It highlighted the fall in predicted savings in its first year from £1bn to about £300m and suggested that a lack of central planning may have contributed to this.

Governance of the programme was changed and 'improved' this summer, but the Local Government Association was among critics who said this undermined the BCF's intention to promote locally led integrated care.

Fast-tracked plans

But what will the development of the BCF mean for GP practices?

Five areas in England have had their BCF plans fast tracked and several of these could have a dramatic impact on the shape of local GP services. In Reading, Berkshire, plans jointly produced by Reading Borough Council and two CCGs include the intention to 'modernise and expand the model of primary care' in the area.

The plans include GPs working in larger units to strengthen integration with community and social care teams, and a 'streamlined' approach to case-managing care for at-risk patients.

Each locally produced set of BCF plans includes a number of individual schemes.

Berkshire, Buckinghamshire, and Oxfordshire LMCs medical director Dr James Kennedy says the level of CCG involvement across his patch in drawing up plans has been varied, but there was no consultation with non-CCG GPs.

'Because of the lack of transparency and communication with local GPs, we are still unclear on the detail of what exactly is being proposed for the fund,' he says.

'There is a concern that it is a diversion of significant NHS resource to prop up a social services budget that has been heavily slashed.

'We can see a logic to having some flexibility between some elements of health and social care funding, but there are huge pressures on primary care funding and resources in particular and we need far more funding and flexibility in primary care resource to get improvements in care for patients.'

Greenwich, south-east London, is another of the fast-track BCF areas.Local GP Dr Rebecca Rosen - also a clinical commissioner for Greenwich CCG and a senior fellow at the Nuffield Trust - says her borough has a long history of integration and its BCF plans are a continuation and development of many existing integrated working schemes.

Integrated care

Some of the work involved 'glueing' existing integrated care working onto groups of practices, she says, and GP commissioners in the borough were involved in selecting projects to go under the BCF label.

But she says the process of how GPs get to work in a more integrated fashion is much less important than their success once working patterns change.

'GPs don't see it as the BCF, they just see it as more integrated working,' she says.

'The label is not important. I think most GPs get the increasing need for collaboration with other professional groups. It produces better outcomes and is more professionally satisfying.

'But this is not new - the oldest slides in my integration presentation go back to 1954. It's just been rebadged and the important thing is to get it working.'

Wiltshire is another fast-track BCF patch, and Wessex LMCs medical director Dr Gareth Bryant says involvement in BCF planning was 'significant' among GPs, particularly the areas dealing with intermediate care, access and seven-day working. But again, these were GPs already on CCGs, and awareness of the BCF outside already engaged commissioning GPs is low.

'I believe there is little understanding of the overall BCF and its potential importance among non-CCG GPs,' he says.

'Most welcome the step-up beds for intermediate care and the development of better integrated local teams, but are concerned about how this will become a reality.'

Dr Bryant says there was no anger among GPs over any specific aspects of the plans. But he adds: 'I don't believe the full implications are understood in the GP community, especially as the plan relies on a 3.75% reduction in emergency admissions.

'The plans for a shared record, "a single view of the customer", will be welcomed, but little detail has yet emerged into the GP community about this.

'The integrated teams, step-up beds and "discharge to assess" schemes are all likely to improve the patient experience, and hopefully quality of care, but there is little evidence that integrated care reduces emergency admissions enough to allow hospital trusts to restructure and decommission services.

'To do this, any reduction in emergency admissions would have to be sustainable in the long term.'

Another area that has had its BCF plans fast-tracked is Nottinghamshire, where LMC chief executive Chris Locke says some CCG members, who also sit on the LMC, expressed concern that public health money was being siphoned off to pay for parks and leisure centres.

Improving services

Another Nottinghamshire LMC committee member, who is also an executive member of Nottingham City CCG, says their CCG saw the BCF as a chance to work closely with the local authority to improve patient care with the limited resources that exist.

A comment from this committee member, who asked not to be named, perhaps reflects the most optimistic outlook many GPs can muster at this stage: 'There are no guarantees it will succeed, though no reasons to believe it will fail.'

Evolution of the Better Care Fund

The scheme was announced in 2013 and was initially named the Integration Transformation Fund.

Renamed the Better Care Fund, it aimed to secure a shift towards better integration of services by investing £3.8bn of funding pooled from NHS and social care budgets.

The government has since announced that more than £5bn has been set aside by local organisations.

RCGP chairwoman Dr Maureen Baker has said that the 'acid test' for the Better Care Fund will be whether it levers more funding into primary care.

The scheme could be one of the mechanisms that shifts funding to GP practices in line with plans for a 'significant increase' in the share of NHS funding targeted at primary care set out in the Five Year Forward View by NHS chief executive Simon Stevens.

Local Better Care Fund schemes fast-tracked by the government look set to move more care into community settings and could see GPs working in larger units.

Revisions to the scheme in 2014 meant all areas were required to resubmit their plans for government approval in summer 2014.

Pooled budgets aimed at driving integration of services across health and social care will take effect from April 2015.

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