What can the Better Care Fund do better?

Since 2015, the Better Care Fund (BCF) has aimed to encourage local leaders to work together in identifying common challenges, and to meet these through the delivery of integrated health and social care. It would be fair to say that the BCF has had some success over the years, particularly in helping to develop services like intermediate care, often where effective partnerships and shared outcomes were already recognised. However, while the use of BCF is a requirement and represents funding above and beyond organisations annual budgets, increasingly its yearly cycle and erratic, time-limited pockets of funding have resulted in its use frequently as one of the ways to plug winter pressure gaps, often through short-term response focused on reducing delayed discharge, and by pushing resource and additional services into the system that suddenly stop at a directed cut-off point. 

This year’s revision

This year’s revision of the BCF, with its planning and funding cycle increased to two years and around £16.8 billion (covering 2023-2025), aims to provide greater certainty around the money, as well as extra time in which to plan services that meet need, have greater consistency and start to help realise systems’ longer-term ambitions.  While two years is by no means long term, it’s potentially a step in the right direction in that its emphasis is on partnership working and devising better integrated care through capacity and demand planning, to drive a shift toward investing in long-term services rather than spending on short-term fixes. The question, as we head towards winter, is whether this revision will have the intended impact.

The revision has been designed to help tackle the (vicious?) cycle that needs breaking

The BCF’s core objectives focus on enabling people to stay well, safe, and independent at home for longer and providing the right care in the right place at the right time. These can be viewed in a similar way to how the purpose of integrated care systems isn’t to provide integrated care, but to create the environment in which they can meet their four core purposes. The revision has been designed to help tackle the (vicious?) cycle that needs breaking.  Integrated care, including upstream prevention and admission avoidance, and effective downstream discharge planning and coordination, could optimise patient flow through the system.  This would help in tackling urgent and emergency care and seasonal pressures as part of effective integrated care that meets identified local needs, rather than lurching from one period of challenge to another and never being able to create consistent long-term services that benefit both patients and staff.

Conditions for success

Successful, effective integrated care requires certain conditions in which to be developed and implemented, or at least the best that can be managed. Systems recognise this only too well. Leaders in our State of ICS report told us that they feel partnership, collaboration and the identification of shared priorities is positive, but that ongoing local and national pressures play a significant role in preventing them from bringing partners together and having the time and space to focus on transformation plans and their delivery. These pressures include but aren’t limited to centrally led targets, the impact of ongoing industrial action, ICB running cost allowance reductions, financial deficits, health and social care workforce issues, winter planning, and COVID-19.    

…it has the potential to contribute to creating some of the better conditions needed, though this still requires further tweaks

So, what can the revised BCF do better? It can’t, of course, remove or eradicate current challenges. However, as one component among a number of policies and funding streams that is dedicated to integration, it has the potential to contribute to creating some of the better conditions needed, though this still requires further tweaks.

Systems had just three months to digest new guidance, organise activity and partnership discussions, and carry out financial planning. For the £1.6 billion discharge funding component, despite encouragement to plan against the allocation over the two-year period, only the 2023/24 funding of £600 million currently has guidance in place. With local authorities in particular preferring to plan for what they know they have with certainty, this unintentionally splits the cycle into year one and year two.  There are also difficulties with data sharing/joint working on capacity and demand planning, seen as both the cornerstone of the planning process and a key contributor to developing services as set out in the Intermediate Care Framework. Good capacity and demand assessment requires not just quality data but effective collaboration, and carries potentially the greatest risk to putting the right services in place. However, while the collaboration element of capacity and demand planning has been emphasised in the BCF guidance, there has been a focus at national level on the plans and the numbers in them, which has inevitably driven the focus in the direction of compliance and making the numbers balance. And of course, where relationships, partnerships and collaboration are not working well, this risks perpetuating previous behaviours.

Two years should mean two years in terms of both planning and the allocation of funding

So currently the BCF is still more of an enabler, but moving in the right direction to becoming a driver if it has greater consistency. Two years should mean two years in terms of both planning and the allocation of funding, and if guidance was published at the same time of year with advance notice, it would help enable partnership development, conversations and planning to be organised in a timely and effective way.

The BCF is unlikely to realise its ambitions within the current cycle, but is maintaining its original aims. Pivoting from just ‘tackling winter’ to providing effective integrated care that incorporates winter pressures won’t happen immediately. However, even though this revision constitutes small steps, it’s a welcome development in the progression of longer-term thinking and planning for transformation, over scrambling to make short term fixes.

Gavin Terry is senior policy adviser for integration policy at the NHS Confederation. You can follow Gavin on Twitter/X @GavterryGt