House of Commons - Planning for the Better Care Fund

Planning for the Better Care Fund - Public Accounts Contents

1 Planning for the Fund

1. On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health, the Department for Communities and Local Government NHS England, the Local Government Association and the Programme Director for the Better Care Fund about their planning for the Better Care Fund.[1] The 2013 spending round set out the objectives of the Fund: to deliver better, more joined up health and social care services for older and disabled people, to keep people out of hospital and to avoid long hospital stays.[2]

2. The government required local authorities and clinical commissioning groups to plan to pool a minimum of £3.8 billion for the Fund in 2015-16, and these local partners have since agreed to pool £5.3 billion.[3] The government asked the 151 health and wellbeing boards, which include local authority, clinical commissioning group and Healthwatch representatives, to plan how to spend the money in their areas.[4] Boards were asked to demonstrate through their plans how they would meet six national conditions for the Fund, including protecting adult social care services.[5] Health and wellbeing boards agreed and submitted plans at the start of April 2014.[6]

3. Local and regional NHS England teams and local authority staff undertook the first round of assurance of local plans. The witnesses' description of events revealed a disjointed process whereby local teams were working towards a different objective from those in national government and at the centre of NHS England.[7] As they were not aware of the need to meet a savings expectation, local authority reviewers and local NHS England teams assessed 90% of local plans as being ready for ministerial approval. However, when the NHS England central team tested the expected savings, it concluded that it had confidence in only £55 million of savings, rather than the £731 million that local areas promised in their plans. As a result of this, as well as other concerns about local plan quality, no plans were approved by Ministers at that time.[8]

4. We asked why the need to save money had not been designed into the Fund from the start. The Department of Health described the original intention to save £1 billion in 2015-16 as "a general ambition". The Department for Communities and Local Government and the Local Government Association agreed that there had been an expectation of significant benefits both for health and local government.[9] The National Audit Office found that the Department of Health and NHS England had shared a planning assumption of £1 billion savings for the NHS.[10] The Department of Health and the Treasury told us that the Treasury had not included this savings figure in the 2013 spending round documentation because it had been based on very rough estimates of local areas' behaviour and of benefits from previous integration programmes in which they had not been fully confident.[11]

5. The Local Government Association told us that there had been an expectation that the Fund would deliver savings but it had never been a party to the £1 billion figure which was why the original guidance issued to local areas, instructing them on how to prepare their plans for the Fund, did not specify a level of savings.[12] NHS England said it was legitimate for local areas to produce plans without knowing about the savings assumption in order for central government to identify what level of savings was realistic. However, between April and July 2014, following concerns about the affordability of the Fund for the NHS and the quality of local planning, the Departments redesigned the Fund and asked local areas to resubmit their plans in September 2014.[13]

6. The changes halved the time available to local areas to prepare for the Fund. The Local Government Association told us that all local areas bar one had submitted plans, demonstrating local support for the Fund. Local areas have chosen to pool £5.3 billion, some 39% more than the £3.8 billion minimum, which also demonstrates that many local areas support the Fund's objectives.[14] However, the Local Government Association considered that the revised policy and subsequent programme management arrangements had moved the integration agenda backwards rather than forwards and told us that, when the redesign was first announced, there had been discussions amongst local government stakeholders about whether the conditions of the Fund had changed to such an extent that local government partners might be wise to "walk away" from it.[15]

7. NHS England and the Departments have strengthened programme management for the Fund. Since July 2014, the Departments have budgeted £6.1 million for support to local areas and assuring their revised plans, including £2.8 million for centrally recruited consultants to ensure local areas produce plans that are of sufficient quality.[16] The Departments and NHS England have also budgeted for around £300,000 on advisers and £400,000 for the Local Government Association for its role.[17]

8. Initially the Fund's senior responsible owners were the policy holders from the Department of Health and the Department for Communities and Local Government.[18] The current Senior Responsible Owner for delivery of the Fund is from NHS England but was not appointed to the role until July 2014 and is still accountable to the departmental policy owners.[19] At local level, health and wellbeing boards approved plans, with ministers overseeing progress nationally.[20]

9. With regard to accountability to Parliament, NHS England and the Department of Health confirmed to us that they are both jointly accountable for the revenue funding which makes up the vast majority of the Fund, while the Department for Communities and Local Government is accountable for the capital funding. Ultimately, the Permanent Secretary for the Department of Health is accountable for the full £3.8 billion Fund.[21] We heard that clinical commissioning groups will release the funding, so they have significant accountability. However, it is not at all clear how local spending will be monitored, for example, who will check that the £750 million of the Fund to be spent on out-of-hospital services is really spent as intended by NHS England. It is unclear how health and wellbeing boards fit into the accountability arrangements for 2015-16.[22]

1 C&AG's Report, Planning for the Better Care Fund, Session 2014-15, HC 781, 11 November 2014 Back



© Parliamentary copyright 2015	Prepared 26 February 2015