Better Care Fund - Mission Impossible?

The government having just made the biggest re-organisation of the NHS is now insisting that local health and social care economies now embark on another! 

Health and Wellbeing Board which only came into existence 12 months ago are now developing plans to use the Better Care Fund.   This fund is drawn from existing funds from health and social care commissioners. The total could be around £4 billion for England and in Buckinghamshire the fund will be nearly £100 million. This is three times the size of the fund that other areas are implementing!  Are they being too ambitious?

What will this fund do?

The Better Care Fund is to be used to integrate health and social care services, especially for older people.  It is hoped that this integration will reduce costs and improve the quality of care (in that order).

Many of us have asked for a closer integration of health and social care and so we should be welcoming this new work.  But should the timer scale for developing the project be longer than 12 months?  Can these new organisations, barely out of nappies, successfully implement such a big change in the way services are commissioned?

 Patients, especially those with long term conditions  & the elderly need care and support and they get that support from many different agencies – the NHS, Social services, the voluntary sector, the private sector, families and friends to name a few. Currently some care is called health care and some is called social care. But patients don’t really care what it is called. Or who commissions & funds it.  What they want is for it to be provided without any gaps, when and where they need it.  

They don’t want to have to go to one lot of people for one sort of care and then go through another assessment for more support! They just want to go to one point to ask for help.

So this Better Care Fund sounds as if it a good idea. But some say it will not save money and will not improve services.  They say there is no evidence that it will achieve these objectives.

I am also concerned that locally the public and patients have not been involved in the design of this new service.   As usual we will be involved and consulted with in the middle of the process rather than at the beginning.   Who is to carry out that involvement?  It is Healthwatch Buckinghamshire who are virtually unknown to the population of Buckinghamshire.   Will they be able to carry out a meaningful engagement with the public, let alone real involvement in the design of the new service?

Finally who is going to manage this fund, who will monitor the quality (and quantity) of the care? Who will be accountable?

It’s a mystery!

You can see the latest update on Buckinghamshire Health and Wellbeing Board's plans here

Here is a review of the evidence recently published by the University of York which suggests that these schemes should be rolled out cautiously and may increase overall costs.

How can the public hold Clinical Commissioning Groups to account

I think that 'holding to account' means that the public must be confident that the Clinical Commissioning Groups (CCGs) are answerable to the public and patients for the decisions they make on our behalf.

The sorts of decisions they will be making (maybe they have already made them) are:

• What healthcare do we need.
• How much.
• The quality of the care
• Where the care will be delivered and by whom.
• How long will it take to get treated.

There will be over 200 CCGs.  Our is a small one with only 190,00 people and a budget of about £200M.  Others will be much bigger and responsible for very large sums of public money. So it is crucial that they use this money for the benefit of their local population and get value for money.

So how can we hold these organisations to account.  It will not be easy as individuals to do so.  Organisations of this sort can hide behind a number of barriers. They use the Freedom of Information Act to delay answering questions.  They can also use the idea of 'Commercial Confidentiality' to avoid giving answers about the value of contracts, especially with private healthcare providers.  They also use jargon to confuse us.  Lastly one of the ways to ask them questions is at board meetings held in public and that isn't easy for many people. It isn't much fun standing up in from the board and holding them to account.

However there are a number of ways that the public can make sure they spend our money wisely and on healthcare that will benefit us.

Ask questions at meetings

CCG boards will have to hold their meetings in public and publish the board papers online.  Go to meetings and ask questions. CCGs will also hold other so called 'engagement' meetings so please go along and ask awkward question. 

Join your Practice Participation Group (Patient Reference Group)

Each GP surgery should have a group of patients, perhaps as an virtual group, who support the practice in many ways. They can ask questions of the GPs who in turn can ask questions of the CCG.  Our CCG intends to have a Patients Forum with one person from each practice participation group on it. Exact details are current unknown. The patients will need to set the agenda not the CCG.

Service User Groups

If you have a long term condition join the service user group/support group or set one up.  They may be able to ask questions about specific services as they are often considered as 'experts'.  These groups are often used when services are being redesigned or changed. 

Local Healthwatch

These groups will be taking over the role of the Local Involvement Networks on April 1st. They will act as the patients champion  and should be seeking the views of patients and the public about the health and social care services. They will be monitoring the quality of services and holding the CCGs to account if the services are not benefiting patients. These groups will be as new as the CCGs and will take time to become effective. Anyone can join a Local Healthwatch and support their activities.

GPs

Our CCG intends to have an 'accountability forum'.  Each practice will have a GP on the forum and their role is to hold the CCG to account on behalf of the GPs and the practices. Even more reason to get involved in your practice participation group so you can influence the GPs.

Local Health and Wellbeing Boards

This is a joint Council & CCG body that is responsible for strategic thinking and priority setting for health and social care. A lay person from the Local Healthwatch will be a member. CCGs should be answerable to the board to show it is matching commissioning to the health needs of the population. How it will hold the CCGs to account remains to be seen but it could be quite powerful.  

Health Overview and Scrutiny Committees

This is a Council committee that monitors the commissioning and delivery of services and can hold the CCG to account.  The meetings are in public and you can go along and ask questions.

CCG Governance procedures

CCG are required to hold meetings in public, publish their papers online and to publish the methods they use to make decisions.  We should make sure that they actually do use those methods when making decisions about our healthcare. There will be much talk of the use of 'evidence' and we need to make sure they use all the evidence and analyse it in a consistent manner. 

Lay people on the CCG board

Each CCG is required to have two lay people on the board and one of those must act as 'the patient and public involvement' champion.  Find out who it is and make sure they act on our behalf.

NHS Commissioning Board

The new NHS reform act makes sure that the CCGs will be accountable for their performance to this national organisation.  But there is nothing in the act to make the CCGs accountable to us.

Monitor

The CCGs will be accountable to this national organisation for their financial performance.

Conclusion

Those of you who have read my previous blogs about patient involvement might notice some similarity to this one. I feel this is inevitable since the two processes of involvement and accountability are two sides of the same coin.  Both rely on good communication and trust. The same limited number of organisations are going to be active in the involvement process as well as the accountability process. 

Meaningful and effective involvement of patients, at an early stage of decision making, and in a sustained manner throughout the process will enhance the trust that the public have in the CCGs.  The accountability process will follow naturally from the involvement of patients and the public in decision making. 

There seem to be very few ways in which individuals can hold their local CCG to account. So it looks like you will need to join one or more of the organisations mentioned above if you want to make sure the CCG does what it is meant to do and 'make no decision about me, without me'.

The trouble with joining an organisation is that you hope that the person representing you is able to stand up to the CCG board.  Will the CCG take more notice of that person than the opinion of an individual?

Lets hope that the evolving CCGs will be different from the old PCTs. and that they will act in an honest and transparent manner so we can be assured that they are working on our behalf. 

  

How Health and Wellbeing Boards can involve the public

It is difficult to get the public involved in decision making about the big, strategic issues in Health and Social Care.  We are much more interested in things that concern us at a personal level.  

The Health and Wellbeing Boards that exist in shadow form in all local authority area are intended to promote the health and wellbeing of all residents in their area. Through the production of a needs assessment they will set the priorities for health and social service commissioning so that the best possible outcomes are obtained for local people. 

Or something like that anyway. 

The members of the board come from the local councils, health and social service managers and one member from Local Healthwatch. They are expected to involve the public in their work 

So I thought I would give them a few of my ideas, a few basic principles on how to involve the public. 

1. The Health and Wellbeing Board must know what it means by 'involvement' AND the purpose of such involvement.
2. The board must inform the public about its ideas on involvement and the purpose of public involvement.
3. The board must inform the public about what it can and cannot do with the results of the involvement process.
4. The board should use lots of different methods to involve the public.
5. The board should involve the public at an early stage in the development of ideas and plans.
6. The board should involve the public all through the process of developing plans.
7. The board should try to ask specific questions rather than vague ones.
8. The board should think and act 'locally' (small scale).
9. It will be more productive to look at single issues, conditions, treatments or groups of patients.
10. Use existing networks, service user groups, charities & voluntary sector organisations.
11. Face to face, informal events tend to be more successful than formal ones.
12. Go out to people, go to the workplace, the schools, clinics  shops, clubs & wards.  Do not expect people to come to you.
13. Use language that people understand, no jargon, and ask short questions.
14. The board must feedback to the public what information in gets through involvement and how it uses it.
15. The board will need to inform people and educate them about how decisions are made and how evidence is used.
16. Read the literature and research on patient and public involvement.
17. Patients and the public are different and so they will need different approaches .
18. We, the public will NOT be 'representative'.. 

 Any more ideas would be welcome.  Feel free to contribute.