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.

Measuring improvement in the quality of care after reconfiguration of NHS services

I asked a question at a public meeting of our local Health Overview and Scrutiny Committee. They have a slot for questions from the public.  I asked if the PCT and hospital would provide a baseline from which to measure the improvement in care promised as a result of the centralising of services on one hospital site.   

I have posted a couple of stories about the difficulty I have had in getting an answer to this relatively simple but important question:  "Like getting blood from a stone" & "What is a 'benefits realisation'?".  I finally arranged a meeting with the hospital managers who are delivering the data. It is really important to talk to the right people.

They were very helpful and, despite being busy implementing the changes, they spared an hour of their time to talk with me about how they are measuring the quality of care.  They reassured me that they have plenty of quantitative data, such as re-admission rates, length of stay, avoidable admissions and mortality rates from before the changes and they will be collecting similar data from the newly reconfigured services.   Now that is good news.

They will not be publishing the data until they have the first set of new data so that there can be a comparison made between the old and the new.   This data will be collected routinely and published regularly. More good news.

We had a discussion about how to present the results in a form that the patients and public can understand.  Not an easy problem to solve. 

We also talked about using qualitative data from the patient experience to complement the hard numbers.  Now I think that the patient experience is a really good test of quality.  The government thinks so too because the 'Friends and Family' test depends on patients feeling they had a 'good' experience in a hospital.  I am not sure that any time spent in hospital can be considered good though.  This sort of data is more difficult to get and use but we agreed that it is important as the patient can have a different perspective compared to a healthcare professional or a manager. 

The hospital has been collecting this sort of information for some years and they said that they will be using it in the baseline measure as well as in the future. 

So my question has been answered at last and I feel reasonably certain that they have the data, both quantitative and qualitative, to measure the quality of the services in some way. 

What will be more interesting is what will the patients and public make of it?  Do they care about tables and charts showing that the number of people re-admitted within 28 days has been reduced by 5%?  Will they care that 95% of patients in a recent survey said that they had a satisfactory experience in the hospital?  Will they use this data to compare the quality of different service providers? Will quality information from other providers be comparable? 

Only time will tell.

Like getting blood from a stone

It started like this.....

Our local Hospital Trust and the Primary Care Trust (PCT) decided that they needed to reconfigure services across two of its three sites. I guess that there are many reasons why they should choose to consider such a redesign. There is the European working hours directive for doctors, medical training requirements &  Royal College recommendations etc etc., all of which suggest that some services needed to be centralised on one site and some on the  other site.

A few years ago they held a public consultation on the general principles of such a change and it passed without too much fuss. Obviously they then went away and developed proposals on how the reconfiguration might look, A number of options were identified, including leaving services as they were. This option appraisal then went out for another extensive round of public consultation.

The consultation agreed with the preferred option (surprise!) but once the implications of the proposals were known and discussed in the press the public began to express their concerns about the effects of the changes at a local level. 

These concerns were a) that it seemed that one of the two hospitals seemed to be reduced in size and in services, b) its A&E becoming an Emergency Medical Centre, and c) the issue of poor transport links between the two hospitals, especially for those living in the villages outside the major towns.

There was an extensive campaign by the local press and a 'Save our Hospital' group held meetings.  Managers from the hospital Trust and the PCT attended these meetings, made statements to the press and a useful debate took place. One of the interesting statements made was that the changes were designed to improve the quality of care and had nothing to do with money.  "Its all about quality".

This got me thinking about how we , as members of the public and patients, would know that the changes have achieved their desired outcome, that of improving the quality of care.  As a scientist and part time 'change manager' I realised that we needed a baseline measurement of the current quality of care provided by the existing services.  So I asked the question.

The County Council Health Overview and Scrutiny Committee was being updated on the reconfiguration and so I asked a question about getting quality information into the public domain.

The important part of the question was:

"Given that the aims of the changes.....are all about improving the quality of care ...can the Hospital and PCT provide the current level of quality of those services in a form that the public can understand."

Their answer in full (names and details removed to protect the innocent) (from the PCT director of communication and engagement) was:

"Quality reports are routinely considered at meetings in public of the PCT cluster Board. These look at issues such as waiting times, levels of hospital acquired infections and delayed transfers of care. In relation to the changes proposed by the programme, a 'benefits realisation' performance dashboard is being developed. This will contain a number of indicators which will be monitored to ensure that any changes are producing a better experience and better outcomes for patients.  This will look at factors such as patient satisfaction, mortality rates, length of stay and admission and readmission rates of these services which have been changed."

Now I know I am just a member of the public but I did spend two years teaching science to GCSE students and I reckon that comes under the category of 'this student did not answer the question'.

Now in my role of 'a stone in the shoe' I had a email conversation with the Trust representative ('the messenger') which resulted in no improvement and so I was allowed to re-ask the question at the next Overview and Scrutiny meeting .

This is the next answer, given by a senior clinician from one of the two embryonic local Clinical Commissioning Groups:

"At the moment a large amount of data is collected the Trust.  This includes data on length of stay, readmission rates and mortality rates. However the way in which this data is currently analysed and reported reflects the current arrangement of services not the proposed new reconfiguration. The Hospital Trust is currently undertaking an exercise to analyse the data to reflect the changes and to determine benchmarks from which outcomes can be monitored. Once this is completed the key indicators will be published and monitored in the public domain".

Once again it seems to me that they have avoided answering the question. In fact they seem to have missed the point about establishing the quality of the current services, entirely. Yet at the same time they say that the way the data is analysed at the moment does reflect the current services!  If this is so they should be able to give some indication of the quality of the current services.

Each time I go over the answers I see more confusion and lack of information.

It seems to me common sense that the baseline for measuring quality improvements should be taken before the changes are implemented and are an essential piece of information that any organisation should use when managing change. 

The more I look at what has happened over the last few months the more concerned I am about the ability of the local health services to understand the quality of service that it provides for the local population. They do not seem to understand the process for monitoring the change process either!

We are being told to choose the health care provider that gives the best quality care but if they cannot give us the information on quality how can we choose?

Or is it that they do not want to tell the public what is happening?