Comment / Better Care Fund: overcoming the barriers

In June 2013, the government announced the creation of the Better Care Fund (BCF) to incentivise closer working between the NHS and local government. The launch in 2015 saw the setting-up of pooled budgets with the aim of reducing barriers created by different funding streams. But, as we move towards the creation of statutory integrated care systems in 2022, where everybody is expected to work more closely together, is the BCF still relevant?

For us in Sunderland, the short answer is yes. We have used the BCF to support integration across our place and underpin our alliance arrangements for out-of-hospital services. The existing section 75 mechanism allowed us to pool our funding with the local authority, but the BCF mandated the approach and set out a specific requirement to do so.

While there is a minimum contribution expected, we have gone much further in Sunderland. Our contribution to the BCF is more than five times that which we are required to provide. So, why have we taken this approach?

In Sunderland we have some real areas of innovation and transformation that we've delivered jointly with the local authority and our other partners. But alongside this we know we have some significant health challenges and inequalities. Our population is generally in poorer health than the rest of the country and life expectancy here is lower than the national average. One in four adults has a long-term illness, health problem or disability.

However, we know that health is not solely determined by the services commissioned by the NHS as there are other factors that impact on this too. There are pockets of significant deprivation across the city, and we have high levels of obesity, smoking and alcohol consumption. These socio-economic factors mean that, in Sunderland, we see health and wellbeing as a shared responsibility between many public bodies.

For us, if the responsibility is shared, then the resources to meet that requirement should also be shared and considered as the Sunderland pound.

The BCF has provided a mechanism to underpin and support the work of All Together Better Sunderland (ATB). ATB is an alliance of commissioners and providers working together across organisational boundaries to improve health outcomes for people living in Sunderland. By pooling our resources, we can invest where we can have the most impact. We can work together to identify need and support our partner organisations to transform and deliver the services to the population that will make the most difference to lives, regardless of whether those services are health or social care.

By using the BCF, we are also supporting better system understanding of what impacts spend. For example, we have included the whole primary care prescribing budget in the BCF in Sunderland. While the clinical commissioning group retains responsibility for the spending, including it in the shared fund means that all partners can see trends in expenditure that link to investment, or not, elsewhere.

In addition, this approach empowers system ownership on addressing financial pressures in a collaborative manner. This approach works for us and recognises the wider factors that can impact on expenditure.

However, administering the BCF is not always straightforward. The guidance can sometimes be delayed – the 2021/22 guidance was issued on 30 September with a requirement to report retrospectively on spend since April 2021. And new guidance sometimes brings changes to how BCF expenditure needs to be reported, which can be challenging when looking backwards.

The BCF sets out four national conditions including the requirement to improve outcomes for people being discharged from hospital, with an expectation to reduce length of stay. The hospital discharge scheme supports the same work, so the same spend and activity needs to be reported twice, in different ways, to meet the conditions of each programme.

While not onerous, we also need to identify which elements of spend come from our minimum contribution to the fund and which come from the extra part. This provides assurance that we are meeting the national BCF conditions.

As we move towards statutory ICSs and the formation of integrated care boards (ICBs), it is anticipated that we will continue to evolve and build on the work we have done to date in the CCG.  Pooling resources in Sunderland has made a big difference to how we work, and we expect that place-based arrangements will continue to be a key feature of ICS arrangements moving forward.

A place-based approach to joint working will be vital as we become part of a much larger ICB. Working together in this way has enabled us to make changes and understand impact that may otherwise have been impossible.

Our experience in Sunderland has underlined what the BCF set out to achieve six years ago. Reducing the barriers associated with different funding streams is fundamental to working together and improving population health. Whatever ICBs bring, we need to recognise the importance of funding flows when it comes to working together.