Health and Wellbeing Board	10 March 2021
Report of the Assistant Director – Joint Commissioning, City of York Council and Vale of York Clinical Commissioning Group

Better Care Fund Update

Summary

1. This report is to provide an update on the progress of the Better Care Fund Review and planning for 2021-22.

Background

2. The background information on the BCF has been previously reported to the Health and Wellbeing Board (HWBB), with quarterly updates now the normal routine, most recently in January 2021.

3. The government published a short statement on 3^rd December 2020, confirming that the BCF will continue for a further year, and stating that the Policy Framework and Planning Requirements for this will be published early in 2021 (still awaited).  The statement advised that planning will take place in February and March for the following financial year. 

4. As this will be the third, successive, single year plan, the council and CCG intend to review the York BCF to ensure we are achieving the right outcomes and the best value from the pooled investment. The HWBB supported the establishment of a small review team and the proposed approach to ensuring that the BCF is delivering the greatest impact possible.

5. Schemes in York have been given an interim commitment of continuation until at least 30^th June 2021.  The intention is to complete the review in four phases, which are set out below.  This may not be concluded before the end of the current financial year.

Main/Key Issues to be Considered

6. The Spending Review 2020 confirmed that the iBCF grant will continue in 2021 to 2022 and be maintained at its current level. The Disabled Facilities Grant will also continue and will be worth £573 million nationally in 2021 to 2022.

7. The CCG contribution will again increase by 5.3% in line with the NHS Long Term Plan settlement.

8. As previously highlighted, the use of single year agreements by the Department of Health and Social Care (DHSC) has created an undesirable level of insecurity for service providers funded through BCF, included for individual staff members across our system where posts are subject to fixed term contracts. The experience of receiving the policy and planning requirements mid-way through the year compounds this, and has made it difficult to refresh or significantly revise plans from one year to the next in recent years.

9. The NHS White Paper, Integration and Innovation: working together to improve health and social care for all, published on 3^rd February 2021, includes the following policy intention:

10. ICS legislation will complement and reinvigorate place-based structures for integration between the NHS and Social Care, such as Health and Well-Being Boards, the Better Care Fund and pooled budget arrangements. The ICS Health and Care Partnership will be a springboard for bringing together health, local authorities and partners, to address the health, social care, and public health needs at a system level, and to support closer integration and collaborative working between health and social care. We will support this by published guidance that will offer support for how ICS Health and Care Partnerships can be used to align operating practices and culture with the legislative framework to ensure ICSs deliver for the ASC sector.

[#5.99, p 54, DHSC, 2021]

11. And:

A standalone power for the Better Care Fund

As set out above, legislation will be amending the process for setting the NHS mandate so that it is no longer set on a rolling annual basis. Currently the allocation of the Better Care fund is tied to this annual process. As such, we will be creating a standalone legislative power to support the Better Care Fund and separate it from the mandate setting process.

This will be a technical change, and will not have any impact on the function, purpose or policy intention for the fund.

[#5.116-5.117, p 58, DHSC, 2021]

12. This confirms the advantage of taking time now to reassess the make-up of the York BCF plan, and to consider any changes in investment or shifts in emphasis, so that we can plan with confidence for the longer term commitments from 2022 onwards.

Scope and dimensions of the review

13. The review is designed to:

· Include all current schemes funded within the BCF, iBCF and associated funding streams in the CCG & Council pooled budget

· Draw on policy requirements, finance and performance reports, and existing evaluations and publications (such as impact reports)

· Take a proportionate approach, linked to the level of investment and the scale of service (i.e. small voluntary sector schemes should not be expected to receive closer scrutiny than large, statutory sector providers, as has often been the case in the past)

· Align existing schemes to known system challenges and priorities – for example the focus on building community capacity, prevention and integration, social return on investment

· Identify areas where we have gaps in services, or opportunities to get better value or greater impact through additional investment

· Identify opportunities for whole system transformation by shifting investment upstream; improve efficiency and effectiveness

· Create longer term view of BCF commitments to overcome the insecurity resulting from single year planning arrangements

· Ensure York’s ability to comply with the BCF national conditions

The review is taking place in the context of:

· System wide financial pressures

· Incremental changes to the plan which have been enacted since the 2017-19 planning period, without full review, as a result of uncertainty in government policy intentions and financial commitments

· Shared system focus on prevention and population health management

· Changes to the health and care economy over recent years, including the requirement to support market development and market shaping

· The impact of the pandemic on services and system finances

· The changing landscape for health and care organisations in York

Progress so far

14. The review team has been established:

· Simon Bell – Executive lead

· Pippa Corner – BCF Performance and Delivery Group chair

· Michael Ash-McMahon – CCG finance lead

· Steve Tait – CYC finance lead

· Peter Roderick – Public Health lead

15. The four phase are:

i. Priority Preventative Schemes dependent on fixed term posts (complete)

ii. Priority Preventative Schemes with possible impact on fixed term posts (in progress)

iii. Remaining schemes in which BCF allocation underpins the cost of ongoing service, but not necessarily linked to specific posts at risk (March / April 2021)

iv. Use the annual evaluation days to consider whole system shifts possible by using the totality of the fund more strategically as an outcome from the scheme by scheme reviews.  We will take account of interdependencies, integration, and opportunities to make a bigger impact through integration, collaboration and transformation.           (May 2021)

16. The first nine schemes (Phase 1) have been reviewed, based on the agreed evaluation criteria and scoring mechanism, through a series of short meetings.  These schemes are appropriately grouped together as they operate in an integrated, inter-dependent model, in the spirit of the BCF. 

17. Wherever possible the review has drawn on information provided by schemes as part of our regular performance framework, and evidence from previous evaluation sessions.  Where necessary, limited requests have been made for specific detail.  By applying a consistent method across the schemes, we are accumulating a baseline of information, allowing us to compare the wide range of activities supported by the BCF.

18. Our discussions have focused on evaluating how well each scheme is aligned to the policy intentions of the fund, and to consider the different approaches to providing evidence of impact.

19. The review team concluded the schemes score highly on the BCF priorities and objectives.  The close partnership working and interdependence of the schemes offers a strength to the system in York, reflecting asset based, placed based approaches.

20. The review team has explored the value of the schemes to the city’s prevention and population health agenda; and considered the relative currencies (e.g. improved individual outcomes, social return on investment, deferred or avoided costs to health and social care) which can be measured when evaluating the contribution of services to the city.

21. In reference to the relative cost of delivering the schemes, the team concluded they represent value for money, and represent significant social value to the city and our partnerships. Pinpointing exact comparisons in value for money is more difficult.  There is clear evidence that all of these services have supported people to independence who otherwise would have needed formal and expensive packages of health / social care.  It is more difficult to assign specific cost avoidance as a cause and effect from prevention services – this is not a new conundrum, and will in the end require an element of professional judgement in decision making, alongside a strong values commitment that prevention and asset-based development is the right thing to do for our citizens.

22. The team has looked at a range of research evidence and independent evaluation which begins to address the challenge of comparing value and cost.

23. The evidence gathering and evaluation process enables a series of goals to be set to add value over the coming year to reduce health inequalities and maximise opportunities for collaboration.  For example:

· Increase the number and diversity (protected characteristics) of community health champions, reach out to more individuals from excluded groups to participate in the programme

· Encourage closer working between existing schemes in / out of BCF such as the Health Trainers in public health and the health champions

· Develop the integration of Live Well York with the RSS system in primary care to enable cross reference and referrals to community assets

· Connect up the various commitments to increased therapy across the system to use our shared resources as flexibly and effectively as possible

· Consider extending even further the hours of service for preventative schemes such as RATS, and undertake an audit of avoidable admissions for a short period (one week) to help inform any decisions about this

· Explore the business case for increasing preventative roles such as Self-Support Champions, and join up with similar teams across York

· Develop further resources or approaches to preventative work on alcohol harm, drawing on research evidence and intelligence about admissions to hospital

· Continue to develop our approach to measuring outcomes and value, and to add value by targeting schemes to priority population groups

· Pursue opportunities to align or pool additional budgets with BCF, such as the PCN social prescribing DES, helping to secure system benefits greater than single organisational gains

· Better align adult social care and Continuing Health Care placements and care packages to gain better value for money through joint commissioning and market development, including working together to use asset based community development to underpin independence and resilience, reducing reliance on formal services , and targeting them to assessed higher needs

· Continue to promote BCF as the platform for investment in further integration between the council and health partners, building on the direction of travel for the York Alliance

Next steps

24. The team is following a timetable of meetings during March and April, to conclude the second and third phases of the review.  We will confirm contract extensions or changes, as early as possible where relevant, prior to the end of June 2021, when the temporary extensions end.

25. During May and June we will develop our approach to the longer term investment plan, and any opportunities to promote the benefits of integration and collaboration.

26. If required, we will aim to implement changes from September, and to prepare for the new arrangements from April 2022, if the legislation has been passed as described in the White Paper.

Conclusion

27. The review of the first cluster of schemes, which form the bedrock of York’s preventative, asset based community development programme, has recognised the value of networked, integrated, flexible approaches between organisations, teams and local people.  On balance, the review found the schemes represent good value for money and can demonstrate high impact in terms of the positive outcomes for individuals and communities, including the ability to attract and deploy resources for the city – both external funding and the social action of volunteers to augment the scale of service delivery.

28. The review team has also considered the challenge of comparing the different currencies or definitions of value, and complementary ways of measuring success.  The review enables a multi-faceted approach to defining and comparing relative value, which takes account of:

· the impact of financial investment, (ROI)

· social return on investment, (SROI)

· the scope for adding value in future by embedding progress,

· social value (supporting our response to the Public Services (Social Value) Act, 2013),

· individual health outcomes,

· diversion from formal, statutory services

· system transformation,

· delivery of strategic objectives, milestones and goals.

29. Measuring the impact of preventative schemes is always difficult, with the perennial problem of proving something that didn’t happen.  We use personal testimony to describe the impact in individual lives, and have now accumulated long term reports and libraries of case studies.  We also have evidence of the impact in communities of the work to build community capacity, which came through strongly for the city during the first lockdown, meaning that York was well placed to rapidly establish community hubs. 

30. Calculating the financial efficiency of preventative services is complicated by the wider context influencing expenditure.  Rising demand on services arises from external factors such as COVID-19, year on year demographic growth (younger people with complex needs moving from children’s to adults’ services and more of our older people living longer with complex needs) and increased costs of care, for example from the increase in the national minimum living wage and market forces. 

31. However, financial pressures are not the only motivation for promoting independence and resilience.  Preventative, strength based approaches are right for people and communities.  Alongside prevention, we need to focus our joint commissioning on addressing market shaping and the unit price of formal care, in tandem with the review of BCF.

32. BCF offers a system opportunity to exert moral and political choice to do what’s right within a defined budget – using population health intelligence to address health inequalities in the city – aligned to the direction of travel for integrated commissioning and delivery under the Alliance model.

Consultation

33. The BCF Plan 2020-21 was developed in a collaborative process with partners, and is co-produced with the scheme providers.  This approach will be continued for 2021-22.  The BCF Performance and Delivery Group discussed and informed the development of the evaluation criteria for the review.  Colleagues across the system involved in BCF were invited to comment on the approach to the review.  The council corporate management team received a full report on this work in February 2021, including a discussion on the specific schemes where CYC staff contracts were affected.

Options      

34. The HWBB will receive further reports on the progress of the review and the publication of the national planning requirements when this occurs.   

Analysis

35. n/a

Strategic/Operational Plans

36. The Joint Health and Wellbeing Strategy is the overarching strategic vision for York; this plan supports the delivery of the desired outcomes.

37. The York BCF Plan 2017-19 provided the foundation for the BCF Plan 2019-20 and 2020-21.  It has evolved each year in line with refreshed intelligence and national directives.

38. This work is congruent with the Council Plan and the NHS Long Term Plan.  The NHS White Paper further promotes the policy objectives of BCF. The link is included below under background papers.

39. BCF schemes have been central to the COVID-19 pandemic response, including the implementation of the Hospital Discharge Policy.

        Implications

· Financial – There are no financial implications as yet from this report. Any future decisions about investment or disinvestment would be consulted upon with partners and would have legal governance and assurance through the section 75 agreement used to establish the BCF pooled budget.

· Human Resources (HR) – many of the schemes funded through BCF are supported by staff on fixed term contracts.  The prevalence of short-term funding and fixed term employment contracts are a significant risk to the stability and continuity of our system.  The review has prioritised the schemes which are most affected.  CYC staff contracts have now been extended where required.

· Equalities - none

· Legal - none

· Crime and Disorder  - none

· Information Technology (IT) – information technology and digital integration forms part of the system wide improvement plan, relevant representatives from statutory agencies attend the project board, and there are plans to engage non-statutory services and the patients, customers and families in our developments.  The national and regional work on this agenda guides our local work.

· Property - none

· Other – none.

Risk Management

40. Governance processes are in place between the partners to manage the strategic risks of the BCF as part of our whole system working.

        Recommendations

41. The Health and Wellbeing Board are asked to:

i. Receive the York Better Care Fund update for information.

Reason:  The HWBB is the accountable body for the Better Care Fund.

ii. Note the progress of the review of the financial allocations for BCF 2021-22 to ensure maximum impact on outcomes for the system.

Reason: It is important for the sustainability and stability of the whole system that the funding commitment is reviewed regularly to be assured of value for money and impact on outcomes.  The Chair and Vice Chair, have approved this approach, supported by the council Corporate Director of People and the CCG Accountable Officer.

iii. Receive further reports on the progress and outcomes from the BCF review at future meetings.

Reason: The HWBB is the accountable body for the Better Care Fund.

Contact Details

Author:	Chief Officer Responsible for the report:
Pippa Corner Assistant Director – Joint Commissioning People Directorate City of York Council & NHS Vale of York CCG 07500973261	Amanda Hatton Corporate Director - People City of York Council Phil Mettam Accountable Officer NHS Vale of York CCG
	Report Approved	√	Date	1.3.21
Wards Affected:					All	x
For further information please contact the author of the report

Background Papers:

Marmot Review – available at:

Build Back Fairer: The COVID-19 Marmot Review

NHS White Paper – available at:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/960548/integration-and-innovation-working-together-to-improve-health-and-social-care-for-all-web-version.pdf

Annexes

Annex 1 – BCF Review evaluation criteria

Glossary

A&E – Accident and Emergency

BCF – Better Care Fund

BI – Be Independent

CCG – Clinical Commissioning Group

CYC – City of York Council

DHSC - Department of Health and Social Care

DToC – Delayed Transfers of Care

ED - Emergency Department

GP – General Practitioner

HR – Human Resources

HSG – Human Support Group

HWBB – Health and Wellbeing Board

IT – Information Technology

KPI – Key Performance Indicator

LAC – Local Area Co-ordinator / Local Are Co-ordination

MDT – Multi-Disciplinary Team

NHS - National Health Service

NHSE&I - NHS England & Improvement

RATS - Rapid Assessment and Therapy Service

SDEC - Same Day Emergency Care

VOYCCG – Vale of York Clinical Commissioning Group

YTH – York Teaching Hospital