Agenda item

In December 2021 it was agreed that a review of the current Better Care Fund (BCF) programme be undertaken and the Health and Wellbeing Board is asked to agree the recommendations from the review.

Items 7 and 8 were taken before item 6.

Witnesses:

Liz Bruce - Joint Executive Director, Adult Social Care and Integrated Commissioning, Surrey County Council and Surrey Heartlands ICS

Jon Lillistone - Assistant Director Commissioning Health, Wellbeing and Adult Social Care, Surrey County Council

Key points raised in the discussion:

1.    The Joint Executive Director, Adult Social Care and Integrated Commissioning (SCC and SH ICS) noted that:

-       The Better Care Fund (BCF) is a mechanism through which to pool, share and target money into priority areas across health and care.

-       Surrey’s BCF totalled approximately £110 million.

-       The overall outcomes of the BCF review were that Surrey needed to: remain in a steady state this year, review the governance at a local commissioning level and establish a common governance framework, shift to prevention spend mapping and focus on prevention and early intervention, focus on health inequalities ensuring that the BCF reflects against the national guidance and Surrey’s refreshed HWS.

-       A shift in the direction of travel was needed for Surrey’s BCF towards more strategic thinking and longer-term investment.

2.    The Assistant Director Commissioning Health, Wellbeing and Adult Social Care (SCC) noted that:

-       Emerging from the BCF review was: the importance of setting system-wide expectations and ambitions for the spend of the BCF, it had been identified that more work needed to be done to strengthen the approach around evidence gathering and impacts and outcomes - particularly important around addressing health inequalities - to share good practice on the management of the BCF at place-level and system-wide. 

-       Community Equipment Services were a key part of the BCF spend system-wide with the majority of places spending around 20% of their budget on that, places spent around 10-12% of their funding on Community Connections Services relating to mental health early intervention, BCF spend was invested in core functions within adult social care and integrated teams within the health system; recognising those key parts of the system was needed for the future strategic plans.

-       Having engaged with colleagues at place-level there was a strong desire to commit to system-wide priorities, whilst having a degree of flexibility.

-       The interface with Surrey’s District and Borough Councils was critical as they were key delivery partners for many aspects of the BCF schemes, the Disabled Facilities Grant made up around 10% of BCF spend.

-       The BCF was comprised of a complex set of relationships, but there were real opportunities to deliver system-wide ambitions.

3.    The Chairman queried whether there was alignment within the system so that the BCF links in with the JSNA and the potentially increasing amount of Section 75 agreements following the Health and Care Act 2022, ensuring that there was a complete picture of what Surrey’s priorities were and how those would be funded.

-       In response, Assistant Director Commissioning Health, Wellbeing and Adult Social Care (SCC) provided assurance that alignment was underway including linking in with the broader prevention spend mapping work underway system-wide.

4.    A Board member referring to the relationship between place and the system with BCF spending at place-level and services commissioned by the local joint commissioning groups, asked about how to ensure that residents across Surrey have equitable access to the services which are important to them such as Tech to Community Connect offered by the Surrey Coalition of Disabled People. Decision-making was at place-level and the inconsistency of services offered Surrey-wide was a problem, so too was the practical issue of voluntary sector organisations offering services having to make a different business proposal to each place which was time-consuming. She asked whether place-based decision-making would continue and how some services would be identified and decided to be provided on a Surrey-wide basis.

-       In response, the Assistant Director Commissioning Health, Wellbeing and Adult Social Care (SCC) noted that the above questions highlighted areas to be worked on in the next phase of the BCF review. It would be vital to ensure that there would be a simple governance process that balances place-level decision-making for their local population and the commitment to key strategic priorities for system-wide provision of identified schemes that could address health inequalities. The consistency in decision-making was fundamental, highlighting the example of the Community Equipment Services where decision-making was made at a strategic system-wide level; having the right interfaces to share good examples would be critical. He was happy to liaise further with the Board member.

-       The Joint Executive Director, Adult Social Care and Integrated Commissioning (SCC and SH ICS) noted that it would be a reoccurring theme in the system working with partners, about what is done and at what spatial level and what the rationale is to do things at a system-wide level, a county level or a local level; having a commonality of governance would be key. The ICS structure would go live in July and included in one of the White Papers was that some of the decision-making around the BCF would go on a legal basis alongside the statutory ICS which would drive those geographical decisions being made as a system.

-       The Vice-Chairman noted that discussions were underway about subsidiarity, a balance was needed between being clear at a strategic level on the setting of high-level outcomes and the desirable outputs for citizens with the delivery of achieving those at community level through the BCF money.

-       The Chairman noted that the ICP would work on how to get BCF spending down to the community level.  

5.    A substitute Board member noted the current discussions underway about what level decisions are made. She noted that those working at the system-level need to have confidence that people who work at place-level make rational decisions; she had not experienced a situation where framing a recommendation to work at scale had not been supported by place-level. To ensure the engagement of places, it was important that they feel that they have some of that decision-making responsibility. She noted the fear from some people who work at a system-level who believe that if decisions are not taken at or delegated from the system-level the right decisions would not be made.

6.    The Chairman highlighted a Board member’s comment in the meeting chat around the ‘Next steps for integrating primary care: Fuller Stocktake report’ which was about how to address primary care and deliver it at community level, also the direction of travel from the Department of Health and Social Care. He noted that clarity was needed around the levels of decision-making, it was not a top-down situation, the ICSs would own the strategy and the budget for the whole system and it was vital to ensure that money is filtered down the right channels to where it is needed. He highlighted recommendation seven from the BCF review which required a structure to be designed to enable its delivery and the upcoming health inequalities White Paper might provide further detail. 

RESOLVED:

Agreed the recommendations from the review:

·         The BCF programme continues in a ‘steady state’ for FY22/23.

·         That we review the governance across each of the Local Joint Commissioning Committees with the aim of creating a common governance framework between the places.

·         That BCF spend is brought into the scope of the ‘Prevention Spend Mapping’ exercise currently being undertaken across the system.

·         That the analysis from this exercise is used to inform a recommendation on the direction of travel to be taken from FY2023/24.

·         This new direction of travel will be presented to ICS exec in Q3 22/23.

·         The new direction of travel includes a commitment to longer-term funding arrangements where appropriate (rather than 1-year contracts). This decision acknowledges that the BCF is likely to continue with 1 year planning frameworks but that longer-term funding arrangements are likely to result in better value for money.

·         That the new direction of travel includes a commitment to use the BCF to address health inequalities, in line with national guidance and the refreshed HWB strategy, which has a strong focus on health inequalities and priority populations.

·         To note the end of year report submission for 2021/22.

Actions/further information to be provided:

1.    The Assistant Director Commissioning Health, Wellbeing and Adult Social Care (SCC) will look to liaise with the Board member (Chief Executive, Healthwatch Surrey) further on the questions asked around the levels of decision-making (place-based or Surrey/system-wide) concerning BCF spending.