North Regional Event Pooled Budgets Thursday 5 th October 10am 3:30pm
Agenda 10.00 Arrival, networking, tea and coffee 10.30 Introduction aims of the day 10.45 Pooled Budgets: - Setting up a Pooled Budget national expectations and how a Pooled Budget operates in practice - Key differences between a Pooled Budget and an Aligned Budget Matthew West (BCST) Presentation of a local experience North East Lincolnshire Bev Compton, Director of Adult Services, North East Lincolnshire Clinical Commissioning Group 11.30 Tea and coffee break 11.50 Workshop One (two groups) The governance/financial arrangements of a Pooled Budget (NHS and LA) can they be complementary? 12.40 Feedback Sharing learning from both groups and identifying key points? 12.50 Lunch 13.35 Workshop Two (two groups) The journey to a true Pooled Budget, setting up and overcoming barriers 14.25 Feedback Sharing learning from both groups and identifying key points 14.35 Round table discussion: Shaun Jones (NHSE, Head of Assurance and Delivery), Matthew West (BCST), Cliff Dalton (CIPFA, Head of Local Government) 15.00 Close
Pooled Budgets 5 October Matthew West Better Care Support Team The Better Care Fund
Integrated financing arrangements If we are to succeed in integrating health and social care to bring about better experiences and outcomes for people, we need real readiness and commitment to work across organisations, and find better ways to pool our collective resources for better overall value and benefit. Dr Jo Farrar, Director General for Local Government and Public Services, DCLG
National position Better Care Fund is intended to support integration of health and social care but it is not the first or last policy to do this. 2006 2006-2012 2013 2014 2014 2014 2015 2016 NHS White Paper Our health, our care, our say Integrated Care Pilots/Early adopters Health and Care Act Better Care Fund The Care Act Integrated Personal Commissioning Five Year Forward View New Care Models, Vanguards and Pioneers Sustainability and Transformation Plans
Drivers Better Care Fund Mandates Section 75 agreement Government Integration Agenda All areas more integrated by 2020 Sustainability and Transformation plans/acs Capitated Budgets
Aligned budgets - features Two or more organisations come together to align objectives and expenditure. Expenditure is incurred by the individual organisations. Funding is allocated within individual organisations budgets to be spent on the activity. Does not require any legislative powers as there is no delegation of functions and no host partner, and therefore each party s statutory duties remain their own. Often used as a stepping stone towards a pooled budget
Pooled budgets - features A pooled budget (or fund) is an arrangement where two or more partners make financial contributions to a single fund to achieve specified and mutually agreed aims. The budget is managed by a single body. A S75 partnership agreement is required to establish a pooled budget. This empowers CCGs and local authorities powers to establish and maintain pooled funds out of which payment may be made towards expenditure incurred in the exercise of prescribed local authority functions and prescribed NHS functions. Pooled budgets established under these powers do not necessarily constitute a delegation of statutory responsibilities. Each locality may have more than one pooled budget.
Integrated financing arrangements why do it? Less fragmentation Scope for genuine joint commissioning Underpins integrated services Shared accountability
Considerations Lead body or joint venture Risk appetite? Links to wider integration STP ACS etc.
Governance and risk sharing In agreeing joint objectives, the target populations should be identified and estimates created of baselines and metrics. Partners should be in agreement regarding the measurement of success and collective decision-making criteria for investment and disinvestment in initiatives. Criteria should include thresholds above and below which action will be taken, to avoid continual change. Disinvestment decisions should be made before action is required to ensure that system priorities remain the focus during difficult decision-making processes. Calculations of risk and reward should include impact and likelihood assessments. Shared risks should be included on a joint risk register, each with a risk owner. Determine each organisations risk appetite and agree on a risk appetite at a system level. Identify the extent to which each organisation can influence the risks and benefits. On this basis, agree how risks and rewards will be shared in principle.
Support
Collaboration for health and care integration in North East Lincolnshire Bev Compton, director of adult services Emma Overton, Care Act implementation lead 5 th October 2017
Quick overview Where we started from Where we are going to An overview of how we use and manage pooled funds
The Journey Begins Formal arrangements between North East Lincolnshire Council and the then Primary Care Trust began in 2004 with mental health service commissioning Partnership working was expanded in 2007 to include adult social care, public health, and children s services, underpinned by a Section 75 Agreement (s75) The s75 was refreshed in 2013 when the then Care Trust Plus became North East Lincolnshire CCG The Better Care Fund was introduced in 2014
North East Lincolnshire s (NEL) Model Initially, NEL worked on a lead commissioner model (based on delegation of functions by each partner to the other); More recently, an ACP has been created: Together Ltd is a community benefit society comprising NEL s key providers (NLaG, Care Plus Group, Navigo and focus independent adult social work). By April 2020 Together Ltd will manage a capitated health and care budget with delegated responsibility for making and/ or buying services NEL s strategic commissioning is now led by the union, which provides more opportunities for joint commissioning
Development of the Union An options appraisal identified that enhanced partnership (union) with single leadership team best supports shared ambition for NEL Each statutory organisation continues to discharge the partners retained responsibilities no new organisation has been created Arrangements via an extended s75 include as much as statue permits, so the partners can better shape/ manage pooled duties and resources, and harness greater commissioning power Development of robust governance arrangements designed to add value, and reduce the burden of governance, process and delivery Creates a powerful single voice for NEL during the wide scale reform represented by the ACP and STP The Union will oversee all spend on health and adult social care, the 0-19 agenda and the broader determinants of wellbeing, such as public health, housing, education and skills etc The union began on 1 st September 2017, led by a joint chief executive
What is NEL s Model Designed to Achieve? Our vision is to deliver the right care, in the right place, by the right people, as close to home as possible, releasing the capacity and innovation which exists within our community to promote healthy living, self-care and prevention
What is a pooled fund? More than one organisation contributes funding Can be used for one organisation to lead and commission services or functions or for more than one organisation to co-commission Section 75 can provide for flexible use of pooled funds In NEL each pooled fund has a defined use and permitted expenditure Host partner is appointed for the fund Holds the money Provides the administrative support for the fund
Pooled fund manager Detailed in the section 75 are pooled fund manager responsibilities: the day to day operation and management of the Pooled Fund; ensuring that all expenditure from the Pooled Fund is in accordance with the provisions of the relevant scheme specification; maintaining an overview of all joint financial issues affecting the Partners ensuring that full and proper records for accounting purposes are kept in respect of the Pooled Fund; reporting on the use of the funds ensuring action is taken to manage any projected underspends or overspends preparing and submitting to the reports
Financial management and risk sharing Different rules depending on whether there is overspend, underspend, pooled or non pooled funding Host partner must ensure pooled fund is not overspent and must put in place actions to remedy if the approved limit looks set to be exceeded Duty to inform the other partner if there is likely to be an overspend in a pooled or non pooled fund Money can be moved around the partnership arrangements to balance the budgets if there is likely to be an overspend. Where there is an underspend, then it is can be returned to the partners proportionate to their original contribution
Thank you for listening! beverley.compton@nhs.net emmaoverton@nhs.net
Workshop One Feedback The governance/financial arrangements of a Pooled Budget (NHS and LA) can they be complimentary? 12.40 12.50 The Better Care Fund 24
Notes from the discussion of Workshop One (1/2) The governance/financial arrangements of a Pooled Budget (NHS and LA) can they be complimentary? Guidance on what can/cannot be done in regards to pooled budgets within individual organisations has to be considered. Timings are important - CCGs and LAs have different timeframes with which to deliver. Reporting: how do pooled budgets effect how/when reporting is done? Shuffling money around seems complex, and dependent on contractual agreements. Contingency services are important to consider in respect to an individual organisation s responsibilities Integrated services need to be better recognised in order to establish a pooled budget Internal auditing can be effected if LAs and CCGs fully integrate their budgeting Other statutory duties may disproportionately effect a specific services if pooled budgets are used How will carrying forward funds work, especially in relation to the balance of contribution between the CCG and LA? One group believed that these arrangements are difficult to make complimentary A lot of it is to do with trust - trust in different places, e.g. finance Lack of trust/confidence can undo a pooled budget We have pooled budgets, but what we may not be doing is pooled governance The key to a complimentary system: putting existing spending into more rational places? Can you comply with BCF guidance and not quite have a pooled budget? Everyone continues doing their own thing and we pull it together Look at the entirety of social care and of health and pull it together To pool you have to identify two parts that create it. Health =/= social care Some areas are more LA, others are more health focused A pooled budget area, or one for six areas? Number of areas identified how pooled budgets are under a contract of joint commission When areas overlap, it is difficult to define where to put it. 25
Notes from the discussion of Workshop One (2/2) The governance/financial arrangements of a Pooled Budget (NHS and LA) can they be complimentary? Would it help to identify and define different models when considering pooled budgets? If so, where does this leave the culture? Priorities on spending are different in social care and in health, so the conversation needs to be around: why - what is the rational; what is the impact; and what is the benefit, instead of how much is helpful to understand each other Leadership and culture are key to a well-functioning and complimentary pooled budget Health and Wellbeing Boards have some role to play in determining the viability of a pooled budget Health and Wellbeing Boards can have the right representation (a balance of health and social care), but not delegate responsibilities; this isn t helpful Leadership without authority can help How useful are Health and Wellbeing Boards? They do provide leadership and decision making BCF focus is meant to be around the integration between health and social care and not just on the pot of money (or on DTOC) If we focus on the wrong end, we are missing opportunities for prevention Total place: where doe is it all fit? Areas with devolution are having difficulties in agreeing priorities are they missing the big picture? What s more efficient and effective: re-designing the way money is pooled, or designing from scratch? Anxiety about relationships of power at national level were discussed, and the impact of that at local level Can joined governance arrangements from the very top help? Would it be helpful to define roles and responsibilities? Commissioning for outcomes: how do CCGs fit with that? Once the money is pooled, don t focus on who is paying for what? Just get on with it and go for outcomes When a budget does not fit within BCF (i.e. some equipment), this can get in the way Health and social care account for things differently, such as overheads, full costs, and assumptions Accountability and statutory responsibilities are different between CCGs and LAs 26
Workshop Two Feedback The journey to a true Pooled Budget, setting up and overcoming barriers 14.25 14.35 The Better Care Fund 27
Notes from the discussion of Workshop Two (1/2) The journey to a true Pooled Budget, setting up and overcoming barriers There are different cash/vat rules for spending in CCGS and LAs; financial priorities are important LA may be best placed to hold the budget as they have more flexibility What about shared posts across CCGs/Las in regards to the administration of a pooled budget? Trust and relationships between the two organisations is vital this has to be evidenced Joint funded posts are a way of demonstrating this Radical review of governance arrangements is necessary in order to determine the eligibility of a functioning true pooled budget It is very time consuming to manage continuous change across two organisations; the viability of a pooled budget has to be considered in this context The climate of austerity: is it the best time to do health and social care integrations? Is now the time to bring forward areas of good practice in regards to pooled budgets? Some people look like good practice and when you talk to them they are not more progressed than other areas. Instead, good practice should be emerging practice - how areas are exemplary of new or changing models and how that first step can benefit other areas. This is true when it comes to demonstrating the usefulness of pooled budgets Not getting too hung up on legal or financial matters, but in the actual delivery of services is important How do we make this work from a financial, legal, and contractual point of view? It would help to be able to describe the barriers (both potential and existing), and how others have overcome these There isn t an instruction manual - you have to be brave Pooled budget = a mechanism. The focus is using mechanisms like pooled budgets to deliver integrated health and social care services 28
Notes from the discussion of Workshop Two (2/2) The journey to a true Pooled Budget, setting up and overcoming barriers Document risks, agreements, etc., as a way of putting them to rest, i.e. getting to a better place in our relationships There is always an anxiety about doing something new and not knowing whether or not it will work Focus should always be on delivery, but basics are always needed. For example: who pays for OT? What s the identity/culture around a pooled budget? We all try to reduce the amount of times we transfer money and try to reduce the money that we transfer; does a pooled budget reduce this barrier, or increase it? We have to set the direction of travel and the vision, be ambitious, and take small steps forward It s not about whether we do or do not have money, but about how we maximise the resources to deliver what we are meant to deliver Pooled budgets are a means to an end: they are not the outcome/the end in themselves Need to be careful with bureaucracy: is it driving the practice, or just enabling it? It needs to be able to deliver better outcomes Numbers, or narrative? Is the BCF just about BCF? The use of pooled budgets seems to blur this line No risk or overspend should be considered as extra money Risk sharing forms part of a dialogue The LA s governance makes it easier to hold the budget, but ultimately the holder is dependent on what is best for the specific areas 29
Roundtable Discussion Shaun Jones (Head of Assurance and Delivery, NHSE) Matthew West (Senior Programme Lead, BCST) Cliff Dalton (Head of Local Government, CIPFA) 14.35 15.00 The Better Care Fund 30
Notes from the roundtable discussion Social care spend claiming back the VAT could be an issue for the CCG; it is therefore better for the Council to lead a pooled budget. The council can then passport the VAT claim money back to the CCG. (An action from this discussion was that Matt West would raise this with the Treasury.) Planning Return Template there was a question on the quarterly reporting around having a pooled budget. It was argued that this should be changed to an aligned budget /description on budget arrangements. (The action from this was that Matt was to follow up with National Team.) 31
Close The Better Care Fund 32