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The main discussions on 20 March focused on one recent and two forthcoming reports:
The longest discussion came on the back of Ashley McDougall’s exposition of the NAO report on Integration and its subsequent presentation to the Public Accounts Committee on 27 Feb 2017. The PAC discussion focused on a concern that the associated measures hadn’t captured what the BCF was trying to achieve. Ashley believed that there were lessons about over-optimistic planning which might be transferable to STPs (only 12 out of 115 planning units had hit all four BCF targets). The NAO could find no evidence that integration leads to sustainable benefits other than patient satisfaction, but that wasn’t to make the policy judgement that integration was the wrong way to go, especially when the alternative is unclear.
It was the view of the meeting that too often when we hit a bump in the road we tend to step back from the right direction – that it was difficult didn’t make it wrong – sustained effort as in Scotland different cultures. The new models of care also display no clear benefits as yet (evaluations are due from three pilots by the end of 2016-17, and a further 18 in 2017-18).
The government has stopped talking about ‘full integration’ by 2020, and it isn’t clear what is intended by then. Devolution is too patchy and locally varied to act as a consistent driver. In a 2015 survey, CCGs and councils differed sharply on who should carry out unitary commissioning. Board members commented that there was no architectural role for H&WB Boards in STPs, as there had been for BCF. That exacerbated the problem of STPs not engaging sufficiently with councils, especially at the political interface.
The NAO report was thought a helpful antidote to the previous government’s hype when the BCF was launched. It was emphasised that older people is not the whole story, though (Learning Disability being a particular pressure and any failings in younger adults’ social care a potential cause of increases in A&E numbers) and a more sophisticated understanding is needed of what is causing the increased numbers attending A&E.
Another factor is that neither local government nor the NHS are themselves integrated in England. The Panel also noted that the government expects the NHS to get something directly from the extra £1.1bn for social care which was announced in the Spring Budget, but social care may well be in a position parallel to the NHS – when £2.1bn was announced as available for transformation, but £1.8bn went on supporting the bottom line problems caused by existing pressures.
The Board discussed CIPFA’s draft paper on STPs, which resonated with the NAO report. The Board agreed that the STP process is good as it brings longer term planning to the NHS, but felt that more was needed on the political interface with LAs, acknowledging that local politicians need to be more fully involved but will be reluctant to support controversial changes so long as the government centrally and MPs locally are not saying "you need to close acute beds" etc. Members pointed out that the imposed footprints of STPs are often a poor fit for democratic accountability and not necessarily a good fit for health locally either.
It was suggested that the paper provides a chance for CIPFA to be bold and distinctive, to emphasise that it’s about people not structures, local not national – more national are plans are not the answer. Time is needed to build local solutions.
The Board was also keen to use the document to reinforce and support members in their professional roles, for example in assessing the realism of savings plans and cautioning against any "optimism bias". That approach makes particular sense given that the statutory backing for the finance professional is weaker in health than in local government.
The Board endorsed the recommendations of the CIPFA-PHE research report Evaluating Public Health Investments, which will now be taken forward. The support it gives to properly grounded account being taken of long term revenue investment decisions is very consistent with what is needed now in the context of STPs. Practical examples are always helpful, and CR agreed to forward details of an exercise in Thurrock which evaluated what savings would have resulted from "looking for the missing thousands" – had they those not registered with GPs been tracked, how many strokes etc would have been avoided?