Page 1

‘A new settlement for health and social care’ Interim Report - Call for Responses Leeds City Council Response Introduction Following the interim report from the Barker Commission and subsequent call for responses, we are pleased to be able to contribute to an important discussion on the future sustainability of the health and social care system. Leeds is a recognised national Integration Pioneer and we believe that local authorities and local health partnerships have a significant contribution to make in finding the solutions for a sustainable, high quality health and social care system. We have set out 7 key principles which we think should steer the solutions for future sustainability. This list is not exhaustive, and neither does it cover all the questions raised by the interim report. However, they do incorporate priority areas for which we can provide useful insight. Overview Broadly, we agree that there needs to be a new settlement in health and social care. Current funding is not adequate for long term sustainability and the system requires significant change. A new settlement would need to be in the spirit of closer alignment between health and social care. This must be done with the assurance of an adequate settlement which is protected and transparent in the allocation of budgets. With regard to entitlements to equal support, we think that they should be set at a national level, in line with some of the principles set out in the Care Bill. Linked to this, we wholeheartedly agree with the statement in the report that it is not productive for the country to get into a ‘sterile debate’ between health and social care as opposing organisations. It is more important to be making the best use of collective resource across the system. This is an underpinning principle of our partnership work in Leeds. The following Key Principles provide more detail on what we consider to be some of the priorities for establishing a sustainable financial outlook for health and social care.

Leeds City Council | LCC Barker Commission Final Response.docx

1


KEY PRINCIPLES We believe that the solutions for ensuring sufficient funding for health and social care should include the following principles in their design: 1. ADEQUACY There needs to be protection of health and social care budgets to ensure that funding is adequate and fair in the long term. 2. LOCAL OWNERSHIP The allocation of funding and setting of budgets for health and social care must be done at the local level. 3. DEVOLUTION Future policy and funding decisions need to support the devolution agenda, where localities have the freedom and flexibilities to address the issues they face at a local level. 4. INTEGRATION The primary goal for integration is better quality care and experience of care for people. Future policy and funding decisions must be taken with more integration, alignment, shared services and system leadership held as key priorities. 5. WELLBEING A focus on wellbeing and the wider determinants of health to create strong, sustainable communities must be pursued for the health and social care system to be financially sustainable in the long term. 6. NATIONAL CONVERSATION There needs to be a reasoned, open, cross-party and national conversation about how to sustainably fund health and social care in the future.

2

LCC Barker Commission Final Response.docx | Leeds City Council


1. ADEQUACY There needs to be protection of health and social care budgets to ensure that funding is adequate and fair in the long term. Local Authority funding pressures Since 2010, local government has had to cope with significant reductions to core funding and a significant restructure of the local government financial system. There has been a 40 per cent reduction in real terms to core government funding over the life of this parliament.1 The Council has had to achieve £94m savings in the last 3 years and faces reductions of a further £81m in the next two. Whilst these savings have been well managed to date, there will come a point where further savings cannot be achieved without significantly compromising vital front line services. The Local Government Association has described 2015/16 as the ‘crunch year’ for council budgets, and when combined with the pressures faced across the system, it is clear to us that the current direction of travel for funding health and social care is unsustainable.2 We are therefore in agreement that there needs to be significant changes in the adequacy and mechanisms for core funding for health and social care. Protected budgets with non-ring-fenced allocations We agree that there needs to be more protection of health and social care budgets. However, this must be done alongside a commitment to reducing ring-fencing. The organisations within a local health and care system are best placed to understand the needs of the people that they serve and non-ring fenced budgets allow them the flexibility to use funding for the best possible shared outcomes across the system. Budget changes should be transparent, clear and accountable Changes in the structure of funding to local authorities and health partners must be done in ways that are transparent, clear and accountable. During the significant restructure of the local government finance system there has not been sufficient accountability for the quantum of funding and its distribution across different parts of the country. If there are to be significant changes in the years to come then annual changes in budgets must be clear in the workings and statements made by government. Localised Council Tax Support, Council Tax Freeze Grant and the Better Care Fund are examples of how national government accounting and publishing of spending power figures have not been fully reflective of what is experienced on the ground by local authorities. This issue has particularly relevance to the recommendation in the interim report from the Barker Commission. We have some concerns about what constitutes the ‘social care budget’ on a national level, and how this would be accurately calculated and shown in national budget reports. The coming years present the biggest pressures on health and social care funding and it is important that any significant changes are transparent and clearly accountable so as not to compromise any well-intentioned changes to protect the budget across the system.

1

Local Government Association, ‘Under pressure - How councils are planning for future cuts’, 12 May 2014 ‘No more cuts councils tell Chancellor ahead of Autumn Statement’, LGA press release 5 November 2013, http://www.local.gov.uk/media-releases/-/journal_content/56/10180/5636691/NEWS 2

Leeds City Council | LCC Barker Commission Final Response.docx

3


Budget decisions need to be coordinated across government departments Local health and social care authorities are allocated funding from a number of departments. It is therefore important that the Treasury develop shared outcomes and budgets across Whitehall to help enable coordination and integration. This is not exclusive to pooled budget arrangements. This has relevance to the recommendation in the interim report from the Barker Commission about having a singly commissioned ‘health and social care budget’. Social care includes services for both children and adults, so we would be interested in how this budget would fit between the two. We would urge that future funding mechanisms should help to facilitate shared outcomes across children’s and adults’ commissioning and improve. It is important that health and social care planning and investment are sufficient across the lifecourse and the transition for children and young people into adulthood is as positive as possible. Localities need long-term financial commitments Previous financial settlements for local government and clinical commissioning groups have been allocated at too short notice with too short a time period. Future settlements need to provide long-term indicative budgets in order to facilitate long-term planning, risk-sharing and early intervention across the health and social care system. Adequate funding for public services as a whole The financial challenge for health and social care is a priority for public services over the next 10 years and beyond. We think that this debate and the associated solutions should not be at the expense of high quality public services as a whole. Local authorities provide a number of services which benefit the wider determinants of health. The transfer of Public Health has played an important role in increasing the contribution from local authorities. Whilst a new settlement may help to protect health and social care services, we think the services and initiatives that would be funded outside of this also need to receive adequate funding so as not to compromise the wider determinants of health. 2. LOCAL OWNERSHIP The allocation of funding and setting of budgets for health and social care must be done at the local level. Local Control and Local Accountability The consequences of combining health and social care budgets to create a single settlement would bring about fundamental changes to the way that local finance is collected and allocated. By so doing, budgets would be combined between the National Health Service and Local Government. It is crucial that if any mechanisms are used to facilitate this, they are done with local control and local accountability for budgets and services. Spending needs to be coordinated across individual localities We believe that the best place to plan and evaluate the quality of integrated care is at the local level. In Leeds we use the concept of the ‘Leeds Pound’ to evaluate how spending operates within the local area. The Better Care Fund will be an important test of how budgets are combined and the effects that this has on quality and expenditure. Any further combination of health and social care budgets will need to ensure that spending is first and foremost coordinated at the local level.

4

LCC Barker Commission Final Response.docx | Leeds City Council


New provider models The development of payment systems and new provider models will be an important part of making local health and social care systems sustainable, integrated and innovative. Leeds will be hoping to trial some of these as part of its Integration Pioneer status. Government needs to encourage these new models so that different models of integrated care can develop according to the needs of local populations. Many of these provider models will be developed independent to how budgets are combined at the national level. Government should focus on this side of integration in addition to infrastructure and governance issues within Whitehall departments. 3. DEVOLUTION Future policy and funding decisions need to support the devolution agenda, where localities have the freedom and flexibilities to address the issues they face at a local level. Genuine and large scale devolution Added to local ownership, the operation of a future health and social care budget needs to support the devolution agenda. This is an important issue for Leeds City Council, which led work on the Commission on the Future of Local Government. More power should be devolved from the overly centralist and silo’d Whitehall, to be closer to communities who have a stake in the success of places and who should then see a closer link between politicians and positive action. Building on City Deals, powers could be given to councils or collections of councils (such as Combined Authorities) that reflect the way in which local economies and markets work. In a decade of low growth and austerity, attempts to rebalance the economy geographically will only succeed if local areas can take more control over their own destiny. This requires new and vibrant public-private ventures that enable councils to become more enterprising and businesses to become more civic. 4. INTEGRATION Future policy and funding decisions must be done with further integration, alignment, shared services and system leadership held as key priorities. Evidence for integration There needs to be more evidence about how additional integration will provide the cost savings that we hope it will. There also needs to be more evidence about how pooling budgets will contribute to successful integrated care. However, we believe that pooled budgets should have a significant role in enabling integrated care and are sure that integration is the right thing to do for quality care that is good value for money. Just because the evidence for both of these changes is not yet conclusive, it does not mean that budgets should not be pooled. The Better Care Fund should be an important test scheme for the effects of pooling budgets on integration. However, the expectations for this fund should be realistic and pooled budgets should be implemented with caution and security for local services. Recognise the limits of combining budgets In Leeds we are clear that a combined, ring-fenced budget which is singly commissioned would not inevitably lead to better services. We note the research from the University of York which concluded that ‘pooling funds across health and social care services is not a panacea Leeds City Council | LCC Barker Commission Final Response.docx

5


that will lead to the successful delivery of integrated care.’3 Integration is dependent on a significant number of dependent factors in addition to pooled budgets. We are clear that an important priority for integration is for it to be led at the local level and its success is significantly dependent on the quality of local working relationships between organisations and services. Again, the experience of the Better Care Fund will be an important test for pooled budgets and joint commissioning. There are many programmes associated with the integration agenda which are largely independent of how a new settlement would be operated on a national level. Data and technology projects, procurement mechanisms, public and private sector dynamics, care planning and management structures are amongst the many aspects of successful integration between health and social care. To achieve successful integration it is important that the limits of combining settlements and budgets is recognised and sufficient resources and developments are focused on other key aspects of the integration agenda. Integration and alignment in order to improve quality We agree that the motivation for more integration and alignment of services should be first and foremost about improving the quality of services and experience for users. Full integration of health and social care organisations should not be a principle policy goal, but the full coordination of services around the needs of people should be. Any resulting savings should be targeted, but solutions for integration should be designed with better quality services as their primary objective. The role of Health and Wellbeing Boards in system leadership and integration Health and Wellbeing Boards are built on the principles of partnership working and democratic accountability. In their first year, boards across the country have made significant developments and in Leeds we are in a strong position to provide leadership for the health and social care system. Any changes associated with the future funding arrangements of health and social care must work to support the position of health and wellbeing boards as a key system leader with democratic accountability. Changes must also work to provide the boards with a clear mandate and robust supporting legislation to enable them to execute this function and make bold choices across localities. 5. WELLBEING A focus on wellbeing and the wider determinants of health to create strong, sustainable communities must be pursued for the health and social care system to be financially sustainable in the long term. No further fragmentation Health and Wellbeing Boards and the transition of Public Health into local government have gone some way to embedding more of a social model of health with a wider focus on wellbeing. We believe that future reforms to funding should help to strengthen this approach. If implemented, a single health and social care budget needs to ensure that there is not further fragmentation or separation from public health and other functions of local government. Protection of local authority budgets

3

Centre for Health Economics. Financial mechanisms for integrating funds for health and social care: an evidence review. CHE Research Paper 97, York: University of York, March 2014.

6

LCC Barker Commission Final Response.docx | Leeds City Council


Inevitably, if health and social care are protected there may be more pressure on other areas of the local authority budgets. We think that any changes should not further compromise the future of local public services as they could lead to more pressure on services that contribute to the wider determinants of health but do not necessarily fall under the ‘health and social care budget’. This is also relevant for the Public Health budget in local authorities, which plays a crucial role in keeping people fit and healthy. It is important that this budget is protected so as to safeguard the development of a more social model of health. The budget should not be subsumed by national reorganisations in order to address local government funding deficits. In Leeds, the Health and Wellbeing Board have given significant focus to projects which improve the wider determinants of people’s health. This is reflected in our Joint Health and Wellbeing Strategy. The Homeless Accommodation Leeds Pathway, “Take a Stand” against high cost lenders campaign, Child Friendly City ambitions and Winter Warmth initiatives are just some examples of how health partners contribute to and benefit from work that helps to develop healthy and sustainable communities. 7. NATIONAL CONVERSATION There needs to be a reasoned, open, cross-party and national conversation about how to sustainably fund health and social care in the future. A number of organisations and reports (IPPR, Oldham Commission, SOLACE, NGLN, The King’s Fund) have called for a national cross-party discussion on the future funding of health and social care. In Leeds, we have obtained cross-party agreement for health and social care initiatives for the city. In order for local health and social care economies to make long term decisions that balance risk across the system, they need secure, reliable and long term funding and policy commitments. This long-term shift needs to happen in an open, transparent and pragmatic way. For this to occur, national cross-party agreement is required. Related to this national conversation, we wholeheartedly agree with the statement in the report that it is not productive for the country to get into a ‘sterile debate’ between health and social care as opposing organisations. We require national and local leaders to approach the future sustainability of health and social care as a joint problem with a joint solution for one system with collective resources.

Leeds City Council | LCC Barker Commission Final Response.docx

7

Leeds City Council Response to the Barker Commission Call for Evidence  

The response from Leeds City Council about the future of health and social care in England, following the Barker Commission's interim report...