There are four sources of funding into the health- and social-care system:
- CCGs who are responsible for the majority of acute funding, mental-health, community health and prescribing
- NHS England who are responsible for primary care, dentistry, ophthalmology and specialist services provided from relatively few centres (such as rare cancers or trauma care)
- Local authorities who are responsible for social-care (including personal budgets) and public health (including sexual health)
- Private contributions from individuals who may fund their own social-care, buy over-the-counter medicines or other well-being services.
Commissioners in each local area need to decide which of their budgets they will pool to fund new models of care. These decisions will be influenced by local circumstances and the outcomes commissioners are funding provider networks to achieve. Private contributions cannot be pooled with health care funds because it contradicts the NHS principle of being free at the point of use.
A working group of commissioners, providers and service users discussed the pooling of all commissioning budgets and reached the following consensus:
Source: Whole Systems Integrated Care Module Working Group
- All CCG budgets, including acute, mental health, community health, prescribing
- Social care
- Primary care
- Budgets all fund services where coordination is critical to holistic care for the majority of population
- Pooling these budgets will give provider networks significant flexibility to improve model of care and achieve desired outcomes
- Excluding some acute budgets, such as elective care, from the pooled fund may also create perverse incentives (see Discussion 1)
- Primary care related additional payments such as locally enhanced services may be pooled rather than the whole primary care contract (see Discussion 2)
- Personal budgets
- Some specialist care
- Public health
- Local authorities have statutory obligations on personal budgets that cannot be delegated. However, pooling with safeguards may encourage greater innovation (see Discussion 3)
- Consider pooling specialist care that is linked to long-term conditions as this provides incentives to avoid escalation
- Public health funds preventative interventions that mostly significantly impact on health
|Unlikely to pool
- Highly specialist care
- Highly specialist care is best commissioned at strategic, regional level rather than by provider network
- Dentistry and ophthalmology have fewer overlaps and dependencies with other care models, so complexity of pooling likely outweighs the benefits
Local areas will need to take the following considerations into account when deciding which budgets to pool:
1. Elective versus non-elective: Acute care budgets can be further divided into elective admissions, non-elective admissions, outpatient appointments and A&E. The working group believed that all these budgets should be pooled to avoid perverse incentives, although local areas may take a different view. For example, if elective admissions were excluded from pooled funds, it risks provider networks choosing to prioritise elective interventions above other alternatives as they would be separate from their budget. The risk of including elective admissions in a pooled budget is the opposite, where provider networks unreasonably discourage them because their high individual cost has a disproportionate impact on any pooled budget. This highlights the need for clear and carefully measured outcomes to avoid perverse financial incentives. More information is available in Chapter 5: What are the outcomes to be delivered?
2. GMS versus APMS: There are restrictions in how General Medical Services (GMS) contracts can be used, restricting the ability to pool to fund a provider network. When operating a pooled budget, an Alternative Primary Medical Services (APMS) contract will be needed. GP practices that are currently funded through GMS contracts may be unwilling to change their arrangements as GMS offers extra protections, such as indefinite duration as opposed to the three- to five-year terms of APMS. NHS England have committed to supporting Whole Systems Integrated Care and are willing to let primary care early adopters experiment with new contracting arrangements, whilst retaining the right to return to current arrangements.
3. Social-care, FACS eligibility and personal budgets: Social-care services are not free at the point of use like the NHS. Instead, individuals are assessed using FACS (Fair Access to Care Services) criteria to determine what services they are entitled to and then complete a means test to determine how much they must contribute. There are four eligibility bands – critical, substantial, moderate and low – that have been specified nationally. The bands grade eligibility needs in terms of risk to individuals’ independence and well-being and the consequences of their needs not being met. After a local authority assesses an individual as FACS eligible, it assumes the obligation to provide an agreed level of social-care to that individual.
Many people now receive their social-care support through a personal budget. This can be managed through one or more of either direct payments to the individual, a managed account held by the council, an individual service fund held by a provider and managed by the individual, or a trust held by a carer or friend. Individuals can top up their personal budgets if they wish. The advantage of including personal budgets in pooling arrangements is that it will provide flexibility to providers in how they are integrated into their model of care. This could encourage their wider use to support people to keep well at home beyond those who are assessed as FACS eligible.
However, if personal budgets were pooled, local authorities must make sure that:
- They retain decision-making about whether individuals are FACS eligible as this cannot be delegated, although advice can be received from other organisations.
- Provider networks meet all FACS obligations in full and they have strong contractual levers to enforce this obligation.
Within each population group, reliance on different commissioners varies as the most important budgets shift. Pooling is most vital where the split in services is most even between CCG, NHSE and local authority funds. For over 75s with long-term conditions, for example, average cost per person is roughly equal between local authority and CCG funding, suggesting the importance of pooling for the development of integrated multi-disciplinary teams caring for individuals in this population group.
Check and challenge
budgets are you going to pool to support Whole Systems Integrated Care?