Figure 2: In your view, what are the main underlying causes of
delayed transfers of care?
Lack of adequate
incentives in the
e.g. speed of
The care provided to those in hospital has been designed around treating
individual isolated problems. However, older people are most in need of coordinated care and are most likely to experience transitions between types of
care. Payment systems do not lend themselves to treating patients with multiple
conditions, as patients with multiple needs may require longer appointment
As one interviewee said: "We need to move towards a system that rewards
outcomes rather than activities. The existing system pays if patients don't get
better, get worse, or even die." Or, as another put it, "independent funding
streams provide no reason for Health and Social Care to change the way
they operate and should be replaced with pooled budgets that foster greater
integration." A significant number of interviewees mentioned significant failures
in the incentive structure. Clearly if what we were told is correct and these
reports are accurate then the system is mitigating against the right results for
An attempt to introduce a more rational incentive is the Better Care Fund (BCF),
announced in 2013. The BCF is designed in to be used for joint NHS-local
authority commissioning of integrated health and social care services.
However, of the total £3.46 billion allocation in 2015/16, £1 billion is made
up of 'payment for performance' incentives. The incentives are only received
if Health and Wellbeing Boards can hit a set target for a reduction in total
emergency admissions of at least 3.5 per cent for the year.75 Where this target
isn't achieved, this proportion of the funding (almost a third) will be handed
back to the NHS leaving local authorities even more financially stretched.
Indeed when giving evidence to the Public Accounts Committee in December
2014, the chief executive of the Local Government Association (LGA) Carolyn
Downs said that the LGA had considered walking away from the Better Care
Fund programme due to the burden of risk placed on councils.76 The concept
behind the creation of the Better Care Fund - to catalyse the integration between
health and social care that we argue is so desperately needed - is very welcome.
However, it is to be hoped that future iterations of the programme can achieve
a more equitable balance of risk and reward for both sectors.
Promisingly, Samantha Jones, the recently-appointed Director of Care Models
NHS England's, stated in her first interview that proposals to develop pioneering
health and social care models will need to demonstrate meaningful clinical 74 The King's Fund, Making our
health and care systems fit for an
ageing population (2014)
75 Department of Health,
Department for Communities
and Local Government, Better
care fund policy framework
76 Peters, D, "Councils 'were close'
to dumping the BCF" The MJ (2
Chapter 3 - What Is The Diagnosis? Or Why Are We Failing Our Elderly?