1. One Budget, One Care: Should
the UK adopt a single health
and care system?
Twitter: #onebudget!
June 25th 2013!

2.  Chair: Andrea Sutcliffe, Chief Executive, Social Care
Institute for Excellence!
 Rt. Hon Stephen Dorrell MP, Chair, Health Select
Committee!
 James Lloyd, Director, Strategic Society Centre!
 Dan Gascoyne, Assistant Director for Corporate Policy,
Strategy and Partnerships, Essex County Council!
 Matthew Flinton, Director of Legal and General Counsel,
Bupa UK!

3. Rt. Hon Stephen Dorrell MP

4. James Lloyd
Director
Strategic Society Centre

5. …Who’s talking about integrated
care?

6. Everyone…
 Health Committee: Report on Social Care
(2012)!
 Department of Health!
 Labour Party – Independent Commission
on Whole-Person Care, under Sir John
Oldham!

7. …What does integrated care mean?

8. Everything…
 Multiple meanings have created confusion, but…!
 Single assessment processes!
 Integrated care pathways!
 Joined up working among providers!
 DH plan for ‘joined up’ care by 2018!
 Joint commissioning of health and care services!
 Single providers of health and social care!

9. All these models lie in different parts of the
‘integrated care matrix’…
 Source: Lloyd J and Wait S (2006) Integrated
Care: A guide for policymakers
Provider(
integra-on(
User(
integra-on(
High%
High%
Low%
Low%
Models of integrated
care can be located in
different parts of this
matrix

10. …What is the most radical vision of
integrated care?

11. The ‘one budget’ approach…
 The full merging of ‘health’ and ‘social
care’ budgets;!
 + Housing!
 + Mental health!
 One integrated budget for achieving an
integrated outcomes framework, enabling
the commissioning of integrated services.!

12. …Why have this conversation now?
A simplified view of the health and
care system in England: ‘before and
after’

13. N!
H!
S!
LA Care
Budget!
Commissioner !
Services!
Outcomes! Outcomes!

14. Health
Budget!
LA Care
Budget!
Commissioner ! Commissioner !
Services! Services!
Outcomes! Outcomes!

15. Health
Budget!
LA Care
Budget!
Commissioner ! Commissioner !
Services! Services!
Outcomes! Outcomes!
Health &
Wellbeing
Board!

16. …Why take a ‘one budget’
approach?

17. Various potential benefits…
 End to cost-shifting between health vs. care
budgets!
 End to arguments over defining types of need!
 Enable development of integrated, holistic
services!
 End to cost-shifting between service providers!
 Enable fewer assessments, Less administration!
 Better user experience!

18. Various potential benefits…
 Incentives to invest in cost-effective social
care services!
 Shift resources from ‘health’ to ‘social care’!
 “Handrails, not falls treatment”!
 More space for innovation in practice and
delivery !
 E.g. development of new professional roles,
such as ‘Local Area Coordinators’!

19. But also some risks…
 Resources may be pulled up to acute care!
 Hospitals important to politicians, so will still
be a priority!
 Complexity, transition risks, etc.!
 Others?!

20. ...Why is there such interest in a
‘one budget’ approach now?

21. Two factors are changing the
agenda…
 Health and Wellbeing Boards present an
opportunity!
 Potential ‘structure’ for full single, sovereign,
integrated health and care budgets; !
 Emergence of a ‘burning platform for
change’: the crisis in A&E/NHS pressures!
 Blamed on division between health and care
system!
 Also blamed on social care budget shortfalls,
which could be met from NHS resources!

22. …So, do Health and Wellbeing
Boards really provide the big
opportunity for one, integrated
budget?

23. Yes…
 Does not require complete reorganisation of local
government financing;!
 Local authorities can ‘devolve’ practical responsibility
for meeting their duties!
 Shift lots of CCG and Local Authority social care staff
to enlarged ‘Health and Wellbeing Commissioning
Boards’!
 Each local HWCB can proceed at own pace!
 No top-down change forced through !
 In line with development of integrated services by
providers!

24. But…
 Still lots of questions/issues to address!
 HWCB legal structure likely requires
enhancement through primary legislation at
Westminster!
 HWB experience so far is mixed!
 Resistance to giving up sovereignty and money!
 So, ‘one budget’ approach would still need a push
from Westminster?!

25. What could “Health and Wellbeing
Commissioning Boards” do?...

26. Health
Budget!
LA Care
Budget!
Commissioner ! Commissioner !
Services! Services!
Outcomes! Outcomes!
Health &
Wellbeing
Board!

27. HWCB!
One
Budget!
Services!
Outcomes!

28. So what are the issues we need to
be thinking about?...

29. Many, but three I want to flag…
 Integrated service providers!
 Personal Budgets!
 Partnership between individual and state
in paying for “social care”!

30. Integrated service providers…
 To be truly worthwhile, ‘one budget’ approach
needs integrated providers!
 Providers able to take a holistic ‘whole person’ view of
person and needs!
 But this is a major challenge to providers:!
 How quickly can providers respond?!
 On what basis will they be happy to be
commissioned?!
 Is the regulatory framework ready?!

31. What is the Personal Budgets issue
for the ‘one budget’ approach?...

32. Health
Budget!
LA Care
Budget!
Commissioner ! Commissioner !
Services! Services!
Outcomes! Outcomes!

33. Health
Budget!
Personal
Budget!
LA Care
Budget!
Commissioner ! User
commissioner !
Commissioner !
Services! Services!Services!
Outcomes! Outcomes! Outcomes!

34. Personal
Budget!
User
commissioner !
HWCB
Commissioner !
One
Budget!
Services!Services!
Outcomes! Outcomes!

35. Questions for Personal Budgets and
‘one budget’ approach…
 How would Personal Budgets be determined
under a ‘one budget’ approach? And ‘choice and
control’ preserved?!
 Local authority Resource Allocation Systems (RAS)
for social care already a contested area!
 Unclear how RAS could be used to determine
Personal Budget when HWCB is commissioning for
single integrated outcomes framework from a single
budget!
 More difficult to determine £RAS on basis of services
available in different market?!

36. And so… what about long-term care
funding?

37. Health
Budget!
LA Care
Budget!
Commissioner ! Commissioner !
Services! Services!
Outcomes! Outcomes!

38. Health
Budget!
LA Care
Budget!
Commissioner ! Commissioner !
Free
services!
Means tested
services!
Outcomes! Outcomes!

39. Option 1: Scrap all means testing…
 Very expensive, despite emerging efficiency
savings from ‘one budget’ approach;!
 Social care will never be ‘free at the point of use’
like NHS;!
 Why? If everyone in residential care receives the LA
‘usual cost’ rate as cash-based Personal Budget,
untenable to prevent private ‘top-ups’!
 Current ‘self-funders’ would use additional LA money
to pay more and get more!
 Implications for care market, prices and inflation!

40. Option 2: Retain means testing and
charging framework, but adapt it…
 Individuals charged for services proportional to
means!
 But which services? !
 ‘One budget’ approach seeks to blur boundaries
between health vs. care needs, services and costs!
 Plus, in context of ‘one budget’, most cost-effective
way to distribute resources may not be to retain care
eligibility thresholds and means tests for what was
once known as ‘social care’;!
 Why? May be cheaper to provide free ‘care’ services to “rich”
people if it keeps them out of hospital.!

41. …And what about how state and
individuals pay for care?

42. ‘Capped cost’ reforms…
 Dilnot Commission published recommendations in July
2011!
 Proposed significant changes to current means tested
system in England!
 Core principle: only the state can protect individuals from
‘catastrophic’ care costs!
 Government has committed to implement ‘capped
cost’ reforms from April 2016!
 ‘Cap’ on notional accumulated ‘Personal Budgets’ that
wealthy individuals are excluded from by LA means test!

43. ‘One budget’ and the ‘capped cost’
reforms’…
 ‘One budget’ approach seeks to breakdown distinction of
health vs. care needs, costs and services!
 So, current local authority FACS (Fair Access to Care Services)
eligibility framework and RAS systems will need to be completely
reworked to enable ‘one budget’ approach. !
 However, these frameworks/systems are building blocks of
‘capped cost’ reforms for metering costs of care in the
community;!
 So, the ‘capped cost’ reforms cannot be implemented in
current form under ‘one budget’ model. !
 Need to rethink how to apply the ‘capped cost principle’ in
context of one budget approach?!

44. Conclusions…

45. Conclusions…
 A&E crisis + HWB framework + political
consensus may be tipping point for radical
integration of health and social care spending!
 But huge questions for Personal Budgets,
integrated providers, definitions of need, and
potential for unintended consequences!
 Opens up again question of ‘partnership’
between individual and state in paying for
what was previously known as ‘care and
support’.!

46. Dan Gascoyne
Assistant Director for Corporate
Policy, Strategy and Partnerships
Essex County Council!

47. Strategic Society Centre Debate
25th June 2013
Dan Gascoyne
Assistant Director for Corporate Policy, Strategy and
Partnerships, Essex County Council

48. • Partners across Essex, Southend and Thurrock have long supported the
development of Community Budgets as a means of improving local
outcomes and have worked to shape the concept since its inception.
• In December 2011 partners submitted a successful expression of
interest to become one of four Whole Place Community Budget pilots.
• Following selection we’ve worked with secondees from central
government to co-design proposals for sustained system-change in
local public services through our Whole Essex Community Budget
(WECB) programme.
• Operational Plan submitted 31st October 2012
• Proposals developed during the pilot phase will deliver total cumulative
net benefits worth £388m to 2019-20 of which £118m will be direct
cashable savings.
• In March 2013 resources were committed to detailed implementation
plans and governance to deliver these proposals and develop further
opportunities.
2
Whole Essex Community Budget: background

49. Overview of public sector spending Essex

50. Moving from business cases to phased implementation
4
WECB Programme Overview
Health and
Wellbeing
Integrated
Commissioning
Economic
Opportunity
Skills for Growth
Community
Safety
Reducing
Reoffending
Reducing
Domestic Abuse
Family Solutions
(FCN)
Strengthening Communities
Essex Deal For
Growth
Social Investment
Housing – new project

51. 5
Integrated commissioning differs from existing joint
commissioning arrangements as follows:
Stakeholders"
Ambi8on"
Governance"
Scale"Margins( Mainstream(
Single(Service(
Mul1(Service(and((
Systemic(Change(
individual((
“charisma1c‟(
lead(
system8wide,((
transparent(
governance((
and(accountability((
Few( Many(
Joint"Commissioning"
Integrated"Commissioning"

52. 6

53. Summer 2012 - OBC
7

54. Where are we now?
8
• Domestic Abuse – Alan Ray
• Strengthening Communities – Jasmine Frost
• Housing -
Project Project overview Update
Integrated
Commissioning
Driving forward strategic
integration across the
Health and Social Care
system in Essex.
Led by the Essex Health
and Wellbeing Board.
• All 5 Essex CCGs have produced Integrated
Plans which set out how they will deliver QIPP
(Quality, Innovation, Productivity and
Prevention) and how they will work with ECC on
integrated commissioning this year and in the
future.
• As part of ECC transformation 5 joint posts are
being recruited to, covering each of the five
Essex CCG areas
• Partners working to define the ‘end state’ and
how we will get there and commit the capacity to
progress the work programme at pace, agreed
programme management approach.
• Integrated Care Pioneer proposals being
developed to support direction of travel

55. Outline framework to progress integrated commissioning has been
agreed by partners across Health and Social Care. Shaped through
five key service areas:
• Older People
• Mental Health
• Learning Disabilities
• Children’s Services
• Public Health
9
2013/14 Commissioning Framework

56. 10
Indicative Commissioning levels & leads (tbc)

57. 11
Principles*
Our work on integrated commissioning is guided by the
principles that:
• services are commissioned based upon customer needs
• where possible, they should be local and easily accessible
• addressing the needs of whole communities
• with an emphasis on prevention and early intervention
• organisations will share resources to maximise value for money
• sharing equally the responsibility for risk
• ensure service quality underpins decisions to allocate resources

58. Benefits
We expect our approach to deliver the following benefits:
• Realising economies of scale and providing services at lower cost
• Improving outcomes by tackling entrenched problems
• Greater focus through prioritisation
• A more stable planning cycle
• Less complexity through clearer governance and accountability
• Streamlined pathways with reduced duplication
• A shared language and common understanding of purpose
• Greater responsiveness to community and individual needs
• Increased service provision in preferred settings e.g. community
• Ability to focus on preventative approaches to service delivery
• Innovation through working across agency and professional silos.
"
12

59. Programme Cost / Benefit - summary
New Investment Costs Cumulative Benefits to 2019/20
2013/14
Further
Implementation (to
2019/20)
Net Cashable
Non-
Cashable
Total benefits
Project £'000 £'000 £'000 £'000 £'000
HWB - Integrated
Commissioning
359 tbc
-91,971
0 -91,971
* exemplar only
Family Solutions 1,583 10,258 -29,112 0 -29,112
Domestic Abuse 370 1,800 49 -4,059 -4,010
Reducing Reoffending 178 1,008 1,186 -113,615 -112,429
Skills 47 90 137 -151,588 -151,451
Strengthening Communities 650 tbc 650 tbc 650
Social Investment 450 tbc 450 tbc 450
3,637 13,156 -118,611 -269,262 -387,873
Opportunity Costs 3,835 14,199
Total 7,472 27,355

60. Some key messages
1. Community budgets should be focused on sustainable system-change: they
have the potential to bring about wholesale system-change in public services:
joining-up and co-ordinating services, streamlining processes and improving
citizens’ experiences.
2. Community budgets should focus on shared outcomes rather than pooled
budgets: there are risks associated with the creation of a single funding pot. A
focus on shared outcomes and integrated commissioning, rather than on the
mechanics of pooled budgets, is what’s needed.
3. Community budgets are a tool to change culture: This offers great value and
requires local innovation and greater flexibility within Whitehall and local partners.
Policy frameworks established by central government departments must be
flexible if they are to support, rather than limit local system-change
4. Government should not seek to artificially limit the scope of community
budget activity: focusing proposals on social outcomes is not enough –
economic outcomes are equally important and complementary to prevention.
14

61. • Dedicated resources, robust programme management &
governance – invest to save, for the long run
• Clear understanding of place: priorities, leadership, behaviours
• Importance of focus
• Genuine co-design – locally and nationally
• Understanding sovereignty
• Deep, lasting engagement and ownership from key stakeholders
• Willingness to flex, adapt and connect with a dynamic system e.g.
12/13 - NHS reforms; PCC; Heseltine; Transforming Rehabilitation;
ECC TMII; Integrated Care; etc
15
Making a community budget successful

62. 16
!
“The only way the world is going to address social problems is
by enlisting the very people who are classified as ‘clients’ and
‘consumers’ and converting them into co-workers, partners and
rebuilders of the core economy.”
Professor Edgar Cahn,
US civil rights lawyer and inventor of time banks.""
www.wecb.org.uk
www.communitybudgets.org.uk

63. Matthew Flinton, Director of
Legal and General Counsel,
Bupa UK

64. Questions for discussion…
 Integration choices – can real efficiency savings be achieved from joint
commissioning, or will they only really be possible from full merging of
health and care budgets to enable a single budget with a single
commissioner?!
 Budget pressures – is integration of health and care budgets made easier,
harder or inevitable by the unprecedented budget pressures confronting the
health and social care systems over the next decade? !
 Implementation – how would a single health and care budget be created
from the new structures in the NHS and local government? Do Health and
Wellbeing Boards provide the key?!
 Defining need – would a single budget for health and care retain distinctions
between health and care needs, or just focus on commissioning services for
outcomes?!
 Paying for care – what, if any, services would individuals be charged for
under a single health and care budget? Would social care still be means
tested?!
 Capped costs – what do radical models of integrated commissioning and
funding mean for the government’s plans to cap people’s care costs?!

65. !
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Strategic Society Centre
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London
SE1 0EH
Tel. 020 7922 7732
info@strategicsociety.org.uk!
www.strategicsociety.org.uk
Twitter: @sscthinktank !
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with limited liability in England and Wales (Company No. 7273418).!