Better Care Fund Support Programme: Scoping diagnostic support - insight and learning report

The following report sets out key themes drawn from insights gathered through the Better Care  Fund (BCF) Support Programme Scoping Diagnostic work with several local systems in spring and summer of 2023. These diagnostics are a structured, joined up conversation with senior leaders, in a health and social care system, led and managed by a senior expert. The objective is to understand and determine the footprint, scale, complexity of issues, capacity, capabilities within the system, features and functions of the support requirements for the system. A full description of the activities involved in a scoping diagnostic support is included as an Annex at the end of this report. 

There was a much greater focus on the cultural and leadership issues that sit behind making difficult decisions and sharing resources as a barrier to better working with data than the technical challenges of interoperability. Underneath that was a key theme of lacking a "single version of the truth", with common feedback around making data available at the right level and improving data quality. Once these basic issues were addressed, systems had ambitions to connect more directly with organisations in other sectors, across both public and voluntary services, with a greater focus on outcomes.

Emergent themes

Developing and delivering a shared vision

A consistent theme across the diagnostics was a focus on system-level relationships, with a number of systems becoming stuck along the journey of aligning behind one vision, prioritising their delivery of that vision, and bringing that into transparent and effective governance and decision-making. Where areas have aligned behind an action plan, they are typically in the early stages of delivery and are concerned about sustainable change.

• “There is no consistent wholly owned narrative and agreement strategically of what needs to be done.”
• “They have programme management across HF projects and reporting mechanisms but we were unable to clarify how they have prioritised delivery of their wide-ranging ambitions...pace of delivery is hindered in part due to resources.”
• “Governance was felt to be complex, time consuming and inefficient...lack of clarity and rationale for decisions...overall system governance and decision-making has evolved to deal with urgent and extreme pressure in the system. This needs to mature further.”

All the areas we have worked with wanted to establish some sort of shared pool of information. Where there was a clear desire to tie new flows of information into new ways of working and shared objectives, it was clearer what support the system would require from us.

• “Comments were made about availability of data and what was shared and available. The patchiness of this means there is no single view of the picture for [Health and Wellbeing Board name] that everyone owns." This is why in many of the places we engaged with, this was closely linked to shared objectives being established.
• “The system has clear enthusiasm and energy to improve outcomes for people but it lacks a clear vision and strategy to which they are all signed up.  People talk of data, capacity modelling, managing flow but there is little by way of a coherent view of this and it does not appear to be driving any decisions. Instead finance pressures drive decisions and the lack of an owned strategy and principles to guide decision making exacerbate this.”
• “We all help to create a business rhythm. I think we are getting to a place where we understand which patients are waiting and why – and the next step, is seeing whether we all agree. That needs us to get the data in a strong place, and we also need to improve input into the data.”

Many areas also highlighted a desire to make more of the data they already have, with issues around the creation of real time data for operational use, as well as poor data quality across organisations or sectors.

• “Lead scoper observed an Urgent Care Oversight Group meeting; the ICB Business Intelligence was one month out of date.”
• “There are two issues impacting on the system’s ability to use information to support decision making and performance monitoring. Data quality as a result of variation in recording and uploading from different operational delivery areas. Agreed monitoring data to underpin assessment of progress.” 
• “We’re limited by the dashboard we use. For example, you can’t flag that there are multiple reasons that someone is delayed for discharge – they might have a hierarchy of needs – for example it could be results/ OT assessment and access to equipment. The dashboard will only show one reason.”

There were also a number of diagnostics where the local system was struggling to bring together information at the right geography or across providers from different sectors, in particular community care and voluntary, community and social enterprise (VCSE) sector organisations. 

"Place" does not necessarily map neatly onto historically defined boundaries, with integrated care systems (ICSs) not always overlapping with local authority boundaries or trusts working across multiple systems. There is also a lack of clarity on how to benchmark or who to benchmark against for insight.

• “Colleagues have articulated either a need to understand how different parts of the system work or have reflected that there is a lack of understanding. Colleagues have reflected that discharge models have been developed in local systems but that these need to be set out coherently to support understanding of warranted variation and unwarranted variation.”
• “There is plenty of data available but the way it is cut is not helpful to the Place model. Data can be viewed by whole ICS or by provider. Given the complexity of flow of people in this ICS this is being seen as an issue in place and a factor in the lack of coherence in strategy and governance.”
• “In addition to this while there are now good data systems to report on individual patients for case management purposes and also has ICB level dashboards the system was doesn’t appear to have access to a sub-system performance management framework and dataset at executive and operational management levels.” 
• “We would be much better off comparing Sheffield to Birmingham, Leeds, Glasgow; we’re much closer to them in terms of demographics and population. LG Inform should be benchmarking us against the core cities. We don’t think our differences have been fully understand when support offers show us these good practice examples that don’t mean anything to us.”

A consistent theme through the diagnostics was a request for support with understanding the demand and capacity on the system and in particular the capacity of services available in the community. There were repeated requests for support with modelling total community capacity to aid with discharge planning.

• “The system does not currently have a clear, system-wide understanding of demand and capacity within the community.”
• “System does not fully understand its out of hospital demand and capacity.”
• “There is an urgent need for a demand and capacity plan across the system including community and primary care services.”

There appeared to be a broad spectrum of offerings on the virtual wards/hospital at home and urgent community response team (UCRT) and retrospective review (RR) offering. These ranged from no mention of these services – in about half of diagnostics – through to a strong local offering operating at capacity.

• “A particular challenge remains in that uptake of virtual ward places remains low, with 50 per cent utilisation currently.”
• “Virtual wards (VWs) have recently been set up and experienced recruitment and mobilisation delays resulting in low bed utilisation in Q1.”
• “The model for the virtual was successfully launched in December 2022 and maximum capacity achieved has been 112 against 107 plan in April.”
• “The system has 352 virtual beds with an aim for 700 by the end of 2024.”

While many local authorities reported strong initiatives around front door flow and admission avoidance (linked to UCRT and VW offering above), discharge flow was much more variable – in areas where this was better, it was typically acknowledged that this has come at the expense of outcomes (see below on outcomes).

The main cause of delay varied between areas but was typically due to capacity issues in bedded care, delays in assessments, and cultures in wards leading to slower discharges. There were repeated requests for service mapping or re-design.

• “The biggest reason for delays is awaiting availability of the bed in a care home, and significant numbers of individuals awaiting assessment prior to discharge.”
•  “LOS (length of stay) in P2  (Pathway 2) beds is adding to the backlog of P2 delays, rapid work needed with ward and discharge teams to reduce LOS…Tomorrow is not OK but has become an accepted norm.”
•  “The internal referral delays show that the move towards a single point of access / Discharge Hub is urgently needed...Urgent work – supported by Emergency Care Improvement Support Team (ECIST) – is required to ensure discharge planning starts at the point of admission.”

While this was only discussed in about half of diagnostics, those that did highlighted a frustration with the complexity of the intermediate care offering, and a need to rethink how this is approached, informed by improved data use.

• “The view was expressed during the scoping discussion that the current intermediate care services are fragmented, given that the two councils across the Integration Care Board (ICB) area have different operating models and separate provision.”
• “The community bed base is not necessarily used to achieve the best outcomes and there is insufficient focus on people’s own homes. Community and therapy services also vary and appear to lack integration with other care services outside of hospital.”
• “Intermediate care was highlighted as a need for improvement but there is no clear strategy to deliver it. There were tensions about who pays for intermediate care. There is a widely held view that if community based services were appropriately organised in a way that enabled better outcomes for those discharged whether that be through intermediate care or home first arrangements then the risk of re-admission would be mitigated and the outcomes for people would improve”
• “There is a need to take a wide definition of community including intermediate/ community nursing/ reablement. The system needs an end-to-end intermediate care strategy with community being the starting point.”

For a number of systems there was a strong desire to move away from a purely operational or performance management perspective towards a focus on outcomes for those being provided with services. There’s a general feeling of a system set up to deal with crisis, resulting in overprescription of care. Several sites reported overuse of bedded settings both when discharged for assessment or longer term. This was also linked to capacity issues in some cases.

• “The system may be interested in some data modelling and use of case reviews to quantify the potential improvements in outcomes for patients and savings”
• “Although discharges from hospital are good, partners suggest that the outcomes for people are not as good as they should be. Allied to this was a desire to see a move towards individual outcomes (rather than organisational ones) through co-production with users leading to an improved experience of hospital discharge and onward services. There is a need to take a wide definition of community including intermediate/ community nursing/ reablement. The system needs an end-to-end intermediate care strategy with community being the starting point.”
• “The system has clear enthusiasm and energy to improve outcomes for people but it lacks a clear vision and strategy to which they are all signed up. People talk of data, capacity modelling, managing flow but there is little by way of a coherent view of this and it does not appear to be driving any decisions. Instead finance pressures drive decisions and the lack of an owned strategy and principles to guide decision making exacerbate this.”

No quick fix

The emerging themes highlight the complexity of the issues and challenges faced by systems. This demands system-wide and structural targeted and bespoke support offers, avoiding disruption and upheaval within already pressured systems and embedding medium to longer term planning processes.

Lack of shared dataset and evidence base

Most health and social care systems will use data to inform their operations. Typically, systems are struggling to create effective means of using data to support these aims, with blame often being attributed to technical issues, either in terms of the technology involved or legal concerns about data sharing.

A shared perspective starts with shared objectives and values before data. If you do not know what you are trying to inform people about, how will you effectively identify what scare resources need to be used to support? If everyone agrees that discharge to assess is a priority, for example, that makes it easier to identify the metrics that require improved data quality. If partners have not mutually agreed on a set of priorities, the risk of disengagement grows, and that partnership may suffer.

High quality data also supports our work within the BCF Support Programme, feeding into our support offers around discharge to assess, and capacity and demand planning, with the results of these scoping diagnostics identifying a number of systems where we will be supporting better use of data through these offers.

Learning from research

In a recent piece, Interoperability is more than technology, the King’s Fund found three main things were identified that sat behind success in bringing people together around data in the health and care sector:

• Relationships based on trust between staff and leaders
• Technology that makes communication and medical information flow as easy as possible
• An enabling environment that provides sufficient long-term funding and targets that support collaborative working while developing complementary workflows across organisations.

The point about relationships is deliberately placed first, as it makes all other aspects of bringing data together easier. In any offer we produce for the sector, this principle needs to sit at the heart- if the relationships between organisations are not healthy and if shared objectives are not in place, integrated working can’t happen.

There’s a lot of overlap in what we’ve seen in the scoping work and this piece- there’s relatively little on the technical side of data use coming from the Lead Scopers, and much more about inter-organisational interest and relationships.

The key objectives that every system shares above because upon closer inspection, many of the scoping diagnostics that talk about improving data use and having well-established objectives only talk about these basic values. This means they are less likely to have had more mature conversations that involve compromise and are less prepared to have difficult conversations when data shows that one party or another bears responsibility for issues around discharge.

In the systems with a more developed inter-organisational perspective, conversations seem to have focused less on discharge process and more on outcomes and intermediate care, with financial performance being supported through those topics.

It's also important not to have too many metrics being fed through as key indicators, East London FoundationTrust Model (ELFT) recommend no more than five to eight to make sure focus is not diluted. These are the questions they recommend asking when choosing what data to use:

• What are the key measures for the service that you work in?
• Are these measures available, transparently displayed, and viewed over time?
• What qualitative data do you use in helping guide your improvement efforts?

This perspective is based on the principle that each department within a trust will look at their own data. It does not necessarily map well onto what a whole system needs to look at for their overarching strategic needs. Our questions will look different, perhaps something more like this:

What are the key measures you need to support your shared objectives?

• Are these measures available across a system, developed and shared transparently and where possible, comparable across time and organisation?
• What qualitative data do you use to support improvements in your services and to challenge your assumptions about performance?
• If shared objectives are in place and relationships between partners are healthy, then the focus can shift towards the more technical end of data use.

There are several long-standing issues within the sector regarding the interoperability of systems (their ability to connect together), including capital issues, such as needing to buy new systems or procedural ones around data sharing.

The BCF Support Programme scoping diagnostic support explained

The objective of the scoping diagnostic support is to establish the system’s shared understanding of the breadth and scope of their challenges and the support requirements most likely to achieve and sustain the desired improvement outcomes.

Scoping diagnostic support involved three phases:

1. Preparation and participation
2. Diagnostic conversation(s)
3. Write up and next steps

Phase 1

We work with the local system to identify the right senior stakeholders to understand the purpose, prepare to participate in the scoping conversations and agree the date in diaries for the scoping conversation to take place. There are introductory meetings with the Lead Scoper and scoping team, which may include regional Better Care managers, Care and Health Improvement advisers and members of the BCF Support Programme Team.

The lead scoper will consider any background information (including a data pack put together by the BCF Support Programme) and any key material sent by the local system and hold pre-meetings with stakeholders as agreed with the local system.

Phase 2

The lead scoper undertakes the whole system conversation. This provides a space for system leads to have an open and honest conversation about what is working well, challenges and issues they are facing and what their priorities for support are. This might be followed up with further clarification conversations if needed. The discussion will be structured to get an understanding of:

• What is working well in the system and why
• The current and emerging challenges
• The priority of challenges to be addressed

Phase 3

The Scoping Diagnostic is written up into a comprehensive and structured form. This also includes a summary of the outcome(s) of the discussions and recommendations for further support. The BCF Support Programme team and the local system will then discuss the write up and the outcome of the support.

The Better Care Fund was established in 2013 as one of the most ambitious programmes ever introduced across the NHS and local government to support local systems to successfully deliver the integration of health, social care and housing. It represents as unique collaboration between:

• The Department of Health and Social Care (DHSC)
• Department for Levelling Up, Housing and Communities (DLUHC)
• NHS England (NHSE)
• The Local Government Association (LGA)

The LGA has managed the BCF Support Programme since 2016.

The 2023/25 BCF Support Programme is expanded and will be in place for the next two years and it brings together the unique expertise and experience of the LGA in partnership with ADASS and Newton Europe to create a stronger improvement partnership.