NHS concern over 'risks' of Lancashire County Council plan to thrash out who covers care costs in Lancashire

County Hall set out the strategy back in November when cabinet members agreed a broader £84m package of savings to help it balance its books in the years ahead. Improvements to what was described as “cost sharing” with the NHS formed the largest single spending reduction.

The new approach was given final approval when the county council set its budget earlier this month. The authority claimed in papers presented to cabinet late last year that “resolving the longstanding 'who pays for what' arguments that exist between the county council and the NHS” would often serve to speed up access to services for residents and “improve decision making about the nature and location of services that people will receive”.

However, it has now been revealed that in a consultation carried out into the full suite of finance proposals that were put before councillors, the NHS Lancashire and South Cumbria Integrated Care Board (ICB) called for a meeting with the local authority in order to get more detail about the specifics of what County Hall was suggesting.

In a council summary of the ICB's consultation response, it said that the organisation was “keen to understand more fully the risks for citizens and patients” and wanted to “discuss how we collectively manage any unintended consequences and financial risks associated with the savings proposals”. The implications of “joint-funded package” schemes were highlighted as a particular area requiring focus.

The region’s ICB was established last July - one of 42 set up across the country - as part of the ongoing push to better join up health and social care services. As of the end of November, the healthcare system in Lancashire and South Cumbria was reporting a deficit of £66.5m, but is nevertheless currently forecasting that it will end the financial year in April with its budget balanced.

However, with Lancashire County Council having had to battle to plug its own black hole – which it was predicted in the autumn would stand at £160m by 2026/27, but has since been slashed to £23.5m – it is clear that warm words and good intentions about integration do not make it any easier for public sector organisations to go dutch in tough financial times.

During the November cabinet meeting at which the Tory-run county council’s savings proposals were published, deputy leader Alan Vincent said that he was not prepared for the authority to bear financial burdens that were “someone else’s responsibility”.

He was responding to concerns raised by Labour opposition group leader Azhar Ali, who cautioned against an attitude that he characterised as County Hall saying, “It’s not our problem, [so] we’re passing it on to someone else.”

Speaking to the Local Democracy Reporting Service just before the county council’s budget was set on 9th February, County Cllr Vincent said of the ICB response to the savings plan that the authority was “always in conversations” with the NHS and that “we want to help them as well as them helping us”.

He added that the pair had a “much better relationship” than before the ICB was formed - but stressed that closer co-operation was a two-way street.

“I think we have helped [them to avoid] what could have been a very difficult winter for the NHS,” he said.

The council's budget papers reveal that a meeting between senior council officers and the ICB will be held in order to answer the latter’s questions. They also note that the ICB acknowledged the “close partnership” that had been forged across the health and social care system - and that there were “significant opportunities in moving forward at pace on the integration agenda”, especially when it comes to how out-of-hospital care is delivered.

At an ICB meeting in December, County Hall chief executive Angie Ridgwell - who represents the local government sector as a partner member on the board - warned of potential “cost-shunting” between local authority and NHS organisations when they all set what are largely still separate budgets. The ICB is responsible for managing NHS funds, while the county council's responsibility is for social care.

She said that as the new partnership arrangements developed, there was a need to explore how best to consider the “whole-system budget” - but that in the meantime, a “mature partnership conversation” was required to reduce the risk of one part of that system making decisions without being fully aware of how they might affect another.

Ms. Ridgwell had previously made an offer at November’s ICB gathering to use local authority experience to help the NHS secure any community care packages it was seeking “at a lower price” than it might otherwise achieve.

Meanwhile, last August, Lancashire County Council’s executive director of adult services, health and wellbeing - Louise Taylor - became one of four new directors of health and care integration appointed to the ICB - a role that she fulfils alongside her County Hall duties.

At the time of her appointment, Ms. Taylor stressed the importance of public services working together, because, she said, “the more aligned we can be with each other, the better the services we can provide to Lancashire people”.

The ICB was approached for further comment on its response to the county council’s budget savings blueprint.

WHO SHOULD BE FOOTING THE BILL FOR WHAT?

Lancashire County Council claims that changing how it shares costs with the NHS - as well as exploring joint funding arrangements and the generation of additional income - will come at “no detriment” to the people who rely on the services whose funding source is being put under the microscope.

The authority aims to save £28.1m over the next four years from a range of measures - with those savings frontloaded to generate £12.7m in 2023/24. It says that the needs of residents will still be met and the “best outcomes” achieved for them, asserting that a more definitive dividing line over financial responsibilities will “assist frontline practitioners” in the health and social care sectors and “improve the overall service user experience”.

County Hall’s budget papers set out a plan to appoint two new members of staff specifically to focus on “additional income recovery”.

The county council intends for the proposed NHS-related savings to come from:

***Continuing Healthcare - increasing the amount the authority claims from the NHS for residents’ ongoing healthcare needs.

The NHS funds the continuing healthcare of individuals who have been assessed and found to have a “primary health need”, rather than simply requiring social care. In Lancashire and South Cumbria, the arrangement has been a source of delay and tension dating back more than a decade.

Shortly after Lancashire and South Cumbria’s Integrated Care Board (ICB) was formed last July, it agreed an £8m settlement in a long-running dispute between seven of the eight clinical commissioning groups (CCGs) it replaced and the three top-tier authorities of Lancashire County Council, Blackpool Council and Blackburn with Darwen Council.

The row related to delays in the completion of assessments to determine whether a person was eligible for continuing healthcare, which, under national rules, should be carried out within 28 days of being set in motion. When that deadline is missed, individuals are often left receiving NHS care - but at the expense of the local authority or themselves, depending on their circumstances.

It had been feared that legal action would be required to resolve what were described as a “significant number” of continuing healthcare cases submitted prior to March 2020 in which eligibility had ultimately been established, but only after lengthy delays.

***Decision-making changes - the county council deciding where to place people when they are discharged from hospital, rather than the NHS, taking into account the costs of that care.

***Better Care Fund (BCF) - reviewing the schemes funded from the BCF pot and increasing the NHS contribution to the fund.

The county council says that NHS investment in the BCF - a fund which pools resources for joint use by the health service and social care across an area - is well below the national average in Lancashire and South Cumbria, falling in “the lower [part] of the lowest quartile”.

The NHS has committed to increase its contribution by £10m for 2023/24 and to work towards increasing that figure to £22m over the next four years - which would see it leapfrog to the bottom of the upper quartile in the list of nationwide NHS contributions.

County Hall also hopes that a BCF review would enable it to free up cash for other services.

***Increasing income from the NHS – for people with a learning disability and those discharged from mental health services.

The NHS contribution to the care needs of residents with a learning disability is “low compared to other areas”, the county council claims. The authority also says that it has not been “consistently review[ing]...ongoing cost sharing arrangements” with the NHS for looking after people who have left a mental health facility.

IS IT DOABLE?

County Hall acknowledged in its budget papers that its plans posed “considerable risks…in relation to the NHS's financial position and its ability to meet the obligations” being placed upon it. However, it said that the challenge had been “somewhat mitigated” by the creation of the Integrated Care Board (ICB) and the new working relationship between the NHS and local authorities in Lancashire and South Cumbria.

This had been marked, the county council said, by a shift in the NHS's position on “sharing and joint funding of some services and recognising the pressures on adult social care budgets”.

However, the authority warned that its proposal was set against a backdrop of "immense pressure on both NHS and local authority services and budgets, which will not diminish in the coming years”. It also recognised that the recovery of the income it was seeking from the NHS would require investment in staff time and resources if it were to be achieved.

The county council said that it would need to “agree the principles” underpinning its savings plans with the ICB and the associated Integrated Care System (ICS).

Meanwhile, staff will be informed of any changes so that they can make the necessary shift in how they work, while patients and their families will be advised of anything that affects them.