Posts Tagged ‘Integrated care’

Better Care Fund will require continued support

By Johnny Marshall, director of policy, NHS Confederation - 11th November 2014 12:00 pm

We recognise the hard work put in by all those involved in developing and agreeing Better Care Fund plans locally, including NHS providers and commissioners, working with local authority partners, but we also echo many of the valid observations and concerns expressed by the NAO regarding the quality of the planning and preparations behind this ‘ambitious’ policy.

We are pleased that the NAO report recognises the areas of concern we have highlighted on behalf of our members regarding the BCF planning, notably the tight timescales set  for submitting local BCF plans; the conflicting directives around the objectives behind the policy, the burdensome ‘tick-box exercise’ nature surrounding the planning process; and the frustration of local areas having to re-submit plans after the original April planning deadline.

We also reiterate our concerns about the ability of some local areas to achieve the reductions in levels of emergency activity and financial savings that the BCF requires.

We agree the BCF’s success rests on “assumptions” which “may still  be over-optimistic” regarding the ability of integrating services to reduce costs. It is our view that whilst there is much evidence that greater integration and personalisation improves outcomes, the evidence that it delivers financial savings is still in its early stages.

It will take time for the new models of care to allow us safely to disinvest in existing services. This is why we will need financial flexibility and extra resources to allow double running of some services while we move to the new models of integrated care. This will require us to consider health and social care spending together.

As the NAO report notes, ‘the Funds effectiveness will depend on local implementation’. This requires the continued development of strong working relationships between the different parts of the health and care system locally around shared outcomes. It is therefore essential that providers are properly involved in the BCF planning process in order to build in local expertise and manage risks to patient safety.

In particular we want to see better alignment with the regular planning cycle for providers and commissioners, allowing for practical timescales to allow time for open discussions to take place between all those involved across health and social care.

Initial NHS integrated care plans inadequate

By Mike Broad - 11:51 am

The quality of early preparation and planning for the Better Care Fund - which encourages greater integration of health and social care services - did not match the scale of ambition.

So claims a National Audit Office report, which suggests early local plans for the fund did not meet ministers’ expectations or generate the level of savings the government expected.

All plans had to be subsequently re-submitted.

The Better Care Fund will pool £5.3 billion of existing NHS and local authority funding in 2015-16.

The aim is to deliver better, more joined-up local services to older and disabled people in the community and keep them out of hospital and avoid long hospital stays.

However, the government’s early planning assumption was that the Fund would save the NHS £1 billion in 2015-16, current plans forecast £314 million of savings for the NHS.

While the report recognises that the government programme to integrate local health and social care services is an innovative idea, it questions the potential for savings.

The Department of Health and the Department for Communities and Local Government developed the Fund’s policy, with NHS England and the Local Government Association responsible for the delivery and implementation of the fund.

It was agreed that local areas would develop plans for spending the fund with minimal central prescription, in order to drive local innovation from the bottom up, and reflecting the fact that no savings target had been formally agreed for the fund during Spending Round 2013.

As a result, there was no central programme team, no programme director and limited risk management and no analysis of local planning capacity, capability, or where local areas would need additional support, the report says.

In addition, the initial scheme guidance did not mention the scale of savings expected from the fund.

All 151 local health and wellbeing boards submitted plans in April 2014 for how they would spend their fund allocations in 2015-16.

But NHS England concluded in May that the Fund plans would deliver only £55 million of financial savings, not the £1 billion the Department of Health and NHS England expected.

The departments concluded that the plans required further development and ministers did not approve any plans in April, as originally intended.

Planning for the fund paused between April and July 2014 while the government reviewed and revised the Fund’s scope and how the £1 billion pay-for-performance part of the fund would work.

In July 2014, the departments revised and improved the fund’s governance and programme management, requiring local areas to submit new plans in September 2014 for expected approval in late October.

However these changes to the fund reduced from 11 months to five months the time available for local areas to prepare for the implementation of the fund from April 2015.

The Local Government Association does not agree with the changes in the Fund’s scope. It has said that the revisions undermine the Fund’s core purpose as promoting locally led integrated care and reduce the resources available to protect social care and prevention initiatives.

Under the fund’s revised conditions, local areas were asked to aim for at least a 3.5% reduction in their total emergency admissions over 2014 levels. Expecting such reductions within one year is ambitious against a trend of rising emergency admissions and feedback from local areas suggesting that some areas will struggle to meet this target.

Local areas have proposed reductions of 3.1%.

Almost two-thirds of the revised plans were either approved by ministers or approved with support and only 5 plans were not approved. The biggest risk area identified is to the protection of social care services with 21 local areas assessed as having significant risks.

Amyas Morse, head of the National Audit Office, said: “The £1 billion financial savings assumption was ignored, the early programme management was inadequate, and the changes to the programme design undermined the timely delivery of local plans and local government’s confidence in the fund’s value.

“Ministers were right to pause and redesign the scheme in April this year when they realised it would not meet their expectations.

“The fund still contains bold assumptions about the financial savings expected in 2015-16 from reductions in emergency admissions. To offer value for money, the departments need to ensure more effective support to local areas, better joint working between health bodies and local government, and improved evidence on effectiveness.”

Make hospital trusts integrated care organisations

By Mike Broad - 24th September 2014 2:31 pm

Shadow health secretary Andy Burnham said the Labour Party would address the “ever-increasing hospitalisation” of older people by transforming all hospital trusts and NHS bodies into integrated care organisations.

Speaking at the party’s annual conference, Burnham said a Labour government would create a National Health and Care Service - with better social care “unlocking the money” and allowing more people to receive care in their homes and communities.

Terminally ill patients would have the right to free palliative care at home, he also announced.

Yesterday, Ed Miliband said he would inject £2.5bn into the NHS to pay for 20,000 more nurses, 8,000 more GPs, 5,000 more care workers and 3,000 midwives by 2020. This would be funded by a crackdown on corporate tax loopholes, a “mansion tax” and a levy on cigarette makers.

Burnham said: “It makes no sense to cut simple support in people’s homes only to spend thousands keeping them in hospital. We can’t afford it. It will break the NHS.”

As part of a shake-up of palliative care, he said patients would be given the right to die at home “where clinically possible”.

Up to 60,000 people on an “end of life register” could potentially be offered free care at home in their final few months, starting with those with substantial social care needs.

He also announced new rights for carers, including ring-fenced funding for a respite break, the right to an annual health check and assistance with parking charges.

Burnham re-iterated the party’s desire to repeal the Health and Social Care Act, and stop the ‘privatisation’ of the NHS.

The NHS would once again become the preferred provider of healthcare services.

He said: “The market is not the answer to 21st century health and care.

“People out there know a minimum wage, zero hours approach will never secure the care they want for their mum and dad.

“So our ten year plan for the NHS is founded on people before profits. We will free the NHS from Cameron’s market and, yes, repeal his toxic Health and Social Care Act.

“We will ask hospitals to collaborate once again and reinstate the NHS as our preferred provider.”

Health secretary Jeremy Hunt questioned why Burnham didn’t mention key NHS failures that happened under Labour - such as Mid Staffs - and suggested his 10-year plan represented another ‘top-down’ reorganisation.

Reaction to Miliband: “We need a meaningful plan”

By Mike Broad - 23rd September 2014 6:37 pm

Dr Chaand Nagpaul, Chair of the BMA’s GP Committee

“GPs care immensely about our patients, and feel dismayed by the constraints impacting on services and undermining our ability to do the best for them.

“The GP service is under unprecedented strain, and is unable to meet the needs of a growing ageing population and the increasing volume of care moving out of hospitals. GPs are working beyond their capacity, seeing a record 340 million patients every year, up by 40 million compared to 2008. Demand on GP services has far outstripped supply.

“A commitment of more GPs will be vital towards meeting the demands on general practice. However we must first address the challenge of getting more doctors to choose to become GPs at a time of falling recruitment and increasing numbers retiring early.

“The figures speak for themselves. A fall of 15% in the number of doctors training as GPs last year, and 451 training places unfilled. We need to address the root causes of this if there is to be any prospect of increasing GP numbers.

“We are already working with NHS England on the best way to create the right environment to make general practice an attractive and rewarding career and whoever is in government next year needs to make this a priority.

“With the NHS facing a perfect storm of rising demand and a £30bn funding shortfall, patients and the public need to see a detailed, meaningful plan from politicians on how they will create a sustainable infrastructure and capacity in general practice to deliver on current and future needs.”

NHS Confederation chief executive Rob Webster

“We will wait for the whole image to emerge when Labour set out their spending plans. It is vital, for example that investment in health services is matched with a settlement in social care that allows a similar, much needed transformation.

“This early and clear commitment is a sign that politicians have taken on board calls to address the challenges facing the NHS and social care. In the 2015 Challenge Manifesto, published earlier this month, the most influential coalition of health and care bodies called for adequate funding for the NHS so that services could be transformed to better meet 21st century needs. More of the same is not an option. So, we asked for longer term funding and a transition fund of at least £4 billion in new money spread over two years. Today’s announcement overlaps with these asks and begins a process by which we can engage in a real debate about the future of health and care.

“The very nature of health service delivery means that most NHS spending goes on staff costs – on nurses, GPs, speech therapists, midwives, oncologists, porters, cleaners and all the other professions that make up the NHS team. So it is right that money for service transformation is targeted at ensuring we have more staff with the right skills working in the right places. Often this is in the community, and includes GPs, community-based nurses, mental health specialists, and staff who can help people live more healthily, for longer, in their own homes.

“Linking transformation to staffing needs to be done in ways that will support local models and the numbers announced today should reflect local plans rather than a top-down allocation of posts.

“No matter how big the pot, a transition fund alone cannot and will not deliver the extent of change needed to tackle the challenges facing the NHS and social care. We need the next government to commit to making much faster progress towards implementing new payment mechanisms that support integrated, personalised care and reward good outcomes for patients, not just activity. And we need the stability which a 10-year funding settlement for health would offer, creating a framework for the kind of change which NHS leaders are chomping at the bit to deliver for patients and local communities.

“What we are missing, however, is a firm commitment from all political parties to ensure none of their proposals will impose yet another top-down structural re-organisation. It is vital that the health service has the stability to implement service changes that reflect local people’s needs and wishes, and take account of the local landscape.

“We have been very clear that the time for action is now. Ed Miliband has today made a powerful speech, which contains much promise. Once the applause from conference delegates has faded, it is vital that he and other politicians move swiftly from words to deeds.”

“Care costs preclude the ‘do nothing’ option”

By Mike Broad - 4th September 2014 10:20 am

The high profile Barker Commission has called for the integration of health and social care.

Here’s some key reaction:

NHS Confederation chief executive, Rob Webster

“Back in May, the 2015 Challenge Declaration set out the main challenges facing our health and care system. This Commission, led by Dame Kate Barker, has outlined in absolute clarity how we might move to solve some of these challenges and is a hook for the debate on how much we invest, where we put that investment and how we join health and social care together.

“While we might not agree with all the recommendations it puts forwards, we welcome its contribution to that debate. We know the impact funding and demographic pressures have on health and social care, and this report highlights the funding gap that is likely to exist in both budgets in the future.

“There does, however, appear to be a political vacuum on many of these issues. The task for politicians now is to address the real financial challenges facing the health and care system and establish a vision for how they want services to be funded. The NHS as ever is committed to ensuring care is delivered. The 2015 Challenge process will continue to contribute to this debate and the NHS Confederation will be the voice of NHS leadership as we look to develop a positive future for the health and care system.”

Professor Chris Ham, chief executive of The King’s Fund

“We asked Kate and the commission to tackle some of the most difficult issues in public policy. They have delivered a robust and convincing report, which remakes the case for change powerfully and makes recommendations that could provide a better and more generous care system based on genuinely long-term thinking.

“The proposals as set out by the commission may not appeal to politicians fearful of commitments to greater public expenditure, but these issues cannot simply be ignored. The commission is clear – there is no “do nothing” option. As the costs of what we now classify as social care grow, these will increasingly fall to individuals and families, creating fear, uncertainty and inequity on a scale that the public would find completely unacceptable if applied to health care. The recommendations are therefore radical – tinkering around the edge of our systems of care is not enough to deal with the challenges we face.

“The issue is not whether health and social care are affordable in future – they have to be paid for one way or another. The issue is how far they are publicly or privately funded and at what level of quality and decency. This report lays down a challenge to politicians of all parties to acknowledge the unsustainability of current funding for health and social care and to set out, ahead of the election, some of the difficult choices that need to be made.”

Barker: radically reshape health and social care around need

By Mike Broad - 10:12 am

The way that health and social care are currently organised and funded creates confusion, perverse incentives and much distress for individuals and families.

An independent commission established by The King’s Fund has concluded that a new settlement is needed for health and social care to provide a simpler pathway through the current maze of entitlements.

The commission, chaired by Dame Kate Barker, proposes a new approach that redesigns care around individual needs regardless of diagnosis, with a graduated increase in support as needs rise, particularly towards the end of life.

The final report of the commission recommends:

- moving to a single, ring-fenced budget for the NHS and social care, with a single commissioner for local services

- social care for those whose needs are currently defined as ‘critical’ should become free at the point of use

- as the economy improves, free social care should be extended to those whose needs are currently defined as ‘substantial’

- by 2025, some support should be provided to those whose needs are currently defined as ‘moderate’ but this should continue to be on a means-tested basis.

It also recommends integrating Attendance Allowance, the benefit paid to older people with care and support needs (which would be renamed care and support allowance) within the single budget for health and social care.

Although mounting funding pressures are being faced in both the NHS and social care, the commission’s report challenges politicians to look beyond the deficit and engage the public in a debate about future care and how it will be funded.

The commission calls on the government to plan on the assumption that public spending on health and social care combined will rise to between 11 and 12 per cent of GDP by 2025. These levels will be broadly comparable to current expenditure on health alone in many other countries.

A partnership model, in which the costs of social care will be shared between individual and the state, would be phased in over time to provide fairer, more consistent entitlements to social care.

The move to make all care free for those with critical needs would end the confusing distinction between social care provided in residential care homes and NHS Continuing Healthcare, which is provided free of charge in nursing homes – a huge source of frustration under the current system.

After careful consideration, the commission rejected extending charges for NHS services, with the exception of prescription charges. Instead, to pay for these changes, the report argues that the bulk of the additional funding should come from the public purse, with wealthier people and older generations – the main beneficiaries of the changes – contributing more.

To fund the initial roll-out of the new settlement, the report recommends:

- radical changes to prescription payments, reducing charges to as low as £2.50 but significantly reducing the number of prescriptions exempt from charges

- limiting free TV licences and the winter fuel payment for older people to those on pension credit

- requiring people working past state pension age to pay National Insurance at a rate of 6 per cent.

- The report also recommends that new recipients of NHS Continuing Healthcare should pay the costs of their accommodation, as those receiving residential social care do now.

As the more generous elements of the new settlement are phased in, the report recommends further measures to raise revenue:

- a 1 per cent increase in National Insurance contributions paid by those over the age of 40

- a 1 per cent increase in National Insurance paid by those earning more than £42,000 a year.

The report also recommends that a review of wealth and property taxation should be undertaken to raise additional funds.

The commission recognised that the Care Act and Dilnot reforms represent an important step forward but considered that they will not be sufficient to address the funding and service challenges that lie ahead.

Kate Barker, chair of the commission, said: “Our challenge was to look at the big and difficult questions about the kind of care system, and indeed what kind of society we wish for ourselves and our families. The prize, if this kind of change can be achieved, is huge – a more integrated service, a simpler path through it, more equal treatment for equal need, a better experience for people who need care and their families.

“We have concluded, as others have before us, that our system is not fit to provide the kind of care we need and want. We propose radical change, greater than any since 1948, that would bring immense benefit to people who fall into the cracks between means-tested social care and a free NHS. This includes people at the end of life and those with dementia or other conditions where too often there is a conflict about who pays at the expense of what people need.

“Our proposals would continue a system where costs are shared between the private individual and the state but with the taxpayer carrying a heavier load of that cost than at present. The cost of a more generous settlement, though large, can be afforded if phased in over time.”

Costs of proposals:

- current spending on social care for older people stands at £6 billion (2014); changes to provide free care for older people with critical and substantial need would require an additional £2.7 billion funding

- costs of free care for critical and substantial need would rise to around £14 billion by 2025 – around £5 billion more than projections based on current entitlement.

A full breakdown of the commission’s funding recommendations and the revenue each would raiseis as follows:

- A reduction of prescription payments from the current charge of £8.05 per item to perhaps £2.50, retaining a cap on the amount any individual could pay in a year but with exemptions limited to those on low incomes (£1 billion a year).

- Limiting free TV licences for the over 75s and the winter fuel payment for older people to those on pension credit (£1.4 billion).

- Ending the exemption from paying National Insurance for people working past state pension age by requiring them to pay a rate of 6 per cent, instead of the standard rate of 12 per cent (£475 million).

- Requiring new recipients of NHS Continuing Healthcare to pay the costs of their accommodation on a means-tested basis up to a cap of £12,000 a year (approximately £200 million).

- A 1 per cent increase in National Insurance contributions paid by those over the age of 40 (£2 billion).

- A 1 per cent increase in National Insurance paid by those earning more than £42,000 a year (£800 million).

The Commission on the Future of Health and Social Care in England was established by The King’s Fund in June 2013. The commissioners include:

Dame Kate Barker, business economist and former member of the Bank of England’s Monetary Policy Committee

Geoff Alltimes, chair of the Local Government Association multi-agency task group on health transition and previously Chief Executive of Hammersmith and Fulham Council and NHS Hammersmith and Fulham

Lord Bichard, cross-bench peer and Chair of the Social Care Institute for Excellence

Baroness Greengross, cross-bench peer and Chief Executive of the International Longevity Centre UK

Julian Le Grand, Richard Titmuss Professor of Social Policy at the London School of Economics.

The commission’s terms of reference asked them to explore whether the post-war settlement, which established the NHS as a universal service, free at the point of use, and social care as a separately funded, means-tested service, remains fit for purpose and whether, and if so how, the settlement should be re-shaped by bringing the NHS and social care system closer together.

Read the full report.

Ring-fence single NHS and social care budget

By Mike Broad - 9:52 am

The government must create a single, ring-fenced budget for the NHS and social care, with a single commissioner for local services.

This is the key conclusion of an independent commission established by the King’s Fund, which is calling for a new settlement for health and social care.

The way that health and social care are currently organised and funded, it says, creates confusion, perverse incentives and much distress for individuals and families.

The commission, chaired by Dame Kate Barker, proposes a new approach that redesigns care around individual needs regardless of diagnosis or assessment, with a graduated increase in support as needs rise, particularly towards the end of life.

The final report of the commission recommends:

- integrating Attendance Allowance, the benefit paid to older people with care and support needs (which would be renamed care and support allowance) within the single budget for health and social care.

- social care for those whose needs are currently defined as ‘critical’ should become free at the point of use;

The commission calls on the government to plan on the assumption that public spending on health and social care combined will rise to between 11 and 12% of GDP by 2025. These levels will be broadly comparable to current expenditure on health alone in many other countries.

A partnership model, in which the costs of social care will be shared between individual and the state, would be phased in over time to provide fairer, more consistent entitlements to social care.

The move to make all care free for those with critical needs would end the confusing distinction between social care provided in residential care homes and NHS Continuing Healthcare, which is provided free of charge in nursing homes – a huge source of frustration under the current system.

As the more generous elements of the new settlement are phased in, the report recommends further measures to raise revenue including a 1% increase in National Insurance contributions paid by those over the age of 40, and those earning more than £42,000 a year.

Kate Barker, chair of the commission, said: “Our challenge was to look at the big and difficult questions about the kind of care system, and indeed what kind of society we wish for ourselves and our families. The prize, if this kind of change can be achieved, is huge – a more integrated service, a simpler path through it, more equal treatment for equal need, a better experience for people who need care and their families.”

The commission recognised that the Care Act and Dilnot reforms represent an important step forward but considered that they will not be sufficient to address the funding and service challenges that lie ahead.

She added: “We have concluded, as others have before us, that our system is not fit to provide the kind of care we need and want. We propose radical change, greater than any since 1948, that would bring immense benefit to people who fall into the cracks between means-tested social care and a free NHS.”

Read the full report.

Personal budgets expanded for NHS patients

By Mike Broad - 9th July 2014 7:51 pm

Personal budgets are to be expanded and cover both the health and social care needs of vulnerable people, the new chief executive of NHS England has announced.

Simon Stevens wants to see the frail elderly, people with disabilities and those with serious mental health problems given joint budgets from the NHS and council-run social care services to spend as they see fit.

The hope is that five million people will be offered them by 2018.

Patients will be given a nominal budget - at least £1,000 - which they can then decide to spend on whatever care and services they want, as part of a drive to give patients more power.

GP and emergency care is not included, and they can use these the same as anyone else.

Nearly 650,000 people currently have a social care personal budget. Under 2,500 patients have them in the NHS.

Speaking at the annual conference of the Local Government Association in Bournemouth, Stevens set out the plans for a new Integrated Personal Commissioning (IPC) programme.

Four groups of high-need individuals are to be included in the first wave from next April 2015, although councils, voluntary organisations, and NHS clinical commissioning groups may also propose others.

These include people with long term conditions, including frail elderly people at risk of care home admission; children with complex needs; people with learning disabilities; and, people with severe and enduring mental health problems.

This will blend funds contributed from local authorities and NHS commissioners (CCGs and NHS England). Individuals enrolled in the programme will be able to decide how much personal control to assume over how services are commissioned and arranged on their behalf.

NHS England will now work with partners in local government, CCGs, patient groups and the voluntary sector to develop an IPC Prospectus which will be published at the end of July. This will formally invite local expressions of interest in jointly developing and participating in the IPC programme from April 2015.

NHS England will provide technical support to develop projects, and fund independent evaluation. Wider scale rollout of successful projects is envisaged from 2016/17.

Experience with pilots have shown that this approach has the potential to join-up services and funding at the level of the individual, for people who often need multiple services.

Stevens said: “We need to stop treating people as a collection of health problems or treatments. We need to treat them as individuals whose needs and preferences should be seen in the round and whose choices shape services, not the other way round.

“That’s the big offer the NHS increasingly has to make to our fellow citizens, to local authorities, and to voluntary organisations.”

£2bn extra health and social care integration fund call

The Guardian - 18th June 2014 10:59 am

Councils and the NHS need an extra £2bn “transformation fund” to help integrate services, says the chairman of the Local Government Association.

Sir Merrick Cockell said the additional funding was needed on top of the Better Care Fund, the £3.8bn project to bring together health and social care services. He also called for the fund to become a five-year commitment, rather than the year it is officially scheduled to last.

Speaking at conference organised by the King’s Fund thinktank in London, Cockell said a transformation fund would “ease the short term disruption to residents and to patients”, and that it would have to be a “significant” amount of extra money towards the £2bn mark.

However, Cockell’s general attitude towards the Better Care Fund seemed to be one of confidence, calling it “our best answer to the questions asked of us in these testing times”.

The Better Care Fund relies on pooled funding from local authorities and the NHS, with the intention of reducing pressure on hospitals by providing more care and support in people’s homes.

Read more in The Guardian.

Integrated care model holds key to solvency

By Jonathan Fagge, CEO of NHS Norwich CCG - 16th May 2014 8:58 am

A week in the life of a CCG chief executive

If winter is the season of pressures, spring is the season of workshops. I’ve attended four this week covering collaborative commissioning, 5 year plans, integrated care for Norwich, and Strategic Workforce Planning.

Regular attenders of these might sometimes substitute ‘talk’ for ‘work’ when they describe them, and for an outsider we must look at times like the Committee of the People’s Front of Judea, but system workshops endure because we have not yet found a better way to bring everybody together to tackle the problems none of us can solve on our own.

The workshop season has been particularly febrile this year; in part because of the very complex and ambitious planning guidance that requires us to plan five years ahead and pool health money with social care; but also because as problems go, we are having to face up to some big ones. Amongst them stride two colossi:

Balancing the budget

This financial challenge is expressed in a variety of ways - the cash, the demographics, the growing burden of disease, even the 24-hour society - but it all relates to the last six years of budget growth below wage growth and inflation, combined with increasing levels of demand for healthcare.

Each year it gets harder for commissioners to balance the overall budget for their system, and providers have to find efficiency savings of 4-5%. They’ve all done the easy stuff, and now have to find ways of cutting into the wage bill without reducing the quality of care.

Our mental health and community providers  got less than a 1% uplift this year, but they have to treat more people, pay a small wage increase of 1-2%, and face higher costs on equipment and consumables. Our mental health provider produced a five year plan that added these 4% challenges all together and described a 20% cost pressure over 5 years. It has been unhelpfully translated by the newspapers into a ‘20% budget cut for mental health’.

These headlines are technically wrong - Norwich CCG for example has increased its spend on Mental Health in 2014/15, and ring fenced at least that level of spend in 15/16 - but there is a truth at their heart.

We cannot pay any of our providers enough to continue with their existing models of care, there is little slack in the system to fund change, and so it becomes increasingly difficult for them to balance the books, and for us to get signatures on contracts.

We have a plan for Norwich that we hope will meet this challenge, and are excited about working with the Kings Fund for the next three years. We will create a whole system model of integrated health and social care for the City - improving  outcomes, reducing costs, and keeping people well, independent, and at home for as long as possible.

I believe this is represents our best chance of emerging from this period of austerity with the quality of care protected and our health system intact and solvent, but it will not be easy and we will need to work together to make it happen. And if an occasional workshop brings us together, reminds us of the mission, and creates a space for us to iron out the tensions, then I will happily sit cabaret style with a mug of coffee and some flip chart paper and give it my undivided attention.

The retirement challenge

The workforce challenge has had less coverage than the money, and yet in some ways it is of greater concern.

In Norfolk and Suffolk, 17% of the health workforce are over the age of 55, and are expected to retire within the next five years. I am told by the Local Medical Committee that almost half of all surgeries in Norfolk have at least one GP vacancy. We expect to be 2,000 nurses short of requirements in Norfolk and Suffolk by 2019. We already need 400 more paramedics for the East of England. And many hospital departments - especially A&E, Stroke, Medicine for the Elderly - report increasing difficulty in recruiting consultants.

Unlike the money problem, government cannot simply turn the tap back on. It takes between two and ten years to train people into these various careers; double the number of nursing commissions at Universities tomorrow and they will begin to join the wards, surgeries, and patients’ homes in the summer of 2018.

Do the same for doctors and it will be later than 2020. The paradox is that although we are training fewer than we need, we are training as many as we can afford.

Health Education England is responding to this challenge -  looking for efficiency savings that will enable them to increase the number of commissions they can afford. Even more importantly they are investing in the training, support, qualifications, and greater recognition for the health support workforce, known internally as ‘Bands 1-4′.

If we can standardise the training and produce a nationally recognised qualification we could quickly create a large skilled and transferable workforce able to perform a variety of health support tasks, and freeing up the time of doctors and nurses.

I have taught on HCA courses in the past (from new to ready to go can take as little as three months), watched them provide care, and talked to both doctors and nurses about the opportunities for sharing their workload with trained assistants. I believe there is huge scope for reducing the costs of care without reducing quality, and this initiative should be a major part of the puzzle to the workforce challenge we face.

I asked a senior clinician that worked on our Urgent Care Unit trial this winter about what had made it so successful. He talked about the developing relationship between community and hospital staff, the proximity of the unit to A&E, and the speed of treatment and discharge.

But top of the list was the Healthcare Assistant that drove frail patients home, settled them in, and made sure they were comfortable and safe. Each journey almost certainly prevented a patient being admitted. This wasn’t nursing on the cheap; it was professional and appropriate assistance that made nursing care on a ward unnecessary.

So, money is tight and workforce is ageing? All hail Bands 1-4!