Look hard before you leap

The Guardian’s splash this morning focussed on the delayed launch of the Better Care Fund. The Fund aims to encourage improved coordination across health and social care but apparently the Cabinet Office has severe doubts about value for money. This may be embarrassing for ministers and officials but, if there is one thing worse than a bad policy being delayed, it is a bad policy being implemented.

Apart from general misgivings quoted in the Guardian, we don’t know the substance of the Cabinet Office’s concerns, but let me offer three reasons why what looks like a sensible response to an obvious problem might be running into difficulties.

First, the Fund was premised on one of the most commonly claimed, and also one of the least often proved, assertions made in public policy; namely, that spending money in one area will reduce expenditure in another. Hospitals are expensive, risky and anonymous environments and so it is surely in the interests of both public sector paymasters, on the one hand, and patients and carers, on the other, that people should stay in them for the minimum necessary time.

The problem is that cash strapped local authorities have always lacked incentives to help reduce bed blocking and now face eye watering budget cuts. The Fund will transfer money from the NHS to councils on the principle that better community provision for councils would reduce pressure on the NHS, both in long stay wards and in the A and E departments where badly cared-for vulnerable people often end up.

I have heard this kind of spend to save argument countless times not just from public sector officials but from people setting up a variety of social enterprises and charities. So I will let you into an open secret, everyone in the Treasury, and now it appears the Cabinet Office, treats such arguments with intense scepticism. Time and time again such promises evaporate as savings fail to materialise either because the policy doesn’t work or – more fundamentally – because the released capacity in one area is immediately filled with new demand. As what is ostensibly a spend to save scheme, the Better Care Fund would have immediately aroused the suspicions of any seasoned policy analyst and in this case those concerns would be loudly echoed by NHS commissioners and providers threatened with having to hand over money to their local council today in exchange for jam savings tomorrow.

Second, I suspect size matters. There are some structural ways one might address the health and social care divide, most obviously putting certain NHS services under the control of local authority social care departments or vice versa, and there are lots of smaller scale innovations which can and have made a difference in particular cases, but the £3.8 billion Fund may have suffered from reverse Goldilocks syndrome: too big and expensive to be genuinely innovative but too small and short term to achieve system change.

Third, when a problem is obvious, bad and persistent the tendency is to think that what is needed is simply more determination to solve it – in this case incentivised by cash. But when a problem is obvious, persistent and bad it also tends to indicate something else – we may be failing to grasp its nature and how difficult it is to solve.

The other day I came across an example of this in a different part of the social care jungle. I was being told that teenage children who fall into the care system (a system which is expensive and has poor outcomes for older children) have very often been seen multiple times by local authorities and other agencies. The obvious point, and one we often hear in tragic cases of neglect, is that none of these interventions grabbed the problem and solved it once and for all. The answer is surely concerted decisive interventions earlier on. So far, so obvious, but this view of the problem is conditioned by the starting point – those who have been failed. What about evidence as to the general efficacy of earlier interventions?

If, for example, we found out that 90% of youngsters subject to an earlier and cheaper intervention (some form of parenting support, for example) had not re-entered the system, we might deem this value for money even though 10% fall through the net. Also, if a system focusses on more intensive interventions the consequence might be that fewer youngsters get any kind of help and that we over-intervene with youngsters who only needed a small helping hand. Thus the case for what seems a more effective and economical solution (one big intervention rather than lots of smaller ones) may not be as open and shut as it seems.

I suspect that bed blocking may be a similar example where, perhaps, most frail people do successfully exit to the community while the few who don’t have particular characteristics such as complex conditions and needs, and a lack of informal support. If those who are bed blocking are the hardest cases then neither the projected savings nor the better outcomes of community care will be as clear cut as they first seem or as ministers – who are desperate to believe they can have a decisive impact - have been led to believe.

There are no doubt lots of bad reasons why the launch of the Better Care Fund has been delayed. There might also be some quite good ones.