Prof Mark Llewellyn and Prof Fiona Verity discuss the tensions in funding programmes for public health transformation.
The nature and level of funding for public services is always a source of debate and discussion. This is particularly the case in times when escalating needs and population changes pose significant challenges for policy makers and those charged with the commissioning and delivery of local services. More than half of the Welsh Government’s total budget is spent on health and social care services, and represents proportionally more so for local authorities. But the ‘core’ funding for health, or the revenue support grant for local authorities, is doing little to transform the system – it is consumed by enabling and providing care and support to those who need it most. As has become the accepted norm, time-limited funds are provided as a way to catalyse change and transformation, over and above the core costs of running public services. But are they effective in ‘transforming’ systems? Do they deliver on the promise of new forms of working and models of care, or lead to the unintended consequence of providing an inadvertent cliff-edge for public bodies when the time-limited funding inevitably comes to an end?
Time-limited funds and transformation
Take as an example the Integrated Care Fund, a multi-million fund allocated by the Welsh Government across Wales between 2014 and 2021. The aim of the fund was to transform integrated working between social services, health, housing, the third sector and independent providers to develop sustainable services. As described by Audit Wales, the fund was initially established by the Welsh Government on a one-year basis for 2014-15 (as the Intermediate Care Fund). After some continuation funding in 2015-16, the Welsh Government then extended the scope of the fund for 2016-17, and again in 2017-18. Both Audit Wales and the independent evaluation report recognised the issues with such an uncertain funding position, and identified recommendations about a need for agreed measures of outcomes and success criteria for government funds of this nature in future.
But the ‘core’ funding for health, or the revenue support grant for local authorities, is doing little to transform the system – it is consumed by enabling and providing care and support to those who need it most.
Complexity and system responses
Against this backdrop, in 2022, the Welsh Government announced the five-year Health and Social Care Regional Integration Fund (RIF), which at the time stood at £144.7 million annually to Regional Partnership Boards. This national policy initiative was designed to advance the government’s health and social care integration agenda. The RIF is a time-limited five-year funding programme with a set of values, aims and objectives relating to an ongoing, accelerated transformation in, and delivery of, integrated, preventative health and social care across Wales.
As a policy instrument, RIF is a response to a health and social care system in need of additional resources in order to make such a transformation. RIF is one of a range of policies working to advance similar agendas, intending to deliver whole-systems change. Yet it is trying to forge new ways of working and amend complex systems in real time, systems under significant strain and stress. The health and care system in Wales, as is the case across the UK, is facing acute resource pressures. Workforce retention is a major issue in Wales. Staff vacancies are high, and there are major and publicly reported financial pressures impacting on the delivery and timely access and availability of health and social care.
Insights
We have been leading the independent evaluation of RIF and have recently published our initial findings. Broadly speaking, there is wide-ranging support for the integrative and collaborative vision and ambition of RIF, for enacting its key principles, and there are signs of positive developments and progress towards the RIF goals. The architecture of RIF has incorporated lessons from previous Welsh Government funding schemes, such as the Integrated Care Fund, which reinforced the importance of dedicated funds in supporting integration and the value of sharing good practice and evaluation insights, and strengthening learning cultures. RIF has explicit principles to guide action, anchored in Welsh Government legislation and policies. Nonetheless, the pressures on core service budgets and funding, and demand management are creating a challenging fiscal environment with potential to pull against some of the RIF intentions.
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Despite the support for the vision of the RIF and the Welsh Government’s policy aspirations, RIF operates in a fast-changing policy and social context. The evidence collected to date raises questions about the best balance between prescribed fund expectations and the capacity for regional and local autonomy and flexibility to plan and deliver integrated care in a changing environment. These tensions are not just particular to Wales.
Issues and tensions within time-limited funds
From our work to date, a complex picture is emerging of the ways in which the principles associated with the integration of health and social care are being implemented, and specifically with regard to a fund with system transformation aspirations. We argue there are opportunities for considering how the underlying assumptions, ideas, and concepts of short-term funding schemes as mechanisms for ‘transformation’ are realised (or not) in practice.
Our analysis has identified six ‘pairs’ of ideas, or concepts on a continuum that were in some way competing with, or in tension with each other. These pairs of ideas are our way of ‘sense-making’ the complexity of time-limited central government funding schemes like RIF. Below we provide a series of descriptions of these concepts.
Our ‘sense making’ of the tensions, as outlined above, is an attempt to map the contours of the challenges, dynamics and opportunities in using such funds for generating the change processes that might make a difference over time.
These are neither formal definitions – to provide such a thing would be to over-simplify an inherently complex situation – nor are they ‘fixed’, as they will change as contexts change:
- Alignment | Aspiration – this speaks to the nature of time-limited funds whose very purpose is to be aligned with and facilitate the implementation of policy objectives, but also have far loftier ambitions, in this case to deliver on the promise of seamless integrated services. There is a tension given the need to deliver on the focused aims of a fund, whilst being part of a whole-systems, whole-sector transformation;
- Control | Collaboration – this pair of ideas is most closely connected to the power dynamics inherent within time-limited funds, and the extent to which sharing power fluxes over time. This dynamic operates between national and regional partners, and equally between regions and their local partners;
- Fidelity | Flexibility – our data highlights tensions around the issues of fidelity with fund ‘guidance’ and design principles, and the desire of those who are seeking to implement such time-limited funds in practice to have additional levels of flexibility, to respond to contexts;
- Accountability | Autonomy – our evidence points to tensions over the ‘right balance’ between a proportionate approach to accountability, governance, and the spending of public money, alongside a greater sense of autonomy that is espoused by such funding arrangements. These tensions operate at multiple levels, and between multiple partners;
- Ownership | Partnership – our data suggests there is an ongoing challenge about where ownership for such time-limited funds sit, and the extent to which its programme of work truly involves a partnership approach, or something different. This speaks to the relationships of trust that exist (or do not exist) across partners; and
- Structure | Agency – more generally, this final pair of ideas recognises the nature of government time-limited funding and that it inherently sits within a certain paradigm. It recognises the challenge and tension within time-limited funds of using ‘agency’ to undertake dynamic forms of transformation, within the context of pre-existing organisational structures. This is compounded when the transformation is actively trying to change the nature of the structures that it is operating within.
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Towards transformation?
Hunter and Bengoa note that ‘Transforming health systems is a complex, messy business with no quick or simple solutions.’ RIF is a ‘fund’ designed as a means to transform both health and care systems, with the sustainable delivery of national models of care integral to this objective. There are clearly questions over the extent to which time-limited funds (which are common across the public sector in many policy areas) provide genuine opportunities to catalyse system transformation, or end up being an artificial ‘cliff-edge’ for public bodies which drives certain types of behaviours and practices, especially as the edge approaches. Our ‘sense making’ of the tensions, as outlined above, is an attempt to map the contours of the challenges, dynamics and opportunities in using such funds for generating the change processes that might make a difference over time. We would also reflect on the extent to which the nature of associated challenges (like developing appropriate and meaningful measures of outcome and impact) is enabled or inhibited by such programmes.
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