Research and analysis

Evaluation of the Better Care Fund Support Programme 2023 to 2025

Published 29 May 2025

Executive summary

Introduction

Ipsos UK, in partnership with the Institute of Public Care at Oxford Brookes University, was commissioned by the Department of Health and Social Care (DHSC) to conduct an evaluation of the Better Care Fund Support Programme (‘the support programme’) in February 2024.

Background to the Better Care Fund Support Programme

The Better Care Fund (BCF) Support Programme was set up in 2019 to 2020 to ensure that local areas have the right support available to them as they work towards delivering their Better Care Fund plans.

The support programme is delivered by the Local Government Association (LGA) (the core provider) and other providers to which LGA subcontracts.

All local support may be requested by local systems (non-directed) or they may be advised to take it up (directed) alongside a universal support offer for all systems. ‘Systems’ are the one or more local authorities receiving support through the support programme.

Purpose of the evaluation

The evaluation is predominantly a process evaluation with elements of impact evaluation at a local level. It focused on:

• the design and delivery of the support programme
• any aspects of good practice and learning that can be scaled up and used to improve the support programme
• outputs and outcomes from individual support projects at a local level, including on system integration and service users

Methodology

The methodology for the evaluation of the support programme reflects that it is a process evaluation with elements of impact measurement at the local system level. For example, case studies detail the wide range of impacts of support projects delivered across particular systems.

The methods employed included:

• case study interviews with systems (16 in phase 1 and 15 in phase 3 across 14 systems)
• a review of supplementary evidence provided by systems
• interviews with 9 Better Care Managers (BCMs) and 5 Care and Health Improvement Advisers (CHIAs) at phase 2
• five interviews with non-participating systems at phase 2
• a survey of 38 BCF leads within systems. Note that this sample cannot be considered representative of all systems at phase 3
• a review of management and key performance indicator (KPI) information

Note: where survey results are displayed in charts in the main body of this report, ‘Number of respondents’ indicates the size of the sample of respondents who specifically responded to that question. Due to limited sample sizes, survey results can neither be considered representative of systems as a whole, nor statistically significant.

Findings

The main findings from the evaluation are as follows.

Design and delivery of the support programme

As of 13 January 2025, 28 universal support projects and 65 local support projects have been completed, with a further 5 universal support projects and 10 local support projects in active delivery.

Of the 65 completed local support projects, most relate to capacity and demand planning (25) or scoping and diagnostic reviews (15). Fifty were referred through directed support, whereas 15 were referred through non-directed support (meaning that the system sought support independently). Due to a lack of engagement, 27 support offers were declined or closed down.

Initial engagement with the support programme

There is a range of methods and approaches to selecting systems for support. Scoping processes are generally viewed as helpful in clarifying needs and setting expectations. In many cases, scoping was viewed positively and as one of the most important stages in any support project.

Enablers to taking up support include:

• the experience and credibility of support providers
• responsiveness and flexibility to match system needs
• collective understanding within a system

Barriers to taking up support include:

• the perception of needing support
• duplication with other support offers
• a lack of system capacity
• inconsistent co-ordination and communication

BCF leads responding to the survey felt that the support offered by the support programme was something that would be helpful for all systems and just under half (17) said it was a way for high-performing systems to improve further.

There was a notable absence of wider partners - such as care providers and voluntary, community and social enterprise (VCSE) organisations - in the initial stages of support projects, due to a lack of demand for them to be involved and capacity constraints.

BCMs can play a crucial role in offering and promoting support, often identifying systems that would benefit from support and tailoring offers to their needs.

Support delivery

Engagement with support delivery is influenced by factors such as:

• the perceived credibility of the support offered
• existing inter-agency relationships
• individual personalities
• practical constraints such as time and resources

Many systems expressed broad satisfaction with the support received. Support providers were commended for their credibility and understanding of both the technical aspects of the BCF and the specific dynamics of local systems. Some systems did not find the support received addressed the specific challenges of their system and wanted tailored support that addressed their challenges, contexts and capacities.

There is limited involvement of VCSE organisations and housing partners in support delivery. However, there is no obvious demand for this from systems and the design of support projects is led by system needs. Other factors may have contributed to this limited engagement, including:

• capacity constraints within the VCSE and housing sectors
• a potential lack of awareness or understanding of the support programme within these system partners

Outcomes and impact generated by the support programme

Evidence of outcomes is patchy and variable in its quality. While there is some evidence of improved inter-agency relationships, development of joint plans and changes in investment decisions as the result of support, evidence related to tangible system improvements or impacts for people drawing on support from the health and social care system is limited.

Much of this is due to the stage at which this evaluation has taken place - it is too soon to measure most of the medium to long-term impacts of the support programme.

The original hypothesised outcomes may be overly optimistic, particularly in relation to system and, in some cases, funding partner expectations of bringing about system change. The nature of partner relationships and other factors makes this complex and difficult.

The systems where progress is most evident tended to be those where there is strong governance and leadership.

Systems often acknowledged the value of the support and the recommendations provided but struggled to translate these into sustained action. This was particularly true in systems lacking dedicated staff or funding for transformation work.

Improvements and implications for the support programme

The following potential improvements and implications have been highlighted for the support programme.

Clarify the support programme purpose and process

Provide clearer communication about the support programme’s purpose, process and expected outcomes. This includes outlining the types of support available, and how systems can access them, in a way that places it coherently alongside other support offers outside of the support programme.

Streamline support access and delivery

Simplify the process for seeking and accessing support, including streamlining procurement, scoping and diagnostic processes where feasible and appropriate. Reduce delays and ensure timely delivery of support to ensure that recommendations are provided within a timeframe that is useful for the system.

Tailor the support offer to system needs

Offer more bespoke support tailored to individual system needs and maturity levels (defined as having aligned priorities and a shared understanding of BCF priorities and issues).

Avoid generic offers that do not address specific challenges or allow systems to contribute to the design, direction and focus for the support. Offer support that is seen as a proactive, positive offer for ambitious systems.

Promote regional expertise

Provide regional BCMs with the resources and remit to engage more proactively with the support needs of their local systems and the support programme.

Promote consistent engagement of BCMs so that all regions receive the same offer.

Consider where in the support process BCMs can make the most valuable contribution and particularly how their role in post-support implementation could be enhanced.

End-of-support outputs

Ensure the end-of-support reports:

• are sufficiently detailed
• are consistent with the tangible outputs and improvement areas identified by and arising from support offers
• support wider scale and impact, so there is value for money and increased utility

Facilitate peer learning and networking

Establish peer learning opportunities and networks for senior leaders and BCMs to share best practices and learn from each other’s experiences.

Showcase examples of successful support projects and use this as an opportunity to positively frame the support programme as something to enhance success, as opposed to something for struggling systems.

Provide implementation support

Offer implementation support to help systems translate recommendations into action. This could include:

• specific implementation support built into the suite of support offers
• connecting systems with implementation experts and peer networks. BCMs could play a role in providing this

Focus on leadership and behaviour change

Emphasise the importance of leadership, culture, collaborative working and behaviour change in driving successful BCF implementation through support offers. Provide specific support and resources to foster these elements, possibly as a standalone element of the support programme.

Targeting support

The support programme delivers a high number of small support projects across many systems. Its impact on individual systems would likely be greater if it focused on longer-term, intensive support across a smaller number of more stringently selected systems.

However, consideration should be given to how systems should be selected to balance offering support to systems that need it most with those best able to make changes as a result.

1. Introduction

The Better Care Fund Support Programme

Ipsos UK, in partnership with the Institute of Public Care at Oxford Brookes University, was commissioned by DHSC to conduct an evaluation of the Better Care Fund Support Programme in February 2024.

The Better Care Fund supports local systems (defined as all the partners within an area involved in planning, commissioning and delivering health and social care) to deliver more integrated health and care services, supporting person-centred care, sustainability and better outcomes for people and carers.

The 2 core objectives of the BCF upon which the support programme is grounded are:

1. Enabling people to stay well, safe and independent at home for longer.
2. Providing the right care, in the right place, at the right time.

The BCF Support Programme was set up in 2019 to 2020 to ensure that local areas have the right support available to them as they work towards delivering their BCF plans.

The support programme is delivered by LGA, working with the Association of Directors of Adult Social Services (ADASS) and Newton Europe (considered the core support programme provider) on behalf of DHSC, NHS England and the Ministry of Housing, Communities and Local Government (MHCLG) (the responsible partners). The core support programme providers then commission tailored support through subcontractors.

Local support may be requested by local systems (non-directed) or they may be advised to take it up (directed). Universal support provided by LGA is also available for any system to draw on.

Systems are encouraged to take up discharge support and work with regional BCMs to identify where they could benefit from non-discharge-related support. It is hoped that this support will encourage behavioural and cultural change, alongside improved outcomes around the provision of person-centred care.

It is important to clarify the distinction between the Better Care Fund and the BCF Support Programme. Ipsos is evaluating the support programme to:

• demonstrate the impact of support (including recommendations for further refining and developing support tools)
• enable the programme to effectively provide support to local systems

Although this report contains references to the Better Care Fund generally, this is to provide context for the support programme requirements and objectives.

Data collected through scoping interviews and a review of important documentation (including the support programme tracker, the programme contract and reports on support delivery) were used to develop an evaluation framework and theory of change (ToC) for the support programme.

The purpose of the ToC is to provide a structure for evaluating the support programme’s effectiveness by linking activities and outputs to desired outcomes and impacts. It is a visual aid that shows the steps towards a desired goal, and the connection between these steps in terms of cause and effect.

ToCs for both the overall programme (Figure 11) and its support delivery contract (Figure 12) are illustrated, with further details provided, in ‘Appendix 3: theory of change for the support programme’.

The evaluation

The evaluation of the support programme is predominantly a process evaluation. There are also elements of impact measurement at the local system level. For example, case studies detail the wide range of impacts of support projects delivered across particular systems.

Evaluation questions

The following evaluation questions were co-agreed as part of the evaluation design process.

The process evaluation questions were:

1. How can the design and delivery of the support offered to local areas through the support programme be improved?
2. What are the enablers and barriers to the uptake and effective implementation of changes identified through support delivery?
3. What elements of ‘good practice’ can be identified, and how can this ‘good practice’ be further strengthened, scaled up and expanded across the support programme?
4. Do support interventions enable local systems to make tangible improvements in the level of collaboration and joint or partnership working between partners across health, social care and housing? Does this lead to improved person-centred outcomes for care users?

The impact evaluation questions were:

1. What are the key outputs, outcomes and impact generated by the support programme to date?
2. How has the support programme supported or enabled local systems to deliver person-centred integrated services and improve outcomes for service users?
3. Has the support programme effectively enabled local systems to deliver improved integration between health, housing and social care services?
4. Has the support that has been developed been effective in improving discharge arrangements or performance and non-discharge aspects of integrated working and transformation, including preventing avoidable admissions?

Delivery phases

The evaluation fieldwork was structured around 4 delivery phases as follows.

The scoping and evaluation design activities (January to March 2024) were:

• 6 scoping interviews
• policy and programme documentation review
• ToC co-design and development process, conducted with DHSC, NHS England and LGA

Phase 1 (April to July 2024) involved:

• 16 case study interviews with systems
• supplementary evidence provided by systems
• review of management and KPI information

Phase 2 (August to October 2024) involved:

• interviews with 9 BCMs and 5 CHIAs
• interviews with 5 non-participating systems

Phase 3 (November 2024 to January 2025) involved:

• case study interviews with 15 systems
• survey of BCF leads within 38 systems
• supplementary evidence provided by systems
• review of management and KPI information

Most of the systems (13 in total) included in phase 1 and phase 3 interviews have been written up as case studies in ‘Appendix 1: individual system case studies’. There were a small number of systems included in evaluation interviews for which the data collected was insufficient to draft a full case study write-up.

The table below indicates how the various methods (which are described in more detail in ‘Appendix 2: detailed methodology’ below) addressed the evaluation questions:

Table 1: mapping of evaluation questions to methods

Evaluation question	Case study interviews with systems	Management and KPI data	Supplementary evidence provided by systems	Interviews with BCMs and CHIAs	Interviews with non-participating systems	Survey of BCF leads within systems
Process - question 1 (Q1)	Main data source	Not used	Main data source	Main data source	Supplementary data source	Main data source
Process - Q2	Main data source	Not used	Supplementary data source	Main data source	Main data source	Main data source
Process - Q3	Main data source	Not used	Main data source	Supplementary data source	Not used	Supplementary data source
Process - Q4	Main data source	Not used	Supplementary data source	Supplementary data source	Not used	Supplementary data source
Impact - Q5	Main data source	Supplementary data source	Supplementary data source	Not used	Not used	Supplementary data source
Impact - Q6	Main data source	Main data source	Supplementary data source	Not used	Not used	Supplementary data source
Impact - Q7	Main data source	Supplementary data source	Supplementary data source	Not used	Not used	Supplementary data source
Impact - Q8	Main data source	Supplementary data source	Supplementary data source	Not used	Not used	Supplementary data source

Limitations

The primary limitations to the methodology applied for this evaluation include:

• sampling of case studies - in practice, the sampling of systems for case study interview was driven by availability and responsiveness. While the systems included did broadly conform to agreed sampling considerations, it is likely that the systems that engaged with the evaluation are those that had a more positive experience of support, or who have used the support outputs meaningfully since
• sampling and statistical significance of the survey - the sample achieved for the survey of BCF leads is limited (only 38) and can neither be considered representative of all BCF leads within systems nor used to apply statistical analysis of the results

Purpose of this report

This report is the final summative evaluation report, which includes summarised findings from all fieldwork and supplementary evidence included in the evaluation. The structure of this report is as follows:

• section 1 outlines the background to the BCF and the support programme, and the overarching approach to the evaluation
• section 2 details findings related to the design and delivery of the support programme
• section 3 details findings related to engaging with the support programme
• section 4 details findings related to the experience of support delivery
• section 5 details findings related to outcomes and impact generated by the support programme
• section 6 summarises the emerging conclusion from the evaluation findings, and the implications for the support programme’s design and delivery
• appendix 1 includes individual system case studies to understand support delivery, enablers, barriers and outcomes holistically in each specific context
• appendix 2 details the approach and methodology for the evaluation, including an outline of the support for each system
• appendix 3 includes the ToC for the evaluation as a whole and another for the activities that the support provider has been commissioned to deliver

2. Design and delivery of the support programme as a whole

The following chapter is a brief description of the support programme design and delivery to date, with the evaluation findings relating to experiences of the support programme presented in later sections of the report.

Programme design

The support programme is designed to support local systems in England with their BCF aims and objectives, focusing on leadership, relationships, data utilisation and capacity planning. The support programme has both of the following:

• the universal support offer comprises tools, webinars and reports, including learning lunch virtual events, winter pressure masterclasses, capacity and demand planning webinars, and BCF conference sessions
• the local support offer is tailored to individual systems and delivered by external consultants who work with systems for a set time period (which varies between systems)

There is a wide variety of different types of local support a system may receive, which include:

• capacity and demand planning, such as reviewing waiting list data, historical trends and forecasts of future needs
• scoping diagnostic reviews, for instance staff surveys, interviews and case reviews
• BCF governance support, for example reviewing current BCF plans
• financial modelling, including in-depth analysis of specific spending areas

All local support can either be requested by local systems (non-directed) - which often happens through engagement with the regional network of BCMs and CHIAs - or they may be advised to take it up (directed).

More details of how systems are selected for or initiate support is covered below under ‘How systems were selected for or initiated support’ in section ‘3. Initial engagement with the support programme’.

Following decisions to engage with support at a local level, an initial scoping phase is conducted. This is a collaborative process designed to assess and define the support needs of a system and involves structured conversations between a senior expert from the support programme and the system’s senior leadership team. These discussions aim to build a shared understanding of the system’s current state, including its size and complexity, available capacity and existing capabilities.

Through this process, system leaders can identify and prioritise their specific support requirements before a contractor is appointed. The outcome of the scoping phase is a documented agreement outlining the system’s needs and a joint commitment to deliver tailored support through the support programme.

Support from the programme is delivered in a range of ways. Respondents to the survey of BCF leads within systems who accessed support indicated that the support was delivered through:

• in-person workshops (7 respondents)
• online training modules (5 respondents)
• in-person consultations and training (4 respondents)
• a blended approach involving more than one delivery method (7 respondents)

The outputs from the support programme consisted primarily of reports and, in some cases, a presentation delivered to senior leaders within the system. These reports often included recommendations for improvement and roadmaps for implementation. Some systems also received additional outputs such as:

• collaborative commissioning frameworks
• memoranda of understanding (MoUs) between partners
• self-assessment tools
• data dashboards
• financial tools

The achievement of desired outcomes arising from the support is then dependent on systems working to implement these recommendations.

Programme delivery to date

The support programme’s delivery of local system support and universal support projects is monitored through LGA’s delivery tracker, along with weekly meetings with LGA’s lead adviser and fortnightly progress update meetings.

Tables 2 and 3 below outline the delivery of each type of support, as of 13 January 2025, and in which regions of the country local systems support has been delivered.

Table 2: universal support project delivery, as of 13 January 2025, by stage

Number of universal support projects completed	Number of active universal support projects	Number of universal support projects in pipeline	Total universal support projects
28	5	0	33

Table 3: local support project delivery, as 13 January 2025, by region

Region	Number of local support projects completed	Number of active local support projects (in ‘delivery’ stage)	Number of local support projects in pipeline	Total local support projects
East Midlands	3	0	0	3
East of England	6	0	3	9
London	3	4	2	9
North East	2	0	2	4
North West	17	4	3	24
South East	12	0	4	16
South West	11	1	3	15
West Midlands	5	1	1	7
Yorkshire and Humber	6	0	2	8
Total	65	10	20	95

In total, 28 universal support projects and 65 local support projects have been completed as of 13 January 2025, with a further 5 universal support projects and 10 local support projects in active delivery. Regionally, the North West, South East and South West have seen the highest levels of local support project delivery to date.

The length of support varied. In some cases, the support was delivered over a number of days - however, in most cases, it was delivered across several months.  

Many of the 65 completed local support projects relate to capacity and demand planning (25) or scoping and diagnostic reviews (15). Of the remaining 25 systems, most relate to other financial modelling, pathway review or wider BCF governance support.

Of the 65 completed local support projects, 50 were referred through directed support with:

• 36 cases referred through the Discharge Support Oversight Group (DSOG)
• 12 cases referred through regional BCMs
• 2 cases referred through MHCLG

In comparison, only 15 were the result of non-directed support requests (meaning the system sought support independently).

A further 27 potential local support offers have been closed down due to a:

• lack of engagement from the local system
• lack of capacity within the local system
• perception within the system that they were not yet ready to receive the support offer

Figure 1: cumulative number of support programme local support projects completed over time (as of 13 January 2025)

Time period	Cumulative number of local support projects completed over time
May 2023	3
June 2023	12
July 2023	14
August 2023	16
September 2023	16
October 2023	17
November 2023	18
December 2023	19
January 2024	21
February 2024	27
March 2024	43
April 2024	46
May 2024	47
June 2024	55
July 2024	58
August 2024	60
September 2024	62
October 2024	62
November 2024	65
December 2024	65

Based on the number of support projects being completed per month, support delivery was relatively slow over the latter months of 2023, accelerated in early 2024, then began to tail off from September 2024, as shown in Figure 1 above.

Initially, support projects completed were more focused on discharge support, with all 25 cases of capacity and demand planning and 7 cases of scoping diagnostic reviews completed by May 2024. The scope of topics in recent months has broadened to include other aspects of BCF governance and delivery including:

• place-based governance
• commissioning and finances review
• BCF reviews
• system leadership support

3. Initial engagement with the support programme

This section details findings related to the initial engagement with the support programme, including the process of selection, scoping and involvement of BCMs and system partners.

How systems were selected for or initiated support

The systems included in case studies for this evaluation described a range of methods and approaches by which systems were selected for or initiated support.

Formally, the support programme divides the support offer into ‘directed’ and ‘non-directed’ support (defined above under ‘The Better Care Fund Support Programme’ in section ‘1. Introduction’) - however, qualitative engagement with systems identified that the distinction between these support approaches is not always clear and that, in practice, more sub-categories exist as follows:

• directed support - many systems, especially those facing performance challenges or identified as needing improvement, were directed to engage with the support programme. This often stemmed from national or regional teams (such as DSOG or regional BCF managers) and was based on data analysis (such as national discharge data sets), performance dashboards or escalation processes due to BCF plan submission issues
• proactive requests (non-directed) - some systems proactively sought support, often for specific needs such as capacity and demand forecasting or strategic reviews. However, this was less common than directed support
• BCM offers - BCMs played an important role in offering support in a few cases, sometimes proactively identifying systems struggling with planning or other challenges. They also promoted the support programme and facilitated connections with support providers
• ad hoc conversations - some engagement arose from informal conversations with LGA or other colleagues, though this was noted as potentially disjointed and not always communicated effectively to BCMs or other stakeholders

Directed support was, in a minority of cases, seen as being ‘pushed’ or enforced upon a system, particularly when focused on capacity and demand planning. Among many systems, there was a lack of clarity about why support was being directed, and whether this was something they were being told to have or something interesting that they should engage with.

There were no reported examples of systems being forced to engage with support. More commonly, systems felt that even directed support is more collaborative, rather than being solely directed at them. In practice, there was always a level of mutual collaboration and co-operation required for a support project to take place.

One system leader said:

We were offered it. We didn’t quite understand why we’d been singled out, and that was not really very well explained I don’t think… so it felt like the kind of offer that was being made would actually just be a duplication of what we’d already been through. And so, there was a level of scepticism from our executive team about what more could this add, given that we knew very clearly what it was we needed and that wasn’t what was being offered.

Other systems explicitly requested support specifically for a more robust demand and capacity forecast. One system sought support, having already developed a specification for a review, which they used as the basis for procurement through the BCF offer. Several areas sought support in response to specific challenges, particularly around hospital discharges.

One system requested independent support due to concerns about centralised adjustments to their BCF plan and a lack of clarity regarding the integrated care board’s (ICB’s) mandatory contribution to adult social care. One system received support following a visit from the national discharge team, although they noted delays in finding appropriate support. Another also received support related to discharge challenges, which system representatives thought had been triggered by a visit from NHS England’s national discharge lead.

Several interviewees mentioned pre-existing relationships with regional BCMs as a catalyst for engagement. Some systems highlighted their strong relationship with their regional contact. This facilitated conversations about their need for a more proactive planning approach and ultimately led to the support programme team offering an independent evaluation. Similarly, another system described a “happy coincidence” where their regional manager recommended the support offer after discussions about their ambitions for collaborative commissioning.

BCMs themselves also reported significant variation in their involvement in initial conversations around support, with the level of involvement often dependent on pre-existing relationships being in place.

One BCM said:

Yes, and I think most BCMs would probably say the same, is it’s variable and it can be very disjointed, so there can be colleagues who just happen to have an ad hoc conversation, usually from the LGA or someone, [who] will think this support is appropriate, but they don’t always let the BCM manager know.

Some interviewees highlighted the breadth of the support programme and the difficulty in understanding its full scope, indicating that a simple list of support offers being more publicly available would have made initial engagement with the programme easier.

One stakeholder noted that the BCF funding is often used interchangeably for different things, including the Adult Social Care Discharge Fund and Section 75 funding, which can add to the confusion around the rationale for support taking place.

A system leader said:

I’d heard of the BCF support offer, but I had no idea what that looked like. We met with [regional BCM] just to say, ‘This is what we’re thinking of doing, do you know anyone who could help us with it?’ And they came back and opened the door to us. So, yes, it was fortuitous that we had that conversation with them.

Overall, systems involved in the evaluation reveal a complex picture of engagement with the BCF Support Programme, influenced by factors such as:

• pre-existing relationships
• specific challenges including:
  • limited resources and capacity at system level
  • existing internal processes or commissioned support being duplicative with the support offer
• each system’s understanding of the support programme’s scope and offerings

Specific examples can be found in ‘Appendix 1: individual system case studies’ below.

Scoping processes for support projects

In general, scoping processes for support projects included various initial engagement and design activities, depending on the nature of the support offer. These most commonly included:

• review of pre-existing literature, evidence and support documentation from systems
• initial engagement interviews with senior systems leaders and those who commission support (sometimes including BCMs)
• wider engagement events such as workshops

The primary purpose of scoping support is perceived by both support providers and systems as a way of defining:

• the scope, parameters and activities compromising the support
• what the primary objectives of the support are

Uniformly, across all stakeholder groups, appropriate scoping is seen as a crucial enabler of an effective support project. Scoping processes are generally viewed by systems as helpful in clarifying needs and setting expectations. As such, scoping was seen as one of the most important stages in any support project.

However, some interviewees from within systems noted challenges, including:

• lengthy and repetitive conversations taking place during engagement activities. One system leader said:

We’ve had a lot of conversations about what support we would like. If I was to guess how many hours I’ve been on those, I’ve probably spent 10 hours in meetings - and I had a programme director doing the same and the ADASS is doing the same as well. I would say they’ve been quite repetitive conversations about what we need, and I think we were quite clear about what we need in the first place.

• a lack of initial clarity and transparency, particularly around process and purpose
• difficulty in securing appropriate support matching the specific identified needs for their system
• onerous initial scoping documents that were hard to review and respond to

In one case, a system reported that the support scoping phase did not sufficiently account for all voices across the system. This included wider delivery partners, such as care providers, housing and VCSE organisations. This system suggested that some form of systems mapping would have been useful in the early stages to account for all the various partners and organisations that needed to be involved.

More broadly, there is also an inconsistency in the way the support stages are approached and delivered, even within the same types of support. This can be beneficial if it accounts for tailoring to system needs but may also reflect a lack of clarity around what is required for scoping to be successful.

A BCM said:

I think, initially, it was quite tricky… The support caused a bit of confusion in the systems because they were saying, ‘Well, hold on a minute, we’ve had a letter asking us to meet with this group of people, and then you’re writing asking us to meet with you.’ So, you know, we had to try and manage that a bit, and there was a little bit of difficulty then getting them to engage with us and our conversations. They were well engaged with the senior level, a national team coming to talk to them, but then saying, ‘Well, why have we got to have the same conversation with you?’

Furthermore, it is worth noting that some systems were very clear on what they would like the support to deliver, whereas, in others, there was a lack of clarity, which can lead to a lack of direction with the support. Those systems that had established a level of maturity and understanding internally before engaging with support tended to be more directive about what they wanted the support to deliver.

This not being established can be a risk for systems where support has been directed to them, particularly if, at the time, they have not agreed BCF plans or local areas of improvement across partner organisations. Exemplifying this, in one system, it took a long time for support to be organised because the system was not clear about what it wanted from the support offer.

A system leader said:

We all just chipped in with our own little view of the world and it took us the best part of a year before we got there. We then got the offer that we really needed… and we narrowed it to discharge to assess and we said, ‘Let’s start there’.

BCMs and system leaders themselves reported that the involvement of BCMs and CHIAs in support scoping varied and that, generally, they were involved when they had initiated or referred the system to the support offer. The involvement of BCMs in deciding the focus of the support offer was viewed positively among those systems who experienced it - however, this is probably reflective of the stronger pre-existing relationships that were in place in these regions.

Several interviewees felt a more consistent approach to their involvement in support scoping would be beneficial to both the development of the support offer and their own support of the systems in their region.

Enablers and barriers to taking up support

Several enablers and barriers to initial take-up and successful engagement with the support programme were identified through engagement with systems (both participating and non-participating) and BCMs.

The main enablers cited by interviewees were as follows.

The experience and credibility of support providers

The individuals and sub-contractors involved in delivering support offers are crucial.

Many systems valued having support delivered by those with strong, senior-level experience, as well as pre-existing knowledge of working with their system or of tackling comparable challenges in other systems.

Given that some systems can be sceptical in general about external support, this was seen by many as crucial to gaining initial engagement and buy-in.

Responsiveness and flexibility to match system needs

Support offers should be able to demonstrate a flexibility to match system needs and tailor their approach to solve local as well as national problems.

In cases where support was viewed as generic or providing a national ‘top-down’ approach, it was often engaged with less well during early stages and subsequently had less impact as a result.

Collective understanding and level of consensus of the support needs within a system

Systems often require an internal shared position or understanding of the contextual factors and challenges that they face, before initially engaging with a support offer.

In addition, agreement among relevant partners, including senior leaders, on the support needs within a system was also noted as important. This was more likely to be the case with non-directed or requested support, where the system had already done this internal work and proactively decided to seek external support.

Conversely, it presented a common risk for directed support, where systems were often struggling to come to a shared internal view (which was often one of the factors that had led to them struggling with aspects of BCF planning initially).

For example, one system leader told us:

It [the scoping process] was really helpful because, I think, it asked the right questions of us, so that we thought, ‘Yes - what are we actually trying to do?’ It really did try to unpick, ‘What is it you’re actually trying to achieve?’ So, it was incredibly helpful.

The main barriers cited by interviewees were as follows.

Directed support concerns

A common theme was the mixed reception of directed support.

While some systems embraced it, others found it unclear why they were selected, potentially feeling it was punitive rather than helpful. A lack of robust explanation and regional involvement in the selection process contributed to this.

Some felt directed support focused too heavily on discharge performance, contradicting the programme’s aim of earlier intervention and prevention.

Limited resources and capacity 

For both directed and non-directed support, systems faced capacity constraints, impacting engagement and follow-through. One issue was the number of people across the systems who needed to be engaged - it required resource across multiple organisations and people to work well.

Systems struggled to dedicate time for scoping and implementation, while the support programme faced challenges in providing adequate resources and hands-on support, sometimes spreading resources too thinly.

In particular, it is likely that the delivery of capacity and demand support was too thinly spread and would have had more impact with fewer larger packages of support.

Communication and co-ordination issues

Inconsistent communication between national, regional and local teams hindered effective engagement. Ad hoc conversations were not always communicated to relevant stakeholders, and handovers between support staff were sometimes inconsistent, leading to delays and confusion.

Perception of ‘support’

The term ‘support’ itself carried negative connotations for some, who associated it with being identified as underperforming. This perception created a barrier to engagement, with some systems reluctant to admit needing help.

As shown in Figure 2 below, despite these negative perceptions among some systems who were interviewed, 27 BCF leads responding to the survey felt that the support offered by the support programme was something that would be helpful for all systems and 17 said it was a way for high-performing systems to improve further. Sixteen systems reported viewing it as a way for poor-performing systems to access support and only one system said it was not something most systems need to access.

Figure 2: responses to the survey question - do you see the BCF Support Programme as primarily…

Number of respondents: 38

Response	Number of respondents
Something that would be helpful for all systems	27
A way for high-performing systems to improve further	17
A way for poor-performing systems to access support	16
Not something worth accessing for most systems	1

Twenty-seven potential local support offers have been closed down due to lack of engagement or a system declining support. When considering whether to take up or decline the offer of support, systems cited the following as being most prominent in their thinking or decision making:

• for directed support, existing internal processes or commissioned support being duplicative with the support offer. One system leader said:

Well, that’s because they’re already getting support elsewhere doing the same thing. When you’ve got multiple offers for the same thing, why would you use multiple offers? You just want to stick to one.

• support fatigue and perceived distraction from existing improvement initiatives. Another system leader said:

It’s not just support fatigue, but it’s a distraction. So, once you’re on a pathway to… deliver and make changes, when something else comes out of left field, it becomes a distraction. Which I think is difficult for systems, whether it be health or social care, to accommodate, because they’re already on a path they’ve already agreed is the way forward. So, the support offers for everything around a topic area like discharge should be pulled together, it should be a single offer. It should be a single conversation, not multiple.

• lack of clarity about the support offer and its potential benefits
• concerns about negative perceptions of needing ‘support’ as a newly established local authority or that engaging with the support offer was indicative of a failing system
• scepticism about what the support would add, given other existing plans or support
• resource constraints and competing priorities, meaning that it was not felt that support was worth the engagement required for it to be effective

Involvement of others in initiation of support

The role of system partners

Most systems reported good engagement from system partners when initiating support, particularly at senior levels.

Often, partners from health and local authorities were involved but there was a notable absence of wider partners such as care providers and VCSE organisations in the initial stages of support projects.

One system leader said:

I think, as a system, we do have really good partnership relationships. We try and have lots of those discussions together… There was really good sign-up and, during the support offer, people did get involved. So, I think we were very fortunate at that time. It probably felt like coming out of the real challenge bit of the pandemic into, ‘Right, okay, let’s lift our heads and start to think forward a bit.’ I think it was 2021 that we started it. There was a really good commitment to it and becoming an integrated care system, all that, it added a lot of impetus to, ‘We need to look at how we do this better.’

Another system leader said:

I’m not aware that it included voluntary sector providers. If you’re talking about acute providers, I don’t know how joined up all the communications were.

When engaging with system partners during support initiation, some challenges were noted by systems including:

• difficulty engaging all relevant partners due to capacity and resourcing issues
• BCF leads sometimes acting as ‘gatekeepers’, potentially limiting access to support for other colleagues - for example, one BCM said:

The BCF lead might be going, ‘I don’t have the capacity for this. I don’t have time to give that thought,’ and actually then there could have been other local colleagues that could have taken advantage of it.

• gaps in stakeholder representation during important scoping meetings, which then subsequently meant that the support offer did not fulfil their needs
• the lack of clear examples of successful support interventions

The role of BCMs and CHIAs    

Both regional BCMs and CHIAs have good knowledge of systems and their specific local contexts, histories and challenges.

This knowledge of their areas, developed over long time periods, could enable them to play an important role in offering and promoting support, often identifying systems that would benefit from the support offer and tailoring offers to their needs. However, ad hoc engagement routes, sometimes bypassing BCMs or CHIAs, led to disjointed communication and potential duplication of efforts.

Similarly, the survey of BCF leads within systems showed that, most commonly, BCMs were involved in suggesting or directing them to the support offer, then initial scoping and post-support review and reporting. However, most reported some meaningful BCM involvement in at least one stage of the support process.

Figure 3: responses to the survey question - which, if any, stages of the support programme was your Better Care Manager (BCM) involved in?  

Number of respondents: 19

Response	Number of respondents
Suggesting or directing us to support	14
Initial scoping and diagnostics	9
Support delivery	7
Post-support reporting and review	9
Supporting us in implementation following support	7

Systems taking part in in-depth interviews reported variable experience of BCMs being involved in the support - some felt that they had played a critical role, whereas others felt they had no involvement. Involvement varied as follows:

• active and positive engagement - several participants described regular contact and support from their regional BCMs. They reported them providing updates, information on templates, and facilitating regional meetings and seminars
• limited or indirect engagement - other systems reported less direct involvement. Some described their interactions as primarily focused on reporting and template completion rather than direct support. In some cases, the BCM’s involvement was limited to attending a few important meetings
• missed opportunities for engagement - one system suggested that the support team could have been more proactive in seeking their assistance to facilitate engagement with stakeholders, particularly in challenging areas such as integrated neighbourhoods

In practice, the roles and responsibilities of BCMs and CHIAs in support delivery included:

• information dissemination and reporting - a consistent theme is the BCM’s role in distributing information, updates and templates related to the support programme, particularly during initial engagement
• facilitating connections and communication - one BCM highlighted their role in connecting the support programme with other relevant NHS initiatives and stakeholders within their region
• providing support and guidance - while the level of support varies, BCMs feel they are expected to offer assistance to support projects as needed and requested. However, the nature and extent of this support are not consistently defined
• relationship building - building and maintaining strong relationships between systems and the support programme was seen by some BCMs and CHIAs as a core aspect of their role, as evidenced by the positive relationships described in some systems

However, interviews highlighted some significant considerations around the level of involvement from BCMs and CHIAs, including:

• scale of support delivery - if several systems within the same region were receiving support simultaneously, greater and consistent BCM or CHIA involvement could present a significant additional time or resource requirement
• BCF plans assurance cycle - the assurance process for systems’ BCF plans resulted in limited BCM capacity during specific timeframes. Some interviewees noted that it would be particularly challenging to be more involved in support delivery during these periods
• system ownership of support - interviewees acknowledged the importance of maintaining systems’ ownership of the support delivered and resulting recommendations and action plans

From the systems sampled as case studies, there does not appear to be a strong association between BCM involvement in support delivery and satisfaction with the support offer and outcomes. However, most systems included as case studies were particularly keen to emphasise the benefits of their involvement in scoping support and working with systems to share and implement recommendations.

4. Experience of support delivery

This section details findings on systems’ experiences of support delivery, including:

• their engagement
• the types of support delivered
• the quality of support
• the involvement of stakeholders from the wider system

Engagement with the support

Engagement with the support delivered varied across systems. This engagement was influenced by factors including:

• the perceived credibility of the support offered
• existing inter-agency relationships
• individual personalities
• practical constraints of time and resources

Some of the enablers for seeking support and taking up the offer (described previously in section ‘3. Initial engagement with the support programme’) also impacted upon engagement with the support offer during delivery.

The tables below summarise the primary enablers and inhibitors in relation to systems’ engagement with support.

Table 4: enablers to engagement with support

Enabler	Description
Engaging respected, credible experts to deliver support	Systems consistently reported positive engagement when the support provider was a recognised expert in the field. Credibility and prior knowledge of discharge processes meant systems did not have to spend time explaining the basics, and the resulting recommendations carried weight. This was also noted to be effective in ensuring buy-in from senior leaders
Flexibility and responsiveness of support providers	Support providers were valued when they were flexible and adapted their approach to the specific needs of the system
Early and consistent involvement of senior leaders	When senior leaders from both health and social care were actively involved from the outset, it facilitated buy-in and engagement from other stakeholders. One interviewee noted that direct outreach to senior leaders by a BCM had also proved effective in overcoming initial hesitation. Examples of these senior roles included chief executive officers, chief operating officers and ADASS
Clear objectives and a structured approach	Systems that had defined objectives for the support and appropriate governance structures (such as steering groups, task groups or regular meetings) tended to have better engagement
Building on existing relationships and structures	The support programme was most effective when it leveraged existing positive relationships and governance structures between health and social care partners within the system
Co-designed support offers	Systems that were able to co-design the support they received with the provider team typically reported better engagement and experiences

Table 5: inhibitors to engagement with support

Inhibitor	Description
Lack of senior leadership engagement	Difficulty engaging senior leaders, particularly within the NHS, was a significant barrier. This was often attributed to competing priorities, capacity constraints and leadership changes. When senior leaders were not invested, it hindered levels of engagement at other levels
Limited opportunities for systems to shape the offer	Where systems felt that the support was ‘pushed’ on them, with limited opportunity to shape the type or focus of the support received, this created a barrier to successful engagement
Mismatched support and system needs	When the support offered did not align with the system’s specific needs or maturity level, engagement suffered. For example, systems with advanced data capabilities found generic data modules unhelpful. Similarly, support focused narrowly on hospital discharge, when broader system issues were at play, also limited engagement
Perceived lack of value	When systems felt the support was simply reiterating what they already knew or would not lead to tangible change, engagement waned. This was particularly evident when initial diagnostic reports lacked specific, actionable recommendations
Limited time and resources	The time-limited nature of the support and the demands on staff time to participate at short notice were barriers to engagement. Systems recognised that participating in reviews and workshops required significant effort on top of existing workloads
Lack of trust between partners	Pre-existing tensions and mistrust between health and social care partners sometimes hampered engagement and open communication during the support process

Types of support received

The types of targeted support received were diverse, ranging from high-level diagnostics and reviews to targeted support for specific areas such as capacity and demand modelling or leadership development (see section ‘2. Design and delivery of the support programme as a whole’ above for further details).

This variety, while intended to cater to different system needs, also led to some inconsistencies in experience and raised questions about the clarity of the support programme overall.

Some main themes emerged, specifically in relation to the types of support delivered to systems, as follows.

Diagnostics and reviews

This type of support primarily focused on assessing systems’ capacity for integrated care, particularly concerning hospital discharge. Overall, this support:

• provided valuable external perspectives
• validated existing work
• identified areas for improvement
• sometimes offered a ‘roadmap’ for change

Some systems found the process helpful for facilitating difficult conversations and bringing partners together.

However, these were also perceived by some as:

• reiterating what systems already knew
• lacking specific or actionable recommendations
• not enough to lead to tangible change

Capacity and demand modelling

This support was generally well received, particularly when delivered by a recognised expert. It helped some systems:

• better understand demand patterns
• identify bottlenecks
• develop more effective models for managing capacity

However, the effectiveness of this support appeared to vary depending on the commissioned support providers’ expertise and the systems’ existing data capabilities.

Some systems struggled to translate modelling outputs into actionable changes, and the focus on hospital discharge was not always relevant to broader system needs.

Leadership and governance

This type of support was highly valued for:

• fostering collaboration
• strengthening relationships
• improving governance structures

Facilitated workshops and the development of team charters or MoUs were seen as particularly helpful.

Conversely, sustainability was a concern, as the short-term nature of the support often meant that initial progress was not sustained. Securing consistent engagement from senior leaders was also a challenge, particularly where there was staff turnover.

The universal support offer includes learning lunch virtual events, which focused on important areas within the health and social care sector. Five sessions covered topics such as:

• ‘hospital at home’
• discharge planning
• the ‘trusted assessor role’
• co-production
• ‘integrated community teams’

Overall, these sessions were well received, with the positive impact of knowledgeable presenters noted by attendees. However, organisers noted a drop-off in sign-ups for the later sessions, possibly due to webinar fatigue or seasonal factors.

Quality of support delivery

The evaluation sought to understand the quality of support delivered by the support programme, through both the survey and in-depth fieldwork with systems.

Overall, many systems expressed broad satisfaction with the support received, often praising the expertise, professionalism, and responsiveness of the individuals and organisations involved.

Many support providers were commended for their credibility and understanding of both the technical aspects of the BCF and the specific dynamics of local systems. The structured and proactive nature of the support, along with clear communication and a willingness to be flexible and adapt to system needs, were also highlighted as positive aspects.

Systems particularly valued the external perspective and practical guidance offered, and the ability of support providers to work within existing constraints. This satisfaction with the quality of support was also noted in responses to the survey.

One system leader said:

I think the quality of the support was really high. The organisation, the individuals involved were very credible… The quality of the products was very high, so we’ve got a lovely, very long slide deck that we can now use as our bible of Better Care Fund in lots of conversations.

Most systems responding to the survey (15 of 19) agreed that the quality of the support was high.

Figure 4: responses to the survey question - to what extent do you agree or disagree with the following? The quality of support was high  

Number of respondents: 19

Response	Number of respondents
Strongly agree	8
Agree	7
Neither agree or disagree	1
Disagree	2
Strongly disagree	1

Furthermore, the same proportion of systems responding to the survey were broadly satisfied with the support delivered.

Figure 5: responses to the survey question - to what extent do you agree or disagree with the following? Overall, our system was satisfied with the support delivered

Number of respondents: 19

Response	Number of respondents
Strongly agree	5
Agree	10
Neither agree or disagree	1
Disagree	1
Strongly disagree	2

Of the 19 systems who responded to the survey, 14 also agreed or strongly agreed that the support they had received was effective in addressing their challenges.

Figure 6: responses to the survey question - to what extent do you agree or disagree with the following? The support was effective in addressing our challenges

Number of respondents: 19

Response	Number of respondents
Strongly agree	4
Agree	10
Neither agree or disagree	2
Disagree	1
Strongly disagree	2

Despite generally positive feedback, some systems identified areas for improvement. A recurring theme was the desire for more tailored support that truly addressed the specific challenges, contexts and capacities of individual systems.

For example, some systems, when considering the reporting outputs delivered, felt they lacked a deeper understanding of local nuances and that recommendations were too generic.

This was particularly true for some of the demand and capacity planning support, which was perceived as too theoretical and lacking practical application - for example, one system leader said:

I was really disappointed, actually, with the output from the [demand and capacity] work… It wasn’t detailed enough, it wasn’t helpful, it was very generic, it was telling us the same thing that we knew…

However, respondents to the survey of BCF leads within systems indicated that most systems who accessed support found that the support met their needs and objectives related to the BCF.

Figure 7: responses to the survey question - to what extent do you agree or disagree with the following? The support met our system’s needs and objectives relating to the BCF  

Number of respondents: 19

Response	Number of respondents
Strongly agree	5
Agree	10
Neither agree or disagree	2
Disagree	0
Strongly disagree	2

Despite these positive survey findings, some interviewees questioned the expertise of certain support providers, particularly regarding BCF specifics or local challenges. These findings suggest a need for more:

• tailored support
• streamlined processes
• consistent expertise among providers

Systems also highlighted that effective communication with the commissioned support provider was crucial to ensuring stakeholder and provider expectations were aligned from the outset and throughout.

While some systems praised clear, regular communication from support providers, particularly through weekly meetings, others found this frequency excessive or the format unproductive. For example, one system initially found their weekly meetings to be too focused on logistics and lacking in emerging feedback on findings.

Some systems highlighted the value of in-person meetings for facilitating open and honest conversations, while others found virtual meetings to be sufficient.

This suggests that the ideal frequency and format of meetings and communication varies depending on individual systems’ needs and should therefore also be tailored accordingly.

Engagement of other system partners

The ToC for the support programme (see Figure 11 in ‘Appendix 3: theory of change for the support programme’ below) describes outcomes that relate to sustained integrated working - not only between statutory health and social care partners, but also with both housing and VCSE partners. The evaluation explored the involvement of these system partners in the support delivered.

While engagement varied across systems and projects, some common themes emerged regarding the:

• types of partners involved
• level of their engagement
• factors influencing their participation

The evaluation found limited engagement of VCSE organisations and housing partners in the support delivery. This echoed findings about these system partners’ involvement in support scoping (see ‘Involvement of others in initiation of support’ in section ‘3. Initial engagement with the support programme’ above).

While the ToC for the support programme and several interviewees acknowledged the importance of these partners for integrated care and effective hospital discharge, they were rarely invited to participate in support activities.

For example, interviewees from one system noted that, while voluntary sector organisations were sometimes co-located with statutory services or involved in specific activities like case reviews, these organisations were not involved in broader strategic engagement.

Similarly, another system reported that housing partners had not been invited to engage with the support programme, although they were occasionally invited to conversations where relevant, such as discussions about overnight care.

One system leader said:

We do commission VCSE for hospital discharge support in [place A]. We’re currently reviewing those contracts because they’re not performing to contractual levels… So, [the support provider] was aware of the services that we commission from non-NHS providers, but I don’t believe we asked [them] to interview anyone from the VCSE, or from the private care sector.

Overall, this limited involvement contrasts with the support programme’s intended outcomes of integrated working across health, social care and housing. It suggests a gap in the programme’s approach to system-wide change, as the expertise and perspectives of VCSE and housing partners were not consistently incorporated into the support delivery. Several factors have contributed to this limited engagement, including:

• the primary focus on statutory health and social care partners
• capacity constraints within the VCSE and housing sectors
• the limited strategic inclusion of these system partners by lead organisations within the system

Addressing this gap and finding ways to meaningfully involve VCSE and housing partners in future iterations of the support programme will be crucial for achieving its longer-term goals of improved integration and outcomes for service users.

5. Outcomes and impacts generated by the support programme

This section details findings related to outcomes and impact generated by the support programme.

Outcomes

The ToC for the support programme (see Figure 11 in ‘Appendix 3: theory of change for the support programme’ below) describes the programme’s expected outcomes across both the short and medium term.

The main beneficiaries of these outcomes are expected to be teams working on BCF-related activities within local systems, with outcomes for people drawing on support from health and social care services expected in the longer term.

Short-term outcomes are expected to include:

• system satisfaction with support
• improved collaborative working
• systems ‘taking action’ based on an improved understanding of the issue or focus of the support delivered

Expected medium-term outcomes include:

• improved BCF plans
• alignment of broader plans across health, social care and housing
• increased sharing of good practice

Interviewees often noted that, while the support programme had been helpful, it was one of many contributing factors to any observed improvements in a system. Other contributing factors that may have influenced the same outcomes included:

• existing local initiatives
• leadership changes
• other support offers

One system leader said:

I don’t want to overplay too much the support we had… It was more facilitative, rather than much more than that, bringing people together in a room and asking the right questions to get us to unearth the difficulties that we were facing… Now we’re in a position where we recognise [the BCF’s] value to help generate and move forward ways of working. I say that we are doing that ourselves. It’s not due to any support that we’re receiving.

Tables 6 and 7 below provide an overview of these outcomes and the extent to which there is evidence that the support programme has contributed to them. The assessment draws on data and analysis from across the evaluation and recognises the range of other factors that could potentially influence those outcomes.

There is evidence that those outcomes originally hypothesised to be generated in the short term are starting to emerge as expected, but progress on medium-term outcomes is more limited. The time frame for the evaluation, challenges in implementing change and difficulties measuring outcomes mean there are still gaps in evidence of progress for both short and medium-term outcomes.

The strongest evidence of emerging outcomes relates to improved:

• buy-in
• relationships
• collaborative working

The largest gaps in observed outcomes relate to:

• improved BCF plans
• greater alignment in broader plans across health, social care and housing

Table 6: summary of evidence against short-term outcomes

Short-term outcome	Extent to which support programme contributed to this outcome	Summary findings
Local system satisfaction with support	Some evidence	While some wanted more tailored approaches, many systems expressed general satisfaction with the support received, especially regarding the expertise of the support providers
Local systems have increased confidence in achieving their BCF ambitions, in line with support objectives and associated metrics	Limited or no evidence	While some systems reported slightly increased confidence, others remained sceptical, particularly about longer-term transformational change
Improved buy-in, relationships and collaborative working in local system	Strongest evidence	This was consistently noted as a positive outcome, specifically between health and social care partners. While not always solely attributable to the support programme, the support often acted as a catalyst or facilitating factor
Local systems have a better understanding of the issue or focus of support delivered	Some evidence	The support delivered generally clarified existing knowledge and fostered a shared understanding among system partners
Local systems have ‘taken action’ in some way - in line with the objectives of the support delivered	Some evidence	While there were some examples of systems ‘taking action’ following support, many systems were still in the planning stages and yet to implement changes
Local systems are able to monitor and evidence their progress	Some evidence	Evidence against this outcome was mixed. While some systems felt prepared to monitor their progress, many faced challenges related to data access and quality, measurement tools, and timeframes for assessment
Increased presence of BCF and BCF Support Programme in local systems	Some evidence	Data suggest that support delivery has increased awareness of both the BCF and the support programme within participating systems. However, some confusion and cynicism about the BCF was noted. While some systems viewed the support programme positively, others perceived it as a response to poor performance or a potential burden
Universal support - local systems have utilised learning from support delivered	Some evidence	Systems reported engaging with webinars, learning lunches and online resources provided through the universal support offering, generally perceiving them as helpful. Some feedback suggested that the universal support could be more interactive and engaging

Note: these outcomes are dependent on the type of support delivered.

Table 7: summary of evidence against medium-term outcomes

Medium-term outcome	Extent to which outcome was achieved	Summary findings
Improved BCF plans that are more detailed and based on more accurate data	Limited or no evidence	Many systems were still in the early stages of implementing changes, and it was too early to assess the impact on BCF plan quality. Capacity limitations and data challenges were identified as potential barriers to achieving significant improvements in BCF planning
Broader plans in health, social care and housing are aligned	Limited or no evidence	While improved partnership working between health and social care was a common outcome, there was limited evidence of broader alignment with housing or VCSE plans. The focus on discharge support in many support projects may have contributed to this limited scope
Increased knowledge of what the BCF is delivering among local system staff	Some evidence	Support often facilitated increased transparency and understanding of BCF processes, funding flows, and intended outcomes among system partners. This was particularly evident in systems where the support involved workshops and presentations to a wider group of stakeholders. However, there was limited engagement with frontline staff and partners outside of health and social care
Improved capacity and demand planning	Some evidence	Some systems reported making progress in capacity and demand planning as a result of the support. However, some interviewees felt that the capacity and demand support offered was too theoretical or high level and did not adequately address the practical challenges faced by systems
Improved discharge planning	Some evidence	Some systems described changes in discharge processes, such as increased use of reablement services and improved pathway management, which they attributed, at least in part, to the support received. Many systems were still grappling with persistent discharge challenges, and it was too early to assess the longer-term impact of the support on discharge planning performance
Improved plans for prevention	Limited or no evidence	There was little evidence of support resulting in improved plans for prevention
Increased sharing of good practice	Limited or no evidence	Both system stakeholders and BCMs or CHIAs expressed a desire for more opportunities to share good practice and learn from each other’s experiences. See ‘Potential improvements and implications for the support programme’ in section ‘6. Conclusions’ below for further details
Local systems have engaged with or requested follow-up support (if needed)	Some evidence	Some systems expressed interest in receiving further support. However, capacity limitations, competing priorities and a perception that the initial support had adequately addressed their needs were among the reasons why some systems did not actively seek follow-up support

Note: these outcomes are dependent on the type of support delivered.

Survey respondents were largely positive about having seen, or expecting to see, changes as a result of the support programme.

The outcomes most commonly reported in the survey related to systems:

• developing a better understanding of relevant issues facing their system (13 respondents)
• understanding how to address these issues (10 respondents)
• experiencing improved buy-in, relationship and collaborative working (9 respondents)

Just under half (8 of 19) of systems who responded to the survey reported that they have seen changes as a result of support received through the support programme.

Figure 8: responses to survey question - have you seen or do you expect to see any changes (such as outputs, outcomes or impacts) as a result of the BCF Support Programme?

Number of respondents: 19

Response	Number of respondents
Yes, we have seen changes as a result of the BCF Support Programme	8
Not yet, but we expect to see some changes in the next few months	4
No, we have not seen any changes as a result of the BCF Support Programme	4
We have seen changes but are unsure if we can attribute them to the BCF Support Programme as we have received other support in the system	2
I do not know	1

Overall, the support programme demonstrated the most success in improving partnership working, particularly between health and social care system partners. This outcome was acknowledged by systems as foundational to achieving improvements in the future.

However, in some of the case study systems, the early stages of implementing changes have been slow and there is little evidence of tangible changes taking place following support delivery.

One system leader said:

I think it’s changed how people view who the team is, and who they go to, to try and sort things out… I think it stopped either party, in terms of health and social care teams, going off in silos - it’s made us all do it together”.

Another system leader noted:

We haven’t implemented anything out of it though… So, you know, it is the [end-of-support] report at this point, which we now need to take forward… It may well be [if you] come and speak to me in a year’s time, I can say to you, ‘Actually, as a result of that report, we’ve made X, Y, Z changes’. And then we could tangibly say [the support] had some impacts here, but it’s too early to say.

The evaluation also found a mixed picture regarding systems’ readiness or ability to measure outcomes.

Some interviewees felt they had adequate data and processes in place, or that the support itself had helped them develop tools and metrics. For example, one system used discharge data, hospital system information, and pathway data to measure the impact of the support on reducing bed days and improving patient flow. They also had specific targets for reducing breaches and improving waiting times.

Similarly, some systems used the support to develop a tool for modelling capacity and demand, which they then used for future planning. However, one system stakeholder noted that updating and maintaining this tool would require an ongoing internal resource commitment from their system.

Other systems reported specific challenges in measuring outcomes. Some systems lacked clear metrics or data collection processes for measuring the results of the support, particularly for less tangible outcomes such as improved partnership working or cultural change. For instance, one system described the organisational development support received as “not very metric-driven”.

In other areas, interviewees described data-related challenges - even where relevant data was available, some systems faced difficulties ensuring consistent interpretation and use of data by the different system partners involved.

These findings were supported by the survey results. Of 19 responses:

• 8 reported that their system was not set up to measure changes as a result of the support programme
• 7 reported that their system was set up for this
• 4 did not know

These findings indicate that, as well as requiring sufficient time for outcomes to emerge, some systems may benefit from additional support in preparation to measure the relevant outcomes, following the implementation of changes or recommendations.

Enablers and barriers to implementation of change

The support programme aims to provide support that enables systems to implement and sustain changes to their working practices.

Survey results suggested that the support programme provided adequate advice and support for implementing change in many systems, with 13 of 19 systems agreeing.

Figure 9: responses to survey question - to what extent do you agree with the following? The support programme provided adequate advice and support for implementing changes

Number of respondents: 19

Response	Number of respondents
Strongly agree	5
Agree	8
Neither agree or disagree	3
Disagree	1
Strongly disagree	2

However, exploring this in greater depth in interviews suggested that this was more complex. Interviewees frequently expressed a need for more support in implementing the changes recommended through the programme.

While this was a common theme, there were differing perspectives on the level and intensity of implementation support required. Some systems wanted a more hands-on approach, with the support programme actively involved in the implementation process, while others suggested a lighter-touch approach, with the focus on providing guidance and resources rather than direct intervention.

The optimal approach likely varies depending on the specific needs and capacities of individual systems.

Case study fieldwork identified several enablers and barriers to the implementation of change, following the support offer.

The primary enablers identified were:

• strong leadership and commitment - leadership, particularly at the executive level, was considered important for championing change, securing buy-in from other stakeholders and maintaining momentum throughout the implementation process. Interviewees noted that, without clear leadership, initiatives could stall or lose priority amidst competing demands
• accountability and ownership - assigned responsibilities for driving specific actions and monitoring progress during the post-support period was suggested to help establish accountability for implementation and ensure that changes are not left to chance
• adequate resourcing - securing resources, both financial and staffing, allowed systems to focus on implementation without overburdening existing teams
• continuation of external support - ongoing support specifically focused on implementation was identified as an enabler, particularly where changes required specialist expertise (such as technical or change management) that systems did not have available internally

The primary barriers to the implementation of change were:

• capacity and funding constraints - limited resources, other ‘burning platforms’, staff shortages and a lack of dedicated capacity to implement changes remained the most significant barriers. The short-term nature of the support and the absence of long-term funding to sustain changes exacerbated these challenges
• cultural, leadership and hierarchical conflicts - persistent cultural differences between system partners, alongside leadership challenges and varying levels of buy-in at senior levels, hindered system-wide change. A perception of hospital discharge and NHS partners being prioritised had the potential to create tension and hamper collaboration
• tension between ‘system’ and ‘place’ - the tension between system-level priorities and place-based needs created a risk of disconnection between strategic plans and local implementation. Differing priorities and perspectives within an ICB exemplified this challenge. Balancing system-wide goals with the unique contexts of individual places remained a significant challenge
• implementation support gap - a lack of ongoing support for implementing recommendations (including capacity building, practical guidance and a clear handover process) hindered the implementation of suggested changes. Some systems described feeling somewhat abandoned after the initial support concluded, lacking the resources and guidance to effectively take things forward

Impacts associated with the support programme

The ToC for the support programme (see Figure 11 in ‘Appendix 3: theory of change for the support programme’ below) also outlines the anticipated long-term outcomes or impacts of the programme.

For local systems, these were:

• sustained joint planning and commissioning
• sustained integrated work on and joint commissioning of issues beyond the focus of the initial support offer
• sustainable funding for and integration with the local VCSE sector

Beyond those expected for local systems, the following impacts are expected for local and central government:

• improvements to primary BCF metrics
• improved evidence of what works
• learning across local systems and regions, catalysing improvements at scale

Finally, the ToC identifies the following impacts for local residents or people drawing on health and social care services:

• increased numbers of people looked after at home
• reduction in those requiring long-term care
• more people receiving rehabilitation or reablement services
• improvements in access to more person-centred care and support
• more joined-up care in general for people accessing services

Overall, the evaluation found little evidence of the support programme contributing to the emergence of such impacts in the lifetime of the evaluation.

This is not unexpected, given the long-term nature of the desired impacts and the timing of both support delivery and the evaluation. Many systems were still in the process of implementing recommendations or actions from the support received, making it too early to assess long-term results. Interviewees mentioned needing significantly more time (between 1 and 5 years) to see tangible, longer-term changes.

Despite this, survey responses provide some evidence that the support received would have a lasting impact on systems, with 12 of 19 systems in agreement.

Figure 10: responses to survey question - to what extent do you agree or disagree with the following? The support received will have lasting impacts on our system

Number of respondents: 19

Response	Number of respondents
Strongly agree	2
Agree	10
Neither agree or disagree	4
Disagree	1
Strongly disagree	2

This was echoed by some interviewees, especially those who had more positive experiences of the support.

However, others were more pragmatic, cautious or sceptical about their systems’ ability to achieve these long-term goals, based on acknowledgement of the challenges involved.

Operational pressures and financial challenges were frequently cited as the biggest obstacles to achieving change. For example, one system leader said:

We have a significant financial deficit as a system - huge. So, we’ve got a financial recovery plan to achieve over the next 2 years and I think that has had a massive impact on our ability to have the time… I think it takes quite a lot of time to do partnership working and really, you know, get underneath where there are collective opportunities.

Sustaining change

As noted above, several of the desired impacts of the support programme are grounded in the aim of sustaining improvements in the longer term.

The evaluation found that, for systems, the prospect of sustaining change after the conclusion of support delivery was often challenging. Systems often acknowledged the value of the support and the recommendations provided but struggled to translate these into sustained action.

The day-to-day pressures of existing workloads and more immediate operational demands consumed available time and resources, leaving little capacity for the ongoing effort required to sustain changes within existing systems. This was particularly true in systems lacking dedicated staff or funding for transformation work.

The short-term nature of the support itself exacerbated this challenge, creating a ‘cliff edge’ where some systems lost momentum and focus after the initial burst of activity. For instance, one system leader said:

That’s the risk, isn’t it? That when you hit those pressures, people revert to past behaviours. Buy more beds, just get them out, whatever the cost… Except all that happens, of course, is that, as soon as you empty those wards, more people come in and then it starts to balloon again and you’re back where you were.

This capacity gap extended to a lack of programme management expertise, which was necessary to maintain momentum and build on the support received. While some systems had established project management structures, many did not have the resources available to effectively manage complex, system-wide change initiatives.

The support programme often provided a valuable diagnostic function and identified important areas for improvement, but systems struggled to translate these recommendations into actionable plans with clear timelines, assigned responsibilities and ongoing monitoring mechanisms.

This lack of programme management capacity hindered the development of robust implementation plans and contributed to a sense of inertia after the initial support concluded.

Interviewees suggested that providing access to programme management expertise - either through training, embedded support or continued access to specialist consultants - could significantly enhance their ability to implement and sustain changes over the long term.

Identifying and sharing good practice

Interviews with both system stakeholders and BCMs or CHIAs revealed a common desire for more robust mechanisms to identify and share good practice.

While the support programme offered some avenues for learning and dissemination, such as webinars and online resources, interviewees highlighted the need for more structured, interactive and context-specific approaches to sharing what works.

Evaluation findings suggested a gap in systematic processes for identifying good practice. While individual interviews uncovered examples of innovative approaches and successful implementation strategies, interviewees did not identify a clear mechanism for capturing and sharing these learnings more broadly.

BCMs and CHIAs, in particular, expressed frustration at not having ready access to information on the outputs and outcomes of support projects, which made it difficult for them to identify and disseminate good practice within their regions. Suggestions included:

• a dedicated online platform
• a searchable database of case studies
• regular regional learning events where systems could share their experiences and access practical tools and resources developed by their peers

Peer support and peer learning opportunities were consistently viewed as valuable mechanisms for supporting systems, particularly if these opportunities could connect similar systems facing comparable challenges. Many interviewees emphasised the benefits of connecting with colleagues in other systems to share successes, challenges and lessons learned. A more co-ordinated approach, where relevant peers could share not only their experiences but also practical tools and strategies, was seen as highly beneficial.

For example, providing access to a toolkit or template used successfully by a similar system, along with guidance on how to adapt it to a different local context, was suggested as a practical way to enhance peer learning by one system leader:

Information, knowledge, intelligence is always helpful… Just like the support offer that came in, the information was gathered, it was produced, it was very clear. There was no rocket science about it, but it’s the implementation. I would learn a lot from my peers, and I do learn from my peers, but the reality is: ‘Can I implement it?’. It’s great that someone else is doing a great job on the capacity and demand, yes… but can I do anything about it? [Not] unless my peers can actually give me a tool and say, ‘This is how we did it’.

Several barriers to identifying and sharing good practice were also reported. Capacity constraints and competing priorities were frequently cited as obstacles to both participating in peer learning activities, and documenting and sharing good practice.

Systems often struggled to find the time to engage with learning resources or dedicate staff time to documenting their own experiences. Furthermore, some systems suggested some may be reluctant to share their challenges and lessons learned publicly, fearing that this would be perceived negatively or as an admission of failure.

This highlights the need to create a safe and supportive environment for sharing good practice, where systems feel comfortable discussing both successes and failures without fear of judgement. Systems’ willingness to share challenges and lessons learned is also linked to overall perceptions of the support programme, and the need to frame it as a positive offer for high-performing systems.

To maximise the effectiveness of sharing good practice, interviewees emphasised the need for a range of options. This could include:

• sharing experiences through case studies, workshops or webinars
• providing access to toolkits, templates and best practice guidance
• facilitating direct peer-to-peer interactions between systems

It was recognised that a ‘one-size-fits-all’ approach would not be effective, given the varied needs and contexts of local systems.

There was also a strong sense that systems wanted opportunities to showcase their achievements and share their successes, suggesting that creating platforms (such as regional or national conferences like the previously held BCF conferences) for this type of positive reinforcement could further encourage engagement and learning.

Finally, there was a slight preference for regionally focused peer learning activities, as interviewees felt that regional networks were often more attuned to the specific challenges and opportunities within their local contexts than national-level networks.

6. Conclusions

This section details the conclusions from the evaluation findings and the potential implications and improvements for the management and delivery of the support programme.

The main conclusions from these summative evaluation findings are as follows.

BCF complexity and relevance

The complexity of BCF requirements and local contexts is, in the view of systems, sometimes underestimated by the support programme.

While this evaluation focuses on the support programme, it is also worth noting that there remains some uncertainty around future national guidance on the BCF and its continued relevance.

Support programme engagement 

Engagement with the support programme has been varied.

Some systems were directed to support after being identified as needing help in a specific area related to the BCF. Others proactively sought support but experienced delays and a lack of clarity in the process. This suggests that there is a latent demand for such a support offer (and the weight of evidence from this evaluation supports this proposition) - however, there are opportunities to improve the targeting and communications.

There are also questions about which types of systems would most benefit from support and what would enable the support programme to best meet its objectives, and these may be in conflict.

Consideration should be given to whether it should be targeted to one or both of the following:

• those systems in greatest need of support, but where barriers to engagement and sustaining change may be greatest
• systems that have a clear idea of their objectives, good levels of system collaboration, and the capacity and motivation to implement change

Support process and quality

The support process has been inconsistent at times, and some systems have found the initiation and scoping process to be slower than expected.

The overall quality of support offers has been generally good and mostly well received by systems. Some systems found specific providers highly effective, whereas others found support to be too generic.

BCMs were seen as potentially pivotal but not consistently engaged.

Outcomes and impact

Evidence of outcomes is patchy and variable. While there is some evidence of improved inter-agency relationships, development of joint plans and changes in investment decisions as a result of support, evidence related to tangible system improvements or impacts upon people drawing on health and social care services is limited.

Much of this is due to the stage at which this evaluation has taken place - it is too soon to measure some of the medium to long-term impacts of the support programme.

However, original hypothesised outcomes may also have been overly optimistic, particularly in relation to system and, in some cases, funding partner expectations of bringing about system change. The nature of partner relationships and other factors often makes this complex and difficult.

Barriers and enablers

Barriers

Primary barriers include:

• stakeholder commitment
• system culture
• short-term support cycles

A lack of capacity to implement recommendations and a perceived lack of bespoke support tailored to system needs were also highlighted.

Enablers

The following were identified as enablers:

• strong leadership and accountability
• shared values
• data-driven approaches

7. Potential improvements and implications

Drawing on the evaluation findings and direct feedback from system representatives, BCMs and CHIAs, a range of potential improvements have been identified for the support programme.

Scoping and initiation

Relevance and tailoring of the support offer

The scoping process could be more robust, efficient and targeted to ensure that the support offered is genuinely tailored to the specific needs of each system, particularly regarding demand and capacity challenges. A ‘one-size-fits-all’ approach is not considered effective by most systems.

Systems should be actively involved in defining their needs, rather than being presented with pre-determined options.

This is most important, but potentially also most challenging, for systems where support is directed. These systems may lack the internal maturity and shared understanding among partners to identify their own needs and be more resistant to external support, which means the process of coming to a shared definition of need as part of the scoping is crucial.

The initial matching process between systems and providers is also important.

Clarity and communication

The following should be more clearly communicated:

• the goals of the support programme
• how it addresses national BCF priorities
• how it fits alongside other support offers available to systems

Many systems, even those receiving support, were unclear about the programme’s purpose and offerings. A clear ‘brochure’ or menu of support options and providers would be beneficial (and, if it already exists, should be made more visible to systems). In the initial meeting, this information should be presented by skilled facilitators who can help systems navigate the choices and ensure alignment with their needs. 

System partner engagement

Wider engagement from system partners within support projects is advised, including:

• providers
• the voluntary sector
• housing organisations

Currently, the focus of most support offers is on NHS organisations and local authorities. The specific benefits to these stakeholders should be determined and communicated to them.

Support delivery

Provider quality and flexibility

The quality and expertise of individual providers are paramount, and their relevant experience should be well communicated to systems receiving support at the outset (including work they have led with other comparable areas).

Providers need to be agile and responsive to evolving system needs and have the experience and credibility to gain ‘buy-in’ from a system. 

They should act as facilitators, helping systems build internal consensus and develop solutions.

Sustaining engagement

Maintaining momentum and engagement throughout the support process is essential. 

Continued involvement from senior leadership and those who will be responsible for implementing recommendations and change is a core enabler for ensuing longer-term impact.

Regional BCMs should be provided with the resources and remit to engage more proactively with the support needs of their local systems and the support programme. This would promote consistent engagement of BCMs across the regions.

Capacity building

Systems often lack the capacity to implement recommendations, both in terms of staffing and expertise. Ongoing support and resources are needed to address this.

The support programme delivers a high number of small support projects across a lot of systems. Its impact would likely be greater if it focused on longer-term, intensive support across a smaller number of more stringently selected systems. However, consideration should be given to how they should be selected to balance offering support to systems that need it most with those best able to make changes as a result.

Focus on leadership and behaviour change

The support programme should emphasise the importance of the following in driving successful BCF implementation through support offers:

• leadership
• collaborative working
• behaviour and cultural change

Providing specific support and resources to foster these elements would help some systems with this.

Maximising outcomes and impact

Focus on implementation

While the support programme has achieved positive outcomes in some areas (such as building consensus, improving relationships and improved system understanding of specific issues), there is a need for greater focus on implementation and tangible change in the medium to long term.

Systems need support to translate plans into action and achieve measurable improvements in areas such as discharge planning and capacity management.

BCMs can play a role in supporting systems to implement changes. There could be an emphasis on the importance of their involvement in implementation, as well as increased consistency in this support across regions.

Capturing the long-term impact of support

There is limited evidence to support drawing a direct causal link between the support programme and long-term system improvements at this stage. However, to fully understand the long-term impact of support projects at an individual system level, more robust, longitudinal evaluations would assess the programme’s impact more comprehensively.

Systems could also be provided with guidance about how to measure and track changes in their local area, including the effects of change. Developing ToCs or monitoring and evaluation frameworks would be a worthwhile exercise for some systems.

Learning and sharing

Peer support and learning

Systems expressed a strong desire for peer support and more learning opportunities after initial support is complete. This should be facilitated in a structured way, perhaps at the regional level (there was a slight preference among systems for regional rather than national activities), ensuring that systems are matched with relevant peers.

Practical tools and resources should be shared alongside experiential learning. Case studies highlighting examples of good practice and how the support programme is a positive step for systems could also be promoted further.

BCMs can play an important role in disseminating this learning regionally.

Promoting best practice

Establish peer learning opportunities and networks for senior leaders and BCMs to share best practice and learn from each other’s experiences. This could be used to promote the support programme as a positive offer for high-performing systems.

DHSC’s role

BCM involvement

DHSC should work with the BCF team to define the role of BCMs and facilitate their consistent involvement in the support programme. Most BCMs would like more consistent involvement.

Their expertise would be invaluable in both setup and ongoing support and, in most cases, would be welcomed by systems.

Commissioning and management

DHSC should consider how the support programme is commissioned and managed, ensuring flexibility and responsiveness to system needs. It should also promote it as a positive step for high-performing systems, rather than a sign that a system is failing.

This should influence future communications about the programme.

Longer-term evaluation

To fully understand the longer-term impact of support (particularly any more intensive and targeted future offer), longer-term evaluation of system change would be beneficial.

This should be paired with support for systems to monitor and share how support has helped them to achieve tangible system change.

Appendix 1: individual system case studies

Case study 1 - non-directed demand and capacity forecasting for hospital discharges

System name

Bedford.

Organisations involved

The partners involved were:

• Bedford Borough Council
• NHS Bedfordshire, Luton and Milton Keynes ICB
• Changeology (the support provider)

Context

The support offer was initiated by the system (non-directed) due to the participants’ concerns about the accuracy of demand and capacity forecasting for hospital discharges. This was particularly important in the context of winter planning, where pressures on the hospital system are heightened.

The aims were to:

• improve the flow of patients’ post-hospital discharge
• reduce pressure on acute services

The support was requested before 2024, but the main work took place over 4 months, starting in the new year and concluding with a final report at the end of April 2024.

Interviews with this system took place during and after the support was delivered.

Support delivered

Changeology conducted a review of hospital discharge integration with social care. This involved:

• interviews - conducted with partners across the system to gather perspectives on strengths and weaknesses
• best practice and benchmarking review - research into best practices in other systems to identify potential improvements
• data analysis - review of existing data, including discharge data and hospital system information on patients, bed days and patient pathways
• recommendations - a set of recommendations was developed jointly with partners, focusing on system alterations to improve flow and how the BCF could support these changes

Outcomes generated

Immediate outputs generated by the support included demand and capacity forecasting. A more robust demand and capacity forecast was developed, which formed the backbone of the system’s winter planning.

The outcomes generated by the support included:

• revised commissioning plans - the main outcome to date has been a change in commissioning plans for winter, shifting from bedded care capacity to community-based care capacity. Budgets have also been adjusted accordingly
• improved system flow - while still early, initial indications suggest improved system flow, particularly during the typically challenging post-Christmas period in early 2025. System leaders hope to see:
  • a reduction in average bed days per person
  • successful flow into the community
  • reduced use of ‘holding care homes’
  • fewer breaches and fails across a suite of indicators
  • a more resilient system less prone to collapse
• BCF planning - while the current BCF plan pre-dates the support programme, the winter plan is directly informed by it. The intention was to use the findings to shape the next BCF plan, but this has been delayed due to a lack of national guidance around future BCF priorities
• knowledge sharing - the participant expressed a desire for greater knowledge-sharing of learning and best practices from the support programme, suggesting online publications and webinars as effective methods

Case study 2 - DSOG-directed demand and capacity-focused support

System name

Sefton.

Organisations involved

The partners involved were:

• Sefton Council
• NHS Cheshire and Merseyside ICB
• Changeology and LGA (the support providers)

Context

Sefton received some directed (through DSOG) demand and capacity-focused support between January and April 2024.

System leaders highlighted the evolution of BCF planning and reporting, over 5 years, from a complex process to a more streamlined, team-based approach.

The support helped them address the challenges of:

• aligning local priorities with national metrics
• the impact of system changes (such as ICB restructuring) on BCF delivery

Support delivered

The support focused on demand and capacity modelling. This included:

• stakeholder interviews (15 were planned and 14 conducted)
• detailed analysis and modelling, using existing data, about different service areas of interest
• a final report with recommendations
• a project roadmap

Those involved in the support praised the professionalism and project management of the support provider and the tangible, practical work programme provided.

The report highlighted a significant finding: while integration is strong at the strategic level, it’s not always filtering down to frontline staff.

It also identified a need for greater clarity around roles and responsibilities.

Outcomes generated

The outputs from the support were:

• a final report with detailed recommendations around capacity and demand planning of services
• wider integration and governance arrangements

Outcomes from the support included:

• clarity of roles and responsibilities - the Changeology report highlighted the need for clearer roles and responsibilities, prompting action in this area
• improved hospital discharge co-ordination - both system leaders included in interviews cited progress in this area, facilitated by the BCF and additional funding. This includes the development of joint discharge teams and a focus on ‘getting people home’ when possible
• better market management - improved understanding of capacity gaps (both in overall volume and the type of care) in the care market, leading to more effective commissioning
• focus on gaps and priorities - the support programmes helped Sefton identify important areas for improvement, such as joint-funded packages and processes. This led to a more focused action plan
• increased integration and joint working - the BCF and support programmes fostered closer working relationships between health and social care partners. This is evident in joint planning and decision-making processes
• development of a ‘home first’ model - the findings and recommendations from the support projects are driving work on a ‘home first’, discharge-to-assess (D2A) pathway

Case study 3 - support suggested by BCM to identify improvements in BCF planning

System name

Suffolk.

Organisations involved

The partners involved were:

• Suffolk County Council
• NHS Suffolk and North East Essex ICB and Norfolk and Waveney ICB
• LGA (as the support provider)

Context

System leaders reflected that Suffolk’s BCF planning had been largely based around maintaining past decisions and principles, and that, while integrated working relationships were strong, BCF planning felt ‘process driven’ and was contributing to - rather than driving - integration.

Based on this, system leaders approved a scope for a review of the BCF. The scope was then discussed with the regional BCM who suggested they seek support from the support programme. In doing this, they aimed to:

• assess the current state of the BCF
• identify opportunities for improvement, particularly in aligning it with the strong locality structures in place across health and care

Financial pressures on the health and care system increased during the review period, along with a greater emphasis on preventative care and the upcoming responses to national reports (such as Lord Darzi’s Independent investigation of the NHS in England), although these did not have a significant impact on the review.

The support took place between February and June 2024, with interviews conducted after its completion.

Support delivered

The support delivered a comprehensive review of Suffolk’s BCF planning and processes. This included:

• review methodology - this document review included local Suffolk documentation alongside a review of other systems and national good practice. The support provider conducted:
  • stakeholder interviews
  • a workshop with district or borough councils
  • surveys (specifically on the Managing transfers of a care - a High Impact Change Model)
• engagement with system leaders - the support provider worked closely with major players and a local steering group to develop their thinking, and presented early thoughts and initial recommendations to the strategic planning group. A final report and presentation to the health and wellbeing board was prepared and presented by officer leads in September 2024
• benchmarking - the review included an attempt to benchmark Suffolk’s BCF spend and outcomes against comparable organisations, but this proved challenging due to inconsistencies in data and reporting across different areas
• High Impact Change Model (HICM) self-assessment tool - the support provider developed a self-assessment tool based on the HICM, which was handed over to Suffolk for ongoing use. The HICM is a practical approach to improving health and wellbeing, and reducing unnecessary hospital stays. It’s used by local health, care and housing partners to identify and implement changes that will have the greatest impact

Outcomes generated

Outputs from the support included:

• report and recommendations - the primary output was a report with clear recommendations and a roadmap for implementation. This was well received by the system
• HICM self-assessment tool - this tool allows Suffolk to track progress against the HICM on an annual basis

Outcomes from the support so far, as reported by the system, include:

• increased awareness and understanding - the review process and its outputs raised awareness and understanding of BCF priorities among stakeholders, particularly elected members on the health and wellbeing board
• confirmation of existing direction - the review’s recommendations largely aligned with Suffolk’s existing direction of travel, but provided greater clarity, legitimacy and focus
• establishment of a dedicated BCF co-ordinator post - this post will take forward the recommendations and develop BCF planning within Suffolk
• improved governance - the review highlighted opportunities to streamline governance processes, although implementation was delayed pending the appointment of the post referenced above

Case study 4 - directed support for admission avoidance and improving discharge through mediation and diagnostics

System name and organisations involved

These have been anonymised.

Context

The system faced challenges related to historic arrangements in BCF plans that had been inherited from previous clinical commissioning groups. The main priorities included:

• prevention of admission
• improving discharge

The system’s complexity added to the challenge. Financial pressures, particularly around agreement on the BCF Adult Social Care Discharge Fund, were a major barrier.

The system entered mediation due to delayed BCF submissions and engagement with the support programme became a condition of the mediation agreement.

The support took place during June and July 2024, and interviews took place after its delivery.

Support delivered

The support consisted of 2 main components:

• mediation - facilitated by an external mediator to resolve disagreements around the BCF with all system partners
• diagnostic assessment - conducted by the mediator to identify the system’s needs and inform the selection of an appropriate support provider

Two elements of future support are planned, pending procurement at the time of interviews:

• leadership panel - to provide system oversight and accountability for BCF delivery and the transformation programme
• programme management support - to help develop, implement and embed the BCF transformation programme

Outcomes generated

The outcomes emerging from the support provided, as reported by system leaders, are:

• embedded governance processes - within 3 months of interviews taking place, the leadership panel and programme management processes are expected to be established and integrated into the system’s way of working
• transformation programme progress - within 3 months, initial impacts on BCF schemes and metrics are anticipated, particularly in admission avoidance and discharge
• improved system alignment and collaboration - it is hoped that the support will foster greater consensus and collaboration among stakeholders
• enhanced accountability - the leadership panel is expected to increase scrutiny and accountability for BCF delivery
• informed BCF planning - the transformation programme aims to inform the 2025 to 2026 BCF planning round, although there are concerns about potential delays in national guidance and further mediation

Case study 5 - directed support for capacity and demand planning

System name

Windsor and Maidenhead (support commissioned at ‘place level’ - Windsor and Maidenhead is one of 5 places within the Frimley integrated care system (ICS)).

Organisations involved

The partners involved were:

• Royal Borough of Windsor and Maidenhead
• NHS Frimley ICB
• Changeology (the support provider)

Context

The BCF Support Programme commissioned Changeology to analyse capacity and demand planning capabilities across 21 health and social care systems at place level. Windsor and Maidenhead was part of this commissioned support. The support offer was therefore directed to the system - however, interview data indicated that the take-up of this offer was also supported by discussions at a regional BCF lead meeting.

The objective was to identify opportunities to:

• improve capacity and demand planning capability
• enhance overall system resilience

The support focused primarily on elements of the system involved in intermediate care.

The support took place over 2 to 3 months, with the final report delivered in March 2024.

Support delivered

Support involved:

• interviews with individuals who were accountable or responsible for the delivery of services - the engagement focused on intermediate care services covering areas such as hospital discharge, reablement and admission avoidance. Interviews aimed to determine areas of good practice and gaps that required action to improve resilience within the system
• analysis of interview responses against competencies related to capacity and demand planning criteria and the HICM
• recommendations - a set of recommendations was developed based on findings from the above, under 6 themes. These were:
  • data collation
  • integration and visualisation
  • capacity and demand forecasting
  • workforce and resources
  • system resilience
  • communication

Outcomes generated

Immediate outputs generated by the support included a:

• report on capabilities analysis - capacity and demand planning
• presentation of the report’s contents, delivered through a ‘feedback session’

Limited outcomes or changes were reported as a result of the support, due to resource constraint. Participants noted that some stakeholders in the system have been more focused on considering the HICM.

Case study 6 - DSOG-directed support to address challenges in hospital flow, discharge and intermediate care

System name

Dorset.

Organisations involved

The partners involved were:

• Dorset Council
• Bournemouth, Christchurch and Poole Council
• NHS Dorset ICB
• University Hospitals Dorset NHS Foundation Trust
• Dorset County Hospital and Dorset Healthcare
• PPL: People Places Lives (support provider for leadership development support)
• LGA (support provider for the diagnostic review)

Context

Dorset faced persistent challenges in hospital flow, discharge and intermediate care, particularly in the Bournemouth, Christchurch and Poole area. The system recognised the need for a more strategic and integrated approach, moving beyond reactive, short-term solutions.

Previous improvement efforts had struggled to achieve lasting change, leading to change fatigue among staff. A tension existed between the:

• focus on acute care needs driven by discharge-related funding
• desire to prioritise preventative care and upstream interventions

Support was directed by DSOG. Interviewees noted that the support was originally offered as a standardised package that focused on areas like capacity and demand modelling. Dorset was keen to engage with the support, but wanted to ensure that the offer was tailored to their specific challenges rather than a standardised offer. This led to a shift in the support provided, becoming tailored to Dorset’s specific needs and context.

Support delivered

Support involved:

• diagnostic review - LGA conducted a diagnostic review of the system’s D2A pathway involving frontline staff and patient surveys, interviews and case reviews. While some aspects were considered standard, the independent perspective and facilitated discussions were noted as valuable
• leadership development - PPL facilitated workshops with senior leaders, focusing on team dynamics, behaviours, communication and decision-making. This fostered shared understanding, trust and commitment to system goals, enabling open dialogue about differing perspectives and solidifying the need for a system-wide improvement partner

Outcomes generated

Immediate outputs generated by the support included:

• a co-created team charter
• a ‘summit’ to bring together the combined reporting and recommendations from the different support elements
• system-wide agreement to mobilise a large-scale transformation programme looking at the wider urgent and emergency care pathway, with support from a strategic improvement partner.

Outcomes associated with the support provided included:

• a shift towards a more strategic focus - the support fostered a shift from reactive problem-solving to a strategic, long-term approach to intermediate care and system flow, emphasising preventative care and upstream interventions
• enhanced collaboration and trust - the programme built stronger collaboration and trust among partners, enabling more honest and productive conversations, breaking down silos, and fostering shared ownership
• development of a 5-year transformation plan - LGA’s diagnostic review, combined with Newton Europe’s subsequent broader diagnostic, generated an evidence base that informed the development of a 5-year transformation plan. This combined diagnostic work represents an important output that is shaping the direction of system improvement efforts. Significant operational, outcome and financial benefits are anticipated

Case study 7 - DSOG-directed support for capacity and demand modelling and leadership

System name

Bristol, North Somerset and South Gloucestershire (BNSSG).

Organisations involved

The partners involved were:

• Bristol City Council, North Somerset Council, and South Gloucestershire Council
• BNSSG ICB
• North Bristol NHS Trust
• University Hospitals Bristol NHS Foundation Trust
• Weston NHS Foundation Trust
• Sirona Care and Health (community provider hosting the D2A programme)
• Whole Systems Partnership (support provider)

Context

BNSSG faced challenges with hospital flow, discharge and bed occupancy, particularly related to high numbers of people in acute hospital beds who no longer have a medical reason to stay there (described as people with ‘no criteria to reside’).

Following an initial system-wide investment case and subsequent diagnostic support (delivered by LGA and Newton Europe in 2022), a dedicated D2A programme was established with a remit to work across all statutory partners. The diagnostic revealed a need for a revised investment case and highlighted opportunities for improvement.

However, the system still lacked a coherent overarching BCF strategy and vision, and financial challenges, historical funding allocations and a lack of shared risk and full budget integration continued to hinder progress.

The support was directed by DSOG, although the system already recognised gaps in its capacity and demand modelling capabilities, and identified the need to address cultural, leadership and learning challenges to ensure effective implementation.

Support delivered

Support was delivered in 2 phases:

• phase 1: capacity and demand modelling - this involved developing a system dynamics model to support strategic planning and scenario analysis
• phase 2: culture, leadership and learning - this involved:
  • senior leader interviews
  • a system-wide survey based on a relationship value tool
  • observation of governance processes
  • development of an MoU outlining principles and behaviours for decision-making

Outcomes generated

Immediate outputs generated by the support included:

• capacity and demand model - this provided a strategic planning tool for BNSSG. While the model itself was considered valuable, the handover process and documentation were reportedly lacking, and the model quickly became out of date. The system highlighted the need for ongoing support and training to maintain and use the model effectively
• MoU - this outlined principles and behaviours for decision-making, aiming to improve system governance. While its development raised awareness of relationship and trust issues, its impact on actual system behaviours was less clear
• survey results - these provided insights into system relationships and trust, but their impact on behaviour change was unclear

Outcomes associated with the support provided included:

• improved understanding of system dynamics - the capacity and demand modelling work enhanced understanding of interdependencies
• increased awareness of cultural and leadership challenges - the culture, leadership and learning support highlighted relationship and trust issues within the system. However, interviewees had mixed views on the extent to which the support had changed system partners’ behaviours
• development of a recovery plan - the capacity and demand model was used to inform a recovery plan to address performance gaps
• improved partner engagement - both support phases facilitated greater engagement and collaboration between system partners, although challenges remained
• identification of further support needs - the support programme helped the system identify further areas for development, such as workforce analysis and data improvement

Case study 8 - governance and finance support

System name

Barking and Dagenham.

Organisations involved

The partners involved were:

• Barking and Dagenham Council
• North East London ICB
• LGA (support provider)

Context

Barking and Dagenham’s integrated care partnership, previously a 3-borough system, was restructured with the formation of the North East London ICB. This change prompted a re-evaluation of the existing BCF to better address local needs within the evolving health and care landscape.

The support was delivered by LGA between April and July 2024 following some delays in the initial set-up phase. The goal was to ensure that the BCF effectively supports local priorities while adhering to national policy.

Support delivered

The system received:

• place-based governance support
• a commissioning and finance review, which included an analysis of Barking and Dagenham’s existing BCF spending mapped against national and local priorities, identifying strengths, weaknesses and gaps

Recommendations for further in-depth analysis of specific spending areas were provided, along with facilitated workshops to define the main principles and characteristics for future BCF spending.

While setting out the scope for the support, several limitations emerged that impacted the depth and breadth of the analysis, including the availability and accuracy information and resource constraints. Given the limitations encountered during the analysis, the focus of the support shifted to addressing Barking and Dagenham’s immediate needs by establishing clear principles aligned with overarching priorities. This aimed to guide future work, ensuring the BCF:

• reflected local needs
• promoted collaboration
• supported broader health and social care integration goals

Outcomes generated

The primary output from the support was a final report, which set out a roadmap with recommendations, timelines and tools for future BCF development and implementation.

Outcomes associated with the support provided included:

• enhanced governance - a new joint commissioning board was established, fostering collaborative oversight and decision-making for the BCF
• improved understanding and transparency - increased clarity on BCF spending, its alignment with local priorities and areas requiring further investigation
• strengthened relationships - improved communication, trust, shared purpose and joint working between the local authority and ICB
• increased capacity - recruitment was initiated for a dedicated BCF officer to manage and develop the fund effectively

Case study 9 - non-directed review of BCF plans and schemes

System name

Cambridgeshire and Peterborough.

Organisations involved

The partners involved were:

• Cambridgeshire County Council
• Peterborough City Council
• NHS Cambridgeshire and Peterborough ICB
• LGA
• Health Integration Partners (support provider)

Context

The Cambridgeshire and Peterborough ICS commissioned a review of its BCF plan, aiming to enhance the integration of health and social care services. Driven by a commitment to person-centred care, improved outcomes and future sustainability, the review sought to identify gaps and opportunities for:

• optimising BCF utilisation
• aligning it with system priorities

The support was delivered by Health Integration Partners between January and April 2024.

Support delivered

Health Integration Partners, supported by LGA, facilitated the BCF review, which evaluated 6 core BCF schemes representing a significant proportion of the total BCF spend (78% in Peterborough and 74% in Cambridgeshire). These schemes included:

• community equipment and technology-enabled care (TEC)
• integrated neighbourhood services
• carers
• reablement or intermediate care at home
• discharge
• market capacity

The review was carried out using a mixed-methods approach, including:

• data analysis - examining population trends, emergency admissions, discharge delays, service costs and BCF performance metrics
• document review - assessing existing strategies, reports and plans related to the BCF and the 6 priority schemes
• stakeholder engagement with over 75 stakeholders across the system - conducting one-to-one meetings, focus groups, an informal health and wellbeing board development session, and weekly core group meetings to gather insights from a diverse range of stakeholders

Outcomes generated

The main output from the support was a final report, which included specific recommendations for each of the 6 priority BCF schemes, including:

• closer collaboration with providers
• developing integrated care models
• improving support for carers

The support facilitated better engagement with partners and is expected to positively influence future decisions, as reported by system leaders. Furthermore, the BCF review provided a foundation for:

• future planning
• resource allocation
• service improvement

System leaders also report that they have continued to work with the consultants on the ‘home first’ programme and discharges, looking at capacity and demand.

Case study 10 - DSOG-directed support for capacity and demand planning

System name

Sussex.

Organisations involved

The partners involved were:

• Sussex ICB
• East Sussex Healthcare NHS Trust
• Brighton and Hove City Council
• West Sussex County Council
• East Sussex County Council
• Newton (support provider)

Context

Both East and West Sussex were experiencing difficulties with hospital discharge, which was impacting overall system capacity. East Sussex had previously received support from the Emergency Care Intensive Support Team for urgent care, while West Sussex had engaged with external consultants for discharge planning with limited success. Financial pressures within the system influenced the use of BCF resources, primarily for baseline services rather than innovative, integrated services.

The support was directed by DSOG. Interviewees report that, despite initial challenges in finding an appropriate contractor, Newton was appointed to conduct a care transfer hubs and D2A review, and capacity and demand planning support.

Support delivered

Newton conducted an 8-day assessment involving:

• data analysis
• site visits
• stakeholder engagement

Outcomes generated

The main output was a report that offered demand and capacity analysis, benchmarking against other systems and a Sussex action plan.

The outcomes were:

• in East Sussex - increased clarity and a shared understanding
• in West Sussex - a new model for intermediate care, reduced reliance on community beds, and a focus on leadership and cultural change

In addition, the report is now used as a reference point for future development.

Both areas reported a desire for more comprehensive support beyond the report and viewed the short duration of the support as a limitation - however, they noted that they were very satisfied with the contractor and work that was delivered.

Case study 11 - DSOG-directed support on organisational development and improving discharge performance

System name

Nottingham and Nottinghamshire.

Organisations involved

The partners involved were:

• Nottingham and Nottinghamshire ICB
• Nottingham City Council
• Nottinghamshire County Council
• Atlantic Consulting (support provider)

Context

Nottingham and Nottinghamshire faced significant challenges with hospital discharge and urgent care performance, particularly related to pathway 2 waits and length of stay. The system recognised a need to embed ‘home first’ principles more consistently across the system, from executive leaders to frontline staff. Financial pressures within the ICS also posed a challenge to implementing system-wide changes.

Support was directed by DSOG following a review of the system’s discharge portfolio, alongside internal recognition of the need for support around organisational development and culture change.

Support delivered

Support focused on organisational development, specifically relating to embedding ‘home first’ principles and improving discharge performance. This included:

• senior leader interviews - the support provider conducted interviews with chairs, chief executives and chief operating officers across the system to understand their vision, aims and objectives related to discharge
• system-wide workshops - an online workshop and a day-long face-to-face workshop were held with system partners to discuss challenges and develop recommendations
• weekly touchpoints - regular check-ins were held between the support provider and the system’s single point of contact to monitor progress and address any issues

Outcomes generated

Immediate outputs generated by the support included a final report with recommendations and a 2-year roadmap. This output reportedly provided a clear timeline and structure for system-wide change, focusing on embedding ‘home first’ principles and improving discharge culture.

Outcomes associated with the support provided included:

• executive review and endorsement - system executives reviewed and endorsed the report’s recommendations, supporting their teams to implement them
• integration into workforce plan - the recommendations were incorporated into the system’s workforce and organisational development plan, although progress against this plan is not yet known at the time of fieldwork
• increased awareness of cultural and leadership challenges - the support helped to raise awareness of the importance of consistent leadership and cultural change to drive sustainable improvements in discharge performance
• improved pathway 2 performance - while not a direct outcome of the organisational development support, the system made progress in reducing pathway 2 waits and length of stay, facilitated in part by the system-wide focus on discharge improvement
• recognition of the need for ongoing support - the system acknowledged the need for ongoing support and engagement to ensure the sustainability of changes

Case study 12 - directed support for capacity and demand planning

System name

Walsall.

Organisations involved

The partners involved were:

• Walsall ICB
• Walsall Council
• Changeology (support provider)

Context

Both Walsall ICB and Walsall Council reported that the BCF had not moved much beyond the required minimum funding. They both viewed the BCF as mainly supporting hospital discharge processes, focusing on short-term care, rather than achieving integration, collaboration or innovation. However, the ICB was prepared to delegate responsibilities from the system level to the place level, creating opportunities for the BCF to become more dynamic.

The support was directed to the system and delivered by Changeology from February to May 2024.

Support delivered

Changeology delivered the support over a 5-day period primarily through individual interviews with significant figures. However, interviewees suggested that group engagements and facilitated discussions could have been more beneficial than individual interviews, particularly for developing actionable plans.

The support was a reflective and exploratory consultancy, not practical or technical assistance. It aimed to:

• provide an objective assessment of Walsall’s current state
• offer comparisons with other systems, reflecting on Walsall’s strengths
• recommend next steps for improvement

Outcomes generated

The final output from Changeology was a report and presentation. The report used the HICM to assess system maturity across 10 core challenges and enablers, followed by reflections and recommendations on next steps.

The engagement with Changeology was viewed positively but not as transformative. The ICB gained confidence and validation, encouraging further integration steps. The council considered the engagement worthwhile but did not see the report as immediately strategically important. While the report did not reveal surprises or controversies, it affirmed that Walsall was not underperforming.

Case study 13 - directed support for capacity and demand planning

System name and organisations involved

These have been anonymised.

Context

As a new system, there was recognition that support relating to capacity and demand planning through the BCF Support Programme could be useful.

This support was directed to the system through the national BCF team and took place between February and March 2024, with interviews taking place after its completion.

Support delivered

The support provider conducted a ‘capability analysis’, which system leaders described as a high-level self-assessment of the system’s BCF maturity. This involved:

• interviews with stakeholders
• a review of planning documents and high-level activity data
• a resulting report, which was delivered in March 2024

System leaders felt the support was not tailored to their needs and that the title ‘capacity and demand planning support’ was misleading. The initial offer suggested bespoke support would follow the analysis, but the system chose not to pursue this after seeing the results of the initial assessment.

Outcomes generated

The primary output from the support was a final report, which included recommendations, some of which the system reports that it was already implementing or would have done anyway.

Outcomes associated with the support provided included:

• validation of existing understanding - the report confirmed the system’s shared understanding of its strengths and weaknesses regarding the BCF. This provided some reassurance but did not reveal any new insights
• gathering stakeholder feedback - the process facilitated gathering feedback from system leaders, which would have been time-consuming for the council to do independently

The experience, combined with feedback from a neighbouring local authority, led the system to decline further bespoke support. It felt the initial assessment did not offer enough value to justify the investment of system resources required for a more in-depth review.

Appendix 2: detailed methodology

Scoping and evaluation design

To understand the rationale for the BCF Support Programme, features of its design, desired outcomes, and any enablers and barriers to engagement and delivery within local systems, the following familiarisation tasks were undertaken:

1. Interviews with 12 primary stakeholders. This included interviews with:

• 8 NHS England and DHSC policy stakeholders
• one advisory contact
• 3 local authority leads or representatives

2. An in-depth review of existing documentation and management information gathered by the support programme’s main support provider (LGA), which included the:

• BCF Support Programme tracker
• programme contract, including specification of the core delivery requirements
• mid-year report for March to August 2023
• quarterly report for September to November 2023

Based on the findings from these activities, and to provide a basis for the evaluation framework, the evaluation team developed a ToC for the BCF Support Programme. The ToC was refined through a workshop with programme stakeholders and consultation with the main support provider.

Engagement with the main support provider highlighted that the full ToC depicts elements that are outside the remit of the current support delivery contract. As such, a second ToC was developed to outline the ToC as it relates to only the activities of the support delivery contract.

Both diagrams of the ToC are presented in ‘Appendix 3: theory of change for the support programme’ below - see Figures 11 and 12.

Phase 1 data collection

For phase 1 case study interviews, the DHSC and BCF national team provided the evaluation team with contact details for representatives from all local systems that had received support through the BCF Support Programme.

The following factors were considered in the development of the sample to enable the evaluation to understand support programme delivery across a range of contexts:

• status of support delivery (ongoing vs complete)
• directed or non-directed support
• referral for support by DSOG
• type or focus of the support package
• region and local system geography

The evaluation team initially planned to conduct online interviews with 2 senior stakeholders from 15 local systems. However, in practice, this plan and the sampling criteria were balanced against the practical limitation recruiting local systems for which appropriate contacts were available, and that were willing and had capacity to engage with the evaluation in the appropriate timeframe.

As a result of these constraints, the evaluation team interviewed 23 senior stakeholders in total, from 16 local systems, as described below in Table 8.

Interviewees’ roles were varied and included BCF leads, and programme and commissioning directors across health and social care partners.

Interviews lasted approximately an hour and were carried out online, either with individuals or multiple representatives from a system, during May to July 2024.

Phase 2 data collection

For phase 2 case study interviews, the DHSC and BCF national team provided the evaluation team with contact details for all regional BCMs in post during the fieldwork period and 9 CHIAs.

All provided contacts were invited to take part, and a total of 13 virtual single or paired interviews were conducted with 15 BCMs and CHIAs during August and September 2024, each lasting approximately an hour. All 10 BCMs in post in September 2024 across 9 regions took part, alongside 5 CHIAs.

These interviews aimed to understand how systems in their respective regions engaged with the support programme. Discussions covered various aspects, including:

• how systems in regions with BCMs and CHIAs had engaged with the support programme
• the role of BCMs and CHIAs in support delivery
• the quality of support
• areas where the support programme could be enhanced
• outcomes and impacts

Regional BCMs and CHIAs provided contact details for representatives in 9 local systems who had been in contact with the BCF Support Programme but had not, in the end, taken up the offer. Five virtual interviews were conducted during August and September 2024 with representatives from non-participating systems, each lasting between 30 to 45 minutes.

The objective of these interviews was to gather insights into the reasons behind their decision not to participate. The following topics were explored:

• the wider context of BCF delivery
• reasons for declining the offer of support
• whether they were receiving or had received support through alternative support mechanisms
• suggestions for future support offers

Phase 3 data collection

Phase 3 case study interviews consisted of supplementary and follow-up interviews with local systems that had received support through the programme.

Supplementary and follow-up interviews (November to December 2024)

The DHSC and BCF national team provided the evaluation team with contact details for representatives from 9 new local systems that had received support since phase 1 of the evaluation. All new contacts, as well as representatives from systems who took part in phase 1 interviews, were invited to take part in an interview.

These interviews sought to monitor progress and provide feedback on BCF delivery and the early or expected outcomes in a rounded way. The following topics were discussed:

• how systems had engaged with the support programme
• the quality of support delivery, understanding of systems context and areas for improvement
• outputs, outcomes and impacts
• future support offers
• their overall view of the programme

As for phase 1, the evaluation team initially planned to conduct online interviews with 2 senior stakeholders from each of 15 local systems. However, in practice, the evaluation team interviewed 28 senior stakeholders in total, from 16 local systems, as described in Table 8 below.

Interviewees’ roles were varied and included BCF leads, and programme and commissioning directors across health and social care partners. Interviews lasted approximately an hour and were carried out online, either with individuals or multiple representatives from a system, during November and December 2024. 

The findings from all case study interviews have informed this evaluation report. We have written up case studies where there is sufficient evidence, which are included in the previous section ‘Appendix 1: individual system case studies’.

Online survey of BCF leads (November 2024 to January 2025)

In addition to case study interviews, an online feedback survey targeted at BCF leads across England was conducted, including both those participating in the support programme and those who had not engaged. Thirty-eight representatives across 35 local systems took part.

Where survey results are displayed in charts in the main body of this report, ‘Number of respondents’ indicates the size of the sample of respondents who specifically responded to that question. Due to limited sample sizes, survey results can neither be considered representative of systems as a whole, nor statistically significant.

The survey took around 10 minutes to complete and consisted primarily of multiple-choice questions with some open-ended questions, including the following topics:

• perceptions of the programme
• programme engagement and quality
• BCM involvement in the support
• expected or observed outcomes
• reasons for not participating in the support offer
• opportunities for peer learning

Data analysis

Interview data across all 3 phases was coded using NVivo qualitative data analysis software, then thematically analysed against the evaluation questions.

The evaluation team held collaborative analysis sessions at the end of each phase to:

• assess findings across:
  • interviews
  • supplementary evidence submitted by systems
  • programme KPIs
  • management information
• build on learnings from each phase of data collection

To analyse the survey data, data tables were created for each survey question, summarising the overall findings and by significant variables (such as whether a system had received support through the programme).

In addition, answers to the open-ended question were reviewed and a code frame was developed to code free text responses. The coded responses were integrated into the final data set.

Table 8: sampling of systems for inclusion in case study interviews

System	Region	Focus of support received	Directed or non-directed	Support status (as of June 2024)	Number of interviews
Bedford	East of England	Capacity and demand planning	Directed	Completed (with follow-up planned)	1
Bath, North Somerset and South Gloucestershire	South West	– Capacity and demand planning – Scoping diagnostic – Leadership support	Directed (DSOG)	Completed (with follow-up planned)	1
Cambridge and Peterborough	East of England	BCF review	Non-directed	Completed	2
Derbyshire	East Midlands	Capacity and demand planning	Directed	Completed	1
Devon	South West	Multidisciplinary working review and community pull model	Directed (DSOG)	Completed (with follow-up planned)	2
Dorset	South West	– System leadership – Care transfer hubs support (Previous directed scoping diagnostic completed)	Directed (DSOG)	Active	2
Hampshire and Isle of Wight	South East	Mediation support (Previously completed: – Directed scoping diagnostic – Financial and planning review – Winter planning gap analysis)	Directed	Active	1
Lancashire	North West	– Intermediate out-of-hospital capacity and demand modelling – Leadership, culture and learning – BCF review (Previous directed scoping diagnostic completed)	Non-directed	Active	1
Nottingham and Nottinghamshire	East Midlands	– Organisational development – Enabling culture – Scoping diagnostic	Directed (DSOG)	Completed	2
Sefton	South West	– Continuing healthcare peer review – Capacity and demand planning	Non-directed	Completed	2
Sheffield	Yorkshire and the Humber	– Scoping diagnostic – ‘One version of the truth’ data support	Directed (DSOG)	Completed	1
Suffolk	East of England	BCF review	Non-directed	Completed	1
Sussex	South East	– Scoping diagnostic – Care transfer hubs and discharge-to-assess review	Directed (DSOG)	Completed (with follow-up planned)	2
Thurrock	East of England	– Review of BCF schemes with partners – Resource gap analysis (Previously completed directed support: – HICM review – Finance and strategy appraisal)	Non-directed	Active (with follow-up planned)	1
Walsall	West Midlands	Capacity and demand planning	Directed	Completed	2
York	Yorkshire and the Humber	– Scoping diagnostic – Pathway 3 review – Discharge stocktake recommendation implementation	Non-directed	Completed (with follow-up planned)	1

Appendix 3: theory of change for the support programme

The following section outlines the development of the:

• full theory of change (ToC) for the BCF Support Programme, depicted in Figure 11
• ToC for the BCF Support Programme support delivery contract, depicted in Figure 12

Full ToC for the BCF Support Programme

Figure 11 is a ToC for the BCF Support Programme, which captures the main elements of change as described below.

Engagement with the support provider (LGA) has highlighted that this full ToC depicts elements that are outside the remit of the current support delivery contract. As such, Figure 12 below presents the theory of change as it relates to the support delivery contract.

Figure 11: full ToC for the BCF Support Programme

A text alternative to Figure 11 follows:

Context and rationale

Although the BCF Support Programme has existed since 2016, since March 2023 it has received increased funding and is now delivered through a contract with the support provider LGA (where previously it was grant funded).

Associated with this increased funding and change in commissioning, there is an increased need to evidence that the support programme:

• has helped to improve integrated working and associated outcomes in local systems
• demonstrates value for money

The specification for the support programme captures the ambition to:

• deliver a broad range of both technical and non-technical support aimed at reaching an increased volume of local systems
• provide integration support that is tailored to the wide range of local system needs as they work towards delivering person-centred services

A balanced delivery model is needed (between directed and non-directed support), with support focused on facilitating and enabling change, action planning and implementation. This will help systems to deliver and sustain improvements in a practical way.

Inputs

Inputs are defined as the resources committed to the activities involved in the programme. Broadly, 3 types of inputs have been identified:

• strategy and planning
• funding
• staff time and expertise

Strategy and planning

Strategic inputs to the BCF Support Programme include several actors. Overarching objectives for the BCF are regularly agreed between the 3 responsible partners at the national level - DHSC, Department for Levelling Up, Housing and Communities (DLUHC) and NHS England. Other strategic stakeholders are also involved in this process, including LGA and DHSC’s DSOG.

The original specification for the BCF Support Programme serves as a primary input. This specification captures the ambition for a broad range of support that is delivered across a significant volume of local systems. The findings of a process review of BCF governance and spending were also identified as an input to the support programme.

Finally, where support is requested by local systems, the respective systems’ strategic objectives and plans represent another primary input to the BCF Support Programme.

Funding

The current round of the BCF Support Programme has a total funding allocation of approximately £5 million over 2 years and one month. The duration covered by this funding was originally planned for 2.5 years but delays to finalising the contract resulted in a reduced duration.

Funding is received by the contracted support provider on a quarterly basis, based on activities undertaken and spend.

Stakeholders involved in the ToC development noted that current progress indicates that, overall, there is likely to be an underspend for the programme.

Staff time and expertise

The third type of input identified can be described as staff time and expertise. This includes:

• staff from the national-level BCF team
• staff from responsible partners (DHSC, DLUHC and NHS England)
• associated strategic stakeholders

The time and expertise of regional staff such as BCMs, CHIAs and NHS regional leads are also an input, as well as staff in local systems.

Finally, staff time and expertise from the support provider is required - including any subcontractors involved in support delivery.

Activities

Activities can be described as the things that have happened or that are expected to happen in the delivery of the programme. Across the BCF Support Programme, activities are undertaken by 4 main stakeholder groups:

• the responsible partners (including BCF team)
• BCMs
• the support provider (including subcontractors and CHIAs)
• local systems

Responsible partners

Staff across the responsible partners undertake programme and contract management and oversight. Other activities include:

• reviewing and approving costed proposals for support, which are prepared by the support provider with occasional BCF team input
• reviewing the end-of-support reports, which are submitted by the support provider once support delivery to a local system is completed

Along with BCMs, staff from the responsible partners (including DSOG) also take on a proactive role in:

• identifying local systems’ support needs
• specifying support offers
• directing these to the support provider

Alongside targeted and bespoke support offers (directed to or requested by a specific local system), universal support may be specified - referring to products such as tools, guidance and online events that can be freely accessed by all local systems.

BCMs

BCMs represent a network of BCF contacts for all 7 regions across England. BCMs sit within each of the regions to:

• provide support to local areas
• work with stakeholders and partners
• gather learning
• co-ordinate support

BCMs play an important role in helping to identify support needs and will act as a primary regional point of contact for the provider of external support.

Support providers

Support provider staff also undertake activities relating to contract management and reporting to the responsible partners. They receive support requests from a number of sources including:

• DSOG (typically involving requests for directed support
• the responsible partners, BCMs, CHIAs and NHS regional leads (typically categorised as BCF partner requests or non-directed local system support)
• directly from local systems (also described as non-directed support)

After receiving a support request, the support provider works through a support definition stage to establish buy-in and agree the scope and objectives of the support offer. This feeds into the preparation of a costed proposal, which is submitted to the responsible partners for approval.

Following this, and where support cannot be delivered directly by staff within the support provider organisation, the support provider procures a subcontractor with the relevant expertise and capacity to deliver the support offer.

Delivery and management of the active support offer then takes place, as specified in the approved proposal.

Following completion of support, the support provider produces and submits an end-of-support report to the responsible partners.

Alongside the delivery of support offers, the support provider also captures and disseminates lessons learned and insights from across support programme delivery.

Local systems

Through the support programme, local systems participate in 2 main activities:

1. Cross-system engagement in the support definition stage (described above) - typically with senior leaders.
2. Engagement of staff in local systems in the support delivered - with relevant stakeholders being defined by the focus of the support delivered.

Outputs

Outputs can be described as what is delivered or produced as a result of the programme.

A primary output of the BCF Support Programme is the support offers that are delivered to local systems, in line with their respective approved objectives.

KPIs for the programme demonstrate expectations around the reach of the support programme - specifically the number of regions represented in the support projects delivered, and the number of support definition conversations offered to DSOG systems, where DSOG has directed a support offer for a local system to the support provider.

Other outputs that are produced as a result of contract and programme monitoring activities include quarterly activity and spend summaries, and reporting against the agreed KPIs. From the financial perspective, a minimum quarterly spend of 80% of the quarterly programme budget is expected.

At the local system level, outputs produced as a result of the targeted or bespoke support delivered are locally owned. Examples of these outputs include:

• BCF plans (for instance, where these are completed or improved as a direct result of a system receiving external support)
• action or implementation plans
• capacity and demand plans
• diagnostic reports

These locally owned outputs are specific to the focus of the support delivered to the local system. For universal support, the products themselves (such as tools, guidance and online events) are the primary outputs.

At the end of targeted or bespoke support delivery, structured feedback from the local system is gathered. This feedback informs the end-of-support report. As per the programme KPIs, this report is expected following 100% of completed support projects, within 4 weeks of completion.

Further structured feedback is gathered from local systems by the support provider, approximately 3 to 4 months post-completion of the support. Structured feedback and engagement metrics are also gathered following the delivery of universal support products.

Finally, insight and learning reports and lessons learned from overall delivery are produced following support programme activities.

Outcomes

Outcomes are the intended and unintended changes that are experienced by stakeholders as a result of the programme. Outcomes for the support programme can be grouped into short and medium term.

We note that the support provider has developed an evaluation framework and logic model for the support delivered, which the Ipsos team has reviewed. While there is naturally overlap between the 2 logic models, there are differences based on the nature, scope and detail of the respective evaluation activities.

The support provider logic model is focused on support delivery to local systems and the timeframes associated with this.

The Ipsos logic model and ToC has been developed to meet the specification for this external evaluation and consider the BCF Support Programme more broadly.

Short-term outcomes

In the short-term, it is hoped that local systems will be satisfied with the targeted or bespoke support they have received. The programme KPIs include an expectation that 80% of systems that have completed support in the previous quarter will rate the quality and frequency of engagement in the last 6 months as either ‘good’ or ‘excellent’, demonstrated through the structured feedback collected. Additionally, it is expected that, separately, 70% of BCMs will rate the quality as ‘good’ or ‘excellent’.

Local systems are expected to have increased confidence in achieving their BCF ambitions, in line with the objectives of the support received and any associated metrics.

As per the programme KPIs, following support completion, a minimum of 80% of local systems are expected to report an improvement in their ability to achieve change and deliver positive outcomes. Improved buy-in, relationships and collaborative working in local systems is also expected.

Depending on the type or focus of the support received, local systems are expected to have a better understanding of the respective topic or issue. It is also expected that, as a result of the support delivered, local systems will have ‘taken action’ in some way, to further progress in line with their integration objectives or action plans.

Local systems will be able to monitor and evidence their progress resulting from the support delivered. Similarly, it is expected that local systems will have used and, where possible, shared the learning gained from universal support products in some way.

At the programme level, support delivery is expected to result in increased presence or awareness of both the BCF and BCF Support Programme across local systems.

Structured feedback gathered as part of the support delivery contract from both local systems and BCMs may provide some proxy indicators that can be linked to the above outcomes. 

Medium-term outcomes

The expected medium-term outcomes of the support programme include improved local BCF plans that are more detailed and based on more accurate data, and alignment of broader plans (particularly integration plans) across health, social care and housing.

Increased knowledge of what the BCF is delivering locally is another outcome anticipated for local system staff, as well as further engagement or requests for follow-up support, as needed.

More broadly, the support programme is expected to result in increased sharing of good practice and lessons learned within and across local systems.

More specific medium-term outcomes - such as improved capacity and demand planning, discharge pathways and plans for prevention - are anticipated depending on the type or focus of the support delivered.

Impacts

Impacts can be described as long-term, sustainable outcomes at a system level.

For local systems, it is anticipated that, through the support delivered and subsequent short and medium-term outcomes, there will be sustained:

• joint planning and commissioning
• integrated working on issues beyond the focus of the initial support delivered

In turn, this is expected to lead to sustainable funding for and integration with the local VCSE sector.

Beyond the local system level, expected impacts at the national level include:

• improvements to primary BCF metrics
• improved evidence of what works
• learning across local systems and regions that catalyses improvements at scale

Ultimately, it is hoped that the support programme will contribute to the following impacts for local residents or service users, which are fundamentally aligned to the core objectives of the BCF:

• an increase in the number of people looked after at home
• a reduction in those requiring long-term care
• more people receiving rehabilitation or reablement services
• improvements in access to more person-centred care and support
• more joined-up care for people accessing services in general

Risks and assumptions

The following risks and assumptions have been identified as those associated with the BCF Support Programme.

Risks

The risks are:

• support offers and responsible partners’ priorities lack focus or are spread too thinly, diluting the impact of directed support
• perceived lack of transparency regarding why systems have been selected for directed support (such as by DSOG) reduces engagement
• support delivered and competing priorities lead to local system dependence on external support
• resistance to direction from central government partners
• support approval process is perceived as lengthy and bureaucratic
• lack of capacity (particularly at a senior level) in local systems to engage with support offer
• lack of capacity or expertise in support provider and subcontractors to meet complex local system needs
• duplication of effort across different support offers available to systems - BCF Support Programme overlapping with other non-BCF support
• local system buy-in is not at a sufficiently senior level to effect change
• unequal spread of support uptake across regions including possible under-representation from some regions
• programme underspend results in decreased future funding
• barriers to sharing evidence within and across systems limit shared learning

Assumptions

The assumptions are:

• responsible partners are clear and responsive in briefing or commissioning support
• local systems are clear, decisive and correct about their support requirements and priorities
• local system leaders are aligned on their support requirements and priorities
• support objectives are clearly linked to core BCF objectives
• support offers are designed and delivered with sustainability and local ownership of change in mind
• local systems are willing and have capacity to engage with support definition process
• support offers are costed and mobilised efficiently
• local systems are willing and have capacity to engage with support delivery
• flexibility of support provider staff (including subcontractors) and support partner or subcontractor involvement in support delivery, as appropriate, in line with the original bid submission
• subcontractors are available with the appropriate expertise and capacity to deliver support
• buy-in from local systems is secured at the correct level of seniority
• local systems are willing and have capacity to share good practice and lessons learned, and can do so in line with the General Data Protection Regulation (GDPR)

Key: relationships between assumptions and risks

Both risks and assumptions have links or relationships to the same causal chains in the ToC. These are represented by a letter key in Figures 11 and 12 as shown in Table 9 below.

Table 9: how assumptions and risks are mapped across both ToCs

Letter	Assumption	Risk
(A)	– Responsible partners are clear and responsive in briefing or commissioning support – Local systems are clear, decisive and correct about their support requirements and priorities – Local system leaders are aligned on their support requirements and priorities – Support objectives are clearly linked to core BCF objectives	– Support offers and responsible partners’ priorities lack focus or are spread too thinly, diluting impact – Perceived lack of transparency regarding why systems have been selected for support reduces engagement
(B)	Support offers are designed and delivered with sustainability in mind	Support delivered and competing priorities lead to local system dependence on external support
(C)	Local systems are willing and have capacity to engage with support definition process	– Resistance to direction from central government partners – Support approval process is perceived as lengthy and bureaucratic – Lack of capacity in local systems to engage with support offer
(D)	– Support offers are mobilised efficiently – Local systems are willing and have capacity to engage with support delivery – Flexibility of support provider staff (including subcontractors) – Subcontractors are available with the appropriate expertise and capacity to deliver support	– Lack of capacity in local systems to engage with support offer – Lack of capacity or expertise in support provider and subcontractors to meet complex local system needs – Duplication of effort across different support offers available to systems - both within BCF Support Programme and across a ‘crowded improvement space’
(E)	Buy-in from local systems is secured at the correct level of seniority	Local system buy-in is not at a sufficiently senior level to effect change
(F)	Local systems are willing and have capacity to share good practice	Barriers to sharing evidence within and across systems limit shared learning
(G)	No associated assumptions	Unequal spread of support uptake across regions
(H)	No associated assumptions	Programme underspend results in decreased future funding

ToC for the support delivery contract

Figure 12: ToC for the BCF Support Programme support delivery contract

Additional notes when interpreting Figure 12

Due to some elements identified in the full ToC depicted in Figure 11 being outside the remit of the current support delivery contract, some elements depicted in Figure 12 relate only to the current support delivery contract.

To interpret Figure 12, refer to the text alternative for Figure 11 above as well as the following additional notes on how the 2 figures differ.

Inputs

Inputs depicted in Figure 12 relate only to the current support delivery contract, including funding, and staff time and expertise.

Activities

Activities depicted in Figure 12 relate only to the current support delivery contract and do not cover the activities of DHSC, DLUHC and NHS England as well as local systems.

Outputs

Lessons learned from overall support programme delivery were considered out of scope for the outputs feeding into the ToC for the current support delivery contract and were therefore removed from Figure 12.

Outcomes

Medium-term outcomes focused on improvements to BCF plans and broader plans in health, social care and housing plans being more aligned were not considered outcomes that were in scope for this evaluation and were therefore removed from the ToC for the current support delivery contract depicted in Figure 12.

Impacts

For this evaluation, impacts to local system only were not considered in scope, therefore the following impacts were removed from the ToC for the current support delivery contract depicted in Figure 12:

• sustained joint planning and commissioning
• sustained integrated working on and joint commissioning for issues beyond the focus of the initial support
• sustainable funding and integration with local VCSE sector