In our research, no funding transfers had occurred; rather, the Better Care Fund had been used to support DHA. This may not, however, be sufficient and there are also drawbacks in that it is short-term and often does not keep pace with inflation. Lack of clarity over these issues had deterred some boroughs from developing DHA programmes. Participants indicated that this was a complex issue with no clear course of action, and may require increased integration of health and social care budgets. 

These are all issues to think through carefully when starting DHA programmes. Effective resourcing underpinned success in three boroughs, whereas attempts to establish DHA programmes in other boroughs had been hampered by lack of resourcing. This was particularly so as they no longer qualified for innovation funding that had supported the DHA Programme Lead roles in the three boroughs with successful programmes. 

Second, is the need to review existing capacity and identify whether existing resource is required. For example:

Understanding existing capacity and building the required resource is vital to effective DHA implementation. Linked to this, it is important to consider how to evidence the financial case for DHA to gain resources; here, building business cases to support requests for additional resources was vital. There was significant interest in the extent to which DHA could achieve tangible cost reductions, although there was
a general absence of hard data. Two boroughs evidenced district nurse time savings: first, in reducing the number of people using services requiring insulin administration and second, in delegating insulin administration to care workers and reducing district nurse caseloads: 

This did not, however, not reduce the cost of district nursing services, rather it released resources so that district nurses could deal with more complex cases. DHA could also increase adult social care costs, for which many care providers were not recompensed. 

It can be difficult to obtain evidence to build a business case, so it is important in seeking to gain resource to be clear about the benefits
of DHA; using this toolkit will help with that. It is important to note, however, that one borough suggested that quantifying identifying cost implications was so difficult, given the complexity of health and social care services, that the focus should instead be on improving outcomes.
It is also essential to consider how programmes will continue to be funded over the longer-term and how resources to maintain or indeed, expand DHA programmes will be identified. Clearly, resourcing is a complex area that will require significant time and thought,

Third, consider the resources required to support increased funding for providers. One GM borough had used Better Care Fund monies to enhance fees for homecare providers and, somewhat less explicitly, for residential care providers. Other boroughs had not increased fees, though all required payment of the Real Living Wage to their adult social care workers. Many providers engaged with DHA on a goodwill basis, but all participants expressed concern about the limits of this. Larger providers were more reluctant to engage without enhanced fees. Implementing a programme will require thought as to whether/ how fees can be increased to reflect the additional responsibilities absorbed
by adult social care.

Provider engagement may be more limited where fee enhancements are not made, which will make scale up more challenging.

Enhancing provider fees will also support extra payment for the care workers that take on DHAs. Here, consider using the Enhanced Care Worker Role which includes DHA, and creates a mechanism to increase pay and offer career progression. While some care workers took
on DHA without additional pay, albeit they were all paid the Real Living Wage, others refused to participate. The Enhanced Care Worker
may help to address this.