Scotland Health and social care , Welfare and equalities

In sickness and in health: how health and social care integration was supposed to work

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Background

In 2014, the Public Bodies Joint Working Scotland Act was passed, with the aims of ensuring care was more joined up and in a homely setting; and achieving better value. As a result, 31 Health and Social Care Partnerships (HSCPs) now control £8.5 billion of funding for care across Scotland.

Integration was the culmination of a number of factors. As Scotland’s population ages, more people are living longer, and with long-term conditions such as arthritis, diabetes or Alzheimer’s which need to be managed. This put pressure on the social care system, while health support was sometimes only initiated once a person reached a crisis point: a heart attack linked to Chronic Obstructive Pulmonary Disease, for example, or a suicide attempt as a result of undiagnosed mental illness.

At the same time, councils were required to provide free personal care, increased support for carers, more choice and control to people needing care, and to work more closely with other public bodies (see ‘related legislation’).

Integration was an opportunity to introduce a more preventative model of care, redirecting funding towards community-based supports which would encourage people to take responsibility for their own wellbeing. Improving people’s diets, increasing their exercise and encouraging them to connect with others has been shown to reduce their dependence on health care services. This would not only produce better outcomes for people, with many more able to live more healthy lives at home, but would also be more efficient in the longer term.

Scottish Government predicted that the integration of health and social care could result in savings of between £138 and £157 million, by getting people home from hospital more quickly, reducing unplanned hospital admissions and sharing best practice across areas.

There was also an understanding that health and social care services needed to work together, so that people knew how to access them when necessary, and so that people could move between settings seamlessly, without hold-ups due to bureaucracy or governance. Voluntary and independent sectors needed to be involved in smoothing patients’ paths through this complex landscape. Allied to this was the ongoing Scottish Government agenda of community empowerment and localisation, outlined in by the Christie Commission, which demanded agencies take into account local needs and priorities. The vision was a more devolved and joined up system of health and care, where people were supported to have healthy lifestyles and, when they needed services, were able to access them locally, or be cared for at home.

Related legislation

Free personal care for all adults, irrespective of income or whether they live at home or in a care setting, was introduced by the Community Care and Health (Scotland) Act 2002.

The 2007 Adult Support and Protection (Scotland) Act obliged public bodies to collectively safeguard vulnerable adults.

The Carers (Scotland) Act 2016 established the rights of carers to be consulted about the care of their loved one, and for their own wellbeing to be supported – for example, through respite care.

Councils are required by the Social Care (Self-directed Support) (Scotland) Act 2013 to offer people choices in how they receive their social care.

Public Bodies (Joint Working) (Scotland) Act 2014

The Public Bodies (Joint Working) (Scotland) Act is the key piece of legislation bringing about health and social care integration. It came into effect in April 2016, bringing an end to community health partnerships. Instead, it offered a choice of either a ‘body corporate’ or ‘lead agency’ model for integration. Regional health boards and councils were required to choose a model, and to produce an Integration Scheme explaining how functions would be delegated.

The Act includes principles for the planning and delivery of integration. Partners were instructed to develop a strategic plan describing how they would deliver their services and meet required national outcomes. It also set out the oversight roles of the Care Inspectorate and Healthcare Improvement Scotland.

Regulations

Various regulations relate to the Act, including setting out the national outcomes health and social care partners must achieve. These outcomes were developed following consultation and include supporting people to live at home; reducing health inequalities; and using resources effectively.

Other regulations specify what information must be included in Integration Schemes, such as the agreed model of integration and governance and finance arrangements. Integration Schemes must also include a workforce development plan.

Finally, regulations prescribe which functions must be delegated. For local authorities, this includes:

  • adult social work
  • mental health services
  • community care, day care and home care
  • care home services
  • respite care and carer support
  • housing support
  • occupational therapy and re-ablement

For health boards, this includes:

  • Adult primary care (for example, GPs, community pharmacy, dental and optometry services)
  • Adult community care (for example, community mental health, addiction services, health visitors, podiatry, speech therapy)
  • A proportion of hospital sector services for unplanned care, to support a shift towards prevention and early intervention (for example, hospital services associated with emergency care)

In addition, health boards can choose to delegate some additional services, such as children’s services.

Statutory guidance

A suite of guidance from Scottish Government covers topics including:

Strategic Commissioning: a method of planning and developing services which focusses on the outcomes to be achieved, and what change might be necessary to do so. Crucially, it emphasises the input of all stakeholders, including service users, and requires planning to be accessible, with ongoing dialogue with stakeholders.

Localities: each health and social care partnership is required to split their geographical area into at least two localities, based on natural communities and GP practice clusters. Localities should provide a forum for professionals, communities, service providers and service users to influence local provision, including funding. Locality plans will then feed into strategic commissioning plans.

Finance: guidance designates how Integration Joint Boards should ensure they have sufficient funding, basing their requirements on previous years’ spending and ensuring any savings are realistic. It also describes how they should calculate and use ‘set aside’ budget – their portion of the budget for unplanned hospital care.

Governance: guidance sets out the roles, functions and membership of an Integration Joint Board (IJB). Membership must include equal representation of local councillors and NHS Board members, plus:

  • The Chief Social Work Officer of the constituent Local Authority
  • A General Practitioner representative, appointed by the Health Board
  • A Secondary Medical care Practitioner representative, employed by the Health Board
  • A Nurse representative, employed by the Health Board
  • A staff-side representative
  • A third sector representative
  • A carer representative
  • A service user representative
  • The Chief Officer of the Integration Joint Board
  • The Section 95 Officer of the Integration Joint Board

There is also guidance on the issuing of binding directions. These are the mechanism by which an IJB requires a local authority or health board to carry out its decisions. IJBs must issue directions on every function delegated to them, while in a lead agency model the integration authority may opt to carry out the function itself.

Models for integration

Of the 31 integration authorities established in April 2015, 30 followed the integrated joint board model. This model allows staff to remain with their existing employer, under the same terms and conditions: it was not envisioned that integration joint boards would directly employ staff.

Only the Highland Partnership, between NHS Highland and Highland Council, chose the lead agency model. In this model, responsibility for services is divided between partners and the Chief Executive of each partner has responsibility for developing the strategic plan. Staff are required to transfer to the partner responsible for their service.

Each integration authority related to one local authority, with the exception of Clackmannanshire and Stirling councils, which together formed an integration joint board with NHS Forth Valley.

Case study: Highland Health and Social Care Partnership

Within the Highland Health and Social Care Partnership, NHS Highland is the lead agency for adult health and social care services, while the Highland Council is the lead for children’s services. Instead of an integrated joint board, the Partnership’s services are directed by committees of the Board of NHS Highland and the Highland Council, overseen by a Joint Monitoring Committee. The Partnership operates over two areas: the North and West Operational Unit and the Inner Moray Firth Operational Unit. This approach was introduced in 2012, with Raigmore Hospital being managed as part of the Inner Moray Firth unit since 2015. However, more recently the partners voted to introduce a programme management approach, setting up a Project Board with representatives of both organisations to deliver efficiencies in identified services.

Case study: Clackmannanshire and Stirling Health and Social Care Partnership

The Clackmannanshire and Stirling Health and Social Care Partnership has an integration joint board including three members from each of Stirling and Clackmannanshire Councils, as well as representatives of NHS Forth Valley. The Partnership is split into three localities: Clackmannanshire, rural Stirling, and Stirling City with the Eastern Villages, Bridge of Allan and Dunblane. It does not manage children’s social care services.

Comment

Integration was always going to be a complex process, attempting to bring together services, organisations, people and budgets in a way which improved and simplified services, rather than adding a further layer of bureaucracy. The requirement to involve and engage with people receiving services, and their carers, add to the complexity, meaning decision-making bodies are more diverse, but also potentially more unwieldy. Councillors sitting on joint boards may wish to ensure they have the development support they need to understand governance and accountability, as well the skills to facilitate open and constructive dialogue.

Strategic commissioning was also easier to embed in regulations than to carry out in practice: it was a cultural leap for some bodies more used to a top-down, cyclical approach to planning. The iterative approach of strategic commissioning, necessitating relationship building and constant engagement, would require levels of organisational development support perhaps not anticipated.  Entrusting such levels of influence to patients, carers and service users would not always sit comfortably with the traditionally hierarchical and risk-averse approach of large public sector organisations.

With the majority of integration authorities choosing an integrated joint board model, strong, trusting relationships between councils and their respective NHS Boards would be key, as the original partners would remain responsible for staff and services, despite having handed over the strategic and budgetary responsibility to the integration board. Here too, the culture and language of different organisations, not to mention the logistical issues of sharing data and IT systems, could present a risk. Authorities who have been most successful in transforming services have tended to be those who have invested in building a cooperative culture, where authority is delegated and innovation encouraged.

In some ways, the legislation and background to integration represents an optimistic devolution of power to a more local level, leaving authorities free to designate their locality areas, services to be integrated, and model of integration. There is surprisingly little mention in the legislation and guidance, however, of the elephant in the room: in a preventative model, focussing on community care, acute services were likely to become more specialist and less widespread. While most people would, in theory, enjoy better wellbeing closer to home, those still requiring expert intervention may have to travel further to access centres of expertise serving larger areas.

How this plan has played out in practice is examined in the related briefing, ‘For richer, for poorer: how health and social care integration has fared in practice’.


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