Health and social care integration a year on - still early days

Health and Social care integration - istock/Holyrood

April 1 2016 saw the realisation of what was probably the most significant and expansive reform passed during the last Scottish Parliament session.

A year on, and the impact of the integration of health and social care is beginning to be felt in some parts of the country. In others, some might argue it is conspicuous by its absence.

The need for services to integrate is clear when sustainability in the face of unprecedented challenges will be a difficult task. 

The number of people aged 85 and over in Scotland is expected to double by 2034, with more and more people living with complex long-term conditions that existing services simply are not designed to treat.

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The 2016 legislation brought together NHS and council care services into 31 local partnerships which see NHS officials and elected councillors take joint responsibility for around £8.2bn of health and social care resources.

This means the local elections in May will be the first ever where voters will be electing councillors with the ability to have a profound impact on the health and social care landscape.

But how profound can the impact be? And where do these new integration joint boards (IJBs) begin? As the boards prepared to launch a year ago, Audit Scotland warned there was a lack of leadership and clear planning among the bodies.

Auditor General Caroline Gardner said they were then focused more on structures and governance arrangements than making a difference on the ground.

“An ambitious vision can be a catalyst for change but without a clear and detailed plan of action, there’s a risk that ambition is overtaken by circumstances,” she said.

And those circumstances mean hospitals struggling to cope with the sheer volume of people with complex needs and multiple conditions who would actually get better outcomes if they were getting specialist help in their own homes.

One of the clearest symptoms of this, and the one quantifiable enough for politicians to cite, is delayed discharge, when a person who is ready to move from hospital back home or into a community setting is stuck in hospital waiting to be assessed or for social care support.

Official figures show a 5.1 per cent reduction in bed days associated with people being unable to be discharged from hospital in 2016 compared with 2015, but how much of this is due to the IJBs is unclear.

And the number of people delayed in hospital increased again at the end of January this year, to 1,139, compared to 989 in December.

The Scottish Government clearly felt the IJBs needed encouragement in December, when it published its health and social care delivery plan.

“We must up the pace of change if we’re to deliver modern, sustainable health services and local health boards and integration partnerships have an important role to play in taking this forward over the next year and beyond,” Health Secretary Shona Robison said.

Audit Scotland has repeatedly said the necessary shift in resource from hospitals to community settings has yet to be realised, and the delivery plan recognised this.

Included within the financial details was a commitment to increase primary care funding by £500m so that it accounts for 11 per cent of the frontline NHS Scotland budget.

And the work of integration authorities must focus on three areas to bring about change, the delivery plan said: reducing inappropriate use of hospital services, shifting resources to primary and community care and supporting the capacity of community care.

This will lead to a reduction in unscheduled bed days in hospital by ten per cent by 2018, it said, adding that by 2021 everyone who is has a terminal condition will be given palliative care, something that is currently only patchily available.

But are the partnership bodies ready to take on such ambitions? It is thought in some cases there have been conflicts within the boards between NHS officials and local councillors over how funding – which is channelled through the NHS – is spent.

Meanwhile the boards are required to consult patients, professional bodies, charities and voluntary groups in strategic engagement exercises to ensure decisions are made with broad views taken into account.

This process is the subject of an investigation by the Scottish Parliament’s Health and Sport Committee.

In written submissions, former patient representatives on the Orkney and Shetland boards told the committee they felt they had little or no influence on planning.

“We seem to be presented with documents to put our stamp of approval on with very limited discussion and no information to put anything into a wider context or allow prioritisation,” Orkney’s Corrine Curtis said of the strategic planning group she sits on.

Meanwhile, many third sector organisations delivering vital services are still struggling to connect with the integration authorities and do not know who to contact when their single level agreement reaches the end of its contract period, according to the Health and Social Care Alliance Scotland (ALLIANCE).

ALLIANCE chief executive Ian Welsh tells Holyrood the relationships at the heart of decisions are key.

“You would have to say probably the progress across Scotland would be patchy,” he says in reference to the engagement exercises, “depending on local history, or on whether a board or local authority had a history of engagement, and depending on whether it was urban or rural in nature.”

Welsh is also chair of East Ayrshire Integration Joint Board. He says the partnerships in Ayrshire engaged “strongly” with the third sector and patient groups.

Interestingly prior to integration Ayrshire had strong and well-exercised community health partnerships (CHPs). Perhaps the process was helped by pre-existing relationships?

“I think that’s a fair point,” says Welsh. “There was a strong CHP structure in Ayrshire, although that wasn’t the only determining factor. Ayrshire started planning from way out and worked very hard at bringing the plans and organisations together.”

Although “sporadic”, the strategic engagement activity is yielding more productive and different links across Scotland, says Welsh, stronger in localities which have “a tradition of community engagement”.

Strategic engagement, however, is not the same as putting the patient in the centre of their care, a recurring theme through Scottish Government policy. While the headlines focus on delayed discharge, integration is also about partnerships on the ground, as services attempt to fit round the needs of the individual.

“Sometimes the challenge is you can get engagement but you don’t necessarily always get co-production in activity and services,” says Welsh.

In its submission to the Health and Sport Committee’s investigation, disability consortium Inclusion Scotland said patient-centred care was yet to materialise.

“There is a view that so far health and social care integration has been more about the management structures within the existing statutory authorities than developing effective partnership working and co-production with service users,” it said.

The context, according to Welsh, is the financial pressures felt by both the statutory partners, with health boards and councils under enormous pressure to make ‘efficiency savings’ to their own budgets.

“I think an analysis of that will show that there has been very significant soaking up of part of that fund to ameliorate service efficiencies,” he says.

“At the same time as that happens, though, there have been, across all the integrated joint boards, some really good examples of new service redesign activity.”

As a chair of an IJB, he says it has been “technically quite a challenging exercise”.

Meanwhile, health and social care staff on the ground are expected to lead their own partnership working in what many warned would require a significant cultural shift.

The Royal College of Nursing (RCN) introduced a toolkit for nursing leaders to support their members to lead service redesign, but in February a rapid review by the nurses’ union revealed many areas are struggling to recruit the community nurses and health visitors necessary for care to move into the community. 

This is despite many IJBs planning for a community nursing workforce and the Scottish Government’s National Clinical Strategy demanding it.

“It is then a great cause for concern that vacancy rates are high, and that Scotland is not training enough nurses to meet future demand,” the RCN told the Health and Sport Committee.

North Lanarkshire IJB has announced a health and social care academy in conjunction with the council and health board, education providers and the voluntary sector in an attempt to plug the gaps.

In terms of cultural change, neighbouring South Lanarkshire has signed up to the international ‘Breaking the Rules for Better Care’ campaign, which encourages fresh thinking from staff and patients.

During the last week in March they will be asked: “If you could break or change one rule to create better care for people in South Lanarkshire, what would it be and why?”

Val de Souza, director of South Lanarkshire Health and Social Care Partnership, said feedback gleaned could have a “profound” impact. 

“We are listening as we move forward. And we are listening carefully. I’m committed to building on the spirit of partnership and working through challenges and addressing priorities – together,” she said.

Meanwhile, social care workers who visit people’s homes are rarely monitored by the councils who employ them, according to UNISON. The trade union raised the issue at a recent community sector conference.

An FOI by the union revealed councils depend on review meetings with third party contractors rather than on monitoring actual service delivery. As such, there is very little way of measuring the quality of care, warned UNISON’s head of public affairs in Scotland, Dave Watson.

“We know the difficulties the workforce face when delivering home care,” he said. “They need better training, fair pay and the time to care for the vulnerable people they look after. They tell us how stressed they feel they are not able to provide the service their vulnerable clients deserve. And we know this happens far too often.”

The IJBs have been tasked with ensuring social care staff are paid the real living wage, but UNISON also warns procurement guidance should include a greater weighting to fair work.

And self-directed support (SDS), which allows people with a disability or long-term conditions to choose how their care is provided, is also inconsistent in what it provides for people depending on where they live.

Those who receive SDS can choose between direct funding, so they can recruit care workers and packages themselves, or arrange with their local authority how the budget is distributed. However, Scottish Government figures show only 20 per cent of eligible people have been offered choice.

“Scotland has only five million people, about the size of Yorkshire, so having 32 different ways of delivering self-directed support is part of the problem,” ALLIANCE policy and outcomes officer Colin Young told delegates at the recent SNP conference. 

An ALLIANCE report will be published imminently which will show those who are on Option 1 of SDS – in which a direct payment is given to the person or their carer – are far more likely to understand the system and to exercise autonomy. But those people are also more likely to be health literate in the first place, potentially widening health inequalities.

Despite all this, Ian Welsh believes cultural change has been evident in the raft of policies around integration which have also described self-management and person-centred care, including the National Clinical Strategy, the ‘Prescription for Excellence’ plan for pharmacy, the Chief Medical Officer’s reports ‘Realistic Medicine’ and ‘Realising Realistic Medicine’ and moves to establish primary care multidisciplinary teams.

“All of those indicate culture change, but if you’re in the thick of it, sometimes all you can see is a maelstrom of change and you fail to recognise it is a significant cultural shift.”
A more difficult thing to shift, Welsh suggests, will be resources.

Attempts to shift spending from the acute sector into communities will be “mediated by the financial challenges”, he says, especially when IJBs are engaging with third sector partners at the same time as reducing their funding.

“Although I’m seeing lots of good work in the integration partnerships, lots of good work at the hospital door, lots of good work in terms of delayed discharge and good work in digital health and home health monitoring, it’s still difficult to see how you’re going to shift a significant amount of your resource from acute to community over the course of the next four or five years,” he tells Holyrood.

Will this be made more difficult by tense relationships over money within the IJBs themselves?

Christine McLaughlin, the Scottish Government’s director of health finance, told the Public Audit Committee recently that those relationships were improving.

“As partnerships plan for the 2017-18 financial year, there is a much greater level of engagement all round between integration authorities, NHS boards and local authorities,” she said.

“That does not mean that everybody agrees all the time, and there are still issues in some parts of the country about signing off on the resources to deliver the plans that are in place, but there is much more sharing of information, and integration authorities and chief officers are part of the discussions about how resources are used on a more day-to-day basis.”

In other words, she added, “there is definitely evidence of more mature relationships in respect of budgets.”

Maturity, it seems, is an ongoing process but with Scotland’s elderly population growing ever larger, the need for services to grow up more quickly is clear.