Home truths for health and social care integration as April deadline approaches

As all local authorities and health boards prepare to launch the joint bodies responsible for sharing services, the integration of health and social care has been a journey.

In 2011, the then Health Secretary Nicola Sturgeon said integration aims “to improve the quality and consistency of care for older people and put an end to the ‘cost-shunting’ between the NHS and local authorities that too often ends up with older people being delayed in hospital longer than they should be and not getting the best standards of care”.

In 2012, her successor, Alex Neil, told Holyrood he expected local authorities and health boards not to wait for legislation. “Step on the accelerator. We want this done and dusted ASAP,” he said.

However, as the April 2016 deadline for the establishment of the new integration joint boards (IJBs) approaches, the journey looks to have some way to go. 

In fact, there has been little improvement in the numbers of patients delayed in hospital, with a shortage of places in social care putting significant pressure on Scotland’s NHS.

More than 270 people died while waiting for their social care packages to start in 2015, 95 of them in Edinburgh, according to recent figures unearthed in a freedom of information request by MND campaigner Gordon Aikman.

And now, as £250m of health funding for social care in John Swinney’s budget is offered as some form of mitigation for a real-terms cut in council budgets, has that ‘cost shunting’ really been brought to an end?

The reaction of councils, who see the offer as another way to control their spending, suggests otherwise.

“They’ve given it to the health boards. I don’t mind the health service getting more money, the health service needs more money, but don’t say they’re giving to us when they’re giving to the health service,” David O’Neill, president of local authorities’ umbrella body COSLA, told Holyrood.

Speaking at the launch of Fife’s health and social care partnership – one of Scotland’s largest – Health Secretary Shona Robison said the boundary between NHS and local government spending will cease to exist.

“The integration of health and social care services will be one of the biggest reforms since the creation of the NHS in 1948,” she said.

The £250m investment would help “protect and grow” services, she said, as part of “over half a billion pounds” the Scottish Government has spent on integration.

“It will allow partnerships to take forward new ways of delivering services based on the principle that hospitals are there to treat people and that recovery is best achieved at home.” 

Fife’s IJB is chaired by a councillor, Andrew Rodger, who added: “Having health and social care under one partnership is a once in a generation change. We’ve been planning for integration for a long time and doing so with the public, partners and staff from the very beginning. Transforming services which truly place the person at the centre will be challenging, but I believe we can achieve it.

“This is due to the many workshops, face to face events, conversations and consultations that have been held across communities and with service partners. Most recently, over 1,000 people across Fife responded to our strategic plan consultation where we asked people what they want from services in the future,” he said. 

"The risk is that in the current budgetary climate, mutual suspicion will triumph over cooperation"

Some IJBs, like those in North and South Lanarkshire, are still consulting on their strategic plans. 

Dr Avril Osborne, vice chair of the North Lanarkshire IJB, said the proposed changes “will not happen overnight”, admitting “a considerable amount of work has to be done to achieve our aspirations for North Lanarkshire. 

“We will report annually on our progress towards our aims and will continue to engage and consult with our communities to ensure that we are addressing the real issues and taking the appropriate actions necessary to improve health and wellbeing in North Lanarkshire.”

However slow progress may be, in April the joint boards are required to be operational and responsible for over £8bn of public money. A report by the Accounts Commission and Audit Scotland in December said the IJB themselves were holding up progress. 

The report warned of “significant risks” to services because the IJBs had not yet finalised their strategic plans. It revealed the partnerships have struggled to agree budgets, complex governance arrangements and workforce planning, leaving them unable to make an impact, at least in their first year.

The fledgling arrangements are so complex, the report found, the public may struggle to understand who is responsible for the care they receive.

Caroline Gardner, Auditor General for Scotland, said: “If these new bodies are to achieve the scale and pace of change that’s needed, there should be a clear understanding of who is accountable for delivering integrated services, and strategic plans that show how integration authorities will use resources to transform delivery of health and social care.”

A major issue, according to the report, lies in workforce planning. The IJBs, it said, “risk inheriting workforces that have been organised in response to budget pressures rather than strategic needs. 

“Other issues include different terms and conditions for NHS and council staff, and difficulties in recruiting and retaining GPs and care staff.”

The findings reflect what is being experienced on the ground, according to surveyed members of Scotland’s biggest public service union, UNISON.

The cultural shift needed to break down the silos in which services work hasn’t begun to be addressed, suggests Dave Watson, the union’s policy and public affairs organiser.
“There’s a strong feeling and concern that individual professionalism is being compromised still,” he says.

How the IJBs will receive and allocate their budgets remains unclear. The £250m allocation awarded in the budget is to be split into two, half going to increase capacity and the other half to implement the living wage in social care, a sector which Watson says is in crisis.

In theory, the money will be allocated by the IJBs, bodies which include both health board members and councillors. 

However, because the £250m is being routed through the health boards as part of Barnett consequentials from increased health spending in England, Watson suggests health board directors of finance may find ways to divert it into their core service.

“First of all, it’s got to get to the IJBs, then it has to be divvied up. From a councillor’s perspective, how much does that go to meet their increasing demand? There’s a big chunk of money needed to cope with demographic change and increased demand, particularly in home care,” says Watson.

Social care providers are already struggling with pension costs and having to pay for travel time for workers doing home visits, he says. “One of my social workers’ reps came late to a meeting on this subject and said, ‘Look, I’ve spent the morning trying to find a package for an old lady who’s due to be discharged from hospital on Monday. This is Thursday and I’ve got six contractors on my list from my council to ring. Not one of them could deliver a care package. Not one,” he remembers.

Home care workers under pressure to see ten clients in two hours are facing a choice between cutting corners or working “double the hours you’re getting paid for”, says Watson. 
Dr Miles Mack, chair of the Royal College of General Practitioners in Scotland (RCGP Scotland), warned the lack of planning ahead of the launch of the IJBs could impact “the quality and safety of care” patients could expect.

“Despite efforts from Scottish government, GPs do not feel engaged by IJBs nor knowledgeable about the oncoming changes to practice. If care is to be provided ‘at home or in a homely setting’ then GPs will clearly be the hub of the system and, to date, they have had little opportunity to develop or influence it,” he said.

Watson agrees GPs could be an integral part of integration via physical local hubs, as illustrated during a recent meeting with a UNISON shop steward.

“The health centre was there, and her base was there, and a number of other things were there, and she said, ‘Give us ten minutes, Dave, I’m just going to pop in to the GP practice’. She popped in, said, ‘Tell Dr McGuffy Mrs Smith is not looking too good in my view, and get him to have a look at her’ and then she said the same to social work in their office, then went back to her base and signed out. 

“The point is that’s exactly how it should work. The home care worker is not claiming to be a doctor or a social worker but she knows and she’s got continuity of care, going in to see the same person two or three times a week.”

The IJBs will succeed if they can implement similar cross-sector working on the ground, but “we’re light years away from them even talking about that. They can’t even agree on baseline budgets at the moment, so the idea they’re going to get to what I’d like to see, this hub model, is a long, long way away,” says Watson.

The problem lies not with the makeup of the IJBs themselves, but in the broader economic climate, he suggests, recalling a secondment he did “in the early noughties” in the health department.
“I did do some work on integration then and I did a number of events where I put councillors and health board members in the same room. What hit me, interestingly, was actually they do bring some different skills. 

“Health board members actually were quite strategic, looking over a bigger area, more of a strategic focus. Councillors had a poorer strategic focus but knew their communities better, and were much better about how this would apply locally. 

“So there is some potential to use skills there, but I think the risk is that in the current budgetary climate, mutual suspicion will triumph over cooperation.”