NHS Scotland chief executive Paul Gray talks integration

Paul Gray, NHS Scotland chief executive - David Anderson/Holyrood

“Clunky. It’s not a technical word.” 

Holyrood sits down with NHS chief executive Paul Gray shortly after he has appeared before the Scottish Parliament’s Public Audit and Post-legislative Scrutiny Committee to discuss what is probably the most ambitious reform of the last parliament: the integration of health and social care.

MSPs on the committee grilled the Director General of Health and Social Care over an Audit Scotland report which was published a year ago, just before the 31 integrated joint authorities were launched. 

Gray pointed out to the committee there has been progress since, not least, the establishment of the boards and the commencement of work across the country to deliver more joined-up services. 

However, the image of elected councillors and NHS health board officials squabbling over budgets has endured, and Gray conceded the budget-setting process had been “clunky.”

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Speaking to Holyrood, he reflected on the comment.

“I think it describes the process of learning that we all had to go through, bringing budgets together from local government and health and making sure they were properly aligned, and that we understood that in bringing them together, there was an opportunity to deliver something better. And different.”

It is also a necessary change, he argues, pointing out how an ageing population and the advancement of medical science and technology mean current and past models of delivery are no longer relevant or sustainable. 

Integration, then, is about taking advantage of these advances in technology and medicine to deliver a more person-centred approach to care that enables people to stay in their own home or a homely setting.

“This is partly therefore reforming in the interests of patients, and that has to be at the forefront, but also in the interests of efficiency and sustainability, and also in the interests of delivering the best possible care at the right location,” he says.

And the new integrated joint boards are delivering new innovative ways to do that, according to Gray.

“If you go, for example, to Ayrshire and Arran, you’ll see three community wards managing high-risk patients with chronic obstructive pulmonary disease, or COPD, falls, heart failure and diabetes. 

“It’s achieving high satisfaction scores and – here’s the point – reducing emergency hospital admissions by 40 per cent and 36 per cent fewer bed days in the first six months.”
In Edinburgh, multi-agency triage teams, or MATTS, operate 24 hours a day to identify people who can be supported to leave hospital early, even at weekends, he says. This has increased capacity by 30 per cent. 

These statistics, says Gray, provide actual data about where improvement is happening as a result of integration. But if something is working, why isn’t it happening everywhere? The pace of change around Scotland has been inconsistent, at best.

“Well, the context in Ayrshire and Arran is different from Edinburgh, which is different from Perth and so on and so forth,” says Gray. “But that’s why it’s so important we have these local partnerships using local data and local intelligence to design services round people.”

Ayrshire and Arran already had a good history of engagement, so perhaps the level of success has been connected to how strong pre-existing relationships have been on the ground. Gray says the chief officers, chairs and vice chairs of the integrated partnerships are brought together with representatives from council chief executives to discuss successes and learn from them.

“We attach enormous importance to people seeing how these relationships are developing,” he says. “Developing relationships not only within the partnerships but across the partnerships, and I think the best way to lead is by example. In other words, not by saying you do this and you do that, but by giving live examples of where it is working well.”

The work of Eddie Fraser, East Ayrshire’s chief officer, alongside chief executive of NHS Ayrshire and Arran, John Burns, has seen “continued growth” in integration, for example. 
Integration can also lead to better data to chart improvements and make comparisons, Gray suggests. 

“Now I’m not expecting everyone to be the same, but I am expecting them to achieve the core indicators set out in the legislation.”

But at only 12 months old, isn’t it too early to get reliable data on what is working? 

“Well, it’s never too early to learn from the best, I would say. I think partnerships are doing that. I believe there’s a strong commitment in the partnerships to developing both their local intelligence but also drawing in the experiences from elsewhere. I know the chief officers are committed to that.”

But if developing relationships is key, then “clunky” could be a problem. The answer, according to Gray, lies in the governance arrangements. 

“We need them,” he says. “But really, it’s the bond of trust and confidence that makes the difference. Staff at the front line in some areas are already used to working together. What you need to do, though, is build that confidence in the governance and in the process, so the people working within that feel comfortable about sharing budgets, sharing risk and sharing responsibility for the people we’re here to serve.”

The required cultural change to achieve joint working was often cited through the passing of the legislation as a possible stumbling block. Gray argues the focus must remain on action.

“There is no such thing as a culture change programme,” he says. “If anyone tells you they have one, they probably don’t. Culture is the way we do things, and if you want something to be different, you have to do different things.”

The very act of implementing the legislation, then, brings about cultural change, but Holyrood points out there will always be people who are resistant to new ways of working.

“One of the biggest hindrances to change is if people take the view that they want everything to be different except them. Now that’s true in every sector, it’s not a health issue, not a local government issue, it’s not a public sector issue, not a private sector issue. Change involves being different.

“The biggest or best example of change is metamorphosis, when a caterpillar turns into a butterfly.

“It’s an old, old example, as old as the ages of time. But what starts off looking like one thing turns into something else, and the outcome is better. You go from something that crawls to something that flies. That’s a big change but it’s also a big improvement. 

“Really, in health and social care integration, I believe we’re going to something that can fly, something that really has the opportunity to make a big difference to how people receive their services.”

Is that a vision the politicians can see, however? Much of the focus has been on the figures for delayed discharge. It is also an indicator given as one of the three foci of activity identified in December’s health and social care delivery plan.

The latest delayed discharge census published by ISD Scotland shows the number of people delayed in hospital for health and social care reasons at the end of January increased to 1,139, compared to 989 in December 2016. The general trajectory has been downward, though, and Gray points to a nine per cent drop in the last annual figures.

“Now that has to be a good thing,” he says. “That’s a good thing for patients, but it’s also good for hospital bed availability. It works for everyone. Has it gone far enough? No, we need to keep working at this.”

He says there is evidence that integration can help people to be increasingly cared for and treated in the most appropriate setting for them. In Glasgow, a method called ‘discharge to assess’ has seen people increasingly assessed on their care needs outside the acute setting.

Under the scheme around 100 intermediate care beds were introduced to enable people to be discharged from hospital within 72 hours of being declared fit to leave. A care manager then assesses them during their stay, hosting a planning meeting after 48 hours to set their aims and objectives. Gray says it has “really compressed” the timetable while keeping the focus on the appropriate location for the person’s care.

He remembers one example from before integration was implemented. 

“Five years ago, an elderly lady with fairly complex multi-morbidities is in hospital and it comes to the point where she is to be discharged. 

“One of the questions she is asked is ‘do you have stairs in your house?’ and she answers ‘yes’. So they bring to her a set of steps for her to climb up to demonstrate her ability to climb the stairs, and she can’t climb up the steps. She’s told she’s not ready to go home, and she’s very distressed about this. 

“Her family come to visit, and they’re expecting Mum to go home and she says, ‘I’m not able to go home because I can’t climb up this flight of stairs’. 

“The question she wasn’t asked was ‘how long is it since she last climbed the stairs in the house?’ – the answer is two years. She didn’t go upstairs. The rest of the family go upstairs, she didn’t. All the facilities she needed were on the ground floor. 

“If she’d been assessed in her home that would have been obvious, but because she simply answered the question factually, [she was stuck in hospital]

“That elderly lady was my mum.” 

The key to progress, then, lies in the quality of conversations, something reflected in the Chief Medical Officer’s ‘realistic medicine’ approach which calls on professionals and patients to work together on the decisions about their care.

NHS Scotland itself introduced the ‘what matters to you?’ campaign to encourage professionals to have such a conversation with the people they care for. 

“Once you know what matters to a person, you’re able to structure and tailor the care they receive in a way that actually helps them,” says Gray. “They’re much more likely to have a good outcome.”

But with so much intention to move services into the community and to put the person at the centre of their care, is it actually happening? Has integration begun to deliver on these lofty ambitions?

“As far as integration is concerned, the future is here, but it’s unevenly distributed,” says Gray. Holyrood suggests this comes back to the issue of sustainability and the warning from Audit Scotland a year ago when 15 of the integrated bodies were already predicting an overspend. 

Gray is already having to juggle shortfalls at NHS Tayside and NHS 24 where there have been difficulties in balancing budgets. 

Auditor General Caroline Gardner has said the levels of efficiency savings now required in Tayside – agreed at £46.5m – were “unprecedented”.

Gray himself admitted to the Audit Committee in February the board might be forced to increase waiting times for treatment as a contingency.

NHS Ayrshire and Arran and NHS Fife also received financial brokerage from the Scottish Government this year.

It doesn’t seem unreasonable, then, to consider there must be a very real concern the integrated bodies might encounter similar issues, particularly when the statutory partners involved are facing harder and harder pressures and calls for ‘efficiency’ savings.

“I think integration is actually part of the answer to sustainability,” counters Gray. “We want care to be safe, person centred and effective, but we also need it to be sustainable.”

The examples he has already given of integration working show how providing care closer to home and delivering better outcomes faster is actually delivering a more sustainable health system, he says. “This is real as opposed to a theory.”

North Lanarkshire’s age speciality service emergency team (ASSET) is another example, he says, where specialists have been sent into people’s homes to assess, diagnose, treat and support them as a paid alternative to emergency admissions to Monklands Hospital.

“The service has about 100 referrals a month, with a daily caseload of 10 to 32 – in that range. Of over 2,000 patients managed by ASSET, 76 per cent have been kept at home at a cost of £689 per admission avoided,” Gray says.

“In other words, we’ve saved £689 per patient by keeping them at home. And mortality is lower than for inpatients, so in other words, we are showing what we said would happen, which is better outcomes from staying at home.”

Indeed, ‘better value’ is a key part of the health and social care delivery plan. But with all these new ways of working, costs coming down seems far from inevitable. One example Holyrood raises is the commitment to double community palliative care services. “By 2021, we aim to: ensure that everyone who needs palliative care will get hospice, palliative or end of life care,” it says.
However, there is no additional budget allocated to what sounds like an expensive ambition.

“If you think about that, people receive palliative care in hospitals and others settings,” says Gray. “What we’re saying is we have the evidence to suggest it’s better if it’s not delivered in hospital where that’s possible, but in a home or homely setting. 

“Doubling what you do in the community doesn’t have to be a net additional cost, it means you’re moving it from a place where it’s less effective to a place where it’s more effective.”

Gray says the staff in North Lanarkshire’s ASSET team aren’t new staff, but staff shifted from their previous hospital setting. 

“This is what we mean by shifting the balance of care,” he adds.

With such a focus on “putting the right people in the right place”, much of the success of integration will then depend on the Scottish Government’s imminent workforce plan for health and social care. 

Gray says integration will influence the plan, which “should give us some insight into the new types of role that would be required to operate effectively in an integrated service”. This will include a focus on not just their professional skills but also how they fit into the integrated service. But for those professionals who feel they are doing great and vital work at the moment, there could be a resistance to change, Holyrood suggests.

“One of the things about needing to transform in order to deliver a sustainable health system, is that there’s plenty of work to go round,” says Gray. “No one is going to be short of things to do.”
The question, he argues, is how to best deploy the resources available, recognising the skills needed in an environment where people are living longer and with complex multiple conditions, and with the commitment to give children the best possible start in life.

“If you look back over, say, a 30-year career as a social worker or as a nurse or a dentist, are they doing now what they did 30 years ago? Almost certainly not,” he suggests.

“So without changing the job title, the content and focus of the job has changed because of improvements in knowledge, improvements in technology, in science. Work changes all the time. I think rather than seeing this as something to be afraid of this is, to me, pretty exciting.”

The professional bodies, royal colleges and trade unions have an “enormous contribution” to make to the plans, he adds.

But what about those working on the front line who feel far removed from change, those working in the areas where they feel integration hasn’t filtered down to them yet? Does Gray have a message for them?

“You have my full and unfettered permission to make things better,” he says. “Absolutely. If folk want to make suggestions on social media, I’m always interested to hear them. I know senior leaders in integration authorities and health boards are too. 

“Always start from a standpoint of what will be best for the people we serve? And if you feel you can make it better for the people we are here to serve then you have my permission and authority behind you.”

And as for facing MSPs in parliamentary committees, Gray appears comfortable that health is a hot political topic. 

“The delivery of a health service free at the point of delivery is a political construct,” he says. “I’m very happy to work in a country with a parliament which believes that is the right way to deliver health services.”

Politicians, he argues, contribute meaningful insight from their direct contact with the public.

“I think it’s right to respect people who stand for election, and we live in a democracy and therefore we should respect the institutions of democracy, and in doing so, I think we are likely to have an improved set of outcomes than those that would be delivered by not listening.”

There is a precision in Gray’s assessment of his own responsibilities. 

He has faced MSPs a number of times and offered them straight-talking appraisals of issues raised, including an apology to patients in front of the Health and Sport Committee in November. 

“I apologise to patients who wait longer than they should have done so in the past. I regard it as appropriate and proper that I should do so,” he told the committee at the time.

Reflecting, he says: “I’m a public servant, and I’m paid to listen to the people who are elected and I’m paid to listen to the people who elected them.”

And there’s nothing clunky about that.