The Scottish Government recently announced that it was leading the UK nations on health and social care integration. Christine Grey examines this claim.
The legal arrangements for the integration of health and care commissioning and delivery came into force in all areas in Scotland in April 2016, and much groundwork for implementation has been operating in shadow form for a few years. Meanwhile, the Association of Directors of Adult Social Services (ADASS) jointly published a report calling for greater commitment, innovation and speed on integration in England, and the Organisation for Economic Co-operation and Development (OECD) has suggested that improvements are too variable and not formalised south of the border. So it could be a good time to look across the national boundaries to see how successfully the neighbours are driving system change to improve individuals’ experiences of health and care services.
The King’s Fund report, Options for Integrated Commissioning — Beyond Barker 2015, said the case for better integration between different types of health services, and between health and care services, is now universally accepted. Unlike in England, though, the Scottish Government has responded to the consensus and the changing health and care needs and expectations of the population by specifically legislating for integration in the form of the Public Bodies (Joint Working) (Scotland) Act 2014. This brings together NHS and local council care services under one partnership arrangement for each area in the country, with the Government’s Health and Social Care Directorate being ultimately responsible for the development and implementation of health and social care policy.
While the Royal College of Nursing (RCN) Scotland highlighted how “constitutional devolution has sped a process of divergence between systems across the UK” with structures, priorities, funding decisions and legislation now looking different in each of the four countries, they still appear to be pursuing similar goals in many areas, not least in their drive towards greater integration and personalisation of the health and care services.
Integrated arrangements have been in place everywhere in Scotland since April, when the 31 new Integration Authorities (IAs) officially took over responsibility for managing health and social care budgets totalling over £8 billion. These budgets and nationally agreed outcomes now apply across health and social care, with the new partnerships being jointly accountable to ministers, local authority leaders and the public for delivery of outcomes.
To support the implementation of the new arrangements, the Scottish Government provided transition funding totalling £7 million and is allocating more than £500 million over three years to new partnerships to support delivery of the national outcomes.
Approaching the April deadline, Scottish Health Minister Shona Robison said her government was expecting merging health boards and councils to generate savings of at least £138 million a year. She announced: “Integration has been over two years in the planning, and a huge amount of work has been undertaken by both the Scottish Government and all of our partners in the health and social care sector, to get us to April 1. These efforts have meant we are making better progress on integrating services than any other part of the UK — a fact recognised by both the OECD and the King’s Fund.”
She was referring to the OECD’s Review of Health Care Quality in the United Kingdom in 2016, which found: “Work to integrate health and social care in Scotland is bolder and wider in scope than that seen in most other OECD systems.”
However, with a shift from assessing clinical targets and organisational processes to looking at how well different services come together to provide seamless support around individuals, making the judgment on success is not easy. As the King’s Fund agreed in its 2015 report, the real impact of integration on people using services is very hard to measure. It recognised: “Evidence on integrated care to date is mixed and success can depend on local context. Measuring its impact is difficult, and in many cases, the results take years to materialise.”
Results and challenges
Despite this, in April, the Scottish Government announced that the reform had already started to deliver results, “including a 21% drop in patients waiting over three days to be discharged from hospital in January, compared to the same time last year”.
However, there are also signs of challenges to the successful implementation of the top-down reform. By 3 December 2015, Audit Scotland published its first progress report, Health and Social Care Integration, which recognised risks such as complex governance arrangements and uncertainty about how services will actually be redesigned. It summarised: “There is evidence to suggest that IAs will not be in a position to make a major impact during 2016/17. Difficulties in agreeing budgets and uncertainty about longer-term funding mean that they have not yet set out comprehensive strategic plans. There is broad agreement on the principles of integration. But many IAs have still to set out clear targets and timescales showing how they will make a difference to people who use health and social care services.”
Auditor General for Scotland, Caroline Gardner said the creation of the new bodies was a very complex process and added: “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 IAs will use resources to transform delivery of health and social care.”
This was anticipated in 2012 by Durham University’s Professor Bob Hudson, in an article for The Guardian, when he wrote that as long as health and social care are in different organisations, there would always be tensions around where the money is spent. The OECD report, Health Care Quality in Scotland, which Shona Robison referred to, confirmed that budgets and plans still needed to be agreed locally, making her positive rhetoric on integration sound premature. In fact, December’s audit report prompted Liberal Democrat Health Spokesman Jim Hume to go as far as to say the reform process was in chaos. He told the Express newspaper: “The Scottish Government must urgently review the support it is giving local authorities and NHS health boards and Audit Scotland’s recommendations must be implemented in full.”
By March, Caroline Gardner warned that new models of innovative practice were generally small-scale and not enough to deliver the Government’s vision. She added: “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.”
After the official reports, RCN Scotland Director Theresa Fyffe highlighted the “huge challenges” that IAs were facing in April, with health and social care budgets under pressure and services struggling with increasing demands from an ageing population. She warned: “Without the right staff and the right services in the right place to deliver integrated services, we’re deeply worried that tensions and confusion will limit the success of these new ways of working.”
British Medical Association (BMA) Scotland Chair Dr Peter Bennie also told his union’s annual meeting in Belfast that the Scottish Government’s plans to integrate health and social care showed “little evidence” of politicians’ pledges to put clinicians at the centre of redesigning care, and that a funding gap could prevent many services that patients require from being delivered. The OECD report supported such concerns saying “sufficiently strong mechanisms to leverage general practitioners’ (GPs) contribution to health and social care integration may be lacking”, and has recommended that GPs’ involvement in local planning and integration be deepened.
With these cautions, Scotland’s ability to achieve the cultural change needed is in question, as well as is its ability to scale up new models of care and adequately resource them, and the risks may increase with the political and economic uncertainty brought about by the results of the EU Referendum.
Measurements of success
To more accurately measure success, IAs will be required to publish annual performance reports setting out how well they are delivering integrated health and care against nine prescribed National Health and Wellbeing Outcomes, which include measures of how well people are able to look after their own health, live independently for longer, have their dignity respected and the reduction of health inequalities. Health Boards, local authorities and IAs are required to work together to achieve these for people in their areas.
An associated Core Suite of Integration Indicators, drawing together measures appropriate for the whole system under integration, has been developed together with a Guidance Framework, and these are to be used alongside the Public Bodies (Joint Working) (National Health and Wellbeing Outcomes) (Scotland) Regulations 2014. The OECD report welcomed the way these indicators were developed and said: “… given that most OECD health and social care systems are exploring how best to monitor person-centred, integrated care, Scotland’s experience with these indicators will be of international interest”.
Another recommendation from the OECD was to improve the integration of the health and social care information systems to more accurately monitor outcomes. It said good data was needed across both systems, especially in social care, and not just on a national level but also a local one. The Health and Social Care Data Integration and Intelligence Project have been taking forward data linkage work across the systems to support commissioners in planning resources, but more also needs to be done to help Scotland catch up with England in producing more user-friendly comparison data that is accessible to the public.
It is still early days, and next year the annual reports should provide a better indication of how well localities are actually doing in bringing services together around the individual, but it is possible that Scotland may not be so far ahead in the delivery of truly integrated services if the risks are not addressed this year.
When looking to measure improvement in integration, the Scottish Government could take a leaf out of RCN Scotland’s new report, Measuring Success: Principles for a New Approach to Improving Health and Wellbeing in Scotland. It says: “Ensuring that the process of choosing, setting and monitoring success measures is conducted with the full involvement of relevant client groups and all sectors and professions with a mandate to make a difference, will, the RCN believes, go some way to ensuring that targeted investment genuinely improves outcomes.”
The report adds: “The cultural shift required should not be underestimated and all health and wellbeing staff should be supported to build new, respectful relationships.”