What progress has our approach on integration in Scotland made so far?
This year public services in Scotland enjoy a couple of milestone birthdays, with the National Health Service turning 70 and Social Work celebrating 50.
Anyone with a broad interest in the history of the welfare state, set up to tackle Beveridge’s five giants of “poverty, disease, ignorance, squalor and idleness”, will enjoy looking back at the public good created by these hugely ambitious reforms.
Those of us who have been privileged to work on a more recent innovation, integration of health and social care, are also reflecting on progress: seven years have passed since the 2011 Scottish election that saw cross-party support for integrating health and social care, and it’s now four years since the Public Bodies (Joint Working) (Scotland) Act 2014 (this link will take you away from our website) was passed by the Scottish Parliament. What does progress look like since 2014?
Integration is one of the most significant reforms since the establishment of the NHS, largely because there has been such progress in wellbeing since the 1940s. It’s also a tremendous opportunity to bring together and learn from the best of different expertise and cultures across public services and beyond, and across communities.
In Scotland, we’ve based our approach to integration on a handful of key principles:
- Health and social care services should be firmly integrated around the needs of individuals, their carers and other family members;
- Services should be characterised by strong and consistent clinical and care professional leadership; The fact that we need to integrate health and social care is, of course, a challenge, but it’s also a cause for celebration, reflecting as it does the longer, healthier lives we generally enjoy.
- Providers of services should be held to account jointly and effectively for improved delivery; and
- Services should be underpinned by flexible, sustainable financial mechanisms that give priority to the needs of the people they serve rather than the organisations through which they are delivered.
Around these core ideas we have built requirements on existing agencies – Health Boards and Councils – to pool their resources and expertise, to share opportunities and risk, to maximise their joint contribution to the wellbeing of the populations that they serve, and to ensure a meaningful role for communities in deciding on services that are appropriate to local priorities.
We have created a new type of statutory body, Integration Authorities, so that people and resources are not only brought together but also empowered to act – to plan and spend – differently and better, to meet and anticipate Scotland’s changing health and social care needs.
We have created new roles, particularly those of Chief Officers and Chief Finance Officers of Integration Joint Boards, which set out in statute responsibilities that were previously held separately and sometimes at odds with one another.
We have set out in law requirements for the role of third and independent sector partners and for clinical and care professionals.
Perhaps most ambitiously, we have set out that budgets for complex care – spanning communities and unscheduled care in hospitals – must be pooled to maximise their impact and to support our long-held ambition to shift the balance of care.
All of this is naturally disruptive – deliberately so – and sometimes uncomfortable and difficult. But is it starting to make a positive difference?
Yes it is; we are seeing progress in terms of improvements in care. Over winter, always a litmus test for health and social care, we have seen Integration Joint Boards make a material contribution to the quality and sustainability of care, particularly in terms of sustaining social care performance and maintaining the trend in reductions in delayed discharge from hospital. The wellbeing of the country is not to be measured only in terms of service statistics and pressure on hospitals, but these are helpful indicators that things are moving in the right direction.
Are we there yet? No we’re not; not yet, but we are making progress.
When the Scottish Government’s consultation on integration was launched in May 2012, the First Minister, in her then role as Deputy First Minister and Cabinet Secretary for Health and Wellbeing, said:
“It is our intention that the integrated resource should lose its identity in the integrated budget – so that where money comes from, be it “health” or “social care”, is no longer of consequence. A practical example of the effect we are looking for is that [Integration Joint Boards] will be able, for example, to spend what is currently categorised as “health” money – used to pay for, say, district nursing – on “social care” activity – to pay for care at home services, for example – or vice versa.”
An honest assessment shows we still have some distance to go on that, despite the progress so far.
Localism – the opportunity for local voices to contribute to decisions and the empowerment of local systems to make the right decisions for local communities – is key, and is built in directly to the mechanisms we have created to support integration. The Christie Commission Report on the Future Delivery of Public Services in Scotland (2011) (this link will take you away from our website) noted that “effective services must be designed with and for people and communities – not delivered ‘top down’ for administrative convenience”: another example of an ambition towards which we’re making progress, with further yet to go.
So, progress? Yes, with large and small gains all the time in terms of stronger relationships in local systems; in terms of better quality and more sustainable care delivering better outcomes; and in terms of recognising that joined-up care is a partnership effort, with shared leadership, shared opportunities, and shared risks. Further to go? Yes of course – but with 120 years’ combined expertise across health and social care on which to build improvement, and clear commitment from the Scottish Government to ensuring the success of integration, every reason for optimism.
The Scottish Government Health and Social Care Integration team can be found on Twitter at: @hscintegration (this link will take you away from our website).
Alison’s Opinion is part of the ALLIANCE’s ‘We Need To Talk About Integration’ anthology which is available at the link below.