Scotland needs a vision for integration

How the Long Term Care Commission and Audit Scotland findings highlight an opportunity for engagement on the NHS to refocus on integration.

In early June, Cabinet Secretary for Health and Social Care, Neil Gray announced that a national engagement on the future of the NHS would take place later this year. The announcement came during a Scottish Government led debate on ‘a vision for the future of health and social care.’ Neil Gray said that he sought to debate “how we can reform and improve our health services, and how we can collectively deliver a transformed system fit for the health challenges we face.” 

Much of the debate focused on working with the life sciences sector and universities to bring technological advancements into healthcare. While important, focusing solely on this aspect of the NHS frankly will not be enough to meet health challenges now or in the future, and we should acknowledge that in this regard the title of the debate was misleading. 

In its review of the NHS in Scotland 2023, Audit Scotland was clear that the absence of a national vision and clear strategy for health and social care is making it difficult for NHS boards to plan for change and to deliver key reform programmes. It recommended that the Scottish Government develop a long term national strategy in partnership with NHS boards, staff, partners and the public. It should include investment in prevention, put people at the centre of services and “recognise the interdependencies across the health care system.” The debate was a missed opportunity to embrace Audit Scotland’s recommendation and reinvigorate the conversation around health and social care integration. 

The need to refocus attention on integration was underscored recently by the findings of the Long Term Care Commission. As Henry McLeish wrote in his foreword to the commission’s report, “the interface between health and social care is of paramount importance, particularly in light of the challenges of co-existing health conditions, socioeconomic disparities and an aging population.” The report, which was published by Alzheimer Scotland, shows that Scotland urgently needs a plan for the future of long term care not only for people with dementia but anyone experiencing complex needs that cannot be neatly categorised into either “social care” or “health.” 

The current market-driven approach to care has created a system that does not offer choice or respect individual’s preferences. We are failing to meet and fulfil the human rights of people with complex care needs, and we will continue to unless we begin to think differently about how we support people holistically. Moreover, it is a system which forces people to pay huge costs – sometimes thousands per week – to access support that is not only often insufficient but that would otherwise be free if provided by the NHS. 

The commission makes it clear that we need new, diverse approaches to long term care with a focus on prevention and intervention to promote positive outcomes and experiences, including smaller-scale living environments, targeted assistance and support, and engagement in meaningful and personalised activities. Integrated care could enable us to do so. 

We need to talk about the future of the NHS. But we also need to talk about the future of care, and how we can advance progress toward aligning the health and social care systems so that people can access the many forms of support that they need to live well at all stages of life. 

That can begin with the commission’s call to action for an open debate on how people want to have their needs met as part of a national conversation. As the commission states, that must include an honest discussion of who actually pays for care and how “the lack of innovation within health and social care systems limits opportunities for future planning and early interventions that might provide alternatives and ultimately mitigate the need for residential forms of care” where they are not meeting people’s needs. 

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