This year, next year, sometime, never

• Written by: Annie Gunner Logan — Coalition of Care and Support Providers in Scotland (CCPS) — Director
• Published: 17th June 2018

Annie shares her perspective on what's needed to quicken the pace of change in health and social care integration.

It’s been two years since Scotland’s new Integration Authorities became fully operational; but it’s been twenty years since CCPS first became involved in the project of health and social care integration. Reviewing the organisational archives for the purposes of writing this piece has been a sobering experience in terms both of assessing progress against the grand plan, and of coolly appraising the level of influence our sector has brought to bear.

What were the hopes and aspirations of care and support providers in relation to integration?  What were their concerns?  And how has any of this panned out in 2018? Let’s have a look.

In 1998, the (then) Scottish Office published ‘Modernising Community Care: An Action Plan’ which introduced two new concepts for us all to consider.

The first of these was the ‘community care £’ (as opposed to the NHS £, or the social work £) which related to the need for public agencies to stop being territorial about budgets. If we fast-forward to the legislative proposals set out for integration in 2011/12 we find this concept preserved, albeit expressed slightly differently: NHS and local government money would, once put into the integration pot, ‘lose its identity’.

Providers were (and still are) in favour of this, not least because it’s the only way we can see how – and here comes another expression from the annals – to shift the balance of care.  From our perspective, this wasn’t only about moving funding from institutions to communities, it was also about shifting the focus from acute and crisis care to more upstream support, preventing escalation of need wherever possible.

So how are we doing on that?  An awful lot of third sector providers will tell you that the volume of low-level, preventive support they’re commissioned to provide has been steadily reducing.  As for money ‘losing its identity’, someone clearly forgot to tell the auditors, since formal accountability for spend is still tracked according to (more or less) the same budget lines as before.

The second concept from 1998 was the ‘tartan of services’ (I know) which was generally understood to mean that the individual threads of health, social care and other services would be woven into a coherent ‘whole systems’ pattern of provision.

Again, this got no argument from providers.  We always wanted integration to be about more than just banging heads together in health and social work.  We were delighted when the Cabinet Secretary told Parliament in 2012 that in introducing formal requirements for third sector involvement “it was the intention that the voluntary sector is [on the IJB] not just to speak for its own resource, but to influence the spend of the totality of the resource in a much stronger way than perhaps it does just now”.

Sadly, this desire to give us more influence stopped short of providing our sector with actual voting rights on the new bodies.  Not us, nor indeed anyone other than the two principal statutory partners, with numerical parity.  The effect of which (you could say) was simply to replicate at IJB level the same impasse from which the whole integration project was supposed to extract us.  And having fought so hard to get a place and a voice, we now find that new, supra-IJB regional planning structures have been created of which we have little knowledge and to which we have no access.

What else has been on providers’ collective mind with respect to integration?

First and foremost, I think, that integration should be a means to an end, and not end in itself.  I’m not sure we’re there yet.  Following publication of the aforementioned ancient text from 1998, a “Joint Futures Group” was established.  Here’s an extract from a CCPS briefing paper published at the time:

“A great deal of the Joint Future Group’s attention focused on structural arrangements between local authorities and health boards – including single management of directly-provided services, the mechanics of pooling budgets, and the challenges of harmonising staff pay and conditions.”

As they say in France, plus ça change.  The 2014 legislation was, ultimately, all about process, with only a brief nod to outcomes.  We said at the time that this may have been because everyone was being very grown-up about the fact that you can’t legislate for culture change, but you can at least set the tone.  Fair enough: but four years later, we’ve still not managed to get fully to grips with the metrics for success in any other way. Sure, we have proxy measures – delayed discharge figures, figures for bed days reduced, figures for emergency admissions – but these remain partial and (critically) they exclude social care almost entirely.  Again, from one of our briefings:

“Without clear parameters for the shift from acute care to community based preventions, there is nothing to hold public authorities accountable for. There is no clear picture of what success will look like, and no sanctions for failure.”

Other worries included concerns that the integration project was constructed almost entirely to address the challenges in older people’s services.  What relevance did it have to learning disability?  Autism?  Sensory impairment?  Children’s services? Despite a recent (and very welcome) push to get mental health further up the agenda, these concerns are still outstanding.

Meanwhile, at the sharp end, voluntary sector staff continue to work with their cross-sector colleagues, and with the people they support, to change lives.  I wonder if we had framed the legislation to support them more explicitly, instead of fretting about what all the people in suits were or should be doing further up the chain of command, we might be further along the road?

What needs to happen next?  Here’s some thoughts.  The integration project needs to stop bulldozing Self-directed Support, and instead be guided by it.  Commissioning and procurement need to change out of all recognition, if providers are to be enabled to deliver transformation and innovation.  And we need to face up to the fact that marrying a multi-provider price-competitive market (social care) with a top-down directly-funded public delivery system (the NHS) has thrown up all kinds of barriers to the potential of our sector to deliver truly integrated services.

We want this to work: we’ve always wanted it to work.  And we’ll play our part in making it work, if we’re given our head.

Annie can be found on Twitter at: @ccpscotland (this link will take you away from our website).

Annie’s Opinion is part of the ALLIANCE’s ‘We Need To Talk About Integration’ anthology which is available at the link below.

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