Will integration of services solve Scotland's health and social care crisis?

The aim of this major reform, put simply, is to shift the balance away from emergency admissions to hospitals – dubbed the “fix and treat” approach – to caring for people in their own homes, with an emphasis on meeting individual needs. A key part of this is also having more preventative health services, which can include everything from dedicated nurses for chronic conditions - such as diabetes - to providing walking groups and tai-chi sessions to help patients stay healthy.

The integration of health and social care services is an ambitious programme of reform which involves £8 billion of public money. Yet it is one which the public remains largely unaware of it – even though it aims to dramatically change the face of care in the future.

What is generally agreed is that change is needed, with health and social care services currently creaking under an ageing population and increasing numbers of patients with long term conditions. Around two million people in Scotland have a long-term health condition and around one in four adults have some form of long-term illness or disability.

With the percentage of the population aged over 75 years old projected to increase by a further 63 per cent over the next two decades, it paints an alarming picture of the looming burden on the NHS and other services.

A recent report from Audit Scotland highlighted estimates from the Scottish Government that demand for health and social care services will rise by between 18 and 29 per cent between 2010 and 2030. It noted starkly: “In the face of these increasing demands, the current model of health and care services is unsustainable.”

David Kerr, professor of cancer medicine at the University of Oxford, carried out a major report more than a decade ago on the future of the NHS in Scotland, which recommended a focus on services in the community rather than the “bricks and mortar” of hospital buildings.

He said Scotland was generally “ahead of the game” when it came to a greater degree of integration between health and social care but it could go further.

“We know 90% of all hospital episodes could be managed at home in the community and therefore the idea about shifting the focus of care from hospitals – which are much loved institutions – to the community would make a lot of sense,” he told the Sunday Herald.

Efforts to integrate health and social care have been underway in various forms since 1999. But a lack of progress led to legislation in 2014 which placed a statutory duty on the NHS and councils to carry out integration of the services – the first time this has been attempted in the UK.

This led to the setting up of Integrated Joint Boards (IJBs) last year, which decide how budgets can be spent and have a mix of board members including councillors and NHS representatives and other members such as social workers, GPs, nurses and representatives of carers and charities.

Dr Peter Bennie, chair of BMA Scotland, said the shift in policy had some parallels with the changes in the care of mental health patients in the early 1990s, when caring moved from large institutions to the community.

He said: “That worked because it was done in a logical way – funding was provided so we had community placements before you were requiring in-patient units to be closing. It stands to reason that is a risky thing to be doing before you have the community services running.”

In a delivery plan published in December, the Scottish Government has outlined a series of targets for health and social care, such as reducing unplanned bed-days in hospitals by up to 10% by 2018, through tackling issues such as delayed discharge – or so called “bed-blocking”.

However Bennie cautioned this was unlikely to be achievable and that the successful integration of health and social care could take decades, rather than a year or two.

“To make this work you have got to be committed to it, you have got to fund it properly and you have got to give it time to work,” he said.

Others, however, have raised concerns that progress is not being made quickly enough. Andrew Strong, assistant director of policy and communications at the Health and Social Care Alliance Scotland, which represents health and social care organisations, said it supported the legislation and the aim of the policy.

But he added: “The position we are at now is that the landscape has not evolved as fast as we would have probably anticipated.

“It feels like integration is in its infancy still – a lot of the work over the last two years has really focused on meeting legal requirements, rather than preparing for the transformational change which we want to see happening.”

Strong said he believed there had to be more understanding from the IJBs of the aim to shift more money into community services.

“Part of our concern is in some areas money is being used to reverse service cuts, rather than thinking transformationally about models of health and social care,” he said.

The issue of how budgets will be spent by IJBs is already proving controversial. Last month the Royal College of Nursing (RCN) Scotland attacked plans by the IJB for Glasgow to make cuts to services that help the elderly, people with learning disabilities, alcohol and drugs dependency and mental health problems in order to save money.

The RCN said the plans to slash £450,000 from community-based care for older people as “unbelievable” and that it would undermine moves to treat more patients outwith hospitals.

However, a GP source told the Sunday Herald there were also concerns that money would be diverted away from healthcare by IJBs to cover gaps in funding for social care.

The source said: “You have a joint board with funding streams coming in and two responsibilities.

“Primary care is desperate for the money, but social care has been cut to such an extent there is real concern that some of the money will be used to cover the gaps in social care, and therefore won’t reach primary care.”

Labour MSP Monica Lennon, shadow minister for inequality, who last week chaired a conference held at the Royal College of Surgeons of Edinburgh examining issues around health and social integration, said one difficulty was many of the IJBs were starting out with a deficit.

“I think across all the parties there is a recognition this approach is the right one,” she said. “It is not just in terms of what we are doing in Scotland – this is happening across the UK, it is happening in Europe and indeed the world.

“The big elephant in the room is around resources – resources are not keeping up with demand.”

The extent to which health and social care integration is being successfully implemented is summed up by many as 'patchy' across the country.

Last week Paul Gray, director general of health and social care and chief executive of NHS Scotland, admitted there was a “degree of unevenness” as he gave evidence to MSPs on the Public Audit Committee.

But he pointed out there were examples where integration was working well, including a initiative in Ayrshire and Arran to manage patients with conditions such as chronic obstructive pulmonary disease, heart failure and diabetes, which has resulted in a 49% reduction in emergency admissions to hospital.

Dr Donald Macaskill, chief executive of Scottish Care, which represents the independent care sector, said in some areas of the country there was recognition that services had to now work together.

But he added: “Where it isn’t working well, we are seeing the typical statutory bunfight, where you have got health on one side and elected members from local authorities on the other side and there is argument and debate over the forward direction.

“Thankfully that is in the minority but it would nevertheless be naïve to say it is all working rosily.”

But he also pointed out that there are successful changes happening, citing the example of a case in Dundee involving an elderly woman in her 90s with dementia, who was going into a care home for periods of time to give her husband a break from looking after her.

However she could not settle in unfamiliar surroundings with strangers looking after her – meaning her husband had to be with her most of the time.

The solution was for staff from the care home to look after her in her own home in the run up to her stay so she would be familiar with them – which is now an idea being extended to other places.

Macaskill also said a key change which would have to take place was valuing the role of care workers much more as a society.

“We need the general public in Scotland to accept that the role of care home workers is as intrinsically important as someone who wears a nurse’s uniform or carries a stethoscope,” he said.

“Until we get to that removal of casual stereotypes we won’t have the system of social care and health we need.”

Cabinet secretary for health and sport Shona Robison said that integration of health and social care services was one of the government’s most ambitious programmes of work.

She said: “More than £8 billion of health and social care funding that was previously managed separately by health boards and local authorities has been allocated.

“In January an additional £107 million was committed to ensure people are supported, as far as possible, in their own homes and communities, which we know is often better in terms of people’s wellbeing, and which can help to reduce inappropriate admissions to hospital, length of stay and delayed discharges.

“Our health and social care system is world renowned and envied across the UK and, as a shared priority between the Scottish Government and local government, spend on this has been protected in Scotland.”