Will in­te­grat­ing health and so­cial care save the Scot­tish NHS?

Each week the Sun­day Her­ald puts the most con­tentious is­sues of the day un­der the mag­ni­fy­ing glass to find out what’s true, what’s false, and what needs to be done. To­day, Chief Re­porter Ju­dith Duffy ex­plores re­form within the health ser­vice

Sunday Herald - - 19.03.17 COMMENT -

EVERY Thurs­day, Sheena Gil­mour meets with a group of walk­ers to lead a stroll around her lo­cal area. “It has given me con­fi­dence in walk­ing,” she says. “I had a knee op­er­a­tion last year and walk­ing with the sup­port of the oth­ers gave me my con­fi­dence back.”

The walk­ing group is one of a num­ber of com­mu­nity-based ac­tiv­i­ties in Ar­gyll and Bute run by Arthri­tis Care Scot­land, which has re­ceived fund­ing as part of a move to­wards in­te­gra­tion of health and so­cial care ser­vices north of the Bor­der.

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 – 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. About two mil­lion peo­ple in Scot­land have a long-term health con­di­tion and roughly one in four adults has some form of longterm ill­ness or dis­abil­ity.

With the per­cent­age of the pop­u­la­tion aged over 75 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 per cent 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 un­der way 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 last 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 per cent by 2018, through tack­ling is­sues such as de­layed dis­charge – or so-called “bed-block­ing”.

But 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 that 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 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 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” in 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 per cent 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.”

Ma­caskill also pointed out there are suc­cess ful 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 look- ing af­ter her – mean­ing her hus­band had to be with her most of the time. The so­lu­tion was for care home staff to look af­ter her in her own home in the run-up to her stay so she would be fa­mil­iar with them – an idea now be­ing ex­tended to other places.

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

Pho­to­graph: Chris Fur­long/Getty

Shift­ing the fo­cus of care from hos­pi­tals to com­mu­ni­ties makes good sense

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