Issue 7: Nov 2013

INTEGRATING HEALTH AND SOCIAL CARE - GRASPING THE OPPORTUNITY

By Fraser McKinlay, Director of Performance Audit and Best Value, Audit Scotland

One of the great achievements of post-war Britain is improved life expectancy; we now generally enjoy longer and healthier lives. As a father of three young children I obviously see this as a good thing. I hope to live long enough to be a part of their lives and of their own children’s lives.

Each year, Scotland’s councils and NHS boards spend about £4.5 billion on health and social care for older people (those aged 65 or over). Currently about ten per cent of older people receive formal, on-going social care services at home or in a care home. The percentage of people with care needs rises with age, and about one-third of people aged 85 or over receives on-going care.

There is widespread agreement that older people should be cared for at home as far as possible. However, more than 30 per cent of the money is spent on emergency admissions to hospital, with a further 30 per cent spent on non-emergency care in hospitals and care homes.

There is widespread agreement that older people should be cared for at home as far as possible. However, more than 30 per cent of the money is spent on emergency admissions to hospital...

Scotland’s ageing population and other pressures are already putting the NHS under significant strain. Audit Scotland’s report on NHS finances, published recently, highlighted increasingly apparent signs of pressure in the system, with health boards missing performance targets and increasing spending on short-term fixes such as agency staff and private healthcare.

And it is only going to get harder. Scottish people are living longer and having fewer children. Older people currently make up 17 per cent of Scotland’s population; the country has more people aged over 65 than under 15 and less than half of the population is under 40. The proportion of older people will rise to a quarter by 2035, with larger increases in rural areas, where care can be difficult and expensive to deliver. The number of people over 75 will grow by 10,000 every year for the next decade. This will increase the strain on services. For example, between 2013 and 2031 the number of people with dementia will rise by more than 50 per cent, to 127,000.

It would be unfair to suggest there is complacency about this. The Scottish Government and others certainly recognise that current service models are not sustainable. It is acknowledged that too much care happens in hospitals and care homes and not enough in people’s own homes, and that too much care is reactive rather than preventative.

The government has made a number of policy moves to try to ensure Scotland’s health and care services, and care for older people in particular, are fit for the future. In 2011 it launched Reshaping Care for Older People, a ten-year programme aimed at shifting resources from institutions to anticipatory and preventative care in the community, and joining up services. It has piloted the Integrated Resource Framework to help NHS boards and councils better understand their local needs and use of resources.

The government also introduced a £300 million Change Fund over four years, with NHS boards, councils and the voluntary and private sectors having to work together to produce joint plans for their local areas. Early next year, Audit Scotland will publish a report looking at progress so far in this and other areas of changing care for older people.

The government has made a number of policy moves to try to ensure Scotland’s health and care services, and care for older people in particular, are fit for the future.

Other wider policy initiatives will have significant impacts; for example, self-directed care will enable people to have more say in their care. Innovations in telehealth will make it easier for people to manage their care at home and for clinicians to oversee this, particularly in remote areas.

But the major policy change is the integration of health and social care, through the Public Bodies (Joint Working) (Scotland) Bill.

We have welcomed the Bill. Audit Scotland has long advocated putting the needs of the service user at the heart of public services and for health and social care to work together better. There is no doubt major change needs to happen, and a more systematic and joined-up approach would make the most efficient use of resources.

However, in our recent submission to the Scottish Parliament Health and Sport Committee’s inquiry on the bill, we did note some concerns. These were informed in large part by the experience of Community Health Partnerships. For example, the Bill needs to be clearer how public bodies will set out and agree budgets and resources to support partnership working, and what roles other policy areas, such as housing, will play.

We would also like more clarity about the relationship between the new health and care partnerships and existing Community Planning Partnerships (CPPs), about audit and scrutiny arrangements, and about governance. The Bill sets out plans for chief officers for the new organisations, and this area should be strengthened with more detail about their leadership and reporting lines and how they will resolve disputes. And getting professionals such as GPs and social workers engaged and involved is crucial.

We believe it crucial that organisations and partnerships get better at addressing the long-term financial picture. Any design of new ways of working must be underpinned by an exploration of the available resources...

So change is happening. A number of factors will affect how successful it is, and I offer three areas I believe are important.

The first is underpinning change with strong long-term joint financial planning between partners such as NHS boards and councils. The recent draft budget for 2014/15 clearly stated that public bodies will be expected to share such planning with CPP partners and to focus on the agreed local priorities. We believe it crucial that organisations and partnerships get better at addressing the long-term financial picture. Any design of new ways of working must be underpinned by an exploration of the available resources, costs and potential scenarios.

The second is clarity about how outcomes will be achieved. The Scottish Government has created these policies; these need to be supported with clear goals and systems for collecting and measuring progress against them.

The third is to remember that at the heart of this are people. The risk when changing services is to think of the system’s needs and overlook the people who rely on the care. At the end of these reforms, the services need to work for the people who use them, and continue to support longer, healthier and happier lives.

By Fraser McKinlay, Director of Performance Audit and Best Value, Audit Scotland

Issue 7: Nov 2013

Issue 7: Nov 2013

HEALTH, WELL BEING AND AGEING: SCOTLAND 2020

Re-energising the move towards integrated care

Scotland's move to integrated care can learn from elsewhere by focussing on two key differentiators between successful partnerships and those paying lip service to integrated working: Shared outcomes and common language is one, the other is demonstrating mutual investments and mutual benefits.

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