Issue 7: Nov 2013


By Fiona Young and Helen Sunderland

 A report published by the Auditor General in 2011 highlighted the limited growth of integrated care following the development of Community Health Partnerships. The Public Bodies (Joint Working – Scotland) Bill proposes the establishment of Health and Social Care Partnerships with integrated budgets, a single senior accountable officer and a partnership agreement covering the local outcomes and scope of services to deliver them.

Looking South to a recent ADASS conference, System Leaders of Adult Social Care in England reflected that forcing current structures into new ones is not the way to improve outcomes, ensure better care experiences and target reducing resources in the right way. 

Health and Social Care services are critical, complex and emotive services to transform. Given the unyielding financial pressure and the headline hitting impact of growing demand, particularly on acute services, a more drastic shift in the financial and operational approach to services is required. 

In April 2013, armed with a new set of statutory duties, Health and Wellbeing Boards (HWWB) went live in England. With the introduction of the Integration Transformation Fund over the next six months, these joint governance bodies will be core to determining how integration will work in local areas. 

To date, Whitehall has not been prescriptive in terms of governance (with the exception of the HWWB), joint organisational structures and financial arrangements (e.g. shared budgets). Commissioners are accountable to HWBBs for delivery of outcomes but there has been autonomy in terms of how this is achieved. As partnerships have found their way and begun to establish local models of care, this has provided lessons learnt in terms of what does and doesn’t work.

EY’s work with the sector over the last three years has highlighted two key differentiators between successful partnerships and those paying lip service to integrated working:

Shared outcomes, common language

In early 2012 a number of Local Authorities began engaging shadow Clinical Commissioning Groups (CCGs), to gauge the potential for integrating commissioning. Partners wanted to collaborate on delivering local outcomes, achieve economies of scale and preserve the local focus of commissioning.

Initially, a concentrated effort to understand the different perspectives helped set the stage for joint problem solving. Different challenges across partners meant priorities needed to be considered and addressed together if a unified approach was to be developed.

At the same time, effort to establishing a common language for commissioning was important. Partners each had significant experience of commissioning, however small nuances in terminology, working practices and approach had previously caused tension. The development of a joint language with a clear definition of the required functions, roles and responsibilities meant all parties were clear on what was being said.

Finally, showcasing the skills, capability and capacity each partner can bring to the table provided confidence on appetite and ability to develop a successful integrated system. This established a level of trust between colleagues where previously relationships had been tense or non-existent.

Demonstrating mutual investments and mutual benefits

Partners are comfortable jointly appraising new interventions to deliver better outcomes more sustainably. Where the debate can become strained is reallocation of resources.

In Scotland, the move to single, integrated budgets for community services will drive a change to focusing care around the person. This means duplication and excessive handovers can be removed from the system, getting people the right care at the right time.

However, the key to successful integration is mastering the community/ acute interface. The relationship between acute and community services is complex and wholly interdependent. The major quality, performance and financial pressure points are between acute and community services, particularly, timely discharge following an event where a patient required on-going care and support and increasing numbers of preventable A&E attendances or admissions.

In England, areas making progress on community integration still acknowledge the presence of a ticking time bomb that risks the service quality and financial stability of acute care.

Fundamentally, commissioning plans need to demonstrate how the revised community service model will contribute to better management of demand on acute services. Equally, the redistribution of financial benefits needs to be discussed.

Put simply in one example, the major financial benefit of an effective community response and reablement service is the reduction of beds required in the hospital. Where the money to fund services closer to home is increasingly scarce, savings made in the acute sector should fund preventative community based services if we are to stand a chance of breaking the ‘fire fighting’ cycle we are increasingly seeing today.

This is a mature financial debate the emerging Health and Social Care Partnerships need to have with Health Boards to ensure aligned thinking on the required changes in the way the system is funded.

Jointly addressing some early exam questions can support this debate:
1.    What is the current and movement of clients through the system – How many? What, Why and Where?
This may seem an obvious but viewing the whole system, collectively must be core to setting out the new way of working

2.    What is the joint funding envelope available and the scope of services it needs to pay for?
Ensuring we define the amount of money jointly and transparently that will be involved in the collaborative delivery of services. This also allows an honest conversation with residents.

3.    What is the investment strategy?
How will commissioning resources be deployed?  Where should we see the impact? What are the dependencies? What is the timeframe for go live and seeing the impact? What are we going to disinvest in to fund this?

4.    What is the capacity model for the new system?
How will staff, estates, IT systems and other elements be deployed most effectively?

Development of the partnership agreement is the opportunity to address the above. Building a common language, level of trust and clear understanding on the financial arrangements will ensure strong relationships are in place to work through areas where there is less clarity and potentially difficult discussions will be required.

Establishing priorities and, operational and financial interdependencies collectively over the next 12 months will ensure Partnerships hit the ground running on patient centred care.

Fiona Young is a Director who leads EY's Scottish Local Government Practice




Helen Sunderland is an Assistant Director in EYs Local Public Services Practice, who leads on Health and Social Care Integration hsunderland





By Fiona Young and Helen Sunderland

Issue 7: Nov 2013

Issue 7: Nov 2013


Integrating Health and Social Care - Grasping the Opportunity

The integration of health and social care, through the Public Bodies (Joint Working) (Scotland) Bill represents a real opportunity to make sure we can support or ageing population, providing we plan for and meet all of the challenges properly.


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