The Scottish Government is current consulting over their plans for the integration of adult health and social care. Proposals include changes to how adult health and social care services are planned and delivered, aiming towards a seamless experience from the perspective of the patient, service user or carer.
Proposals for the integration of health and care services go back at least to the 1970’s and post devolution the Joint Future initiative introduced the single shared assessment approach. In recent times we have seen a variety of organisational solutions, each with its own shiny new acronym – LHCC, CHP and now Health and Social Care Partnerships (HSCP). Despite these efforts joint working has not worked well in all parts of the country, although staff at the sharp end usually manage to work together. Demographic change has provided a new impetus for change with the demands on care services likely to rise in the coming years. The Scottish Parliament Health & Sport Committee report is a good overview.
The Scottish Government claims that these plans are not another “centrally directed, large-scale structural reorganisation and staff transfer”, and that any changes would be “designed and agreed locally” to suit the needs of local people. This UNISON Scotland briefing outlines the proposals but the key elements are:
• Nationally agreed outcomes across health and social care.
• Joint accountability via the Chief Executives of the Health Board and Local Authority to Ministers, NHS Chairs, Council Leaders and the public for delivery of outcomes.
• CHP’s replaced by Health and Social Care Partnerships.
• Jointly appointed accountable officer reporting to the Chief Executives of the NHS and Local Authority
• Integrated budgets for community health and social care, and for some acute hospital services
• Strong clinical and professional leadership, and engagement of the third sector, in commissioning and planning of services
As the sector digests the proposals, there are growing concerns that that these plans have not been thought through and could have wider implications. Elderly care involves much more than NHS and council care services. UNISON Scotland has outlined these in our Care Integration Statement and a more detailed response will be submitted to the consultation.
Let me highlight just a few reasons why councillors, MSP’s and health board members should look at these plans closely.
A major concern is that this is beginning to look like another centralising initiative by the Government. The democratic accountability arrangements look very weak when you consider that the new organisation will control around 15% of a local authority budget and there could be even wider service implications for health boards and councils. A few seats on a board and a jointly accountable officer is not unusual for a quango, but is no where near sufficient for democratically accounatable local authorities. Ministers will have powers to set outcomes and the “local flexibility” looks pretty limited.
One of the aims of care integration is to reduce unplanned admissions to acute services, even though the structural mechanisms for achieving this look weak. The new bodies will control some acute budgets in order to achieve this resource transfer and that could involve ward closures to an extent that may make some hospitals no longer viable. Now that might be the right decision, but hospital closure decisions should not be outsourced to a body with limited democratic accountability.
At present when an elderly person needing care is referred to hospital they are NHS patients and there are no charges. If under these plans they are provided services outwith hospital, then some charges are possible. This shifts the costs of care from the NHS, not just to councils, but to the individual. Again, this may be the right care option, but decisions like this should be made under democratic scrutiny.
These are just three reasons for looking more closely at this consultation, all with a common theme of lost local democratic accountability. The UNISON statement covers many other concerns including procurement, privatisation (including the NHS) and finance. The workforce considerations in the paper are also minimal.
All the evidence shows that top down reorganisation doesn’t achieve integration and these plans are much more prescriptive than they claim to be. A more constructive approach would be to focus on joint outcomes, with local partners agreeing operational arrangements relevant to their local circumstances.
So, if you haven’t looked at this consultation, or are involved in considering a submission, take a closer look at the direct and wider implications.