Care integration - 5 reasons to be wary

I have been involved in several meetings this week on health and care integration, I have previously blogged on some of the reasons we should take a close interest in this issue and UNISON has now published our submission to the Scottish Government consultation.

Rather than going over that ground, I am going to highlight five reasons to be wary based on these discussions and what I have seen of other submissions on the Scottish Government proposals.

One. The key issue, not just for local authorities, has been democratic accountability. The new partnerships could have a huge impact on wider council and health board services including service and hospital closures and individual charging. These may be the correct outcomes, but those making these decisions need to be democratically accountable to the local community. In these plans the governance model is weak and holds out the prospect of central direction.

Two. There are really only two models being proposed. Almost every submission I have seen argues for local flexibility to reflect local needs. Yet the consultation reads like an attempt to impose a centralised model on local communities with performance management from the centre. This is a trend I have highlighted in other posts.

Three. Health and care services are delivered by people. Carers and paid workers in the statutory, voluntary and private sectors. Yet the consultation paper and questions are almost entirely silent on workforce issues. The UNISON submission highlights the importance of a staff governance framework and other issues. While the new partnerships are not intended to be employers in their own right, the budgetary and governance issues open up a complex array of employment law issues.

Four. There is a lot of talk about engagement with the third and private sector. But in my view there is a role confusion here. Voluntary organisations and users clearly have a role in the design of services. However, the loudest voices here are the delivery providers in the Third sector who have a clear commercial interest. The procurement aspect, coupled with budget cuts, is driving a race to the bottom in care. Staff in voluntary sector are particularly badly treated and, as the best in the sector recognise, is impacting on quality of care. Sadly others simply see it as the best selling point for the third sector.

Five. Self-directed care is the new buzz word and clearly is important for certain groups. But as Lord Sutherland said at the Holyrood conference, "it is really a middle class thing". Most service users, particularly the elderly, don't want to self direct anything. Plus as we have already seen, it can be used as cover for budget cuts and the closure of community service provision. The NHS is already having to pick up the pieces and it is being used as a Trojan horse to further privatise care provision.

Almost everyone agrees that integration is a good idea. However, there is no evidence that top down structural change of the type being proposed will work. Instead we need to look at what is working locally and allow democratically accountable services to develop a model that suits each community.