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It mostly covers my work as UNISON Scotland's Head of Policy and Public Affairs although views are my own. For full coverage of UNISON Scotland's policy and campaigns please visit our web site. You can also follow me on Twitter. I hope you find this blog interesting and I would welcome your comments.

Wednesday, 16 May 2018

Care integration - lessons from Wales

Delivering better health and care integration is a challenge in all parts of the U.K. and internationally. We should try and learn from experiences elsewhere, and I was in Cardiff today contributing to the Cymru/Wales UNISON seminar on the issue.

Wales faces similar challenges to Scotland - austerity and Brexit. The Welsh health minister told the conference that reform should be about better ways of delivering services, not just about saving money. They have had a parliamentary review of care integration that has made recommendations for going forward and a new government plan will be published soon.

The minister was not convinced that big structural change was the way forward, but he was in favour of better partnership working between health and local government. There are good examples of integrated system change locally that can be scaled up nationally. He was strong on the need to engage staff in finding solutions - making it a formal part of the system. As he put it; "Motivated staff are much more likely to do a better job."

Wales has similar problems to Scotland with fragmented domiciliary and residential care, many of which are struggling. The minister said better commissioning and standards had to be part of the solution. He recognised the need to increase funding and they are looking a levy to specifically fund the increasing cost. Something that hasn't really been part of the debate in Scotland.

The research report launched at today's conference highlights a very complex picture of care integration in Wales. Words like 'partnership', 'integration' and 'seamless' service are used, and abused, with means often confused with ends. As in Scotland, the driver is collaboration not competition, but that has its challenges around trust and power. Previous reports have been critical of progress and they have similar problems with short term funding initiatives rather than increasing core funding. 


The core of the report is three case studies on integration. 

The Bridgend approach shows real improvements in outcomes like unscheduled care and long term placements. Anticipatory care is key to preventing inappropriate admissions and building trusted relationships between staff.

Monnow Vale in Monmouthshire is a good example of how locality based health and social care hubs can work. Staff are co-located, they talk to each other and staff are empowered to find solutions that work locally. This is an approach that we should do much more of in Scotland as recommended by the Social Care Commission. It resulted in a more welcoming approach for users and greater continuity of care - creating a relationship with the carers. Trade union involvement in designing services and getting pay and conditions right was important in building trust in working together and redesigning home care.

Ynys Mon (Anglesey) case study is an example of enhanced dementia service using a residential home as a base to integrate services with community health staff. It was obvious that staff had a real sense of ownership, being engaged in service design from the outset.

The parliamentary review, independent of government with a cross-party reference group, pulls some of this together. They recognised the case for change is compelling, but it hasn't always compelled action. Amongst ten key recommendations, it makes the case for co-location of staff, a focus on outcomes (what they call the Quadruple Aim) and a recognition that staff are a key element in service delivery. It is not about restructuring, it's about effective implementation of a seamless service across all services.

In my presentation I set out the lessons from Scotland's experience in health and care integration. Many different models have been tried, but it is still work in progress. Demographic change places additional costs on an already underfunded service, particularly in the local government half of the process. In social care we have a hugely fragmented service that makes workforce planning very difficult. And of course there is always Brexit! We do have decent procurement frameworks, including the living wage, but councils put insufficient weighting on workforce matters and do very little monitoring of the quality of service delivery. 

My colleague from London, outlined developments in England. There is very little action on a national basis in England and just a few local initiatives. In essence it's a mess.

Finally, workforce regulation in Wales is following the Scottish model, with the phased regulation of domiciliary care staff. They have similar challenges in terms of recruitment and retention of social care staff.

Scotland is probably a bit ahead of Wales in terms of legislation and structure. However, the challenges are very similar and they do have some impressive examples of best practice, highlighted in the report. On that basis the research report published today is well worth a read. No one has got integration right yet, so we can all learn from experience elsewhere.

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