Health and social care integration/Update on progress. Summary & Recomendations

Audit Scotland – November 2018

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Key messages

  1.  Integration Authorities (IAs) have started to introduce more
    collaborative ways of delivering services and have made improvements
    in several areas, including reducing unplanned hospital activity and
    delays in discharging people from hospital. People at the end of their
    lives are also spending more time at home or in a homely setting,
    rather than in hospital. These improvements are welcome and show
    that integration can work within the current legislative framework, but
    IAs are operating in an extremely challenging environment and there is
    much more to be done.
  2. Financial planning is not integrated, long term or focused on
    providing the best outcomes for people who need support. This is
    a fundamental issue which will limit the ability of IAs to improve the
    health and social care system. Financial pressures across health and
    care services make it difficult for IAs to achieve meaningful change.
    IAs were designed to control some services provided by acute
    hospitals and their related budgets. This key part of the legislation has
    not been enacted in most areas.
  3. Strategic planning needs to improve and several significant barriers
    must be overcome to speed up change. These include: a lack of
    collaborative leadership and strategic capacity; a high turnover in IA
    leadership teams; disagreement over governance arrangements; and
    an inability or unwillingness to safely share data with staff and the
    public. Local areas that are effectively tackling these issues are making
    better progress.
  4.  Significant changes are required in the way that health and care
    services are delivered. Appropriate leadership capacity must be in
    place and all partners need to be signed up to, and engaged with, the
    reforms. Partners also need to improve how they share learning from
    successful integration approaches across Scotland. Change cannot
    happen without meaningful engagement with staff, communities
    and politicians. At both a national and local level, all partners need to
    work together to be more honest and open about the changes that are
    needed to sustain health and care services in Scotland.

Recommendations

It is not possible for one organisation to address all the issues raised in this
report. If integration is to make a meaningful difference to the people of
Scotland, IAs, councils, NHS boards, the Scottish Government and COSLA
need to work together to address six areas outlined below.
Commitment to collaborative leadership and building relationships

The Scottish Government and COSLA should:

• ensure that there is appropriate leadership capacity in place to
support integration
• increase opportunities for joint leadership development across the
health and care system to help leaders to work more collaboratively.

Effective strategic planning for improvement

Integration Authorities, councils and NHS boards should work together to:
• ensure operational plans, including workforce, IT and organisational
change plans across the system, are clearly aligned to the strategic
priorities of the IA
• monitor and report on Best Value in line with the requirements of the
Public Bodies (Joint Working) (Scotland) Act 2014.

The Scottish Government should:
• ensure that there is a consistent commitment to integration across
government departments and in policy affecting health and social
care integration.

Integrated finances and financial planning

The Scottish Government should:

• commit to continued additional pump-priming funds to facilitate local
priorities and new ways of working which progress integration.

The Scottish Government and COSLA should:
• urgently resolve difficulties with the ‘set-aside’ aspect of the Act.

The Scottish Government, COSLA, councils, NHS boards and Integration
Authorities should work together to:

• support integrated financial management by developing a longerterm
and more integrated approach to financial planning at both a
national and local level. All partners should have greater flexibility in
planning and investing over the medium to longer term to achieve
the aim of delivering more community-based care.

Integration Authorities, councils and NHS boards should work together to:

• view their finances as a collective resource for health and social care
to provide the best possible outcomes for people who need support.

Agreed governance and accountability arrangements

The Scottish Government and COSLA should:

• support councillors and NHS board members who are also
Integration Joint Board members to understand, manage and reduce
potential conflicts with other roles.

The Scottish Government, COSLA, councils, NHS boards and Integration
Authorities should work together to:

• agree local responsibility and accountability arrangements where
there is disagreement over interpretation of the Public Bodies (Joint
Working) (Scotland) Act 2014 and its underpinning principles.

Scenarios or examples of how the Act should be implemented should
be used which are specific to local concerns. There is sufficient scope
within existing legislation to allow this to happen.
Ability and willingness to share information

The Scottish Government and COSLA should:

• monitor how effectively resources provided are being used and share
data and performance information widely to promote new ways of
working across Scotland.

The Scottish Government, COSLA, councils, NHS boards and Integration
Authorities should work together to:

• share learning from successful integration approaches across
Scotland
• address data and information sharing issues, recognising that in
some cases national solutions may be needed
• review and improve the data and intelligence needed to inform
integration and to demonstrate improved outcomes in the future.

They should also ensure mechanisms are in place to collect and
report on this data publicly.

Meaningful and sustained engagement

Integration Authorities, councils and NHS boards should work together to:

• continue to improve the way that local communities are involved
in planning and implementing any changes to how health and care
services are accessed and delivered.