Integration of Adult Health and Social Care in Scotland: Consultation on Proposals

Chapter 2 Outline of proposed reforms

Objectives and principles of reform

2.1. Our vision of a successfully integrated system of adult health and social care for Scotland is that it will exhibit these characteristics:

• Consistency of outcomes across Scotland, so that people have a similar experience of services, and carers have a similar experience of support, whichever Health Board or Local Authority area they live within, while allowing for appropriate local approaches to delivery;
• A statutory underpinning to assure public confidence;
• An integrated budget to deliver community health and social care services and also appropriate aspects of acute health activity;
• Clear accountability for delivering agreed national outcomes;
• Professional leadership by clinicians and social workers; and
• It will simplify rather than complicate existing bodies and structures.

"We are not starting from scratch or with a blank sheet of paper. There is already a great deal to be proud of in Scotland in health and social care provision."

Nicola Sturgeon MSP, Cabinet Secretary for Health, Wellbeing and Cities Strategy
15 December 2011

2.2. In Scotland, we have long recognised that effective partnership working between the NHS, local authorities and independent contractors and professionals is a prerequisite for achieving good health and social care outcomes. For the last decade the focus has been on achieving better outcomes through partnership working, service redesign and the development of integrated clinical and care pathways.

2.3. We recognise that changes in society mean that we now need to go further. Our proposals are based on four key principles:

a) Nationally agreed outcomes will be introduced that apply across adult health and social care;

b) Statutory partners will be jointly accountable to Ministers, Local Authority Leaders and the public for delivery of those outcomes;

c) Integrated budgets will apply across adult health and social care; and

d) The role of clinicians and care professionals will be strengthened, along with engagement of the third and independent sectors, in the commissioning and planning of services.

2.4. Our proposals for reform are not based on centrally directed structural reorganisation, and will not impose a single operational delivery arrangement on partnerships. Nonetheless, we will address features of current structures that act as barriers to better integration, and result in too much focus on organisations rather than the needs of patients and service users. Examples include the difficulty of ensuring that money for health and social care services can move around between partners, and between primary and secondary care in health, effectively; and the need to bring non-statutory partners, such as the third and independent sectors, clinicians and other professionals, and particularly GPs, into the processes of planning and commissioning services much more effectively.

2.5. Lack of centrally directed structural change should not be mistaken for lack of ambition, or determination to succeed. The proposals outlined here will require significant effort to implement, by every professional working across health and social care. Success will be characterised by strong leadership and ownership of culture change at every level, and within every contributing organisation (Health Board, Local Authority, GP practice, etc.).

Framework for integration

2.6. The chapters that follow provide greater detail on our proposed framework for integration, and invite your comments. Key features of our proposals are:

• Community Health Partnerships will be replaced by Health and Social Care Partnerships, which will be the joint and equal responsibility of Health Boards and Local Authorities, and which will work in close partnership with the third and independent sectors and with carer representation. The focus will be on making sure that people have access to the right kind of care, at the right time and in the right place.
• Health and Social Care Partnerships will be accountable, via the Chief Executives of the Health Board and Local Authority, to Ministers, Local Authority Leaders and Health Board Chairs for the delivery of nationally agreed outcomes. These outcome measures will focus, at first, on improving older people's care and will be included in all Community Planning Partnerships' Single Outcome Agreements.
• Partnerships will be required to integrate budgets for joint strategic commissioning and delivery of services to support the national outcomes. Integrated budgets will include, as a minimum, expenditure on community health and adult social care services, and, importantly, expenditure on the use of some acute hospital services. Where money comes from - health or social care, or, indeed, housing - will no longer be of consequence to the patient or service user. What will matter instead will be the extent to which partnerships achieve the maximum possible benefit for service users and patients, together and against the backdrop of shared outcomes and an integrated budget.
• A jointly appointed, senior Jointly Accountable Officer in each Partnership will ensure that partners' joint objectives, including the nationally agreed outcomes, are delivered within the integrated budget agreed by the Partnership.
• The role of clinicians, social care professionals and the third and independent sectors in the strategic commissioning of services for adults will be strengthened. Health and Social Care Partnerships will ensure that effective processes are in place for locality service planning led by clinicians and care professionals, with appropriate devolved decision-making and budgetary responsibilities.
• Proportionally, fewer resources - money and staff - will be directed in future towards institutional care, and more resources will be directed towards community provision and capacity building. This will mean creating new and potentially different job opportunities in the community.

2.7. Within this broad framework for integration, local leaders will be free to decide upon delivery mechanisms and organisational structures that best suit local needs and priorities. Partnerships can choose to delegate functions and budgets and responsibility for some aspects of service delivery to each other if there is local agreement to do so, as in the type of arrangement being implemented in Highland¹⁰, but they will not be required to do so.

What does this mean for me as a patient, service user or carer?

2.8. We are proposing these changes because we believe they provide the most robust, effective way to deliver on our ambitions for patients, service users, carers and families:

• People should be supported to live well at home or in the community for as much time as they can;
• People should have a positive experience of health and social care when they need it; and
• Carers should be supported to continue to care and to have a life outside caring.

2.9. The changes described in this document are by nature quite technical. Much of the detail is about changing the way that our current systems of health and social care work and interact with one another - how money flows round the system to support people, how professionals are held to account for the performance of the system, and so on.

2.10. The proposals that follow are, we believe, necessary, but not sufficient by themselves, to transform health and social care in Scotland. As previously noted, there will be opportunities in the coming months and years to get involved in, and indeed to lead, the other types of improvement work that must go alongside these "system" changes to deliver truly integrated health and social care in Scotland.

What do we want to know from you?

Question 2: Is our proposed framework for integration comprehensive? Is there anything missing that you would want to see added to it, or anything you would suggest should be removed?