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

Chapter 5 Integrated budgets and resourcing

What do we want to achieve?

5.1. A key priority for these proposals is to improve the quality and consistency of care, and to put an end to the cost-shunting between the NHS and Local Authorities that too often ends up with people being delayed in hospital longer than they should be, and not benefiting from the best and most appropriate standards of care.

5.2. It is our aim to create a system of health and social care in which resources - money and people's time - can be used to best support the individual at the most appropriate point in the system - regardless of whether what is needed is "health" or "social care" support.

5.3. An important aspect of this part of our proposals is the requirement that there should be an integrated budget, which will include the budgets for community health and social care, and also the budgets for some acute hospital services. Our commitment to shifting the balance of care from institutional to community based settings, as clinically appropriate, will only be achievable when the people who are planning services can work within the entirety of the resource committed to services. A shift in the balance of care requires a shift in patterns of resource allocation and utilisation, and that can only be achieved if the integrated budget includes the full range of spend on services.

5.4. Under these proposals, Health Boards and Local Authorities will be required to integrate resources for adult services. Health Boards and Local Authorities will be free to integrate resources for other areas of service if they wish, but will not be required to by national direction under these proposals.

5.5. The new, integrated budget will be managed by the Jointly Accountable Officer on behalf of the Health and Social Care Partnership. Further information on the role of the Jointly Accountable Officer is provided in Chapter 6. This role is key to the success of the integrated budget; this post-holder must have sufficient authority over the integrated budget to make decisions about resource prioritisation without needing to refer back up the individual lines of accountability in the partner organisations.

5.6. It is our intention that the integrated resource should lose its identity in the integrated budget - so that where money comes from, be it "health" or "social care", is no longer of consequence. A practical example of the effect we are looking for is that the Jointly Accountable Officer will be able, for example, to spend what is currently categorised as "health" money - used to pay for, say, district nursing - on "social care" activity - to pay for care at home services, for example - or vice versa.

5.7. The availability of robust, trustworthy information and evidence will be particularly critical to success in terms of planning and service design, joint management of risk, benchmarking across systems and accountability for delivery. A more integrated approach to sharing information across services and local systems, within appropriate boundaries, will be required to enable and evidence improvement.

How will this approach be different from current arrangements?

5.8. Current legislation permits delegation of budgets between Health Boards and Local Authorities. Until now, however, budgets have largely been managed separately in health and social care, apart from in a few relatively small instances of pooling, such as pooled budgets for some mental health services, or shared equipment stores.

5.9. At the moment, there can be unhelpful financial consequences for Health Boards and Local Authorities that affect them both, but cannot be resolved by either on their own. For example, where someone is ready for discharge from hospital, depending upon the provision of an appropriate package of care at home, the cost of the delay falls upon the Health Board. Similarly, the consequence of any delay can be additional costs for the Local Authority, as a delay in hospital can result in a worse outcome - higher dependency and care needs - for the individual. These proposals are intended to remove that tension, so that the total cost of the care pathway is managed within the totality of the integrated budget, and there are no financial incentives or disincentives getting in the way of ensuring the best possible outcome for the individual.

5.10. Most important, of course, is the human cost within current arrangements of such tensions, in terms of wellbeing. By eliminating the distinction between "health" and "social care" budgets, we believe we can create a financial environment in which professionals can, rightly, focus their attention on what is best for the individual - without worrying about whose budget is providing which service.

5.11. These proposals are not about saving money - they are about using money more effectively in clinical and practical terms, to ensure that the support provided to people is available in an environment which will best assure their wellbeing and quality of life.

5.12. This Chapter describes in broad terms our proposals for integrating budgets between Health Boards and Local Authorities. Some of the information in this Chapter is, by its nature, quite technical. However, the principle that we describe above - that public funds should be used effectively and efficiently, and to achieve maximum benefit where need is greatest - is important to everyone.

Options for integrating budgets

5.13. We have described two options via which Health Boards and Local Authorities could integrate budgets. Under these proposals, local partnerships will be free to choose which approach they took to integrating budgets. Under each option, a Partnership Agreement will establish the nature and scope of the Partnership. Staff could move between employers to support a shift in functions, if there were local agreement to such a change.

a) Delegation to the Health and Social Care Partnership, established as a body corporate

The Health Board and the Local Authority could delegate agreed functions to the Health and Social Care Partnership, which would be established as a body corporate of the Health Board and Local Authority.

The Health Board and Local Authority would agree the amount of resources to be committed by each to the integrated budget for delivery of services to support the functions delegated to the Partnership.

The integrated budget would be managed on behalf of the Partnership by the Jointly Accountable Officer, whose authority and accountability in relation to delivery of the Partnership's delegated functions would be determined by his or her statutory functions. The integrated budget would consist of the respective contributions from each partner organisation, each managed by the Jointly Accountable Officer and subject to the respective financial governance arrangements of each partner.

A Partnership Agreement would establish the terms of the arrangement between the Health Board and the Local Authority, and would establish the facility that the partners would transfer resource between the two budgets at the discretion of the Jointly Accountable Officer. Each delegating partner would retain their legislative responsibility for the functions that had been delegated to the Health and Social Care Partnership. The governance Committee referred to in Chapter 4 would form the Board of the Partnership.

Employment arrangements for the Jointly Accountable Officer are considered in Chapter 6.

b) Delegation between partners

One partner can under current legislation¹¹ delegate some of its functions, and a corresponding amount of its resources, to the other, which then hosts the services and integrated budget on behalf of the Health and Social Care Partnership. The financial governance system of the host partner applies to the integrated budget. A Partnership Agreement between the Health Board and the Local Authority establishes the functions and resources to be delegated between the partners.

Example

In the model currently being implemented in the Highland partnership, the Local Authority is delegating adult social care services to the Health Board, and the Health Board is delegating children's community health services to the Local Authority.

NHS Highland "hosts" the budget for adult social care, which is delegated to it by the Highland Council, and the financial governance system of NHS Highland applies to the adult health and social care budget.

Highland Council "hosts" the budget for children's community health services, which is delegated to it by NHS Highland, and the financial governance system of the Highland Council applies to the children's community health and social care budget.

In a delegated model, the delegating partner retains its legislative responsibility for the functions that have been delegated. So, in the example given above, Highland Council retains its legal obligations for the effective delivery of adult social care services, and NHS Highland retains its legal obligations for the effective delivery of children's community health services.

Who will decide what is included in the integrated budget?

5.14. The question of who will decide what is included in the integrated budget is important. It is our proposal that Ministers will provide local Health and Social Care Partnerships with direction on the categories of spend to be included as a minimum. Examples could include Local Authority spend on care at home and home care provision, along with NHS spend on appropriate acute medical specialties, primary care and prescribing, and so on.

5.15. Beyond the minimum requirements that will be defined in regulations, Health and Social Care Partnerships will be free to add other aspects of spend subject to agreement within the local Partnership Agreement.

How will we go about achieving this change - what will change in legislation?

5.16. Health Boards and Local Authorities will be placed under a duty to put in place an integrated budget for adult health and social care, using one of the models described above.

5.17. A Partnership Agreement will be required, to establish the contribution of the Health Board and Local Authority to the integrated budget, which 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 as well.

5.18. Health Boards and Local Authorities will be required to jointly appoint a senior, Jointly Accountable Officer who will have authority over the discharge of the integrated budget to deliver the outcomes agreed nationally and within the Partnership Agreement.

5.19. Each Health and Social Care Partnership will be required to produce integrated strategic commissioning plans for use of the integrated budget over the medium and long-term. These will build on the approach taken to develop joint commissioning plans to support the Change Fund for older people's services.

5.20. To support the most effective use of resources, any existing barriers to the efficient procurement of facilities, goods and services will be considered.

What do we want to know from you?

Question 10: Do you think the models described above can successfully deliver our objective to use money to best effect for the patient or service user, whether they need "health" or "social care" support?

Question 11: Do you have experience of the ease or difficulty of making flexible use of resources across the health and social care system that you would like to share?

Question 12: If Ministers provide direction on the minimum categories of spend that must be included in the integrated budget, will that provide sufficient impetus and sufficient local discretion to achieve the objectives we have set out?