Evaluation of Integrated Resource Framework Test Sites

2 INTRODUCTION

2.1 This report presents the findings of the evaluation of the development and implementation of the Integrated Resource Framework (IRF) in four test site areas in Scotland. The study was commissioned by the Scottish Government in March 2010 to be undertaken by Fortuno Consulting and Partners. It builds on the findings of the baseline and interim phases of the evaluation, which were shared with test sites in October 2010 and June 2011.

What is the IRF?

2.2 The IRF was designed to enable partners involved in planning and delivering health and social care services to ask two related questions: "How do we currently spend the money that we have available?" and "Is there a better way to do this?" It aimed to inform partners of the current distribution of their resources in order to enable them to make better informed and equitable resource investment decisions and secure improved outcomes for individuals and communities.

2.3 In order to achieve these aims, the IRF pursued two workstreams: (i) Mapping cost and activity data - collation and analysis of cost and activity data for health and social care; and (ii) Trialling new models of integration - development of new protocols for resource transfer and integrated service provision. The details of these are outlined below.

Mapping cost and activity data

2.4 The IRF mapping aimed to engage NHS and Local Authority partners in joint analysis of patient and locality level cost and activity information for health and social care. It was anticipated that this would provide a detailed understanding of existing resource profiles for partnership populations. In order to inform the broad objective of greater integration in the planning and deployment of health and social care resources, both within the NHS and between NHS and LA partners, two objectives for the mapping work were conceived at the outset of the IRF process:

• Measuring and understanding variations in the resources used for health and social care at the individual patient/client level;
• Measuring and understanding variations in health and social care resource use at higher levels of aggregation e.g. CHP/CHCP or general practice populations.

Trialling new models of integration

2.5 The second workstream aimed to develop relationships, both within NHS Scotland and between the NHS and Local Authority partners, in ways that would facilitate the realignment of resources to follow the patient/client as directed by care professionals and clinicians. It sought to develop protocols for more effective partnership relationships through improved governance, performance management and risk management.

2.6 This aimed to create worked examples of how integrated approaches could support shifts in the balance of care and improve outcomes for patients and communities by: increasing efficiency of allocation and utilisation of resources; improving equity of allocation of resources; reducing variation in inputs, outputs and outcomes; improving quality of care indicated by patient and user satisfaction measures and performance in relation to appropriate national outcome measures; and clarifying accountability for use of resources by clinical and care practitioners (see Appendix 1 for a list of pilot models).

Who was involved in the IRF?

IRF test sites

2.7 All NHS Boards and Local Authority partners have, since April 2008, been supported by the Scottish Government to undertake the first IRF workstream and map resources to communities. The Scottish Government also invited applications from NHS Boards and Local Authorities to take part in the second workstream of the IRF programme to trial new models of integrated working and develop worked examples of protocols for realigning resources. The selection process for this was completed in August 2009 and four test sites (comprising four Health Boards and 12 Councils) were identified:

• Highland test site: NHS Highland with Argyll & Bute Council and Highland Council;
• Tayside test site: NHS Tayside with Angus Council, Dundee City Council and Perth and Kinross Council;
• Ayrshire test site: NHS Ayrshire and Arran with East Ayrshire Council, North Ayrshire Council and South Ayrshire Council;
• Lothian test site: NHS Lothian with City of Edinburgh Council, East Lothian Council, Midlothian Council and West Lothian Council

2.8 Test sites were provided with financial support (£400,000 per site) between 2010 and 2012. This funding was designed to support organisational development, provide project management and free up local staff and professional time to implement mechanisms that would facilitate detailed mapping work and resource realignment. All test sites were expected to:

• Use the IRF approach to analyse and understand the cost, activity and variation of their current resource use patterns at population level (this was described as a mapping exercise).
• Undertake the mapping across Health and Social Care, linking-in other areas as appropriate.
• Use the Integrated Resource Framework to form the basis of a new approach towards planning and investment for resources.

2.9 However, within these boundaries, test sites were encouraged to take different approaches to developing IRF protocols and creating worked examples of resource integration. Three test sites (Ayrshire & Arran, Lothian and Tayside) opted to trial new ways of working with a number of smaller pilot populations based around localities, care groups or disease programmes. Appendix 1 sets out descriptive details of each of the pilots identified across these test sites. Highland explored a similar approach to piloting new protocols for smaller populations but decided to undertake larger scale integration by introducing a Lead Agency model between NHS Highland and Highland Council in April 2012.

Policy context

2.10 The Integrated Resource Framework was developed in response to mounting evidence that current models of health and social care delivery are not producing the outcomes expected, with significant variation across the country. There are demographic pressures associated with an ageing population, as more people are living with the effects of serious chronic disease.¹ Although the health budget overall is forecast to grow over the next two years, this is at a slower pace than in previous years.² At the same time the NHS faces continued cost pressures, as demand for its services grow and increases in prices (e.g. prescription drugs) outstrip increases in funding.³

2.11 The IRF is driven by the priorities articulated in Better Health Better Care.⁴ These point towards the majority of care being delivered in the community, as locally as possible, with a focus on improving health and reducing health inequalities; providing more integrated and targeted care in local settings; reducing hospital admissions; and providing systematic support for people with long-term conditions.

2.12 The Scottish Government developed its Shifting the Balance of Care (SBC) strategy in order to increase the emphasis on health improvement and anticipatory care, as well as provide more continuous care and ensure more support was available closer to home. The national SBC Delivery Group coordinated the work of NHS Scotland and the Convention of Scottish Local Authorities (COSLA) to develop the IRF. It aimed to support their shared strategic objective of shifting the balance of care by working across health and social care in a more integrated way. A review of Community Health Partnerships by Audit Scotland underlined the need for this.⁵ It stated that integrating care involves significant and complex issues that no single partner can resolve on their own; and that there has been no significant shift in the balance of care despite this being highlighted as a key priority since 2000. Similarly, in their recent report on commissioning social care, Audit Scotland recognised the importance of joint planning and resourcing between NHS Boards and councils, in light of the interdependent relationship between health and social care services.⁶

2.13 The IRF is, therefore, driven by the premise that more effective integration of health and social care, along with the voluntary and independent sectors, will improve the effectiveness and efficiency with which services are provided while at the same time working to improve outcomes and people's experience of services. It has the potential to enable partnerships to align their resources more effectively, providing better services without increased costs.

2.14 Since test sites began work to deliver IRF locally, there have been significant developments in the integration agenda. These have been informed by ongoing work in the IRF, and they are, in turn, giving added impetus to the process of change to which IRF has contributed.

2.15 In 2011 a Change Fund was introduced to support the implementation of the Reshaping Care for Older People Programme. Change Fund guidance was agreed by the Ministerial Strategic Group (MSG) for Health and Community Care and required local partnerships to prepare Change Plans that set down how the transitional funding would be used to achieve a shift in the balance of care. The MSG has overseen this development process nationally and local Change Fund plans were submitted to the MSG to ensure that a coherent national picture was achieved.

2.16 In December 2011, the Cabinet Secretary for Health, Well-Being and Cities Strategy announced that legislation will be introduced to Parliament with the purpose of revising Community Health Partnerships. Key elements of the new system will include the following:

• Community Health Partnerships will be replaced by Health and Social Care Partnerships, which will be the joint responsibility of the NHS and Local Authorities, and will work in partnership with the third and independent sectors
• Partnerships will be accountable to Ministers, leaders of Local Authorities, NHS Chairs and the public for delivering new nationally agreed outcomes. These will initially focus on improving older people's care and are set to include measures such as reducing delayed discharges, reducing unplanned admissions to hospital and increasing the proportion of older people who live in their own home, rather than a care home or hospital.

2.17 Consultation ahead of the introduction of new legislation has commenced following the local government elections in May 2012. Partnerships are currently working to develop their approach to joint strategic commissioning plans. Future development of Health and Social Care Partnerships will be an important element of this approach.

Evaluation aims

2.18 The overall aims of the evaluation were to: monitor progress in the test sites; assess the impact of the work of the test sites; feed evidence back into the process of change itself; and draw out implications from the findings for other partnerships moving towards financial and resource integration, both within and across, health and adult social care services in Scotland in the future.

Evaluation methods

2.19 The evaluation has taken place over three phases (a baseline review in summer 2010, an interim review in summer 2011, and a final review in spring 2012). Locally agreed evaluation frameworks were developed with each test site, to fit with national milestones and suggested measures of change, while taking into account the characteristics of each site.

2.20 Five main methodologies were used to gather information:

• review of IRF documentation in test sites
• reviewing processes and discussions at IRF Project Team and Programme Board meetings
• interviews with key strategic partners
• an email survey of delivery staff at each test site (carried out just after the baseline phase and repeated at the final phase of the evaluation)⁷
• focus groups with operational (patient and client facing) staff.

2.21 The information gathered during the baseline, interim and final evaluations was analysed using a diffusion of innovation framework adapted from Greenhalgh et al.'s work on the introduction of complex change in the English health service (see Appendix 2).⁸

Report structure

2.22 This report summarises progress across the test sites, identifying the positive impact of the IRF as well as the barriers and challenges faced. The focus is on the potential lessons that can be learned from this programme in the context of future integration of health and adult social care.

2.23 Chapter 1 gives an executive summary of the main findings and provides an overview of the lessons learned. Chapters 3 and 4 report on the creation and use of mapping information as a fundamental component of the IRF. Chapter 5 examines the ways in which test sites approached piloting service redesign and the possibility of resource realignment. Specific case studies are then considered in Chapter 6. Chapter 7 identifies the more general lessons that can be taken from this evaluation. Each chapter contains a key findings section which summarises the main points considered. The final section (Chapter 8) of the report outlines recommendations based on the report findings.