Evaluation of Integrated Resource Framework Test Sites

8 RECOMMENDATIONS

8.1 Local and national partners should examine the lessons from the IRF test sites and learn from this to improve the alignment of policy direction, planning structures, financial mechanisms, and mapping information. Failure to address all of these may result in unnecessary barriers to integration. It will be important for the Scottish Government and its partners to ensure that the learning from the IRF test sites and this evaluation inform legislation that will introduce the development of new Health and Social Care Partnerships.

Policy development

8.2 The Scottish Government is currently consulting on proposals to improve outcomes by better integration of adult health and social care based on four key principles:

• Nationally agreed outcomes will be introduced that apply across adult health and social care;
• Statutory partners will be jointly accountable to Ministers, Local Authority Leaders and the public for the delivery of those outcomes;
• Integrated budgets will apply across adult health and social care; and
• 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.³⁰

8.3 The proposals outlined by the Scottish Government consult on many of the issues raised in the IRF evaluation and point to greater clarity and commitment in the delivery of integrated services. The following two recommendations would support the proposals by encouraging synergy across policy areas and promoting communication with the public as a central tenet of service change.

Recommendation 1. In order to support the implementation of its proposals for integrated adult health and social care, the Scottish Government should develop an integration assessment tool. This would provide a standard checklist of questions to be used by national and local partners to review current and future policies and strategies on individual service priorities (e.g. cancer care, delayed discharge, self directed support, and palliative care).

Recommendation 2. The Scottish Government should work with NHS Board and Local Authority partners to develop consistent national and local communication strategies to better engage and inform the public about the anticipated benefits of new ways of delivering integrated health and social care services.

Planning structures

8.4 The Scottish Government should work with COSLA, the Royal College of Physicians, The Royal College of GPs, The Royal College of Surgeons, NHS Boards and Local Authorities to consider how future planning structures such as the introduction of HSCPs can address the issues raised in this report. The following three recommendations focus on incentivising engagement, improving representation, and providing training.

Recommendation 3. The Scottish Government should work with NHS Boards and Local Authorities to examine how the potential for improved patient outcomes, increased professional standing, financial rewards, and workload balance can be used to create incentives for health and social care professionals to engage more fully in the development of integrated health and social care services. The first step in addressing this should be to review current contractual arrangements for GPs, hospital clinicians and social care service managers in order to check that these reflect the prioritisation of integrated working. Broader engagement would also be facilitated by ensuring appropriate support for professionals with direct patient/client service delivery commitments to attend relevant meetings.

Recommendation 4. The Scottish Government should work with partners to develop guidance for the formation of HSCPs and locality planning arrangements which includes:

• an approach that ensures that professionals and staff are effectively included in service planning and commissioning;
• effective local engagement structures to expand awareness and involvement beyond those directly involved in HSCP meetings;
• clear and appropriate levels of delegated decision-making.

Recommendation 5. The Scottish Government should work with NHS National Education for Scotland (NES) and Scottish Social Services Council (SSSC) to support all those involved in new HSCPs and locality planning structures so that partners have the necessary skills and knowledge to:

• analyse information on cost, activity and quality;
• evaluate and prioritise care options;
• negotiate complex partnership decisions in the context of strategic joint commissioning.

Integrated information

Recommendation 6. The Scottish Government should continue the process of sharing lessons from the work in the IRF test sites on patient-level mapping with other partnerships, giving consideration to the level of detail which should be shared. Test sites which have positive examples of analysing and using IRF mapping information should consider ways in which these could be written up or shared more widely in order to allow other areas to learn from this work. Links to documents on a centralised webpage may offer the simplest way to facilitate this.

Recommendation 7. The Scottish Government, ASD and ISD should work with NHS Boards and Local Authorities to prioritise the information gathered and simplify its presentation. This should aim to increase the efficiency with which mapping data can be produced, and the ease with which it can be compared - although a degree of local flexibility could remain valuable. A standard patient-level costing methodology should be applied by local costing groups consisting of NHS Board and Local Authority partners.

Recommendation 8. The Scottish Government, ASD and ISD should work with local partners to find ways of addressing the following four data limitations identified by the IRF:

(i) The concerns of some GPs about sharing Community Health data which accounts for about one fifth of total health and social care expenditure.

(ii) The need to involve additional partners whose work has an impact on health and social care (e.g. education and police departments).

(iii) The need to include quality and outcome measures alongside cost and activity data.

(iv)The possibility of extending analysis to include: public health activity (in key areas such as obesity, mental health, alcohol, smoking and drugs); demographic pressures; and future cost implications based on assumptions about cost of illness.

Recommendation 9. The Scottish Government should create guidance on how improved mapping information could be proactively shared with a wider range of stakeholders - including service providers, service users and the public - to examine unwanted variation, improve outcomes, and increase efficiency. NHS Boards and Local Authority partners should then use this guidance to proactively engage with a wider range of stakeholders on a regular basis.

Financial mechanisms

8.5 The limited evidence from the IRF evaluation indicates that where integrated working has led to more efficient use of resources this has not resulted in cost savings or the transfer of resources to other parts of the health and social care system. The evidence from this evaluation indicates that joint commissioning arrangements will require a specific focus on the release of fixed costs. Further work is needed to examine the opportunities for addressing fixed costs and the possibilities for releasing savings.

Recommendation 10. The Scottish Government should work with the IRF test sites to evaluate the new financial mechanisms which are now being introduced. This should seek to quantify the level of efficiencies created and analyse whether these result in improved services being delivered for the same level of cost, or in cost savings which can be released from the system altogether.

Recommendation 11. The Scottish Government should facilitate a series of workshops with NHS Boards and Local Authorities to develop a better understanding of fixed costs, and how these limit improvements in the planning and delivery of health and social care services. The Scottish Government should also produce a national briefing document on fixed costs which includes:

• the components of the costs of care with discussion on the extent to which these are fixed or variable
• options for making fixed costs more variable (discussing the pros and cons of each option)
• examples of successfully addressing fixed costs to improve services.