Integration of Adult Health and Social Care Consultation Analysis Report

EXECUTIVE SUMMARY

Background to the consultation

1. In May 2012, the Scottish Government launched a public consultation to inform recommendations for legislation to support the integration of adult health and social care in Scotland. This report presents the views expressed by respondents to the consultation proposals.

2. Scottish Ministers' proposals for integration of adult health and social care, as described in the consultation document, are based on four key principles:

• Health and social care services should be firmly integrated around the needs of individuals, their carers and other family members;
• There should be strong and consistent clinical and care professional leadership in the planning and provision of services;
• The providers of services should be held to account jointly and effectively for delivering improved outcomes; and
• Services should be underpinned by flexible, sustainable financial mechanisms that give priority to the needs of the people they serve, rather than the organisations through which they are delivered.

3. The consultation set out six key proposals to achieve integration:

• 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.
• Nationally agreed outcomes will apply across adult health and social care. Health and Social Care Partnerships will be jointly 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 those outcomes. Outcome measures will focus, at first, on improving older people's care and will be included in all Community Planning Partnerships' Single Outcome Agreements.
• Health and Social Care Partnerships will be required to integrate budgets for joint strategic commissioning and delivery of services to support the national outcomes for adult health and social care. 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 Health and Social Care Partnerships achieve the maximum possible benefit for service users and patients, together and against the backdrop of shared outcomes and integrated budgets.
• A jointly appointed, senior Jointly Accountable Officer in each Health and Social Care Partnership will ensure that partners' joint objectives, including nationally agreed outcomes, are delivered within the integrated budget 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.

4. The purpose of the consultation was to seek people's views about the legislative proposals for the integration of adult health and social care.

Method

5. The consultation period ran from 8 May to 11 September 2012. It was made up of two main elements: the invitation to individuals and organisations to submit written responses to the consultation document itself, and nine public and practitioner consultation events, providing an opportunity for discussion and direct engagement with a wide range of stakeholders.

6. The Scottish Government promoted the consultation on its web site and invited written responses to the consultation paper from all sections of society in Scotland. The consultation paper included 20 questions to which written responses were invited. A total of 315 responses were received. The non-confidential responses^[1] have been published on the Scottish Government website.

7. Nine public and practitioner consultation events took place between May and August 2012 in Edinburgh, Glasgow, Dumfries, Perth and Elgin. The target audience included health and social care professionals from statutory and non-statutory organisations; carers; users of health and social care services; and members of the public more widely. Chapter 4 provides a summary of the key themes from the discussions.

8. Around fifty local events including focus groups and meetings were arranged by various organisations and local forums including the Scottish Health Council, Health Boards, Local Authorities, third sector organisations and carers' groups. The Scottish Government provided input at these local events. In some cases, stakeholders indicated that discussion at local events was used to inform their written responses.

Summary of views from consultation responses

9. Questions were asked under the five main chapter headings of the consultation, covering:

• National outcomes for adult health and social care;
• Governance and accountability;
• Integrated budgets and resourcing;
• Jointly Accountable Officer; and
• Professionally led locality planning and commissioning of services.

10. Most of the questions offered respondents the opportunity to answer 'yes' or 'no'. In addition, respondents were invited to provide a textual response. Most respondents chose not to answer specifically 'yes' or 'no', instead providing a more discursive response reflecting the complexities of their experience and viewpoint. This input provides a richness of insight, which is most helpful to the process of taking forward legislation.

11. The remainder of this section provides a brief summary of key points made in response to the proposals in the consultation.

National outcomes for adult health and social care and scope

12. The majority view supported nationally agreed outcomes to be included in Single Outcome Agreements and for statutory partners to be held jointly and equally accountable for delivery. However, there were differing opinions about the proposal to focus initially, after legislation is enacted, on improving outcomes for older people, and then to extend the focus to improving integration of all areas of adult health and social care.

13. Those in favour expressed the view that it is sensible to start with the largest group of service users, allowing Health and Social Care Partnerships to incorporate improvements before extending to all adults.

14. Other respondents indicated concerns that, by focusing on 'older people' first, an artificial divide may be created that may have a negative impact on other groups of patients and service users, who did not meet the 'age criteria'.

15. Some respondents appear to have interpreted the proposed scope as being limited to older people. Where this point was raised at discussion events, Scottish Government officials reiterated the point that Ministers intend to legislate for all areas of adult health and social care, allowing integration beyond adult health and social care services, for example including children's services, where there is local agreement to do that.

Governance and accountability

16. Respondents noted that joint accountability requires robust information, clear outcomes, evidenced performance management and public reporting through external scrutiny. Most respondents expressed the view that the proposals should be strengthened with respect to plans for performance management arrangements, and that these should focus on the delivery of outcomes which are clear, balanced and not solely target driven. There was also reference to the importance of involving non-statutory partners in the development of performance management arrangements.

17. Many respondents expressed the view that a Health and Social Care Partnership should be about the synergy between a single council and a single Health Board. Concerns were raised that should a Health and Social Care Partnership span more than one Local Authority area then local issues could be lost in larger partnership considerations, and that it may over-complicate existing structures. Additionally, some respondents felt that experience shows that small partnerships are more effective at delivering the needs of the individual and their communities, and that funding should be devolved more locally.

18. On proposals regarding committee membership, Local Authority respondents asked particularly for flexibility regarding the number of Councillors who could sit on the Health and Social Care Partnership committee. There was a consistent view that accountability should be to the full Council and not the Leader of the Council or its officers.

19. Concerns were raised particularly by stakeholders from the third and independent sectors, carers' representative groups, and public and service users' representative groups that the proposals for accountability arrangements focussed particularly on the statutory partners. The view was expressed that other groups should also be recognised and involved in integrated accountability arrangements.

20. There was also a consistent view that the proposals should be strengthened with respect to assuring effective public participation in the processes of planning services. Public Participation Forums were quoted as an example of a successful means of engaging with the public and building in the views of unpaid carers and service users.

Integrated budgets and resourcing

21. Most respondents expressed the view that the models described within the proposals could successfully deliver the objective to use adult health and social care budgets to best effect for the patient or service user. Preference was given in most responses to the 'body corporate' model. However, some respondents, mainly from Local Authorities, expressed the view that more options should be available, and that decisions regarding which model to use should be made locally.

22. In terms of whether or not Ministers should give direction on minimum categories of spend for inclusion in the integrated budget, there was a general view in favour of Ministerial prescription kept to a minimum spend, to allow for local discretion and flexibility and to accommodate local priorities. A few respondents expressed concerns that, if Ministers prescribe a minimum, only that minimum will be included in the integrated budget.

23. There were mixed views regarding whether or not Health Boards and Local Authorities should be free to choose whether to include the budgets for other Community Health Partnership functions (beyond adult services) within the scope of the Health and Social Care Partnership. The majority of respondents expressed the view that this should be left to local determination. A few respondents suggested a stepped approach, starting with the minimum and when Health and Social Care Partnerships can demonstrate it is working, move to include more services. There were some respondents who expressed the view that Ministers should prescribe the extent of the integrated budget in order to assure consistency of approach. Some respondents also expressed the view that budgets for children's and housing services particularly, should be included within the scope of the integrated budget from the start.

Jointly Accountable Officer

24. Respondents expressed differing views regarding the appointment of Jointly Accountable Officers and expressed a need for further information on the role and remit of the post. Some respondents thought that responsibility for planning and delivery of integrated services should sit with the Chief Executives of Health Boards and Local Authorities, and existing Community Health Partnership General Managers. Others felt that the role would be necessary in order to manage the integrated budget effectively.

25. There was general agreement that if Jointly Accountable Officers are appointed they need to be multi-skilled, experienced, knowledgeable and expert managers, able to operate with autonomy, wield influence and exercise authority within both statutory structures, as well as within the Health and Social Care Partnership. Many respondents expressed the view that the Jointly Accountable Officer post must be senior enough to reflect these requirements.

Professionally led locality planning and commissioning of services

26. The majority of respondents expressed a desire for locality planning arrangements to be developed locally, supported by Scottish Government guidance. A few respondents expressed the view that the Scottish Government should direct locality planning arrangements to ensure consistency across service delivery areas.

27. The proposal that a duty should be placed upon Health and Social Care Partnerships to consult local professionals, including GPs, on how best to put in place local arrangements for planning and implementing service provision was welcomed. However, some respondents asked that the duty be strengthened by using the terms 'involve' and 'engage' rather than 'consult'. Reference was also made to the need to make specific mention of other clinical staff, health and social care professionals and service users.

28. Respondents expressed the view that, in order to encourage active participation of clinicians and social care professionals in planning service provision, they would need to have a clear understanding of the requirements of their localities. Many respondents added that Health and Social Care Partnerships could be strengthened by setting up joint professional and stakeholder advisory committees to contribute to the development of joint strategic commissioning plans. It was suggested that structured support for stakeholder involvement would be required.

29. Opinions were split regarding locality planning being organised around clusters of GP practices. Whilst many supported this approach in principle, many respondents supported locality planning being developed at the level of 'natural communities'. There was also a consistent view that the size of localities should be determined locally. There was a mixed view of the level of devolved responsibility for decision-making to localities. The strongest proponents of devolved decision- making came from professional membership organisations, Local Authorities and public representative bodies.