This article was originally published in the Health Service Journal.

“We are bringing together the very substantial resources that we commit to health and social care… to make it easier for local systems to deliver joined-up, effective and efficient services.”

Sound familiar? Those are the words of the then Scottish health secretary, Alex Neil, to mark the passing of legislation to integrate health and social care through new statutory bodies back in 2014.

Two weeks ago it was Matt Hancock’s turn to promise the goal was to “integrate decision-making at a local level between the NHS and local authorities as much as is practically possible”.

But the experience north of the border has been far from straightforward. At the time, integration was billed as the “most significant change to health and social care services in Scotland since the creation of the NHS in 1948”.

Legislation passed in 2014 paved the way for new statutory bodies combining health boards and local authorities to launch in 2016, although some areas – notably the Highlands – had already pushed ahead.

The 2014 Act set up 31 integration authorities generally matching council boundaries. The idea was to merge large chunks of NHS and council budgets, which would then be directed by new IA boards with equal numbers of councillors and NHS non-executive directors at the table.

As would be expected in a country of 5.4 million, these are far smaller than integrated care systems. The largest, Fife Health and Social Care Partnership, serves less than 400,000 people, while the smallest, Orkney, has just 22,000.

Today, IAs manage around £10bn. However, it is never their money. Instead, it is allocated from the budgets of the local NHS Board (roughly what it spends on primary and community care) and council (much of its social work and social care budget) each year.

If it sounds complicated – it is, and it’s fair to say that progress has been patchy. While it was initially hoped that IAs would be responsible for a range of hospital-based services to incentivise more community-based care, this has proved difficult to achieve, so health boards retain a portion of the funding they should be handing over to IAs.

Roadblocks

Many of the challenges come from trying to bring together two distinct cultures and workforces. That’s before considering thousands of independent care providers.

The head of the leadership body for IAs has said the model worked well where there was “total commitment” from all parties – echoing the sentiment that early ICSs were “coalitions of the willing”.

But this year the Fraser of Allander Institute reported a “top-down approach” in some areas had led to little change on the ground.

Getting the structures right has – perhaps predictably – not been straightforward. A lot of complaints centred around funding processes that have been described as “clunky” and “complex”, prompting warnings over a lack of transparency from the Scottish Parliament’s health committee.

It could be argued that, by virtue of their slightly awkward position, IAs lacked enough heft. The only permanent staff member is the chief officer who holds no funds directly – indeed, has no bank accounts and directly commissions nothing.

One solution mooted by a wide-ranging review of adult social care that reported this month – headed by former NHS Scotland CEO Derek Feeley – was to take responsibility for care away from councils and give it to newly-empowered IAs that would report directly to the Scottish government.

They would have more staff and, crucially, receive a single pot of funding straight from government. The proposals, backed by the SNP, look likely to be implemented, despite opposition from councils.

'Most people, including a fair few employed in health and social care, do not know much about integration – underlining the importance of change management and public information'

New delivery bodies need to have the power and independence to drive change forward themselves. This includes direct budgets, rather than asking legacy organisations to slice chunks off their own funding.

The experience showed high-level organisation change is one thing. But most people, including a fair few employed in health and social care, do not know much about integration – underlining the importance of change management and public information.

Another lesson can be drawn from the failure to effectively include hospital-based secondary care services from the outset.

But there’s a more fundamental challenge. The health service is free at the point of use, better-funded and delivered by 14 regional health boards. Social care is heavily rationed, means-tested and delivered by more than 1,000 providers.

All this adds up to the near-impossibility of integrating health and social care when the latter has been neglected for so long. The Feeley review recognised this, arguing that social care needed to be on an “equal footing”.

One recommendation, which the SNP has thrown its weight behind, is to make all social care free at the point of use – an eye-wateringly expensive prospect likely to be viewed nervously by UK government ministers.

 

Read more: ‘Covid showed ministers should be in charge of care’; Irons: Care review offers fix for funding tensions; Review calls for national care service; Health Secretary signals health funding review  

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