The covid-19 crisis is testing not just the people delivering health and social care across Scotland in a way nobody could have imagined, but also the systems and structures they work within.

Concerns have been raised that the care sector was not involved in pandemic planning exercises.

But evidence from care providers ahead of the crisis was that, in terms of planning and joint working even at a local level, the lines of communication have not been as robust as they would have wanted.

Four years ago, what the Scottish Government at the time called “the single biggest reform to the way health and social care is delivered in Scotland since the creation of the NHS” went live, creating an integrated health and social care service with an annual budget of over £9bn.

Earlier this year, in the run-up to a planned inquiry by the Scottish Parliament into social care in Scotland, healthandcare.scot ran a series of seminars with social care providers from across Scotland who were members of the representative organisation, Scottish Care.

One of the issues we were keen to explore was whether integration was working for them and the people they care for.

“One of the biggest issues with integration,” the owner of a care at home service in the West of Scotland told us, “is that we are not one of the partners around the table everywhere. There are some partnerships where we are at the table, which is good, but, of course, we don’t have voting rights.”

Another provider told us: “Integration has only gone so far. We have moved to a halfway house. We now have integration of health and social work.

“But, if you don’t work for the NHS or the council, you don’t feel that integrated.”

One care at home manager from the West of Scotland we heard from leads an organisation that works across six partnership areas. She told us that the voice of independent providers was being heard more loudly in some places than others:

“When I look at where it works, it is where we have got independent sector people influencing the partnerships and helping them get a better understanding.

“Mostly, they are very heavily NHS-biased and, for me, the biggest problem is they don’t understand the sector. They don’t understand the issues we face.

“They have these massive monsters of organisations and then on top of that they’ve got people like me coming in, and they’ve never really had to deal with someone else coming in and questioning them.”

The political driving force for integration of community health and social care was the government’s 2020 Vision of shifting the balance of health and care closer to people’s homes. The ambition has always been that, by bringing people together across boundaries – of the NHS, local government, providers, carers and users – a sometimes piecemeal and disjointed approach to looking after the most vulnerable people in society could be unified, and everyone, regardless of who employed them, could work together seamlessly for the people who needed their help.

At the start of April 2016, 31 health and social care partnerships went live, the result of legislation requiring local authorities and health boards to work together to deliver both health and care services for adults in their communities.

Apart from Highland which has a slightly different model, oversight of each health and social care partnership is by an integration joint board (IJB), on which sit equal numbers of councillors and non-executive directors from that region’s NHS board.

One of the requirements is that this core voting group is surrounded by representatives of those delivering services at the front line. Alongside the medical, nursing and adult social care leads – employed by either the local authority or NHS – the IJBs are also expected to have a third sector, a carer and a service user representative at the table.

The Scottish Government’s guidance also encourages local arrangements to add to the minimum membership and involve others:

The Independent Sector for example provides a significant proportion of social care services and will therefore play a key role in the successful delivery of integrated services in local areas. As part of their strategic planning responsibilities, Integration Joint Boards should consider their membership cohorts and seek appropriate additional representation as suggested by local priorities.

According to Audit Scotland, care providers are more often to be found on the groups involved in drafting the mandatory strategic plans for IJBs than on IJBs themselves.

“I was asked to attend one but that fizzled out after three meetings,” one manager told us. “I tried to comment on a strategic plan but was told they hadn’t reached the stage that they wanted comments yet, and I didn’t see it again before it was published.”

To try to get social care providers at the IJB tables, Scottish Care has been funded through the Scottish Government and health and social care partnerships to create and maintain a network of ‘Independent Sector Leads’.  These are development staff with backgrounds in education, social care, health and the voluntary sector who work to ensure national and local representation of independent sector care providers and support partners to collaborate in discussions and decisions.

But one representative told us providers are not always invited to be part of strategic planning:

“In 2018 at our Scottish Care conference the Health Secretary Jeane Freeman said to the audience “we need you” – that was the first time that audience of 600 providers had heard that, that their work was valued.

“We aren’t saying the government message isn’t clear, but the way it trickles down isn’t right and hasn’t come down to any partnership working in IJBs. It’s just not being implemented on a local level – we still feel we are a tick box exercise.”

Another said that, in their experience, the approach varies:

“At a strategic level, we aren’t even at the table in some areas, despite effective operational relationships. There is inconsistency in terms of relationships: different providers have different relationships with partnerships meaning there are different outcomes.”

The question healthandcare.scot asked was whether a lack of engagement at IJB level really made a difference to the way things were being done on the front line?

Several providers around the table at our four meetings in Highland, Fife, Lanarkshire and Ayrshire, reported they sense a divide on the frontline: they are less partners more contractors.

“Each week I get a phone call from the council telling me who they have allocated a bed to and each week they get upset when I tell them I will absolutely be the one to make that decision, not them”, a care home manager at our meeting in Inverness told us.

“They get the people with the highest dependency and allocate them to us first with no idea of what my current dependency is in the home and the pressure anyone incoming would put on my staff and resources, and they wanted the cheapest rate possible. I have spent a long time fighting this corner – for a long time we have had people being placed on a residential basis when what they need is nursing care. I take great offence at being told how to run my business when I am the one who knows how to do it.”

In contrast, we heard of several instances where the system is not only working but working well for people and communities – often because of the work of individual social workers.

“We have very good social worker in North Ayrshire who works across hospitals and she talks to us all the time,” a care home manager told us. “She has built up a good rapport with us.”

A care home director at the Inverness meeting agreed:

“We have designated social workers that work with us and that’s comparatively new. It’s working really well because those social workers come into the care home and know the people they are dealing with very well, know the care home and what skills we offer.”

Across our four meetings, the healthandcare.scot team did not meet a single provider who believed that integration of health and social care was, in itself, a bad thing. Indeed, many reported they were seeing far better communication between the different players as a result.

However, there was a belief that the potential of integration cannot be achieved under the current approach to funding, in which money saved by keeping people out of hospital does not come back to the health and social care partnerships.

As both the Scottish Government and the Scottish Parliament’s health and sport committee promise post-covid-19 inquiries into the future shape of social care provision in Scotland, it’s likely we’ll hear about mindsets as well as systems: that integration of health and social care needs a meeting of minds as well as joined-up systems.

As one care at home provider in the Highlands put it, Scotland simply does not currently see care services and health services in the same way:

“There’s an interesting question around the incentives and disincentives to deliver quality care and, to me, it highlights the imbalance between health and social care.

“In the health service, the way to attract additional resource and revenue or capital expenditure is to do a really crap job. For instance, waiting times money gets spent in areas where the waiting times are worst. The political response every time is to invest more heavily in that environment.

“If we, as care providers, do not maintain the highest grades, the response is different. It is to sanction us, to threaten us with losing our contracts, and ultimately to close us down.”

 

On the basis of the evidence we gathered across the four meetings, healthandcare.scot submitted a response to the call for evidence from the Scottish parliament’s health committee which you can read here.

 

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