2 Integration of Health and Social Care
2.1 Since 2016, work has been underway across Scotland to integrate health and social care support services. This is to ensure those who use services get the right care and support for their needs, at the right time, and in the right setting at every point in their care journey. It is also about increasing the focus on community-based and preventative care.
2.2 The people most affected by these developments, and for whom the greatest improvements can be achieved, are older people, people who have multiple, often complex care needs, and people at the end of their lives. Older people, in particular, are admitted to institutional care for long periods when support in the community - and support for their carers - could better fulfil their needs and wishes.
What we have done - Health and Social Care Integration:
2.3 Positive progress is being made with a number of Integration Authorities reporting good performance across key national indicators such as unplanned bed days and delayed discharges. Between the 12 months ending December 2016 and the 12 months ending December 2018 approximately 319,000 unplanned hospital bed days were saved across all specialties in acute, mental health and geriatric long stay (5.6% reduction), including reduced bed days associated with delayed discharges.
2.4 The number of unplanned hospital bed days has reduced since the launch of the Delivery Plan, and projections from Health and Social Care Partnerships suggest it will continue to do so. However, there are ongoing challenges in reducing, or mitigating against projected increases in, the numbers of A&E attendances and emergency admissions in the context of increased demand due to demography.
2.5 Between the 12 months ending December 2016 and the 12 months ending December 2018, the number of A&E attendances increased by 2.5% overall whilst the reduction in emergency admissions was very small, at 0.02%. Meanwhile, the estimated percentage of health and care resource spent on hospital stays where the patient was admitted in an emergency has remained fairly constant (25.1% in 2017/18), indicating ongoing challenges for Integration Authorities in shifting the balance of spend towards community settings. The reduction in bed days noted above is to some extent reflective of a gradual reduction (shortening) of average lengths of stay in hospital over the past few years.
2.6 The percentage of older adults (aged 65+) living at home rather than in an institutional setting has increased from 95.6% in 2015/16 to 95.9% in 2017/18. Although the percentage change appears small, it represents an additional 31,000 people aged 65 and over living at home (up from around 940,200 in 2015/16 to around 971,200 in 2017/18). Statistics also show an encouraging increase in the percentage of people who are spending the last 6 months of their life in their own home or in a community setting, from 86.7% in 2015/16 to 87.9% in 2017/18. For the 6 months ending September 2018 there was a further improvement, to 88.2%.
2.7 Enabling people to live and die comfortably, which for most, is usually at home or in a homely setting, is a key aim of our work to ensure seamless support and services in Scotland. We have put in place a number of steps to ensure that by 2021 everyone in Scotland who needs palliative care can access it. These are set out in our Strategic Framework for Action on Palliative and End of Life Care. As part of this work we have focussed on supporting medical and other professionals to have and record the necessary anticipatory care planning conversations with people to allow them to stay at home or in a homely setting where possible.
2.8 Despite the progress made above, a number of challenges remain that need to be addressed to ensure continued improvement. A recent Ministerial Strategic Group for Health and Community Care (MSG) review of progress with integration of health and social care, published in February 2019, concluded with 25 practical proposals to achieve this. The proposals sets a challenging and ambitious agenda for Integration Authorities, NHS Boards and Local Authorities, working with key partners, including the third and independent sectors to increase the pace and effectiveness of integration by March 2020.
2.9 Since the publication of the MSG review, extensive work has been underway to address all of the proposals. Progress reports are provided regularly to the MSG and the Review Leadership Group (co-chaired by the Scottish Government and COSLA). The Leadership Group meets every 6 weeks to oversee progress. The review report contained an expectation that Integration Authorities, Health Boards and Local Authorities would collectively evaluate their current position in relation to the proposals. The completed self-evaluations demonstrated that there is a considerable range of work underway within and across local systems, with considerable variance in where local systems had evaluated themselves in delivering integration. We have recently requested improvement action plans which are being developed as a result of the self-evaluation process, to ensure work is taken forward in a systematic way and at pace.
Integration in Action: an illustrative example
Dundee Enhanced Community Support Acute Team (DECS-A)
Mr A is over 70 years old with a history of multiple long term conditions including dementia. He was referred by the acute frailty team with functional decline over the past month with further decline over the past week associated with 2 falls but no head injury or loss of consciousness. He also had to pass urine frequently, and was suffering hallucinations and a reduced appetite. His GP had treated Mr A with antibiotics to cover a urinary tract infection but requested he be admitted to hospital as it was unclear why Mr A had deteriorated so rapidly over the course of the week.
Following an initial assessment Mr A was found to be unable to leave his bed but able to stand using a handrail and required the assistance of 2 people to move around. He had symptoms suggestive of a lower respiratory tract infection and from previous records it was noted he had a poor swallow and was at risk of aspiration.
The main carer was his wife and their grandson was providing assistance with bathing and showering. Power of Attorney was already in place and the family had agreed for a DNACPR with the GP just prior to referral to the service.
Mr A was looked after at home by the DECS-A team and he continued to be treated with antibiotics for aspiration pneumonia. The team was able to speed up his physiotherapy referral and brought him into day hospital for follow up and to perform x-rays of his hips as he was complaining of hip pain which confirmed osteoarthritis in both hips. He significantly improved, however it was felt his conditions were progressing so the DECS-A team liaised with the Parkinson's disease palliative care nurse and his geriatric consultant who agreed to no further increase in medication. The team felt he would benefit from follow up from the specialist nurse to educate the family, as per their wishes, on the progression of his condition and how they could prepare for the future as they were aware that he was on the whole deteriorating.
Mr A was medically discharged from DECS-A after 14 days, however he remained on the caseload as his family requested ongoing input from the team. A referral to the speech and language therapist was also put in place regarding Mr A's potentially deteriorating swallow.
If DECS-A had not been available, Mr A would have required a long in-patient stay and required step down to some form of rehabilitation and would have been exposed to hospital acquired infections and other potential further conditions.
The Red Cross and community rehabilitation team were integral to prevent admission to hospital. Had this patient been admitted to hospital he may not have been able to return home and may have required step down to a nursing home following rehabilitation.
The family was grateful that Mr A was supported to stay at home and felt involved in their management.
Prevention of admission ultimately allowed better use of resources and avoided a long inpatient stay with the high probability of step down to 24 hour care. This also reduced the chances of Mr A contracting further infections and allowed health and social care professionals to work collaboratively taking a patient centred approach keeping the patient at the heart of all conversations.
Supporting the Capacity of Community Care
2.10 Social care support is essential for thousands of people in Scotland to live independently; be active citizens; participate and contribute to our society; and maintain their dignity and human rights. It employs a workforce of over 200,000 - just under 8% of all employment in Scotland. However, we are facing significant challenges. Scots are enjoying longer lives, and with that often comes more complex care needs. Demand for social care support is growing faster than our traditional services were designed for, and change is needed to ensure positive outcomes for people, their unpaid carers, and staff.
2.11 In the Delivery Plan, we committed to working with COSLA and partners on the National Care Home Contract, models of home care, and social care workforce issues.
2.12 Substantial progress has been made to address the social care workforce issues, and agreement on the care home model for direct care costs has been reached, with COSLA and Scotland Excel shortly seeking a mandate from COSLA leaders to commence negotiations with providers. New models of care are also in development, including Neighbourhood Care approach pilots modelled on Buurtzorg.
2.13 Progress in these areas has emphasised the need for a more comprehensive consideration of social care reforms. This has led to a whole system approach being taken through the development of a partnership programme to support local reform of adult social care, which was formally launched in June 2019.
2.14 The programme has been co-produced with a wide range of people, professionals, and organisations, in particular people with lived experience of adult social care support and unpaid carers, and people who run services. Central to this has been the People-led Policy Panel, a group of 50 people who use social care support and unpaid carers. Since the Panel was established in October 2018, it has been working side-by-side with leaders from across the sector to develop programme priorities and workstreams.
2.15 The programme has joint political leadership from the Cabinet Secretary for Health and Sport and COSLA's Health and Social Care spokesperson.
2.16 The following are the programme priorities:
- A shared agreement on the purpose of adult social care support, with a focus on human rights.
- Social care support that is centred on a person, how they want to live their life, and what is important to them - including the freedom to move to a different area of Scotland.
- Changing attitudes towards social care support, so that it is seen as an investment in Scotland's people, society and economy.
- Investment in social care support, and how it is paid for in the future.
- A valued and skilled workforce.
- Strengthening the quality and consistency of co-production at local and national level with people with lived experience and the wider community.
- Equity of experience and expectations across Scotland.
- Evaluation, data and learning.
2.17 The co-production process has led to the development of a set of documents which set out the programme vision and framework. These were published on 12 June 2019.
2.18 The full implementation of self-directed support is integral to the programme for adult social care reform. We recognise that self-directed support is not yet fully embedded as Scotland's approach to social care support and are taking action to accelerate change. This has involved co-developing a refreshed implementation plan for self-directed support (2019-2021), engaging over 350 people across Scotland in the process.
2.19 Embedding carers' new rights under the Carers Act is equally relevant to adult social care reform - improving outcomes for unpaid carers and those they care for by expanding preventative support. We are one year into supporting the implementation of the Carers Act, in line with priorities agreed with carers, carer organisations, COSLA and health and social care partnerships.
2.20 The reform programme is a long term programme which will take several years to make the changes it is aiming towards. The next step is to develop plans for the projects and activities in the programme and set milestones to track progress. This will be done by co-production and will happen over the summer. The intention is for all plans to be in place by end December 2019.
2.21 A key aim set out in the Delivery Plan is that our health and social care system focuses on care being provided to the highest standards of quality and safety, whatever the setting, with the person at the centre of all decisions.
2.22 The "Health and Social Care Standards: my support, my life" were published in June 2017 and took effect on 1 April 2018. The Standards seek to provide better personal outcomes for everyone and to ensure that the basic human rights we are all entitled to are upheld. Underpinned by five principles: Dignity and respect; Compassion; Be included; Responsive care and support; and Wellbeing, the Standards are focused on the individual experiences of people using health and social care services.
2.23 The Care Inspectorate is rolling out new inspection methodologies to reflect the Standards and to help ensure the needs and choices of individuals are met. The Standards are being embedded to continually improve the quality of services across health, social care support, early learning, childcare, children's services, social work and community justice.
Shifting resources to primary and community care
2.24 Increasing investment by £500 million for primary care over the lifetime of the Parliament will take spending on primary care to at least £1.28 billion and to 11% of the frontline NHS budget by 2021-22. £250 million of the increase will be in direct support of general practice. The next step towards this in 2019-20 will see £941 million to support the new GP contract and primary care reform. We are also investing to support wider primary care services. In 2019-20 we project that total spending on primary care will represent approximately 9% of the frontline NHS budget.