Chapter 1 - The case for change
1.1. As we noted in the introduction to this consultation paper, there is a great deal to be proud of in terms of health and social care provision in Scotland. We recognise, however, that we should go further to ensure consistently good outcomes for patients, service users, carers and families. Separate - and sometimes disjointed - systems of health and social care will no longer adequately meet the needs and expectations of increasing numbers of people, particularly those living into older age, often with multiple, complex, long-term conditions, who need joined up, integrated support.
1.2. There has been very significant progress in improving pathways of care in recent years. Nevertheless, many clinicians, care professionals and managers in health and social care currently describe two key disconnects in our system of health and social care. The first disconnect is found within the NHS, between primary care (GPs, community nurses, allied health professionals etc.) and secondary care (hospitals). The second disconnect is between health and social care.
1.3. These disconnects make it difficult to address people's needs holistically, and to ensure that resources follow patients', service users' and carers' needs. Problems often arise in providing for the needs of people who access many services over prolonged periods, such as people with long term conditions, older people, and people with complex needs. Problems are also encountered at transition points, particularly as children with complex needs reach adulthood.
"The traditional separation of health and social care - the 'fault-line of 1948' - was probably harmless at the time. In the early post-war era there was little overlap between their respective patient/client groups. Health care was still largely acute, and social care focused mainly on deprivation and 'the problem family'. Since then, as a result of improved health in youth and middle age and the dramatic ageing of the UK population, care needs have changed massively, in the direction of multiple pathology and long-term conditions, with the resultant frailty and dependency now largely compressed into the later years of life . . .
"Yet the two care systems have - for various reasons - adapted only slowly, reluctantly and separately and, despite the existence of a main task in common, have broadly failed to establish and generalise reliable, effective and cost-effective means of working together on their central challenge now and for the foreseeable future: that of the care of older people, particularly those at home."
Colin T Currie, Senior Lecturer in Geriatric Medicine, University of Edinburgh, and Honorary Consultant Geriatrician, NHS Lothian
Journal of Integrated Care Volume 18, Issue 6, December 2010
1.4. From the perspective of people who use the system - patients, service users, carers and families - the problems we are seeking to address can be summarised as follows:
- There is inconsistency in the quality of care for people, and the support provided to carers, across Scotland, particularly in terms of older people's services;
- People are too often unnecessarily delayed in hospital when they are clinically ready for discharge; and
- The services required to enable people to stay safely at home are not always available quickly enough, which can lead to avoidable and undesirable admissions to hospital.
1.5. In terms of older people's services, we know from the public engagement exercise of Reshaping Care for Older People7 that these are the main problems that people want us to address. We also know from clinicians and other professionals who provide health and social care support that, as far as possible, it is better for people's wellbeing if they are supported in their own homes or another homely setting in the community, rather than being admitted unnecessarily to hospital.
1.6. We also know from our work on Reshaping Care for Older People that8:
- We spend almost one third of our total spend on older people's services annually on unplanned admissions to hospital;
- There is little association between the amount spent currently on health and social care services, and the outcomes that are achieved - spending more does not necessarily result in better outcomes, or vice versa;
- We spend more annually on unplanned admissions for older people than we do on social care for the same group of people; and
- Even allowing for the possibility that people may live longer and in better health in future, and taking account of our current emphasis on improving anticipatory and preventative care, Scotland will in future experience a material increase in the number of older people who need care. The resources required to provide support will rise in the years ahead.
1.7. Despite a good track record of partnership working over many years, our current system of health and social care still incorporates within it barriers in terms of structures, professional territories, governance arrangements and financial management that often have no helpful bearing on the needs of the large, growing group of older service users, and in many cases work against general aspirations of efficiency and clinical/care quality. We need to reform the system to deliver care that is better joined up and as a consequence delivers better outcomes for patients, service users and carers.
1.8. Our goal for integration of health and social care is to tackle these challenges and, in particular, to address the disconnects described above - so that the balance of care shifts from institutional care to services provided in the community, and resources follow people's needs. This is in line with our commitment to a person-centred approach, which builds upon our policy on Self Directed Support and the principles of the NHS Healthcare Quality Strategy.
"Public service providers must be required to work much more closely in partnership, to integrate service provision and thus improve the outcomes they achieve.
We must prioritise expenditure on public services which prevent negative outcomes from arising.
And our whole system of public services - public, third and private sectors - must become more efficient by reducing duplication and sharing services wherever possible.
Experience tells us that all institutions and structures resist change, especially radical change. However, the scale of the challenges ahead is such that a comprehensive public service reform process must now be initiated, involving all stakeholders."
The Christie Commission Report
Commission on the future delivery of public services, June 2011
Scope - demographic considerations
1.9. Our ambitions for improving integration of health and social care services are not limited to improving older people's services but extend to all adult health and social care services. People can, and do, experience complex care and health support requirements at any age, and we recognise the importance of ensuring that better integration of health and social care services results in improvements for all patients, service users and carers.
1.10. However, the factors driving closer integration are particularly relevant to care and support for older people. We know that, too often, older people are admitted to institutional care for long periods when a package of assessment, treatment, rehabilitation and support in the community - or more support to their carers - might have served their needs, and maintained their independence, better.
1.11. Demographic change in itself also makes the case for change urgent, and suggests that we must focus as a priority on improving services for older people. The Registrar General has projected that the number of people in Scotland aged over 75 will grow by around 10,000 every year, over the decade ahead. Changes in demography will vary in scale depending on location. Around one quarter of Scotland's population will be aged 65 and over by 2033; for some of our more rural areas the proportion is predicted to rise to nearly one third.
1.12. Given these pressures, it might seem appropriate to focus our proposals for integration of health and social care on older people exclusively. However, we recognise a number of arguments against limiting our plans for integration in this way. Conditions associated with old age and frailty are often experienced much earlier than 65, particularly but not exclusively in areas with high levels of deprivation. People with disabilities also have requirements for care across all age groups. A focus on older people alone would create an artificial divide within adult services, with people at transition from children's services, and with younger adults with physical and learning difficulties.
1.13. In terms of demographic scope, our proposal is that we will legislate to enable Health Boards and Local Authorities to integrate planning and service provision arrangements for all areas of adult health and social care. We recognise however, within that context, that assuring the ongoing provision of quality, sustainable services for older people is a priority.
1.14. We propose that the initial focus, after legislation is enacted, will in terms of performance management be on improving outcomes for older people. This consultation document includes, at Annex A, a set of draft outcomes for adult health and social care. We will work with partners and stakeholders to develop outcome measures for monitoring progress in terms of older people's services in the first instance, and also, over time, further measures to enable us to establish the impact of integrated services beyond older people's services.
1.15. These proposals also bring with them potential implications for a number of other functions, including children and families social work services and criminal justice social work. The Chief Social Work Adviser is exploring wider implications with social work professionals and a range of other stakeholders. A summary of progress to date with this work is included at Annex B. We recognise furthermore the importance of ensuring alignment and coherence between these proposals and the concurrent legislative proposals for planning, design and delivery of children's services.
Scope - enabling integration beyond health and social care
1.16. These proposals are designed to enable locally-implemented integration. They focus on bringing together the accountability of statutory partners - Health Boards and Local Authorities - to deliver better outcomes for patients, service users and carers. It will be important that, within local partnerships, partners beyond health and social care are also fully and appropriately involved in planning and decision making within the partnership arrangements.
1.17. Other areas of service also play a key role in the delivery of better outcomes, for people with long term conditions, complex needs and older people in particular. Housing is an important example of this. The national strategy for housing for older people9 highlights how the right housing and related services (such as adaptations and handyperson services) can help to support independent living, and can contribute to health and social care objectives. It will be important that, in bringing primary and secondary health closer together, and health and social care closer together, partners ensure that housing services (including those provided by housing associations and the third sector, as well as by local authorities) are fully included in the integrated approach to service planning and provision, and that health and social care planning and local housing strategies are mutually supportive.
1.18. The third and independent sectors, including carers' organisations, also provide significant levels of care and support and are crucial partners, with the statutory services, in the provision of a wide range of support. As we work with partners and stakeholders to deliver this agenda for integration of health and social care, it will be particularly important that we focus on building on the principles of inter-agency working enshrined in the Change Fund for Older People's Services. The fundamental purpose of our proposals for integration is to improve people's wellbeing; we will not succeed if, in bringing health and social care together, we overlook the need to build upon the progress that has been made in bringing third and independent sector partners to the table when planning delivery of services. The contribution of the third and independent sectors in enabling delivery of better outcomes is also a crucial factor in our wider public service reform plans.
What do we want to know from you?
Question 1: Is the proposal to focus initially, after legislation is enacted, on improving outcomes for older people, and then to extend our focus to improving integration of all areas of adult health and social care, practical and helpful?
Email: Gill Scott