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AP - Alison Petch
MD The Public Bodies (Joint Working) (Scotland) Bill that has passed through Scottish Parliament is aimed at ensuring closer integration of health and social care services across Scotland. Given a growing older population on the one hand and a past history of sometimes difficult working relationship between health and social work services on the other, any measure which will result in more joined-up services with less people falling through the gaps is to be welcomed. At the same time, it is clearly important to learn the lessons from previous attempts to improve joint working and to explore the implications of these changes for inter-professional education and working. These are some of the issues which Alison Petch, Director at Iriss explores in this seminar, based on her extensive research in this area.
AP So, status change - why this title? I am not actually on Facebook, I’m a Twitter fan, but I understand that one of the options and status on Facebook is “it’s complicated”. This came to my attention actually on the grapevine when one of my offspring’s, actually his now former wife, changed her status to “it’s complicated” - and that seemed an appropriate headline in respect of the whole health and social care integration debate. And as Ian says, it’s been around for a long, long time. And for me, I think, the big question is whether we really will crack it this time. But, just to kick off - a sort of health warning - there is so much terminology around the whole area of integration, partnership working, collaboration - we really need to make sure when we use the term or when we have discussions like this, that we are all talking about the same thing. There is a real danger that we use the same words when we are actually meaning different things or we use different words when we are meaning the same things. And obviously because we are talking about inter-professional working, different disciplines working together, there is a particular danger of that happening. So really a warning to make sure that we know what we are talking about. And just to add to that call for clarity - one critical distinction that will be found throughout the discussion I put to you is the difference between integration across organisations, structures getting together and what we might look to as integrated care and support - the delivery of integrated support, which might be regardless of the organisational structure. And there is forests written around integration, partnership working, call it what you will - but some helpful definitions identify these distinctions from the structural level, the organisational level, the individual level and all those different types of integration you can get - between different service sectors, between professions, between settings and so on. And then another way of looking at it, which also gets lots of attention is the distinction between horizontal integration and vertical integration. Now I am not going to go into any of the detail of this - for those of you who are interested in it there is lots written, but really just to set the scene. And then a final element - I find this quite helpful - the notion of a partnership continuum, and this is particularly when we are talking about perhaps health and social care as organisations working together. At the one end, at your left you can have relative autonomy, people perhaps occasionally interacting around a particular issue. You can get some more formal coordination, possibly the emergence of joint appointments. Then, maybe getting a bit more serious about partnership working - and then finally, at the furthest end of the continuum, the notion of full structural integration. And Jon Glasby who is one of the gurus around integration, he talks about the trade-off between breadth, which is the whole range of organisations that might be wishing to work together - not just health and social care - the broader you go, that could include education, non-statutory sectors, and then his depth is similar to this - ranging, for example, from sharing information at one level to a formal merger at the other.
So with that as a backcloth, what I am going to do is talk briefly, hopefully, in 4 sections. I am just going to touch a little on the historical context, just to highlight what a long, winding road this has been. I am going to touch on the evidence base, but for those of you who want lots more on that there are the publications from Iriss. I am then going to, I suppose, give my headlines from the Public Bodies … whatever it is, I completely forget the title of it, the Bill - and then, and for me this is the most critical element, finally I’ll address how we can actually set about delivering integrated care and support.
In terms of the historical context, this, as I say, has been going on a long time and I have sort of characterised it as an increasing move from a more permissive set of initiatives and structures to the current legislation … there it is, Public Bodies (Joint Working) (Scotland) Bill - which is really seeking a much more mandated new set of structures. I think there is a sense that the politicians had become impatient with the pace of change. They wanted it sorted out once and for all. Indeed I heard the Health Minister say “right, we have got a year to get this fixed”. Well frankly, I think he is going to be disappointed. I have my doubts whether this, given we have been at it for many decades, will necessarily be sorted in a year. Those of you with long memories may remember, for example, the whole set of initiatives around Joint Futures, the Joint Future Group, their mantra “improve joint working in order to deliver modern and effective person centred services” - pretty similar to what we are striving to do today. And then, 15 years ago they introduced the Rapid Response Teams, the Joint Intensive Homecare, requirements for short breaks and the introduction of practical support for shopping, some of the more domestic tasks. So you can perhaps begin to get the sense that there have been a lot of bites at this particular issues - a lot of different strategies introduced over the years. And as I say, for me the characteristic is that we are moving from the more permissive to the more formal structures.
However, if you look down that list, often you could argue some of those are much more driven by political expedient than necessarily by the evidence base. So what I would like to do is just give you a flavour of the evidence base - and I appreciate that some of you in this room may be real experts on this, some of you this may be less familiar - so my apologies to those of you who are wise already in this area.
A lot of the initial research, the work that was done around partnership working, very much focused on the process of different groups or different organisations working together. People have done studies that showed how the vast majority of the emphasis was on how individuals, particularly professionals, were getting on together. Were they communicating better? Did the fact they were perhaps co-located make any difference, etc, etc? There was remarkably little emphasis on whether it actually made any difference to the individual who was receiving support at the end of the day - and yet you, certainly I, might argue that surely that is the whole purpose of the thing. We are not really here just to make a nice or not nice working experience - we are actually here to make a difference for those access support at the end of the day.
In more recent years there has started to be a sort of slow trickle of studies that actually do start to focus a little more on outcomes and outcomes for individuals. And really again, just to give you a flavour of those studies. There was a whole raft of integrated care pilots that were funded south of the border and they had a very substantive research programme alongside them, and as can be seen from that quote, the summary results of our work showed that although in general the integrated care sites had lower than expected outpatient and elective care, there was no evidence that these sites were reducing the level of emergency hospital care.
Now the type of outcomes they were looking at there were very much in relation to the organisation - were they changing the patterns of flow in and out of hospital? And that was a major ambition of those pilots - but as you can see, they weren’t necessarily very successful in achieving that.
In Scotland we have had the Integrated Resource Framework - that has been 4 test sites where they have tried to develop transparent financial mechanisms to ensure individuals can move very easily around the system and across traditional boundaries. The evaluation of that has not been a glowing success. It didn’t provide evidence of integrated work resulting in the release of resources, or of significant changes to fixed cost - a plea for integration requiring clarity of purpose and outcomes, issues of leadership which I will come back to, and so on. Integration of health and social care requires alignment to all available drivers - policy, legislation, structures, information, incentives and outcomes to create momentum for change.
Now those are only 2 very small elements from quite a significant and wide evidence base … unlike some social care areas where there isn’t a particularly well developed evidence base. There is some pretty consistent evidence in relation to integration which pretty much all points in the same direction, and that direction is we are not really quite certain yet that it is going to make a whole lot of difference. There are some green shoots from some international evidence - this is particularly relating to older people, and that range of projects has shown some success in reducing institutional care, which is very often the focus of these initiatives, and there have been some common features identified - case management, specialist teams, single point of entry and financial levers. But again, just a point of warning, these are often special, funded, targeted projects that get all that special attention, rather than the day to day mainstream where it can be much more difficult to sustain the focus.
However, as I said, my real interest, and I hope many of yours, is really in the difference this makes for individuals. Does it actually make a difference at the end of the day to Joe Bloggs on the street? And the evidence review that I undertook a couple of years back from ADSW, I conclude din that, that the extent to which partnership working delivers effective outcomes for the individual is best described as “unproven”. And again, Jon Glasby, Helen Dickenson, who have done a lot of work in this area, they suggest that perhaps the more appropriate question, as in a lot of evaluation, is to break it down a little - to say what we need to know and what we should sort of put our energy into exploring is what sort of partnerships can produce what kinds of outcomes, for which groups of people who use services, when and how. So we perhaps shouldn’t be overly negative - it’s just that we really need to root around a bit more and get into some of the nuances, the complexity that is there. And perhaps just a bit of a warning from Northern Ireland where they have had integrated health and social care structures for a long, long time - and often people trot out a mantra that it works in Northern Ireland … well the research, the evidence that has looked at Northern Ireland suggests that it doesn’t - health dominates social care, very much … the values of social care get lost. Priority is given to health agendas, health targets, focuses on cancer, on obesity - not the sort of, the more rounded elements that social care would ask for. And there has also been a very limited focus in the integrated approach - things like direct payments, for example, have hardly crept onto the agenda. So I think we have got some warnings from over the sea that we should heed.
That may all sound a bit negative - so perhaps I should start building up a case perhaps for a certain approach to integration.
In England, south of the border, there were some earlier doctors, some of the ones … some of you may be very familiar with Torbay always being cited, Moseley … Somerset - there was a lot of study by Edward Peck and his colleagues looking at the Care Trust in Somerset, Mosely, North East Lincs. There are some very important messages from these early cites - firstly, they were all very different and they all took very different routes. The influence of the local history, the context, leaders who knew the local area and built on that is a very important lesson. Secondly, and this is the headline always attached to Torbay - Torbay, over 10 years, focused on improving quality of life for Mrs Smith. I actually lived down there while I was at Dartington, and it was actually plastered all over the signs and so on - we were trying, they were trying to improve outcomes for Mrs Smith - it was the individual who was driving their approach to integration. The importance of leadership, the importance of integrated teams and the need to always be reflecting, checking where they were at and so on. And again I will come back to the implications of some of these points in a moment.
There is also very often an assumption that if only we worked better together, for example health and social care organisations, surely common sense would say that that would save some money - it would be a more economic option? Well again the Scottish government commissioned a study in 2010 which again … it’s only very, very tentative evidence that financial integration can be beneficial. Robust evidence for improved health outcomes - by which you should really read health or social outcomes or cost savings, is lacking. And I often cite these sorts of findings as almost counterintuitive, because you would think that these things should be better, should deliver better outcomes, etc. So why isn’t it? And then if you only take one message away from tonight, this is the one I would like you to take - that structural integration does not deliver effective service improvement. Putting all the energy into putting structures together, the evidence shows, decade after decade, that it fails to deliver what people hope it will deliver. And I have been quoted on a number of occasions as saying “if you focus purely on a structural route, you will end up in a cul-de-sac”.
There is actually some interesting evidence from the private sector which sometimes gets used in this context - evidence on mergers between companies - showing they can be very disruptive, they can stall positive service development for at least 18 months, and again they typically don’t save money.
So against that rather gloomy evidence base, what does seem to work? The NHS Confederation and ADAS in England did a survey of their members on what had helped and hindered their progress. They used that partnership continuum that I flagged up at the beginning, and they found that all the things that helped were the things that could be controlled locally. So friendly relationships, good leadership, commitment from the top, a joint strategy and vision and co-terminosity of boundaries. The things that hindered integration were the national and structural issues - being driven by performance regimes and targets, having financial pressures, ever changing leadership and both financial and organisational complexity.
So, in a nutshell they were concluding that what you should be striving for is integration based on outcomes, not targets - based on cultures, not structure - based on place, not organisation - based on delegation rather than transfer of functions - and based on clinical and professional engagement. Now that is a very quick taster of some of the evidence, but hopefully enough to set the scene.
The policy driver that really … or the drivers that lie behind the current legislation - and I am sure that this is very familiar to most of you. In Scotland, for older people, more money is spent on unplanned admissions - £1.4billion a year, than on social care, which is only £1.2billion. And that is out of a total of £4.5billion on care and support for older people by the NHS and by local authorities. And as many of you again will know from Audit Scotland reports that have been critical both of the CHP’s, the Community Health Partnerships, and of the Reshaping Care for Older People Strategy - we haven’t been very effective a shifting the balance of care … of realising the ambition of supporting more people, particularly older people, in their own homes or at least in homely settings, rather than the massive occupation of hospital bed days. So there has been a real driver to prevent unnecessary admission to hospital - lots of evidence that once you go in, you tend to stay there, your health often declines - and if you do go in, to try and facilitate rapid discharge. Avoiding the cost shunting, the endless table tennis, ping pong of “you pay for that”, “no, your responsibility”, etc., and then removing some of the gaps, the black holes where people actually fall between the boundaries of different organisations. So those are, you know, very briefly some of the drivers that lie behind the current Bill - Public Bodies (Joint Working) (Scotland) Bill, which received its third reading and was passed on 25th February - it is now just awaiting Royal Assent before implementation from April next year. And for those of you who aren’t familiar with it, I’ll just give you the very briefest of headlines - the Bill offers people, in the requirement that health and social care work much more closely together - they are required to establish one of two models for closer working - either the body corporate model whereby health and social care delegate certain functions to a joint body, which will have a designated Chief Officer, or alternatively the lead agency model, which is very often called the ‘Highland model’, because they have already done it - and it looks as though they will be the only people that do do it, and this is where you delegate functions from NHS to local authority, or local authority to health - so in Highland, adult social care has gone to the Health Board, and children’s health and of course the local authority responsibility for children has gone to the local authority. So those are the … I mean the Bill talks about 4 models, but the other 2 are just variants of that.
There is the requirement to produce integrated strategic plans of what is going to happen in the area, and critically there is the requirement to pool money for an integrated budget. We had the opportunity of pooled budgets 15 years ago, but everyone went for a parallel budget rather than a proper pooled one. There are some national outcomes that have to be achieved, and there is a focus on localities and the requirement that every area, every partnership has at least 2 localities - which, if you live in Shetland, may seem a little odd as to how you divide a population that size into 2 localities. And of course, the Public Bodies Bill is set within the context of Christie, the Christie Commission and the whole drive for public service reform.
Now as I said at the beginning, what really interests me is how we can improve the delivery of integrated care and support, and this is really the focus of a second review of evidence that I did for ADSW which was really saying “okay, there is all that sort of evidence about structures and outcomes and so on - but how can folks like yourself, either working or soon to work in agencies - how can you try and crack this one and for all? To make sure this isn’t the last … well perhaps, yes hopefully it is the last - it isn’t just another initiative on that long list?” And my argument is that we have to place personal outcomes, outcomes for the individual, making a difference for the individual, at the very heart of this endeavour. And then there are a number of key elements around that, to support that delivery, and I will touch briefly on each of those.
However, outcomes is almost as bad as integration, partnership working, as a word that can mean many things to many people and gets banded around and used in different ways. So again I am going to plea for clarity when you are talking about outcomes, and to see it as a 3-layered cake or whatever …3-tiered cake. We have national outcomes, the 16 national outcomes, the draft 7 for health and social care integration - they are the very top level, government level. We have organisational or community outcomes, for example the single outcome agreements that each local authority has to work with, the HEAT targets from Health - reduction of this or use of that. But the really important element, I would argue, is the third and underpinning layer, the personal outcomes. What difference does it make for the individual? Talking Points, some of you may have heard of - work of Emma Miller and Ailsa Cook, over a number of years, which is hopefully being adopted across Scotland as one very useful approach for ensuring a focus on personal outcomes. In Housing there is something called ‘Better Futures’ - in Health, and individual outcome might relate to functional status, perhaps an OT’s assessment of whether an individual was able to do something.
So really, Outcomes for Mr McKay, is the Scottish equivalent for the Outcomes for Mrs Smith in Torbay - an argument that the focus should be on making a difference for the individual, the Talking Points approach, for example, has 3 core components - quality of life, staying well, seeing people, having things to do, feeling safe. Process outcomes - about how people experience, their interaction perhaps with a professional - are they given choice, are they listened to, do people feel their support is reliable, is it responsive? And then change outcomes which may apply in situations where, say someone has been to hospital, they come out and they want improved mobility, or for someone say with mental health issues, it may be around reduced symptoms.
So how can we ensure that the focus on integration is not on who is going to be the joint responsible officer, or how this particular team is going to communicate with that particular team - but on delivering a decent life for individuals. And these are the elements that were round that circle - we have to have a vision - integration cannot be an end in itself - it must be for a purpose, and that purpose must be clearly articulated, owned, communicated, embedded within the organisational culture - something to believe in and something to motivate people. And that will be critically dependent on having good leadership. But there is quite a strong body of argument and evidence that suggests that to achieve integration we really need to move from the traditional heroic individual leader, driving whatever forward - to a much more collective leadership - identified and owned across all levels of an organisation. I mean obviously you will have some people who are at the forefront of that, but it’s a much more dispersed leadership. It’s about being outward facing, it’s critically about breaking down and transcending all that professional tribalism that I am sure you are all exceedingly familiar with. It is about positive risk taking, it is about role modelling … a bit of jargon - I don’t know how many of you have heard about ‘boundary spanners’ - but these people that can really negotiate across boundaries, who aren’t afraid of putting their heads above the parapet and getting on with things - embracing change rather than trying to fend it off is at the heart of this.
People talk about culture change and we need culture change, and it trips off the tongue, and of course it is not as easy as that - I was quite intrigued that I was going some training up in Highland, ironically, and they were about to become an integrated Older People’s Team the following week - and so instead of all the sort of broad brush stuff that I had been talking about in the other areas, they were really down to the nitty gritty - you know, “why doesn’t the social care staff have to wear uniforms?", and “social care have lunches on a Friday and they are going to be bringing in smelly food”. And one of the elements was literally a discussion about the kettle in the kitchen - and I was a bit amused, because I came back and a couple of days later I was browsing through the literature and there was actually an article entitled “you know you’ve cracked it when there is only one kettle in the kitchen”. So that rang true.
One of the big debates around the whole culture of integration is whether we want to sort of mix together a completely new culture, the melting pot approach, put all the existing but something new comes out - or whether you want what was described by Edward Peck when he looked at the Somerset situation - building on the existing, the orange juice with added vitamin C approach. Now again the evidence seems to point that it is much better to create a new shared culture rather than seek to sew the old together. And again, because we happen to be in Paisley, I will refer to Jon Glasby again who seems to be getting quite a lot of hits this particular talk - but he, I remember, likened good integrated working to a Paisley pattern - where all the different threads were woven together in a very complex pattern, so that you couldn’t really see the individual threads, but together they created a rather attractive design … and I couldn’t resist using that given where we are.
And just to remind you that there is nothing new in all of this - this particular characterisation of drivers and barriers, just a summary, comes from a piece of work I did with Ailsa Stewart many years ago, in the early Joint Future days, when we looked at the drivers and barriers for integrated working. And again, I won’t tediously go through them, but the overriding message that those who have a ‘can do’ attitude, who say “we will find a way” - they are the ones that manage to progress. And the ones that never really get there are those who are always waiting for the perfect plan - who want to have all the T’s crossed before they can move forward.
I have touched, at a number of points, for example in relation to those earlier doctors, on the need to make this local - there is no overarching template that we can impose throughout Scotland - it has got to be built on the local knowledge. And I actually think that is a very positive aspect of the legislation that is coming through. We need to build on that in-depth knowledge of the strengths and needs of the locality, in our current jargon the assets, the coproduction, we need to not just look at health and social care - it needs to be a total understanding of the local community and of all the partners from all sectors who might be involved in that. And of course we have got to get beyond this crazy non-sharing of data and lack of communication and so on.
In relation to teams, a very good place for teams, integrated teams in this whole structure - but there is again no single prescription for an effective team. What is important is that everybody knows their lines of accountability and there is one ultimate manager with final accountability. But within that, any of you around long enough to know (… unclear) and all his multitude of diagrams - you can have all sorts of different structures.
Colocation alone is not sufficient. People often think if we just shove everyone under the same roof or in the same room, hey presto it will be sorted. There is a story that may be familiar to at least one person in this room - of an area where they put a health and social care team … or health and social care teams within the same room - and the teams ensured that the filing cabinets went down the middle. And when the health phone rang, social care wouldn’t answer it, and vice versa. So colocation may be helpful but it is not sufficient.
Time … I hinted at the beginning that 12 months is going to change not a huge amount - people will still be in the very foothills of integration, and again lots of evidence - this particular quote is from work in Sweden, that change does not occur overnight - time is needed, and we should be realistic about that, otherwise expectations are going to be very quickly dashed. Again, looking at Torbay, it was 10 years to get some of that early movement.
So what should we do in driving forward? I think we need to capture imagination and motivation. We need to assert the Social Services identity so that it doesn’t get swamped by Health. We need to very much broadcast the positives. We need to demonstrate the unique contributions of different professions, but also where in fact there can be much greater, for example, generic working. And we need to be creative about doing things.
So finally, perhaps just some issues that might spark off some of the discussion - the initial legislation will require implementation for Older People, but there is nothing to stop partnerships addressing all Adults, and indeed Criminal Justice and Children. And I know of at least 2 partnership areas that say they are actually going to go for the whole whack. I think it will be interesting the national outcomes they finally decide upon, because there has been, you know, traditionally national outcomes are nothing to do with impact on individuals - they are to do with, you know, reduction of this or increase of that. But there appears to be a bit of a shift, not a sea change, but a bit of a shift to introducing more of a focus on what difference is this making for the individual. During the course of the Bill there was lots of lobbying from third sector organisations, from Housing, and Housing got an amendment in at the third reading of the Bill which I think is absolutely critical - because we talk about Health and Social Care - but I was taught many decades ago that it was really a 3-legged stool - Health, Housing and Social Care. But I think that stool is always very wobbly, because Housing very rarely gets much of a look in.
I am concerned whether we do have the leadership capacity in Scotland at the moment for that transformative leadership which I spoke of, for those boundary spanners - so that is a challenge for you - leaders of the future. We still have some of the age old wicked issues - tribalism, collaboration between different professional groups - and then for me perhaps the big, big question - are people really going to manage the achievement of integrated budgets? There is a very telling weasel phrase which talks about some of the acute budget being put into the pot - and for me, one of the tests over the next 5 years will be how that really happens - whether people are willing to give up some of that acute budget, without which the achievement of all those ambitions around … there has been a focus on Older People, but it’s for many other … for all citizens whether that will be achieved. So I must stop so that you can talk. Thanks very much indeed.
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