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A question of trust: health and social care integration in Scotland

David Eardley, a senior manager at public sector business advisers and accountants firm Scott-Moncrieff, explores the change coming to health and councils in Scotland.

According to John Swinney, Scotland’s deputy first minister, “the balance between acute, primary and social care is the meat and drink of the sustainability of public services”. He said councils and health boards should stop playing a costly game of “ping pong” and work more collaboratively.

This is why the Scottish government has introduced health and social care integration legislation, compelling health boards and local authorities to work more closely. Shadow board arrangements are being put in place to meet the 1 April 2016 deadline. The new arrangements are designed to replace and address challenges encountered with Community Health Partnerships.

Two options are available for structuring this change: 1) A new, shared entity can pool resources and commission services (a ‘body corporate’ model, with governance through an Integration Joint Board); or 2) A ‘lead agency’ model can assign responsibility for planning and delivering aspects of integrated care to either the health board or local authority. This will be overseen by an Integration Joint Monitoring Committee.

There are some simple principles organisations must follow to make the new arrangements as efficient and effective as possible. These include:

• Effective change and project management – This is crucial both to get integration off to the best start and to support its formative years. Early on, have a clear, detailed and regularly reviewed project plan, supported by work stream plans. Build in measureable milestones and make contingencies.
• Trust – From leadership to the front line, belief in and commitment to mutual goals is crucial. What trust base are you starting from, and what are you doing to set the tone for the future?
• Openness – Aim for honest and realistic discussions about resources, costs and budgets. For example, in the NHS in Scotland, primary care budget underspends often offset acute overspends. How does this impact on financial planning and resource transfer under the new arrangements? And how will over- or under-spends be resolved?
• Vision – Be very clear what you aim to achieve. Back this up with a strategy and detailed plans. Service standards/agreements are crucial, as are SMART objectives for unbiased measurement.
• Governance – Integration brings another layer of governance. Take time to ensure the governance fits the operating structure, and not the other way around. Close ranks to keep strong personalities suitably in check; stroking egos or empire-building won’t deliver the best outcomes for service users.
• Clear roles and responsibilities – How will accountability be built in? Is it clear exactly how each employee will help deliver the vision?
• Communication and coordination – Especially critical where one health board area aligns with several local authority areas.
• Patience – Success takes time, and everybody needs to appreciate the longer term objectives. I’ve heard very senior people observe how arrangements are ‘working well in practice despite some management decisions’. Appreciate the missteps and wrong turns; ‘the man who never made a mistake never made anything’ is a cliché for good reason.
• Embrace change – Are you doing this because of the legislation, or is it because you want to? Ultimately, integration can’t be avoided where legislation exists, but ‘have to’ must become ‘want to’ for the full potential to be realised.
• Focus on service users – For every integration decision ask, ‘how does this benefit the population?’ If it doesn’t or if it’s unclear, reflect on this and seek alternative approaches before committing effort and resources.

In 2010, NHS Highland and The Highland Council took the initiative and integrated. From 1 April 2012, the health board and the council have been responsible for adult services and children’s services respectively.

The partners expected challenges, acknowledged risks, yet went ahead in pursuit of greater strategic benefit.

It’s too soon to fully evaluate the outcome, but principles such as those above underpinned and supported Highland’s decision to integrate. Bodies now working towards integration will look at Highland and learn from that bold move.

Change is on the way. The choice is how, not if, services will be redesigned and delivered. It’s time for Scotland’s health boards and local authorities to break down the silos, work around the political stumbling blocks, blur previous boundaries and fuse organisational cultures.

By 1 April 2016 that’s what it will take to put local people at the heart of public services.

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