One of the things that the current crisis does is to provide both time and cause for reflection. And one of the things I have been reflecting on has been health and social care integration – as you might expect. The current situation has shown just how vital care services, care homes and carers are, as some of our oldest and frailest citizens are cared for by them. Some care homes are seeing a very significant death rate, as well as serious impacts on carers; the difficulties over supply and access to PPE have also brought the question of whether we value them into sharp relief. And that made me think about the system more broadly. How did we get to where we are, and what might the opportunities be?
So, a bit of background. From December 2013 to February 2019, I was Chief Executive of NHS Scotland, and the Director General for Health and Social Care. It was a role in three parts – principal policy advisor on health and social care to the Cabinet Secretary for Health and other Ministers as required; a member of the Scottish Government’s Executive Team and its Strategic Board, with the corporate responsibilities that came with that; and the Chief Executive of NHS Scotland, accountable for a budget of £13 billion and a staff complement of some 160,000, in 22 health boards, each led by their own CEO and Health Board.
The Public Bodies (Joint Working) (Scotland) Act 2014 led to the formation of 31 integration authorities, partnering local authorities and health boards across Scotland. These arrangements were in place by April 1, 2016, with some authorities having shadow arrangements in place in the preceding year.
The aim of integration authorities was to improve the quality and consistency of health and care services delegated to them – with a focus on better outcomes for the public, the people we are here to serve. A key intention was to deliver care in community settings, rather than in hospitals, as far as possible.
NHS and local authority partners delegate budgets to integration authorities so that they can direct spending on the services delegated to them. And I had a key role in overseeing the arrangements for putting the health and social care integration programme in place, and for helping to make it work, under the direction of the Ministerial Steering Group, jointly chaired by the Cabinet Secretary and COSLA. The credit for much of the excellent work to design the legislation, to develop the implementation plan and the guidance that goes with it, and to set up the partnerships, goes to others rather than to me. But as CEO and Director General, I had a role to play in getting health boards to engage, and in working with COSLA and local authority partners to support the implementation and development of integration, in accordance with the legislation.
The aims of integration were right, and in my view they remain so. People who need care and support should not have to navigate the boundaries between the health service and social care in order to get what they need. Joined up services are better for people – more effective, more efficient, more foresighted and offering better outcomes.
But it was not straightforward – not that anyone thought that it would be. Breaking down institutional boundaries is not easy. We had collectively been trying to integrate care in the community for many years; everybody agreed in principle but in practice it was hard because of a range of factors including protection of budgets, elements of self-interest, and differences in governance and political accountability. These were all excuses, and not good reasons – and the decision was taken to legislate for integration; by putting it on that footing the intentions of government, both local and national, would be clear and the framework for governance would be set out in statute and supporting guidance.
Some partnerships made faster progress than others. There were some outstanding examples of joint working, many of which involved the third sector and care providers. Integration was possible, and where there was commitment and leadership it worked. But it was patchy, and Audit Scotland said so, commenting on financial planning, governance and strategic planning arrangements, and leadership capacity. In 2018, the Ministerial Steering Group commissioned a review, jointly led by COSLA and the Scottish Government health directorates. The CEO of COSLA and I co-chaired the review, which was accepted by the Ministerial Steering Group and published in February 2019. Everybody agreed that there was more to be done, and that the pace of change had to improve.
It would be easy for me to say what I think other people should do, and where I think they are getting things right, or wrong, and what they should do next. But I know that I am looking in from the outside, without access to the latest information or to the discussions that take place and to the advice that is given. So against the background I have set out, I thought instead that it might be fairer to say where I think I got it wrong, or didn’t go far enough. I could have done these things but I prioritised other things – whether I would have been successful in doing them is another point, but you never know until you try.
I tended to work within a framework of trying to organise things at 5 levels – national, regional, local, community and personal, with the emphasis on doing as much as possible at personal and community level. But I have to question whether I prompted sufficient changes to funding mechanisms so that prevention and community support are better rewarded and recognised, because they are fundamental to changing the way that care is delivered.
The governance arrangements for health and social care are still complicated and circular. Local authorities and health boards delegate to health and social care partnerships, who in turn commission inputs, outputs and outcomes from these delegating authorities (and others). It’s unusual for delegation to run one way, and commissioning to flow the other – and it makes for complicated accountability which in turn makes scrutiny more difficult. This is set down in legislation, so it’s arguable that there is no option, but I could have done more to seek improvement and clarity, for the ultimate benefit of the people public servants are here to serve – the public.
There is (despite genuine attempts on both sides) not yet real parity of esteem between the NHS and local government. Some of the best and most productive – and challenging – discussions I had, were with locally elected members but I am sure that we could have found more ways to engage local politicians, as well as officers, in design as well as delivery. I could also have done more to encourage health boards to free up some of their excellent people to engage more fully with partner organisations. There were outstanding examples of what could be achieved when that happened, but I ought to have taken more steps to spread that learning and good practice more widely.
Speaking of esteem, what of the third sector? They have some amazing insights and ideas, and make a huge contribution to supporting those who are most in need. They also have some really valuable community connections, which give people who are in need of support a voice which really is essential to understanding what works and what doesn’t. Yet they are too often treated as hired hands, to be picked up and dropped every time a budget is reviewed – with the loss of continuity and erosion of trust that such an approach inevitably generates. I should have done more to insist on treating them as equal partners.
In the context of both local government and third sector capacity and capability, I did try to get everyone to stop saying ‘hard to reach’ and start thinking about how to meet and engage with people on their terms and not ours. We need to think about how individuals and households are facing problems largely incomprehensible to us – and tailor support accordingly. We can only do that by hearing what they say, on their terms. Investment in smoking cessation doesn’t help if you are in an abusive relationship and it won’t be a priority until you are in a better context with more hope. Local government and the third sector have a great deal to offer in this context, given their closeness to communities, and I could have tried to make more space for that, and ensure it was more valued and recognised.
We are also making clear statements about what we value by the way we pay and train social care workers (and people who look after small children). If we cannot give people a good start and a good end to their lives, we are falling short. Looking back, I wish that I had done more to prompt thinking and action about that.
I also knew that we needed a good hard look at the way care services are commissioned, the way they are paid for, and the way good care is recognised and rewarded. Our attitude to the private sector was unresolved. We don’t ‘procure’ hospital care, but we do ‘procure’ home care and care home services. We know that if people can stay at home, or in a homely setting, their prospects of good quality of life are enhanced – yet we have a system which makes it more likely that cuts will fall in these areas. I should have done more about that.
Despite these things, there were some outstanding examples of health and social care integration, largely driven by people who exercised strong and effective local leadership, who worked collaboratively, and who cared less about institutional boundaries than they did about the people they served. These examples came from all sectors – social work, social care, the third sector, the NHS and privately run care homes. Nobody had the monopoly on excellence.
That gives me hope for the future. These same people are the ones who are responding positively to the current crisis and they are the ones we should listen to as we emerge, in small steps, from it. They are the ones who can help to deliver some of the changes that will have the greatest impact, as the mist clears and there is an opportunity to make some sustainable changes with longer-term benefit. To any who doubt that new ways are right or possible and who want to carry on with what was before, to keep things are they were, I offer this plea. There is no place where things are going to be the way they were, except perhaps in sepia photographs – so put away the aspic (please) and learn from my mistakes instead.
Professor Paul Gray was chief executive of NHS Scotland, 2013-19