What can England learn from Scotland on integrating health and social care?

Countries are responding in different ways to the increasing number of older people, but should we be looking closer to home? By Bob Hudson

There is widespread agreement that our systems of health and social care can no longer adequately meet the needs and expectations of the increasing number of people living into old age.

Across the globe, countries are responding in different ways to this challenge, and that difference is also apparent between England and Scotland, which offers an intriguing “policy laboratory” on “what works”.

The English approach has been developed over the past two decades and is now reaching its denouement under the coalition: the deepening split between purchasers and providers; the creation of an internal market followed by the shift towards ‘real’ markets underpinned by competition law; and the encouragement of the private sector in both providing and commissioning healthcare.

Some see this as a prelude to the end of state-funded universal healthcare and the creation of an insurance-based system. The appointment of Jeremy Hunt as health secretary will do nothing to assuage such fears.

We do not have to go far, however, to see an alternative model. The Scots have never had much truck with healthcare markets, even before devolution. The creation of separate NHS trusts and foundation trusts has been firmly resisted, as has GP fundholding and its subsequent variations.

Since devolution, the two countries have gone in very different policy directions, and the best example of this is the current focus on integrated care (rather than markets) in Scotland as the solution to meeting patient needs.

A consultation on proposals to develop integrated care was published earlier this year with a deadline of 11 September to submit responses. Legislation is expected to follow and this will be a flagship policy for Alex Salmond’s government.

Those involved on the ground are greatly exercised about the practicalities, and much political kudos will ride on being able to show the Scottish way can work better than Cameron’s rolling back of the state. But will it?

The rhetoric around integration is also loud in England. What appears to be different is the seriousness with which the endeavour is regarded. In England the policy focus on integration only arose belatedly and reluctantly as Andrew Lansley was forced to “pause” his market-led reforms and genuflect to the messages from the NHS Future Forum.

Few doubt that the real action is around markets and competition, with only a handful of establishment thinktanks touting the view that competition and collaboration make comfortable bedfellows.

The emphasis in Scotland is very different. The proposals include nationally agreed outcomes that will apply across health and social care – unlike the disjointed outcomes frameworks in England, a requirement to introduce integrated budgets will apply across health and social care, which will ensure new health and social care partnerships are jointly accountable to ministers, local authority leaders and the public for delivery of outcomes.

However, the jury is out on whether this model will deliver.

The proposals will also doubtless alter in detail in the light of the consultation process, and these changes won’t be introduced for a good two or three years.

Top-down prescription can never be sufficient to guarantee effective local partnering (as the consultation paper acknowledges) but what it can do is create a context within which partnering is more, rather than less, likely to flourish.

Much will depend on political impetus and here the loss of Nicola Sturgeon from her role as cabinet secretary for health and wellbeing to head up the independence referendum is significant – her successor, Alex Neil, has a hard act to follow.

As the policy forms, the key considerations will be structure and culture. The current proposals for new structures and governance arrangements will inevitably be unsettling to some and will attract resistance.

Indeed, the idea that the integrated budgets will somehow constitute a blank cheque that will drive change and innovation has to be questioned; as long as health and social care are in different organisations there will always be tensions around where the money goes.

The only way to address this is by a firm focus on cultural change. This is partly about clear management and political leadership, but also about arguing the case for change with professionals, patients and the public.

It means – importantly – central and local politicians acknowledging that some services will need to be decommissioned, albeit in the face of popular opposition. Partnership working for the sake of it, with no improved end product will simply be an expensive distraction.

But more fundamentally, what is at stake here is a battle for the soul of public service delivery and ideas around collective solidarity. The policy divergence on integration versus markets is really a question about how we want to live together as a society.

There is more at stake here than meets the eye, and for this reason alone we must hope Scotland can rise to the challenge.

Bob Hudson is a professor at the school of applied social sciences at the University of Durham