To really care we must focus on the outcomes

Plans to integrate health and social care across Scotland are being pushed ahead despite the fears of those providing the services that costs will spiral while quality may suffer. Maureen Ferrier reports

The Scottish government has its own directorate for health and social care integration whose purpose is “to ensure that where care is needed it is of high quality and is provided in a timely, efficient and effective way as close to home or a homely setting as possible”.

The focus of that mission almost inevitably falls on the elderly – since 2002 personal care services for the elderly have been free in Scotland.

A policy introduced under a Labour administration now has far-reaching – and expensive – consequences for the Scottish government that will last long into the future.

And now plans to integrate health and social care services are rolling out, despite warnings over costs – and results – from the providers of the service.

The Association of Directors of Social Work (ADSW) leads the charge. Its president Andrew Lowe says that a centrally driven structural reform would be “misguided” and “an expensive waste of time leading to no real benefit”.

Research commissioned by the professional body showed that restructuring services in itself does not lead to improvements and that locally devised solutions are the best way of solving issues.

“The only consistent way to improve services is to set out what they need and work back,” says Lowe. “Everything we do must be focused on improving outcomes.”

ADSW wants to see a nationally agreed set of seven to 10 outcomes which partnerships would work towards, based on helping as many people as possible to live safely and independently at home.

Lowe concludes, like others: “We need a partnership of all the talents: social care, NHS, voluntary, independents, carers and the people who use our services.”

And local government body COSLA warns that transferring social care functions from councils to health boards would cost £300m with “no evidence that the public would end up with a better social care service,” according to the organisation’s health and wellbeing spokesman Douglas Yates.

Yates describes the transfer as not a good use of public money “to change the badge on a social care worker’s shirt.”

“There are huge challenges that we need to address but the plans to move social care into the NHS are an expensive distraction designed to gain short-term electoral advantage,” he says.

It’s a huge problem that care services face – in just 20 years there are expected to be 1.36m pensioners in Scotland, with a concentration of the “older old”. By 2031 the number of people aged over 90 will have doubled and during the same period the number aged 75 and over will grow at an annual rate of 2.4 per cent.

While free personal care last year cost local authorities alone £318m – an increase of 139 per cent in six years – the bill across Scotland is much higher. In 2010 the then health minister Shona Robison told council leaders that the figure for 2007/08 was £4.5bn across council and health services. A more recent figure is not available.

And in his review of free personal and nursing care three years ago, Lord Sutherland called for long-term planning for provision, with a focus on funding, highlighting a £40m shortfall.

Political thinking leans towards helping older people stay at home longer. Professional consensus is that to achieve this ambition early intervention is necessary, but opinions vary on what to do, other than improving integration between the services involved.

But an Audit Scotland review of the Community Health Partnerships, set up to improve joint working between health and social care, published in June this year, found “very few examples of good joint planning”.

Accounts Commission for Scotland chair John Baillie says: “In order for partnerships to deliver high quality services to people in their communities, there needs to be leadership and a shared vision at a local level.

“For a decade there has been a focus on improving partnership work between councils and NHS boards, however the added value of these partnerships is not clear. The report makes strong recommendations for all partners to address this together. Greater clarity is needed from councils and NHS boards about how money is currently spent and where this could be better targeted to make a positive difference to people’s lives.”

At the same time, Health Secretary Nicola Sturgeon has pledged that integration of health and social care would be a government priority: “There is no doubt that the time for bringing health and social care into a single integrated system has arrived,” she says.

“That is the way to ensure that we accelerate the progress of shifting the balance of care from acute settings to the community, get better at early intervention and make sure that no older person with care needs falls through the gap between the NHS and local authorities or becomes caught up in budget disagreements.”