Integration of Adult Health and Social Care: Consultation on proposals

Question 1: Do you agree with the general principles of the Bill and its provisions?

By its very nature, the third sector will focus on ensuring that services are person-centred, asset based and sustainable.  This focus is not well reflected in the Bill e.g. in terms of guiding principles.  We support the Christie Commission proposition that what happens on the front line is more important than any changes to the infrastructure.   Again, the Bill’s focus on structures, bodies and process miss the point – and risks diverting attention away from policies with real potential to help built the community and family capacity needed in the current context e.g. self-directed support.  Changes needed are cultural, based in better communication between services and from services to the people they serve; there must be a less ‘risk averse’ environment which recognises that local, community focussed interventions - not necessarily delivered through statutory services - can create and lasting outcomes for people. As a matter of principle we think that the third sector, alongside users, carers and the general public, ought to be represented at the highest levels in the planning of services and in prioritising investment.   This is not about producer interest; it’s about shifting power back to the people who are at the receiving end of the services which will be affected by this Bill.  We argue for this because we believe that the Bill in its current format and with its very technical focus will not ensure that above all else, disabled people and unpaid carers have a central role in developing and shaping integrated services which empower, enable and support them within their local communities. A major shift to bottom-up, asset and rights based approaches in planning, prevention and delivery is required.   The Public Bodies (Joint working) Bill needs to align more closely with the theory and practice of self-directed support if it is to make a significant contribution to meeting the challenge of creating a sustainable health and care system in the future.   The fact that there remains real ambiguity or any sense of real direction in where, how and how much resources will be transferred does not help.  As CCPS point out in their response to this call for evidence, the leadership needed from the Scottish Government is lacking in this regard – it could have sought to integrate key budgets at strategic level before they are directed to local partnerships.  There is still an opportunity to consider this, and more widely, (as we outline in our response the regulations relate to the Self Directed Support legislation) a specific opportunity to integrate eg. Community Care Grants and potentially a ‘devolved Independent Living Fund to ensure there is a more connected pot of money which is aimed at achieving the goals of wellbeing and independent living. Perhaps the bill does not go far enough to recognise opportunities for more effective and wide reaching reforms. Restatement of the principles underpinning the self-directed support legislation at the front of the Public Bodies Bill would help in this regard – although we must recognise that for unpaid carers, the Self Directed Support legislation does not necessarily give them equal status to service users.  Please see our response to the Self Directed Support regulations. It is not clear how the provisions in the Bill will, of themselves, accelerate investment in prevention, sustainability or provide a more joined-up approach between health and care services at the front line. Cultural change, more effective communication less risk aversion are needed to ensure more joined up pathways for individuals and their families.  Legislation in and of itself is not enough and this bill needs to be much stronger if there is to be any hope of achieving the policy intentions.

Question 2: To what extent do you believe that the approach being proposed in the Bill will achieve its stated policy objectives?

The Bill itself does nothing which will improve the quality and consistency of services for patients, carers, service users and their families.   It creates the conditions and possible structures and infrastructures which might facilitate the provision of seamless services but this is not guaranteed. What is likely, in looking at the detail in the Bill, is perhaps greater confusion and concern for people.  There are no provisions in the Bill which will ensure that resources are used effectively or efficiently - only a contestable assumption that joint working will make this possible. It is also worrying that, as outlined above, the amount and direction of resource shift is not detailed.  We are also concerned, along with many other third sector colleagues that despite the positive contribution of the third sector to reshaping care – and its considerable role in health and social care - it will have no say in decisions around those resources and perhaps a limited role in planning service delivery. Meeting the demographic challenge and dealing with the increasing number of people with longer term and often complex needs requires a whole suite of changes to policy, practice and service configuration – the Bill could have provided a starting point for this, beginning with a strong understanding of how the RCOP Change Fund has – or has not – made any difference in terms of moving more towards prevention and capacity building.

Question 3: Please indicate which, if any, aspects of the Bill’s policy objectives you would consider as key strengths?

Question 4: Please provide details of any areas in which you feel the Bill’s provisions could be strengthened.

We have already answered these questions above and believe that the question we should be asking is what can’t be achieved without this legislation?  Will this legislation make any real difference to the quality and consistency of care for people (given these factors are not addressed by the legislation, and potentially could be)? Will it tackle a culture where resources in one sector are ‘protected’ to the detriment of an individual or family’s wellbeing?  Ministerial intention may be strong, but that is not enough.  The Local Government Committee’s recent report on public service reform would certainly back this assertion.

Question 5:  What are the efficiencies and benefits that you anticipate will arise for your organisation from the delivery of integration plans?

We should be considering how we secure sustainable of health and care provision – and that is by reducing demand for formal services through a much greater appreciation of the role of stronger, more resilient communities, self and mutual help and high quality social and housing infrastructure.  Integration plans which focus on providing services to people in need are not sufficient.   They need to be cognisant of local infrastructure needs, community needs, how connected people are to their communities and so on.  Links with Community Planning are important but we must see the wellbeing of people more widely than health and social care e.g. as cuts to local transport services bite, people will become more isolated. Sadly, this Bill seems to have lost the Christie vision and ideals rather than considering how we strengthen the assets of people who are already being driven to breaking point by cuts to public services and the impact of welfare reform. If the Bill is to proceed along the lines that are indicated then it is essential that the make-up of local partnerships takes us beyond the planned split between health and local authority representation.   This approach sends inauspicious messages about power, responsibility and control which are the very opposite of the intentions behind integration.   What matters in the future provision of health and care services is that local, user and carer groups and public interests have much greater involvement and shared ownership of plans and services – and not just at local level.   Co-production techniques are increasingly used to drive quality services which are responsive to user needs so it seems logical to extend this to co-produced governance.    Putting service users in the driving seat is accepted as the central purpose of the Self Directed Support legislation but is very absent from this Bill. Professional and provider interests, including the extensive involvement of the third sector in care delivery, ought also to be included more strategically in the structure of these new partnerships.   We are particularly aware of the emergence of an inconsistent narrative surrounding the involvement of the third sector - a full and necessary partner at the top table of Community Planning but simply a set of interests to be consulted and engaged in the development of local health and care plans in a process which is dominated by statutory interests.   The sector has much to offer and stands ready to do so.

Question 6:  What effect do you anticipate integration plans will have on outcomes for those receiving services?

This really depends on the quality of the plans and the willingness of local statutory partners to work inclusively and strategically with the third sector and the people affected by these planned changes.   Experiences from the Change Fund and Change Plan processes have been decidedly mixed whilst early development of strategic commissioning plans illustrates how far there is to travel in developing sustainable approaches to health and care provision in the future. If the integration plans mean more of the same and refuse to tackle tightening eligibility criteria, charging and the loss/reduction of services which are essential to enabling people to live independently then we have lost an important opportunity.  This is not about delayed discharge or bed blocking – we must remember the assets, ability and contributions of people receiving support through health and social care. This would be a positive starting point.

Wider feedback

Business Regulatory Assessment The BRIA misses out the likely impact of integration on implementation of the Self Directed Support legislation.  There is a real risk that the focus on structures, finance and process could divert attention away from implementing the SDS legislation Also missing is impact of welfare reform on the Bill and subsequently on services which will be delivered under new arrangements.  Not least is the potential impact of welfare cuts to the income from charging, but we must also consider the impact of welfare reform on the health and wellbeing of people and communities already vulnerable and who face challenges to achieving their own wellbeing. Guidance issued to health boards via the Scottish Public Health Network (ScotPHN) outlines the UK Government’s welfare reform programme and potential impact on health and health services in Scotland^[i] – likely to cover acute and primary care as well as specialist supports e.g psychiatric and mental health care.   The Deep End report on Austerity and welfare reform remains the most insightful and powerful summary of impact to date on health and social care services – also highlighting how demand for support from third sector is increasing as statutory services struggle. Recent work carried out by SCVO^[ii] suggests that almost 90% of respondents to a substantial survey expect demand for support from people affected by welfare reform to increase over the coming months.  As many work to support the wider wellbeing of families and individuals, welfare reform creates a perfect storm for them as organisations – not only are some organisations being diverted from their core purpose, but the potential changes which the Public Bodies Bill will bring present yet another challenge in a challenging operating environment for the third sector.  The Bill must take cognisance of and at least begin to outline what specific challenges welfare reform might bring to achieving the goals and outcomes sought. We feel that it is potentially a mistake that the Financial Memorandum does not include or recognise costs to the third sector which are likely to arise from having to work with new structures and developments to create more integrated pathways. Involvement of the third sector in development and scrutiny of strategic and locality plans is critical to success given the contribution, experience, knowledge and skills it brings in the wider field of health and social care.  Other responses to the call for evidence e.g VHS, Alliance etc emphasise this important point. The sector will need to change how it works, and any changes to commissioning and procurement could have a substantial and potentially negative impact.  Already, procurement practice in Scotland presents significant challenges to the third sector.  The bill and the development of integration plans could be an important opportunity to realign how we commission and procure  wide range of services and interventions which drive a more preventative approach and focus on wider outcomes and wellbeing, not a narrowly constructed review of health. As CCPS outlines in its response to the call for evidence: “If joint commissioning is effective and successful at a) prioritising more ‘upstream’ and preventative support that helps people to stay well and out of the care ‘system, and b) embracing the (third) sector as a key partner in the achievement of the national outcomes, then we might see a greater involvement in investment and activity” – ie the sector could play a significant role in achieving the outcomes.

Conclusion

Building strong communities, individual and family resilience and prevention are factors which are largely absent from the recent debate about bed blocking and the current ‘crisis’ in the NHS. The role of the third sector in helping people to remain at home, in supporting families who provide care, in helping people, including older people to stay connected to their communities is also missing. This Bill must provide a framework for reshaping how health and social care operates.  It must recognise the need for better investment in preventative support; in community interventions and services which provide local infrastructure and services which actually make a concrete difference in people’s lives. It must recognise the importance of housing, of our local environment, of transport for helping people to remain independent and to be connected to their communities, to jobs and to each other.  Strategic planning must include the third sector because of its knowledge and expertise and more importantly, its connection to people who use health and social care services. A link to locality planning is not enough. Community transport, housing providers, care providers, carer and disability organisations are, in come cases, already around the table in terms of Reshaping Care/Change Fund activity. The Public Bodies Bill has a focus on only two parts of the jigsaw puzzle – health and social care.  Activity to bring health and social care together, to improve quality and outcomes of support will fail unless all key partners are around the table. Real change in the experience of all who use health and social care services will not come from restructuring but from cultural change, less risk aversion in service provision, investment in community solutions and by involving the people who matter most in shaping integrated services – disabled people, older people, unpaid carers, families and local communities.