Geoff Huggins: Integrating and reshaping care - lessons from Scotland

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  • Posted:Thursday 22 June 2017

Geoff Huggins, Director of Health and Social Care Integration, Scottish Government, shares lessons from Scotland on reforming adult social care.

This presentation was recorded at our event, Reforming adult social care - is it just about the money?, on 22 June 2017.


I'm very pleased to be here this morning to talk a wee bit about what we're doing in Scotland and at the Scottish Government.  What I'm going to do, is I'm going to place some of the activity that we're taking on, in respect of social care reform within the wider context of health and care integration, within Scotland.  Which, as Richard's described, the emerging policy in England is very much place based and commissioning based.  

    So I'm going to talk a bit about integration to give a context in that.  It's becoming increasingly difficult for us to think about social care as a separate service.  Now, we understand social work to be a separate profession, but social care as a service which is separate from other services.  And in the same way in which we're increasingly thinking about how we look across the unscheduled care pathway and across the community and primary and social care spectrum, we're thinking differently about how we bundle and think about services.  And I'll say a bit about that. 

    We're also, I think, very  much welcome the focus of the conference which goes beyond simply asking for more money, in that it's always easy to say that the challenge is money.  But as public officials, we also have the responsibility to use that money effectively.  And only to ask for money where we can say that we will provide something which is better, or of greater value, than what was there before.  

    So, across the UK, across the world, and I talk in North America, I talk in Europe, the challenge that we face is very similar.  I was in Vermont about seven or eight weeks ago, and this is exactly the place where they are.  I was then in D.C. two days later and it's exactly the same story.  It's more people living longer; it's chronic conditions; it's multi-mobility,; it's  new medical treatments; it's health care inflation and changing expectations of access. 

    And with all of this, what we face is, not simply a sustainability challenge, it's a quality challenge.  And a story which I often tell is from Woody Allen and he tells a story at the beginning of Annie Hall.  And he's in the Catskills at the beginning of the 60s, when he was a comedian and hears two women talking in the restaurant and one says, "The food's terrible here, isn't it?" and the other says, "Yes, and such small portions."  And my experience is that across the world we've tended to be focused on portion size rather than the quality of the food.  And so the discussion about the nature of the service that we're providing, I think, is also very material.  

    When Richard came to Scotland seven or eight weeks ago as well, I think, you presented in the Grassmarket, you very helpfully brought this slide from the Health Foundation, which shows the increasing divergence across the United Kingdom of spend on social care.  And I think it gives something of a sense of where we are and maybe does suggest that across the UK we actually have different problems.  There may be parts of the UK where portion size is as material as quality.  I think that's significant as well.  

    If I was to take a step back and think about the point at which we probably began to change direction from other parts of the UK most recently, it would probably be the spending review process for the 2016, 2017 budget.  So going back to the autumn of 2015.  And during that process in Scotland, we had a long discussion about where it would be best to deploy the additional resources that were coming to Scotland in respect of health funding.  

    So we have a commitment in Scotland to ascribe the resource, or the share of the resource, that comes to Scotland from Barnett, our formula share, which is devoted to health care in England, to health care in Scotland.  So in the 2016, 2017 year that meant we had an additional £400 million to spend on health care in Scotland, a simple formula.  And in 2016, 2017 what we decided that we would do, is that we would take £250 million of that and spend it on social care.  

    So we took 60% of the resource, that came across the border in respect of enhanced NHS funding, to spend on social care.  And it very much reflects this phrase from John Swinney who, at that time, was the Deputy First Minister, who still is the Deputy First Minister, but is Minister for Finance, that we needed to think differently about how we approached the use of resources and the structure of care and health within Scotland.  So we took a deliberate step to say that we thought we would get greater value from buying more social care, than from continuing to invest all of the resources that came across the border into health care.  

    And that was very much in the context of the work that we're doing in Scotland on health and social care integration.  And this is a process which now goes back to December 2011 and Nicola Sturgeon standing up in the Scottish Parliament and saying that we will reform health and care.  We continued to describe this as the  biggest reform programme in respect of health and care since the creation of the NHS in Scotland in 1948.  

    And the commitment to that, in doing that, that we would build health and social care services firmly integrated around the needs of individuals, their carers and other family members.  So a rethinking of what the system was there to do.  The system is there, ultimately, to help people live the lives that they want to live, and a reorientation away from the focus on the needs of organisations.  

    We still struggle, as you do. with this, but I tried to rebalance away from the relentless focus on A&E targets or elective-time targets, to actually think about the value of the health and care system for people's day-to-day lives.  But within integration we saw that as the mechanism by which we can begin to change our approach to health and care, both in terms of the quality, but in terms of the sustainability.   

    So in thinking of spending that extra £250 million on social care, what we were doing was investing that within a new way of commissioning and developing services, in the belief that we would get broader system benefits to that.  But also that we would be doing more to aid and help individual people and their families.  

    The structure of integration in Scotland, I could do three hours on this, but I'll do one slide on it, is national outcomes which move away from targets in terms of their being more broadly based.  A structure under which primary care, community care, community health care, social care and aspects of hospital care.  So A&E, unscheduled care, are all brought together under new integration authorities.  

    And these new integration authorities, effectively are required to commission back from the NHS and from social care, services, in terms of buying the services which they expect will produce the greatest benefit across the area.  These boards are separate legal entities, are required to publically account.  And, if anything, in terms of their structure and legal format are probably closer to councils than trusts, minus the requirement to have been elected.  Although a  number of the members of the board will have been elected as councillors.  

    Importantly they have a single budget and in this year they will spend something like £8.3, £8.4 billion of the overall £13 billion which is spent on person-facing services within Scotland.  So they're spending about 70%, 60% of all of the resource now in Scotland.  The residue which is left, and at times we do talk about a residual NHS, is largely the elective and specialist service that sits behind that in terms of the services which are unintegrated.  Although in a couple of areas those have been integrated as well.

    And across the country, what we're seeing, largely also, is operational integration of services.  So Chief Officers who are the lead officers for these integration authorities across the country, in most cases, will have full operational responsibility for all community, primary and social care services.  So a single manager working across teams.  And we're in year three in some place, year two in other areas and we're increasingly seeing new ways of working, new formation of teams, single management structures.  And people working across boundaries and thinking differently about how they use the resources and talent.

    So that sets up a system in which we have a new way of working across the system to produce benefit.  Two things I'm going to bring out from the data and we have strong-linked data which enables us to understand how we're using resources across the system and what that tells us about the allocation and management.  I'm going to bring out two quick points here, and then I'm going to talk a bit about exactly what all of this means for social care.  

    First of all then, Richard in his opening remarks, talked about variation and the degree of variation across England in respect of a number of items and variation is really interesting.  Many of my colleagues, who work on the hospital side, are very focused on it, on the basis that they believe we shouldn't have variation.  

    I'm a firm believer in localism and so I love variation.  Variation reflects different approaches and different ways of structuring and producing outcomes for people, which reflect local circumstances.  So variation for me is great.  At the same time, any conversation about variation needs to begin from the point of actually trying to understand why there are differences and if those differences are good.  So it's a way into the space.  

    What we have here is your likelihood, if you are in Scotland, of being in hospital if you're over 65 on any given day.  So on any given day, in Scotland, in Glasgow, you have something like a one in 60 chance of being in hospital.  So 1.6% of all of the over 65s in Glasgow city are in hospital today.  

    If I go to Aberdeenshire, what I find is that you have a one in 200 chance of being in hospital on any given day.  And it's the same in Moray and Clackmannanshire.  And what we see across the left hand side of the band there, are those areas which tend to be a wee bit more rural.  They're more likely to have intermediate care, they're more likely to have community hospitals.  And at the far right we tend to have those areas which are  more urban.  

    We usually have a conversation, at this point, if we're doing Q&A, which is about, this is all about deprivation isn't it?  It's all about poverty.   But when we actually look at the data, because we can do it by poverty quintiles, and what it shows us is that the impact of deprivation is negligible on this data.  For the under-65 population, it's a big factor, over-65 population, if you make it that far, you're likelihood of hospitalisation is pretty much the same, irrespective of social class.  So we're looking at a 300% variation.   

    What we then do, is if we then take a step back and actually think about what is producing that.  So where does that fit in?  Now for the pointer, what I'll do, is I'll tell you, on the far right, we're looking there at those services which are hospital services.  So those are the 1.6% or the 0.4% of people which are in it.  But then across the green area of this, you have all the community services that are actually pulling together and either reducing demand for hospital services or enabling transfer back from hospital, back to the community.  Or preventing the need for hospital services in the first place.  

    So this is for one local authority, one integration area in Scotland.  Now, I'm not allowed to tell you where it is, but I do live there.  But it shows the complexity of what's going on behind that degree of variation, such that if you simple look at one of the indicators in the story, without looking at the whole story, you're going to get the wrong answer.  And social care is a big component of that.  

    So if you see the purple blobs, these are all the social care services, as part of the mix.  And, again, this is why thinking about social care as a separate service, or as a separate area away from all the other things, just doesn't make sense any more.  So that's the first data problem.  The first data problem is everywhere is different and we love local and it means you need to start from where you are.  

    The second one is, my slide's gone a bit wonky here, but that's okay.  This shows a second factor within this.  And this is showing the distribution of resource used by individuals.  So you've become more interested in this south of the border in the last year or so, Lord Darzi, I think did a nice op-ed in The Times, I think, about it about seven or eight months ago.  

    This is the data from Perth & Kinross, and it shows us that this group of people here, the 2% of the population, they use 50% of the resources in any given year.  We then look at the next 10%, using the next 33% and we've got about 57% of the population only using 2% of the resources.  When we pull across ... apart the Perth & Kinross data a bit further, what we discover is these people here at this end of the spectrum are more likely to live in Perth city, where there is a hospital, and which may be coincidental, but it could also be one of the factors in that.  

    So you're seeing a very different challenge from the way in which people traditionally understand services.  They understand them as universal.  They are universal, but their use is very much skewed by a parallel. For all of that, we can pull apart all of the data within that to produce the individual care pathways that people have gone through, over the last twelve months, for each of these people. 

    So this is Mr. Smith, who was in the previous data and this shows how he became a high-resource individual within the system.  So he had emergency admissions, he had a delayed discharge, he had care-home stay.  He had a planned admission, he had a further emergency admission and then he died.  He used, when we add it all up, somewhere around £70,000 worth of health and care resources across a particular year.  It made him the 34th highest resource user within the area of Perth & Kinross.  So there's 33 people who used more.  

    But it gave us an understanding of the sort of challenge that we're looking to fix.  We're not looking to fix a universal, general challenge.  We're looking to address the needs of a relatively small number of people within the population, in a different way, to enable them to live better lives.  Because in this space high-resource utilisation, while it may offer good clinical care, is not offering good outcomes to Mr. Smith.  

    Mr. Smith has not had a good year in this.  Mr. Smith has had a bad year and spending Mr. Smith's year was not good in any way.  A delayed transfer of care, frequent emergency admissions.  He had two attendances in one day and the second attendance was the point at which he got admitted.  And all of this suggests that the services that could have been available within the community to find alternatives to that, to find either anticipatory or step-up or preventative, could have been deployed better in a way in which met his needs better. 

    So that takes us, I guess, to one of the key insights that we've got to, in terms of the work which needs to frame the work that we're doing on social care.  Which moves from a model where, and very much coming out of the acute system and the hospital system, which is defined as solution one-time, and roll it out 100,000 times.  We now need to understand far better that we need to find 100,000 solutions, in that the degree of customization that we require to deliver good quality care, sustainable services, is significant.  Simply thinking that we can do and offer the same things for individuals across the piece, no longer works.   

    That's a key insight I think for understanding the nature of the challenge that we now face.  And it does call into question, discussions about spread and about roll-out and about path finders.  Because it does suggest that while you need to develop services within localities, you then have to have the services which are able to customise care for individuals, rather than simply box it up and hand it out.  

    So what does that mean in terms of what we're doing for social care?  Work that we're looking at, at the moment, is trying to bring together both the strategic direction, what we're trying to do as a national policy.  And I'm not particularly keen on policy.  Policy tends to suggest that we have an answer that we're giving to people, which they need to adopt and they'll do well with.  But a strategic approach to what we're doing and bringing that together with the local delivery system.  

    And I'm going to say a wee bit about how we actually work across that.  And  bringing that together and seeing that as part of a broader programme of reform.  So a matching up between what we're doing nationally, with what the delivery system is doing locally.  And sufficient interaction between those processes to give confidence that we're getting the sort of change that we want to get.  

    It gives us five broad domains of areas that we're working in.  So top left, what we buy.  And this is the idea that we're moving beyond, and it was in the SNP manifesto, moving beyond a process of procuring on the basis of time and task.  We have basically, in Scotland from 2002, 2003 onwards, with competitive tendering, with procurement-driven approaches, have taken social care ten years backwards in terms of the approach that we need to deliver.  

    So an approach that moves away from time and task and increasingly focuses on commissioning for outcomes.  And understanding that we're commissioning for outcomes in the context of a wider set of services.  So the people who are doing the commissioning are also commissioning primary care.  They're also commissioning community health.  And within that space, what we're beginning to talk about is the degree to which you can commission NHS services alongside social care, to get better impact and better quality.  

    But also looking within that to drive innovation.  And, again, it's interesting as to whether that comes at the commissioning point, or whether the commissioning should be setting the question in such a way that allows for innovation to come back from providers and from those delivering and managing services.  So a set of issues around that, but a key insight within that, is that we are very much moving into a commissioning landscape. 

    Secondly, around workforce.  And we have significant Brexit issues, as you will as well.  At the moment, this year, 207,000 people work in social care in Scotland, which is one in twelve of the working-age population.  So we have a challenge that, even if we had more money, whether we could get more people, is less likely to be true.  

    We've found that the work we've had in Scotland to implement that national living wage, the £8.45 figure, not the £7.20 figure, has actually changed the relationship in many areas between local authorities and providers.  We effectively had to renegotiate every social care contract that we had in place over a six-month period, as opposed to over a three- or four-year rolling period.  And that changed the nature of the relationship between providers.  

    It allowed us to see some of the issues across multi-local authority area providers.  But also issues around differentials of the same service costing very different things across the place. We're driving activity around the value of care and how much we pay care.  And so you can be sure that in Scotland, if you work in the social care sector, you will get at least £8.45 an hour.  And that's probably still not enough in terms of what we're trying to do. 

    We've a National Health and social care workforce plan, again an integrated plan that will come out later in the year, thinking across the piece.  And we've got further work on Fair Work in Scotland under the Fair Work Convention, which is not a 1960's skiffle band, which some of you may remember.  

    We've the same set of issues around who pays, who gets.  So we have free personal-nursing care within Scotland.  We've had charging reform which focuses on further fairer charging in Scotland.  Fairer charging has yet to result in anybody paying more and it's part of a general Scottish drift towards universalism.  And that's beginning to bring out the challenges to us.  Free nursing and personal care has also probably reshaped the nature of the service which is offered.  And so, I think the likelihood that you'll get anticipatory or preventative services is now lower, on the basis of the statutory requirement to provide personal care.  

    But also looking at issues around eligibility and assessment and portability.  So a set of issues here where we've watched Dilnot, we've watched Barker, we've watched the conservative manifesto.  We've now seen the Queen's speech.  The issues that are unresolved here about the balance between public payment for services and private payment for services, we are in the same space.  And we are probably no further forward than you are in terms of finding an answer to that.  It hasn't yet got out of balance for us, because of how we've deployed resources more generally.  

    We've a set of issues also around developing community capacity.  And that's thinking beyond the direct provision of services to people, to how we actually tap into wider third and voluntary sector activity, support carers more effectively.  But also begin the reform process within the third sector.  And it's interesting that integration has gone through waves.  As first of all it was for the NHS and they understood that they were changing.  

    And then local government understood it had to change, it didn't really think it was going to have to, it thought it was all about the NHS.  And we've now got as far as the independent and third sector, who now understand that, actually, they need to change as well.  And this wasn't just for their benefit.  National Health and Care Standards published about ten days ago in Scotland again, also trying to bring common definitions of quality across the health and care sectors.  And we're about to review the regulatory frameworks that the care sectors work to underneath that.  

    That's the strategic agenda, those are the issues that are wrong and I can't imagine that they're any different here. And we don't have answers to many of them.  We have some answers, but we don't have all the answers.  And we have big commitment to reform programme.  

    The second thing, I think is quite interesting though, is  how we work across the system.  So we don't have a Scottish Government NHS split.  So I sit on the Board of the NHS in Scotland.  We meet every two weeks on a Wednesday morning.  And we effectively are the management executive for the NHS in Scotland, in terms of how we engage with that.  So we don't have the split like you do with Simon Stevens.  

    That means that when things are not going well, I am the person who's pulled in to see the Cabinet Secretary, or indeed the First Minister, to account for what's going on within a system.  And that's quite challenging, because I'm an arch-localist, I want to push autonomy and authority out to the system.  So in that setting where we're trying to create the space that localities can do the exceptional things that we would never think of, how do we then manage that interface across it a national expectation and a local delivery?

    And we do a few things.  So we use the data, which I showed you earlier, because the data is disruptive.  At some point there's a book out there which is 'everything you thought about health and care is wrong', because every time we pull the data apart people's beliefs about what was going on are shown to be false.  Really interesting.  

    We invest significantly in improvement support.  We work with the IHI, we work with the Health Foundation, but we also have work from Healthcare Improvement Scotland, that operates across the system to provide support to integration authorities to take forward change.  Because if we have a belief that localities will need to build their solutions from their local assets, with their resources, with what's available to them, we also need to understand that change doesn't just happen.  In the same way it doesn't happen by me writing a strategy, it doesn't happen by people sitting down and saying things will be different.  It takes work and it takes support.  And there's an evidence base as to how to do that.  And we then give national direction and support to that.  

    So I spent last Friday with all the Chief Officers.  Over the next six to twelve months I will go out and visit each partnership at least once.  I'll meet with the Chief Officer, I'll meet with the Chief Execs of the Health Board and we will spend time on the ground with partnerships, learning about what's going on, talking to them.  Hearing what the issues that they want to give back to us, but also offering challenge to them in terms of how they're making progress.  

    And that's a process which is iterative, and the agenda's developed out of that.  But it gives us an engagement which gives confidence, such that if we think that things are going awry in one of the areas, we can get on the phone and talk about what's going on and what support might be required, or what other factors might be in place around that.  But built within a space of trust, so I don't ring up and shout at people, although there is apparently an evidence base for that, my acute colleagues tell me. And I don't require them to report more than once on a regular cycle, rather than three times a day, which again I understand there's an evidence base for.

    So where are we in terms of integration and the work on this?  The integration story's  been quite interesting and I think what we're going to see is a very similar story around the social-care reform process.  So while people say they want to talk about the fundamentals, the outcome's what it's about achieving.  People do tend to gravitate back towards the safe space, which is arguing about organisations and process and structures.  So keeping the discussion in the right place.  So the slide earlier is, helping people live the lives that they want to live is a touchstone for all of us.  So if you keep that in mind, as to what we're trying to do, you are less likely to go wrong.  

    Key throughout the process is behaviours.  And we're seeing an interesting phenomena across 2017, 2018 already, as Chief Officers begin to engage in commissioning hospital services.  And I think none of my NHS colleagues ever expected that they would do that.  So they're beginning to say, "This year I will buy less unscheduled care from you.  And I'm going to take that money and I'm going to spend it on social care or primary care or additional community nurses."  But in that context we're seeing a lot of push back.  

    So this is a very challenging environment, it's a very tough environment where there are very strong personalities and people who have got ... built careers around doing things in a very particular way, are now being challenged on that.  It's requiring a different sort of leadership, in that the expectation is collaborative.  And so people who present and say, "I can fix this for you if you give me all the power".  They're not our people anymore.  We don't need them, they had their chance, and where are we now?  Everybody wants change, but it's easier when other people have to do it.  So change is about everyone.  

    And one of the biggest challenges in that has been for us in the Scottish Government, in terms of the models that we have, about how we interact with the system and understanding that we need to learn new behaviours for the new system.  And that is remarkably challenging, particularly in the political context, where we have to show progress.  Some really hard-edged challenges where it has to work quickly.  

    And one of the examples of that, and Richard mentioned delayed transfers of care.  Around two and a half years ago when the current administration came in, following the independence referendum, Alex Salmond resigned, Nicola Sturgeon took over, we had a wobbly week around delayed discharge and my Cabinet Secretary committed to eradicating it, which is quite a bold offer. 

    And my Director General, brought me in and said, "Geoff, I want you to think differently about this and I'd like you to eradicate delayed discharge in Scotland."  And our traditional method for that would have been to set a target, throw money at it, to make demands and shout at people.  All of which have an evidence base, my acute colleagues tell me, but we said that we wouldn't do that and we would try and avoid short-termism. 

    So we have thrown almost no money at it and certainly no recurring money at it, over a period.  And I'm currently sitting at a figure which is 70% of the figure it was two and a half years ago.  So I've taken the number of delayed discharges in Scotland down by 30% by working differently across the system and building.  

    And that has given confidence to the First Minister and Cabinet Secretary that locality-based long-term approaches, community-orientated approaches, which act to reduce admissions and build capacity, build re-enablement is actually driving building the evidence base into the process.  But within a context where we say to people, "We don't want you to give us a short-term fix.  We want you to find a solution to this, which is sustainable."   

    And finally it's iterative.  So if I came back in six months' time I'd probably talk to you about something else and that's the reality of where we are.  So thank you Richard.  



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