Learning by doing: integrating health and care in Scotland

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Imagine a place where you could debate and refine policy on integrating health and social care for three years, leading up to legislation. And then, organisations and staff could take a full year to learn new ways of working together in shadow form, with unwavering political support, before becoming accountable for bringing services together to improve health, care quality and value. There’s no need to imagine; that’s what is currently happening in Scotland.

We have been working with the chief officers of integration authorities who are leading the integrated agenda in the 32 local authority areas of Scotland, and we have summarised their experiences so far in a report. When looking at another country’s health and care system it is always interesting to look for similarities and differences with England, and so we offer some reflections.

In many ways, Scotland’s approach to integrated care is similar to England’s. The focus is on getting services to work differently – not on structural reorganisation. Each local authority area decides its own strategy: there is no top-down, one-size-fits-all template. And different rates of progress – in areas with long-established histories of joint working progress is faster than where partnerships have only recently started to develop – are visible both north and south of the border.

But look in more detail, and differences quickly emerge.

In Scotland, more than half of the total NHS and adult social care budget is now delegated to an integration joint board (IJB) for each area (apart from Highland, which has a unique arrangement). IJBs have a statutory basis and are not ‘owned’ by either the NHS board or the local council. This gives them unprecedented scope to work collaboratively to shift resources to community-based services and to develop new models of care as a shared, cross-system endeavour. They are now in their second year of operation and we’ve been able to reference various examples of their work in our report.

Chief officers are the visible embodiment of integrated health and social care in Scotland. They occupy a third seat at the table, to ensure discussions are not just about the NHS agenda or the social care agenda, and they balance a complex set of multiple accountabilities. Strategically, they are accountable to the IJB for how they use their commissioning role to transform services, delivering nationally defined outcomes through integration. But day to day, they are also effectively operations directors, with accountability to the NHS board and the council for day-to-day delivery of delegated health and social care services.

The upside of this way of organising is that chief officers are members of both NHS and local authority leadership and governance bodies as well as the IJB. The downside is that this can be a complicated arrangement – time-consuming and requiring chief officers to wear multiple hats. But this complexity may just be a symptom of a system in transition: different to the old system (although many pre-existing structures are still in place) and not yet the new system (roles and relationships still emerging). 

In a typical Scottish hospital, medical specialties are delegated and overseen by the chief officer, and since medical specialties account for so many unplanned admissions they usually have a high profile in transformation plans. But all the supporting services – from diagnostics through to pharmacy and IT – and all surgical services remain under the NHS board. Nothing illustrates more clearly how tension will arise if the chief officer and NHS board do not work in close partnership. It may create uncomfortable moments, but this symbiosis certainly focuses the mind on the need for effective relationships.

As part of our work, we identified capabilities and ways of working that both chief officers and their partners in the NHS and local authorities will need to work together effectively. Not surprisingly, these centre around developing relationships, managing uncertainty and interdependence in a complex system, and influencing so that others see progress as possible and offer commitment. Sound familiar? The difference is how starkly these issues stand out, when so much is vested in one person as the leader accountable for delivering integration. It can be all too easy to either blame or idealise an individual in this situation and thereby position them as solely responsible for shared system agendas which, by their very nature, belong to the collective leadership community. Chief officers have often needed to hold these system-wide agendas while both they and the other leaders locally go through a process of understanding what integration will really mean for pre-existing organisational and professional roles. Leaders of sustainability and transformation partnerships and integrated care systems in England no doubt also experience this tension. They might be interested in how the chief officers’ role makes it so visible and to share learning about ways of managing it. 

There is much talk in Scotland of developing a social movement to bring health and social care services together around patients’ needs. Again, this may sound familiar to southern ears. But the Scottish approach has a specific orientation arising from the Christie review, a re-set of public sector values that has built consensus on how supporting communities to achieve their potential is the key purpose of public service. Within that context, the absence of a centrally imposed plan leads directly on to the question, so how can local communities and staff come together to develop a collaborative, shared approach to change? 

It is tempting sometimes to think that others – in this case the Scots – have ‘solved it’ (do they look south and think the same about us?). Let’s be clear: they haven’t. Integrating health and social care is far too difficult and messy to have a single solution, and it’s all still work in progress. Given that we are all learning by doing, we should think further about sharing learning across the border – in both directions.

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