Lloyd D Hughes, out of hours GP, NHS Tayside and NES GP Academic Fellow, University of St Andrews
The challenges facing the UK’s social care services are well-documented. An Age UK report estimates that, in England, 54 000 people — or 77 a day — have died while waiting for a care package in the 700 days since the UK government declared (in March 2017) that it would publish its social care green paper.1 The broader challenges of local authority funding, and the care-home market crisis have exacerbated these challenges.2
A commonly proposed approach to developing health and social care is integration – purposeful working together of independent elements in the belief that the whole is greater than the sum of the individual parts.3 System-wide approaches to health and social care integration may make intuitive sense, but evidence to date has not been positive. In Wales, the 2014 National Integrated Care Fund was introduced to develop a system wide approach to health and social care. However, an Audit Wales report in 2019 noted little evidence of successful projects being mainstreamed and funded as part of public bodies’ core service delivery.4 Audit Scotland has criticised the slow progress towards health and social care integration in Scotland.5 The 2018 report was published 4 years after the 2014 Scotland health and social care legislation was introduced, with the formation of 31 integrated joint boards (IJBs) and Health & Social Care Partnerships (the associated delivery arm of service).
“We need a system that is controlled nationally, that delivers locally, has the person at the centre, that does not cost the earth”.
On this challenging background, the Independent Review of Adult Social Care in Scotland (IRASC)6 makes fifty-three recommendations within three overall themes: shifting the paradigm, strengthening the foundations and redesigning the system. A core recommendation is the development of the National Care Service, a significant structural reform within the Scottish healthcare system. The report comments “We need a system that is controlled nationally, that delivers locally, has the person at the centre, that does not cost the earth”.
The implementation of such a vision will be a challenge.
There are three important areas for primary care: Firstly, the IRASC proposes that implementation of the National Care Service should involve reforming the current integration authorities (all but one are IJBs) into Community Health and Social Care Boards (CHSCBs). It is proposed that the CHSCBs will become the local delivery body for the National Care Service, funded directly by the Scottish Government and accountable to Scottish ministers. They will be the sole model for local delivery of community health and social care in Scotland, which does provide concern regarding the model being appropriate for different areas with significant health needs (social-economic / geographical etc). Crucially, the CHSCBs will employ staff, hold assets and contracts, including the GP General Medical Services (GMS) contract. This is a huge step-up for these relatively new bodies, which at present only employ relatively small numbers of staff and have been noted by the IRASC to lack strategic capacity and integrated financial planning.
…the new structure may simply divert money from one area of need to another on a background of underinvestment in primary care.
Secondly, the scope of the National Care Service and its role in contractual arrangements with primary care, with CHSCBs holding the GMS contract is significant. GPs have held contracts directly with NHS Trusts directly for decades and have strong working relationships. The level of understanding that CHSCBs have of general practice is perceived as weak in several areas, and there have been concerns with regards to GP representation on several IJBs. Indeed, the new structure may simply divert money from one area of need to another on a background of underinvestment in primary care. There should be utter clarity that the redesign will not be used to undermine the independent contractor status of general practice, and that there will be continued commitment to invest and support primary care. The nature of involvement of GPs and the current cluster model within CHSCBs should be clarified to ensure that general practice is fully involved in the process at all stages. At present, the IJBs simply do not involve GPs and primary care teams enough, reflected on the make-up of the boards, and as such are not able to inform best general practice.
Thirdly, the IRASC vision of developing a seamless integration and data sharing between health and social care is commendable but not achievable at present. There are much more pressing areas where information technology investment is required, such as developing data-sharing between Scottish NHS Boards which have regular cross-over of patients, and improving communication between secondary and primary care IT systems which at present is limited at best. There is a risk that over ambitious IT visions will simply lead to high costs and poor outcomes,7 so focus on important clinically important IT improvements should remain the focus presently.
There are numerous barriers to successful implementation of integrated care systems. These include a lack of commitment across organisations with different aims and objectives, limited resources, poorly functioning information technology, poor coordination of finances and care pathways, and direct conflict within teams.8 It is unclear at present how the proposed model will address all these barriers. Furthermore, there are concerns that the current proposal will simply exacerbate the well documented inverse care law, with CHSCBs who are more financial astute, able to recruit more effectively and have better engagement with their community likely to lead to much better health outcomes for their patients and communities. There must be a worry that over 30 CHSCBs in the size of Scotland represents a risk that there is significant divergence in health outcomes. Integration policy needs a greater a focus on inequalities for our vulnerable communities, and the current proposals simply do not address this. Other work focused on integrated care such as employing care navigators within primary care teams and embedding social care workers within enhanced care support teams require investment9. Indeed, Scottish work looking at improving care for patients in the 100 GP practices with higher level of deprivation noted the important of a sustained and integrated package of measures with 6-key elements9 (see below).
Six elements to deliver sustained and integrated general practice9
- Deep End practices need more time and capacity to address unmet need.
- Best use needs to be made of serial encounters over long periods.
- Practices need to be better connected with other professions and services as hubs of local health systems.
- There need to be better connections between practices across the front line, following the example of the Deep End Project.
- The front line needs to be better informed and supported by NHS organisations.
- Leadership needs to be developed and supported at practice and area level for all of these activities.
Significant redesign and change within an already fragile and stretched system will take time to deliver the vision highlighted in the report. To that end there must be a plan to manage the challenges currently faced. As a first step, the Scottish government should urgently address short-term funding pressures, to prevent further deterioration in access, experience and outcomes for people needing social care support. This needs to be accompanied by immediate work to aid the fragile provider market10, including supporting an increase in the amount local authorities can pay for care. Policymakers should consider that adequate supply of social care services (long term care and community). Furthermore, social care sector reform must be underpinned by improved pay, conditions and training for the social care workforce, bringing these more into line with those seen in the NHS, or there will be a chronic shortage of skilled staff to provide the care our society needs. The diverse nature of the sector and significant independent sector provision means this is likely to require a combination of central funding, regulation and legislation.
Overall, the IRASC makes some useful recommendations for the improvement of the adult social care economy. Focusing upon the implementation of the National Care Service and associated large-scale structural reform of Scottish general practice is not the place to start.
1- Age UK. More than 50 000 older people have now died waiting in vain for care during the 700 days since the Government first said it would publish a Care Green Paper. 2019. https://www.ageuk.org.uk/latest-press/articles/2019/february/more-than-50000-older-people-have-now-died-waiting-in-vain-for-care-during-the-700-days-since-the-government-first-said-it-would-publish-a-care-green-paper (accessed 29 Sept 2021)
2- Hughes LD, Keeble M. Investing in social care to reduce healthcare utilisation. Br J Gen Pract. 2019 Dec 26;70(690):4-5.
3- Berwick D. Medical associations: guilds or leaders? British Medical Journal 314:1564-5.
4- Auditor General for Wales. Integrated Care Fund. Cardiff 2019. Available from: https://www.audit.wales/sites/default/files/integrated-care-fund-report-eng_11.pdf (accessed 10 Oct 2021)
5- Audit Scotland. Health and social care integration: update on progress. Edinburgh 2018. https://www.audit-scotland.gov.uk/uploads/docs/report/2018/nr_181115_health_socialcare_update.pdf (accessed 10th October 2021)
6- Scottish Government. Independent Review of Adult Social Care in Scotland. Edinburgh 2021. Available from: https://www.gov.scot/publications/independent-review-adult-social-care-scotland/ (accessed 10th October 2021)
7- Kaplan B, Harris-Salamone KD. Health IT success and failure: recommendations from literature and an AMIA workshop. J Am Med Inform Assoc. 2009;16(3):291-299.
8- Kozlowska O, Lumb A, Tan GD, Rea R. Barriers and facilitators to integrating primary and specialist healthcare in the United Kingdom: a narrative literature review. Future Healthc J. 2018;5(1):64-80. doi:10.7861/futurehosp.5-1-64
9- Watt G, Brown G, Budd J, et al. General Practitioners at the Deep End: The experience and views of general practitioners working in the most severely deprived areas of Scotland. Occas Pap R Coll Gen Pract. 2012;(89):i-40.
10- Department of Health. Competition and Markets Authority. Care homes market study. London 2018. Available from: https://www.gov.uk/cma-cases/care-homes-market-study (accessed 10 Oct 2021)
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