Health and social care – all in this together?

Tough bananas
Tough bananas. Picture: Wonderlane
Tough bananas
Tough bananas. Picture: Wonderlane

So we’re having another go at integrating health and social care – about time too: it’s been a good eight years since LHCCs transformed into CHPs or CHCPs, so we must be due for a change of acronym by now.

Step up Health and Social Care Partnerships (HSCPs? HaSCPs?). These new bodies will replace CH(C)Ps, and are at the heart of the Scottish Government’s vision for an integrated health and social care service, initially for adults, but local areas will be free to be a bit more wholesale about it if they want.

The key difference is that the new organisations will be the joint responsibility of the NHS and local authority. This will be written into law – so if, for example, a local authority doesn’t want to delegate budgets, then tough bananas, they’ll have to. NHS boards and local authorities will be required to produce integrated budgets for adult health and social care services, and partnerships – working with the third and independent sectors – will be responsible for delivering new nationally agreed outcomes.

It should mean – as the consultation document published today says – that there is “a system of health and social care in which resources – money and people’s time – can be used to best support the individual at the most appropriate point in the system – regardless of whether what is needed is ‘health’ or ‘social care’ support”. In other words, there will no longer be any excuse for a quarrel over whether something is a “health” bath, or a “social care” bath, with the bill going to the “loser”.

Personally I really, really hope this works, but forgive me for sounding cautious. Who was it who said a second marriage was a triumph of hope over experience? Well that’s kind of how I’m feeling. Back in 1999 when local health care co-operatives were formed I thought they sounded a great idea: essentially voluntary groupings of GP practices, LHCCs were supposed to work together with local authorities and the voluntary sector to deliver a wide range of primary and community health services.

Now, much as LHCCs are often seen through rose-tinted spectacles, believe me, they weren’t perfect: far from it. While some were fabulous, and achieved great things for their local communities, it was generally acknowledged that development was patchy, at best. Major concerns included a lack of clout – they weren’t statutory bodies – and, despite the fact that they had GP practice involvement baked in, as it were, there were still fears about a lack of clinical engagement.

Five years later we saw the launch of CH(C)Ps – again, I was quite excited (I don’t get out much). These were statutory bodies, so they actually had some financial rights (albeit only to health board community budgets) and they had more involvement from the wider primary care team – in other words, it wasn’t just GPs.

There was however, in hindsight, a lack of prescription from the centre – in an attempt to allow local flexibility, to cope with Scotland’s varying needs in terms of geography and demography, health boards were actually pretty much allowed to develop CH(C)Ps in their own way. Again, some were great; others less so. Indeed, the rows and contortions around development of some of the “partnerships” in Greater Glasgow in particular will probably make a film at some point, or at least a BBC Scotland radio drama. A lack of clinical engagement with CH(C)Ps, especially from GPs, has been a particular issue, across Scotland.

And now we have HSCPs – and I really, really want to be excited again. As we’ve seen, the consultation document published today tries to address some of the major issues with both LHCCs and CH(C)Ps – including making GPs and other clinicians a bit more involved in the process. But will it be enough?

Nicola Sturgeon is under no illusion that it’s a big task, and is keenly aware that this is not the first time that this marriage has been attempted. In evidence to the Health and Sport Committee, she said that previous lack of success was in part due to “too much local choice about the degree and extent to which integration happened”.

She added: “We had no genuine joint accountability; we still had separate silos of accountability. I do not blame health or local government for that because, in truth, on different occasions one or the other will have been more responsible, but the separate lines of accountability have meant that it is too easy to pass the buck.”

The current consultation makes it abundantly – and rightly – clear that legislation is only a part, indeed, quite a small part, of the change which will have to happen if this new attempt at integration is to be a success. Cultural change is a phrase that is often bandied about, but it’s apt here. Creating truly integrated care will involve a great big melting pot in which professional, organisational and other differences will have to be put aside. And, put bluntly, that involves changing people, which isn’t easy.

Nicola Sturgeon - current systems make it "too easy to pass the buck"

Initial reaction from the relevant trade unions has been cautiously positive, with both the BMA and RCN in Scotland welcoming the document’s recognition of the important role to be played by clinicians. Indeed, RCN Scotland director Theresa Fyffe sounds almost optimistic, if a bit battle weary. “After numerous attempts to better integrate health and social care over the years,” she says, “there is growing impatience among patients, and the staff who care for them, to provide seamless services which no longer allow patients to fall through the gaps.

“With the right political will, coupled with the commitment of nurses and other members of the health and social care team, it should be possible.”

The BMA’s Scottish chair Brian Keighley is chuffed that it’s ciao to CH(C)Ps (the BMA was calling for that even before the first CHP was set up!), but hopes HSCPs won’t get “bogged down” in bureaucracy. “We are therefore pleased that the Scottish Government has explicitly stated that the role of doctors will be strengthened in these new structures,” he says.

But – as controversy over integration already taking place in Highland only underlines – it’s a rough road ahead, and one which, moreover, is being taken at a time when resources are pretty thin on the ground.

Despite my previous disappointments, however, I’m still rooting for this to work – frankly, with ageing populations, more ill health and less money around, it bloody well has to. My optimistic self even hopes that the current financial and other pressures might prove a spur to successful change, rather than a barrier.

So I’m a bit excited – cautiously excited, but excited nonetheless. I do wish they’d called them something else, though: HSCP sounds more like a bank – and that wouldn’t augur well…