Where does health care end and social care begin? 20 years along the road to integration

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As part of the programme to mark 20 years since the creation of the Scottish Parliament, SPICe has been publishing twenty “20 year” blog posts on SPICe Spotlight over the course of 2019.  Our earlier post sets out more information on the programme and the series of blogs.

You may already have seen the earlier blog on the NHS in Scotland since devolution, which asked “Has devolution been good for our health? This one focuses on the current efforts to integrate health care and social care in Scotland.

A bit of unpacking: the difference between health care and social care

 Broadly, health care is all things NHS, while social care covers the extra, non-medical support people might need at home or in a care home.

 However, contrary to popular belief, care isn’t free. No really, social care has never been free to all. Well, who knew? Don’t most people think that our health service, (and by extension, social care,) is a “cradle to grave service”?

In 1948, when the NHS was established, the collective financial risk was pooled across the population. Social care, such as care for older people and adults with disabilities, was not included. It was to be means tested. It still is.

What’s interesting is that in the 1940s there was no definition for what we now think of as social care. Doing the right thing in terms of public health and care just didn’t work that way. The links between poverty and poor health were the striking preoccupation that led to the NHS, and the main focus was on improving the health of the nation to remove that inequality. Social care’s heritage, on the other hand, goes back to Victorian Poor Laws, and centred on local responsibility for looking after those who were without financial means.

If you’re interested to know more about this history, you could read what Pat Thane, Leverhulme Professor of Contemporary British History at the University of London, wrote when she sent a memo to the House of Commons Committee Inquiry to help them with their social care inquiry in 2009.

So what is health and social care integration about?

 Health and social care integration has been established in law in Scotland since 2014, when the Public Bodies (Joint Working) (Scotland) Bill was passed. As outlined above, the two spheres – the NHS and social care – have a different history and legislative basis, making a seamless ‘integration’ a challenging venture. This 2014 Act has more direct impact on how health services are governed, designed and organised rather than on social care. I go into the legislation a bit more below, but in brief, the Act requires the formation of a new body to aid the collaborative organisation, by health boards and local authorities, of health services locally to improve population health. Many hospital services are also included. Perhaps having both terms, health and social care, under a combined working title demonstrates optimistic anticipation that the two domains will become one, on a continuum of prevention, care and support.

So how does it work when there are two different systems running things?

 Well, five years in, integration has not been straightforward, not aided by a common and pervasive misapprehension that social care is free. Successive governments have not loudly proclaimed the separation between the two realms, so people arrive at the point of needing extra help and find out, at their most vulnerable, that all they have the legal right to is an assessment of their care needs, not free social care.

To put the problem another way, people might ask “Why should someone with dementia pay for their care needs while someone with cancer is cared for within the NHS?”

But what about ‘free personal care’ I hear you ask?

Some argue that this has been a transformative policy, recently extended to those under the age of 65, and everyone is eligible regardless of income. There is no such policy in England. However, it is not as simple, or as free to all as it sounds. And this goes back to what local authorities are required to do for people in need under Sections 12 and 12A of the 1968 Social Work (Scotland) Act.

The Community Care and Health (Scotland) Act 2002 introduced free personal care for adults, regardless of income or whether they live at home or in residential care.

Free personal care is available to cover help with basic care needs such as washing, dressing and eating.

All sounds very good. However, there is a rather large ‘BUT’. Such care is available to all of those that social services assesses as needing it. National criteria based on risk, are used to assess needs. These have a subjective element that means, in short, that when local authority finances are stretched, and as need increases, then someone who was assessed as needing care in more affluent times might not be deemed eligible when times are tougher.

A bit about the aims and integration’s backstory

 And so, back to the attempts to integrate these two disparate, and highly emotive policy areas.

As you can see below, the journey to integration started with the Scottish Parliament’s inception. By the time we get to the introduction of the Bill in 2013, the ambition was clear: to improve the quality, consistency and seamlessness of services across the two domains of health and social care, which would also result in budget efficiencies of up to £157 million(SPICe Briefing 16/70) through finding a solution to ‘bed blocking’ and preventing people going to hospital with avoidable injuries and conditions – falls in the elderly population and type 2 diabetes, for example.

Audit Scotland have been following progress very closely, as has the Parliament’s Health and Sport Committee, and below is a time line covering the last twenty years, which shows how this major reform has developed. You’ll notice that the focus has been on healthcare:

SPICe_2019_Blog_20th Anniversary_ Integration_Timeline

The legislation – the final piece of the jigsaw?

The title of the Public Bodies (Joint Working) (Scotland) Act 2014 is not particularly descriptive of what it entails. The public bodies involved are the 14 NHS territorial health boards, and all Scotland’s 32 local authorities.

Despite the working title of “health and social care integration”, how social care operates in practice is not really been changed by the legislation. What has changed is that aspects of healthcare are now within the scope of local authority responsibility, in collaboration with health boards under a new legal organisation, an “integration authority”. The intention is that local authorities and health boards become equal partners in how services are organised to meet the needs of their populations.

Councils and NHS boards have to integrate the governance, planning and resourcing of

  • adult social care services
  • adult primary care and community health services
  • some hospital services.

The hospital services included in integration are the inpatient medical specialties that have the largest proportion of emergency admissions to hospital. These include:

  • accident and emergency services
  • general medicine
  • geriatric medicine
  • rehabilitation medicine
  • respiratory medicine
  • psychiatry of learning disability
  • palliative care
  • addiction and substance dependence service
  • mental health services and services provided by GPs in hospital.

The Act also allows NHS boards and councils to integrate children’s health and social care services and criminal justice social work.

This reform is radical, and, as you can see, most health care is covered by the legislation. The integration authorities should direct the budgets for all of the integrated services. How successfully this has happened over the past three years has been the subject of considerable scrutiny by the Health and Sport Committee and Audit Scotland

So who is responsible and accountable for what?

Health boards and local authorities are very different kinds of public body – with the former being directly accountable to the government of the day, and the latter accountable to local electorates. So how could accountability operate under integration?

With the legislation, all the parties were invited to decide how they wanted to integrate, in one of two ways.

NHS Highland and the Highland Council had been piloting one model, the so-called ‘lead agency’ model, meaning that one body – the health board or the local authority would take the lead in planning and delivering services, and no new tier of accountability is required. In Highland’s case, the health board take the lead on adult services and Highland Council take the lead on children’s services. Highland is the only integration authority using the model. All of the others decided to create an Integrated Joint Board (IJB).

Audit Scotland have produced this graphic summarising the relationship between the various bodies and where accountability lies. As you can see, it isn’t straightforward. Further complexity arrives when we consider that local authority boundaries and health board boundaries do not map onto one another. So, one health board might have relationships with one IJB or several.

SPICe_2019_Blog_20th Anniversary_ Integration-03.png


SPICe_2019_Blog_20th Anniversary_ Integration_IJB Model

So what’s next?

It is fair to say that bringing together two very different cultures, each with a different ethos, not to mention different structures, pay scales and notions of medical and social models of care, has had its challenges.

The other, perhaps bigger challenge is that of public perception, one in which health is associated with doctors, nurses and hospitals, and not with local authority services and infrastructure.

As well as streamlining services, integration is also intended to steer us (and integration authorities) away from a focus on clinicians and hospitals, and towards supportive, community-based services that prevent ill health and maintain independence into old age.

Some things continue to challenge this huge shift, some of which sound surprising, such as medical and technological advances in acute care, risk aversion and the rising costs of medicines. Of course, there are also more familiar issues, such as an expanding older population and people with a number of health conditions requiring treatment. There is also a lack of funding to be able to continue to pay for and invest in expensive hospital care (and all of the innovation and new medicines) at the same time as investing in all the things that will prevent us needing that hospital care in the future.

The question that hangs around over this new world, is whether health and social care integration was really intended to save money for the country’s most expensive service, the NHS? In the context of a budget of around £14 billion, £157 million  is not a huge amount. Can we really stop, or would we want to stop, medical advances? And do people, as they age need more medical care or a social care service that ensures their independence? Both require investment, especially as the number of older people rises.

The journey of integration is not complete. Possibly social care is where the next big reform in Scotland will happen (despite the promise of Self-directed Support legislation). Watch this space.

Anne Jepson, Senior Researcher, Health and Social Care