This blog will explore the progress of health and social care integration. It will evaluate this progress against the core suite of integration indicators and summarise progress since 2019.
The blog has been written by Noorjahan Hossain, who has been on a placement with the Health and Social Care team in SPICe during Summer 2021.
What is integration?
Health and social care integration seeks to link social care services and healthcare to create a coherent, person-centred approach. Distinctions between ‘health’ and ‘care’ needs and separated service delivery should disappear.
Integration is seen to have two major benefits:
- It should improve community-based health care, reducing risk of hospitalisation
- It helps to support independence in the increasing ageing population, who are at a greater risk of disease and emergency admission to hospital.
For instance, 90,000 people in Scotland have been diagnosed with dementia. This mainly affects older people and is best treated socially and medically. Integrated services could support patients to remain in their community for as long as possible and improve quality of life.
The Public Bodies Act (2014) aimed to ensure that integrated care services are designed collaboratively. The Act created 31 Integration Authorities (IAs) or Health and Social Care Partnerships (IAs). Each has its own localities and the Boards are made up of members of the health board and local authorities. Together they create Strategic commissioning plans to integrate services.
How is integration progressing?
This blog is an update on SPICe’s summer 2019 research briefing ‘Health and Social Care Integration: Performance and Spending Update’. Here we will consider whether performance has improved since 2019. In an accompanying blog ‘Health and Social Care Integration Part 2, we shall see which the data gaps highlighted in the 2019 briefing have been addressed?’
How is integration assessed?
The image below shows the nine expected outcomes of integration, and associated indicators. A core suite of 23 integration indicators were created to measure progress against these outcomes. IAs see these indicators as targets that all their strategic commissioning plans should work towards. However, there are no minimum standards/values accompanying the indicators. They are formulated to inform how services should be developed.
The first 10 indicators gauge people’s experience with services. The remaining 13 show hospital derived data. Comparing this data should help the Government, Parliament, MSPs and all other interested organisations and individuals understand the progress of integration.
The public experience with integration
This section will investigate indicator 1-9 results from 2019-20, collected form the health and care experience survey.
The figure below shows that on Indicator 8, the ‘percentage of carers who feel supported’ has decreased in several areas since the 2017-18 survey. The reasons for this are not clear from the data, but it might be expected that, following implementation of the Carers (Scotland) Act 2016, carer satisfaction might have improved in more areas.
In the next chart, we use a ratio to compare the progress of indicators 1-9, about how people experience services, against optimal results. This approach indicates whether the population feels supported by services and whether they feel they are positive about their health and wellbeing. Scores range from 0-1, where 1 is the best result.
As we can see from the chart below, there is some variation in the scores, although most areas score over 0.75. This suggests, as would be expected with 31 IAs, implementation of integration is progressing at different speeds in different areas of Scotland. While this is a useful snapshot, more analysis is needed before we can determine other factors that may influence this score.
IAs with higher scores show a statistical correlation with:
- reduced emergency readmission to hospital within a month of discharge
- higher proportion of last six months spent at home or in a community setting
- reduced percentage of health and care resources spent on hospital stays
Whilst correlation, of course, doesn’t mean causation, it could indicate that community-based services are functioning better, leading to a reduction in emergency admissions and long hospital stays.
Service utilisation and integration
This section investigates indicators 11-20.
Hospital data was last updated mid-2020. The graph below shows change from 2019 data to 2020 in four indicators across all IAs: delayed discharge, emergency admissions, over 65 falls, and percentage of adults with intensive needs receiving care at home.
The indicators show, in the main, better performance in all of these indicators, with a few exceptions – fewer falls, fewer emergency admissions, more people receiving intensive support at home and reduced delayed discharges.
Hospital data can act as a proxy for community-based care, inasmuch as fewer emergency admissions would mean better preventive care is in place, and lower delayed discharge rates suggest better availability of social care support. However, the pandemic’s influence on hospital data means that the picture isn’t as clear as it might be.
Indicator 16 (over 65 falls) is a good indicator to understand the support provided to older people. In most IAs, falls have reduced, suggesting more focus might have been placed on falls management with older people.
Finally, integration should mean that home care is available to support all those who wish to remain living independently at home. Indicator 18 data on the chart again highlights variation across Scotland.
Are the indicators accurately measuring the outcomes?
Indicators 1-10 attempt to show how the population perceive their health and support. This information is gathered from a survey, which will be influenced by an individual’s awareness of health matters more generally.
For instance, Indicator 1 measures how well individuals can look after their health through the question: “In general, how well do you feel that you are able to look after your own health?”. This is a subjective measure and relies on/assumes a level of health literacy. Access to health information, healthy foods and healthy environments are not distributed equally across the population.
Qualitative indicators are harder to interrogate. However, the results provide a starting point for integration authorities in carrying out follow-up work in why people provide the answers they do to these questions.
Outcome 8: Engaged workforce
This is measured by ‘percentage of staff who recommend their workplace as good’. There could be scope to deepen insights in this area, with further, more detailed questions.
Hospital data indicators
Indicators 11-23 are made up of health statistics to understand hospital utilisation and population health. The majority focus on hospital care and don’t investigate the impact or use of social care services. Theoretically, improved integration would reduce the risk of hospitalisation, however this doesn’t effectively evaluate social care services. The next section will explain this further.
Outcome 5: Health Inequalities
Health inequalities are defined as ‘unjust and avoidable differences in people’s health across the population and between specific population groups’. This is measured by:
- premature mortality rate
- emergency admission rate.
Health inequalities can increase the risk of premature death and emergency admission; However, these inequalities can be a result of socioeconomic factors, so this set might be improved by adding further information in these areas.
What do social care services data show?
My Local Council shows information on homecare hours provided by IAs. Only half of local authorities show an increase in homecare hours since 2016, when all the IAs were formed, as shown below. This indicates that there could be issues in providing homecare, either because of budgetary constraints, demand, or staff availability. Again, further work is required in understanding the variation across the country.
In 2018, there was a detailed report explaining social care services in each locality. However, the report saw various data gaps and didn’t link the data to the nine outcomes of integration or healthcare data.
- Integration data (and therefore understanding of progress) has been impacted by the pandemic and the measures put in place
- There is, as yet, little available data on social care activity that aligns directly with the indicators and outcomes
- Integration of health and social care data shows wide variation across the country, making conclusions about progress difficult. Further, the data isn’t sufficient to explain that variation
Noorjahan Hossain, MSc Global Health Student from Aberdeen University, who is interested in the development of community-based care and the adapting nature of the healthcare system, Health and Social Care Team.