The Dis-Integration of Health and Care

Nick Kempe

It is now ten years since the Public Bodies (Joint Working) Act 2014 created “integration authorities” with the ostensible intention of improving primary health and social care services for adults by forcing them together under one structure. This followed over a decade of more voluntary attempts, from Local Health Care Cooperatives to Community Health Partnerships, to do the same. It hasn’t worked, as anyone with any experience of health and social care services should know.

Audit Scotland’s latest report, published two weeks ago, is important because it provides official confirmation of the failures of IJBs to deliver. As evidence for that:
• “The health inequality gap is widening, there is an increased demand for services and a growing level of unmet and more complex needs.”
• “We have not seen significant evidence of the shift in the balance of care from hospitals to the community intended by the creation of IJBs”
• “Collaborative, preventative and person-centred working is shrinking at a time when it is most needed.”
• The percentage of adults supported at home who agree that their health and social care services seemed to be well coordinated is down 73.5 to 61.4%
• “Data quality and availability is insufficient to fully assess the performance of IJBs.

However, available national indicators show a general decline in performance and outcomes. Sharing of data has not improved and performance information, ten years later, remains patchy at best”.

Audit Scotland’s report is also important because it shows that the biggest single factor explaining these failures of Integration Authorities is a lack of resources. This debunks the idea, which it had advocated in previous reports, that if only “Integration” was better managed (e.g. better leadership, better financial planning, better governance etc) this would create efficiencies which would help the Integration Authorities meet the demands being placed on them.

In reality, efficiencies have been replaced by cuts, or as the latest report states:
“Overall funding to IJBs in 2022/23 decreased by nine per cent in real terms or by one per cent in real terms once Covid-19 funding is excluded. The total reserves held by IJBs almost halved in 2022/23, largely due to the use and return of Covid-related reserves. The majority of IJBs reported notable savings, but these were largely arising on a non-recurring basis from unfilled vacancies.”

The result has been many people with care needs now cannot get any service, those that do increasingly have less say on how services are delivered and responsibility for care support is increasingly being shoved onto unpaid carers. While the report makes no attempt to measure the extent of unmet needs or suffering” it does cite evidence from Public Health Scotland which shows:
• The percentage of adults who agree they have a say (“a say” note, not control) “in how their help, care or support was provided” is down from 75.4% in 2019-20 to 59.6% in 2023.
• The percentage of carers feeling supported is down 40% in 2015/16 to 31.2% in 2023/4

Unfortunately, instead of Audit Scotland report dealing with the root of the problem, the lack of resources, it continues to peddle myths that existing resources could be used more effectively and recommends “IJBS need to share learning to identify and develop” a number of actions which it is impossible for them to deliver:
• “service redesign focused on early intervention and prevention” won’t happen because there are not enough resource to meet those with urgent high level needs;
• “approaches focused on improving the recruitment and retention of the workforce” can’t work unless the Scottish Government provides to resources to improve the pay and conditions for staff;
• “improvement to the data available” can’t happen while IT provision is outsourced to a multitude of competing private providers whose commercial interests are incompatible with a joined up system that would enable staff, service users and informal carers to share information effectively;
• “commissioning approaches that improve outcomes for people” is incompatible with much care provision being outsourced to the private sector which puts profit before people; and
• “ensure that their financial plans are up to date” is asking the impossible when, as the report shows, a large percentage of IJBs don’t even know their financial allocations from health boards until after the start of the financial year.

As a consequence, there is no hope of IJBs meeting Audit Scotland’s final recommendation “the need to work together and with other stakeholders to ensure that the annual budgets and proposed savings are achievable and sustainable.” Unfortunately, because of its statutory remit, which is effectively about forcing the public sector to do more with less, Audit Scotland is part of the problem and unable to take a proper critical look at the whole system.

The need for that is pressing because the Scottish Government’s proposals for a National Care Service promise more “integration”, not more resources. Their original model was for centralised ministerial control to force health and social care together, i.e Scottish Ministers thought they could achieve what Integration Authorities had failed to do. The revised model, following the Verity House agreement with Cosla, inserts a ministerially appointed National Care Board between the Integration Authorities and Scottish Ministers but retains all the other measures which will centralise control over primary health and social care (powers to set objectives and priorities, dismiss individual board member etc). This is the opposite of what Common Weal advocated in Caring for All, our vision for a National Care Service.

While grossly inadequate and ever decreasing resources are the biggest single problem facing primary health and social care services, the main way the Scottish Management is trying to manage this is through “integration”. The two are therefore connected. There never was any significant evidence to show putting health and care services under the same management would improve outcomes for those in need: neither health nor social care staff need to share managers to co-operate, all they need is the time to do so and IT systems that share information effectively.

What the integration of health and social care has done is create large and unaccountable structures, where board members owe their positions to patronage, where the primary task of most managers is budgetary control, where the focus of the system is driven by the political imperative of reducing delayed discharges from hospital and where all other “unmet need” gets lost. Much of the truth about the crisis in social care is still being covered up.

While there could be better ways to “integrate” health and social care services than those proposed by the Scottish Government, the question Common Weal thinks needs to be asked is what would happen if care was once again separated from health, with the NHS managing health care services and local authorities managing social care on behalf of a National Care Service? From our perspective, the disintegration of Integration Authorities, as recorded in the Audit Scotland report, offers an opportunity for the sort of radical reforms we advocated in Caring for All.