agenda no a-.. - north lanarkshire...first is addressing the ‘postcode lottery’ relating to...

NORTH LANARKSHIRE COUNCIL AGENDA ITEM No ...... a......-..

Date: 4 SEPTEMBER 2012

REPORT

Ref: DM/AB

To: POLICY & RESOURCES COMMITTEE Subject: INTEGRATION OF HEALTH AND SOCIAL CARE

From: HEAD OF SOCIAL WORK DEVELOPMENT

1. Purpose of Report / Introduction

The purpose of this report is to seek approval for a proposed Council response to current Scottish Government consultation on the integration of health and social care.

2. Background

2.1 At the most recent Scottish Parliament election the parties adopted differing manifesto positions on the future integration of health and social care services. This is a complex policy area as research shows there is no clear relationship between integration, efficiency, performance and outcomes. There is, though, legitimate public expectation that peoples’ journey through health and local authority systems should be characterised by smooth transition where required, and therefore demand a whole system response.

2.2 On 12 December 201 1 the Cabinet Secretary announced headline proposals for integrating services for older people. This was followed, on 8 May 2012, by issue of a formal consultation document on the planned legislation that is intended to be introduced to Parliament later in the year. The proposals go considerably further than the earlier statement, now relate to all adult health and social care services and state that, whilst older people are the priority, the Scottish Government “will legislate to enable Health Boards and Local Authorities to integrate planning and service provision arrangements for all areas of health and social care”. The proposals have major implications for partner agencies as to how their statutory functions are fulfilled.

3. Content and Analysis

3.1 In announcing the policy, the Scottish Government were clear that they wanted to solve what they perceived as three-pronged problem relating to older people. The first is addressing the ‘postcode lottery’ relating to performance across Scotland’s health boards and local authorities. The second is that they believe there is no incentive to get people out of hospital. The third is that they consider that it is easier to get older people into hospital than it is to arrange health and social services to prevent admission.

3.2 They have set out 4 principles of reform: nationally agreed outcomes; joint accountability (to Chief Executives, Council Leaders and Ministers involving annual accountability meetings); integrated budgets; and strong clinical, professional and partnership engagement, including the independent sector.

3.3 Legislation is proposed to stand down Community Health Partnerships, to be replaced by Community Health and Social Care Partnerships. This would therefore require partner agencies to consider a range of related governance and management matters, including the challenging notion that a single, senior jointly accountable officer can meaningfully oversee such a complex system. Acute systems in particular are highly complex when it comes to older people (as the great majority of care and

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treatment is not provided by ‘care of the elderly’ specialists). Because of this complexity, it has proved easier to integrate primary health and council services - in which respect there is a solid track record in North Lanarkshire- than acute and community health services.

3.4 If they become law the proposals will impose extensive new duties on Health Boards and local authorities to:

0 Create a Community Health & Social Care Partnership with representation from elected members “which will be a Committee of the Health Board and the Local Authority” .

0 “Put in place an integrated budget for adult health and social care” that “loses its identity” within a partner agency. Appoint a “jointly accountable officer” to report to the two Chief Executives - the postholder “will have authority over the discharge of the integrated budget.. . “without needing to refer back up the line within either partner organisation”. Consult local professionals on arrangements for planning service provision and produce joint commissioning strategies.

0

3.5 The document states that “these proposals provide national leadership in relation to what is required -the outcomes that must be delivered - and leave to local determination how best to achieve those outcomes- the delivery mechanisms that will best suit different local needs”. As can be seen from para 3.4 though, the document is actually very specific regarding the required joint governance arrangements; presents two alternatives for integrating financial integration; devolves decision making on the use of resources to the jointly accountable officer and defines their reporting lines; and seeks inclusion of all adult health and social care spend not just older people as originally proposed.

3.6 The North Lanarkshire Health and Care Partnership has long sought to achieve success by extending the boundaries of collaborative working and develop integrated services where they can demonstrably deliver improved outcomes for citizens in more efficient ways. This approach has yielded high performance levels, consistently evidenced by external inspections and evaluations, and led to the development of a suite of integrated services. Performance is overseen by robust joint governance arrangements led by the North Lanarkshire Health & Care Partnership.

3.7 The efficacy of the approach gained high profile recognition as recently as July 201 1 when the Nuffield Trust published “Integration in Action: Four International Case Studies” featuring North Lanarkshire Health & Care Partnership, Community Care North Carolina (USA), Greater Rochester Independent Practice Association (USA), and Regionale HuisartsenZorg Heuvelland (Netherlands).

4. Implications

4.1 The proposals have far reaching organisational and governance consequences. They intend that legislation will create formally constituted Health and Social Partnerships with equal numbers of Health Board Non-Executive Directors and “a minimum of three elected members”, together with a rotating chair who holds a casting vote. It will require Health Boards and local authorities to “devolve budgets made up from primary and community health, adult social care and some acute hospital spend to the Health and Social Care Partnership”, which it describes as a “body corporate”.

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4.2 The proposed delegated financial authority of the jointly accountable officer has profound implications for the way local government funding is deployed. This requires to be considered in the context of the Council’s financial regulations, as the proposals devolve levels of authority to a single officer that far exceed current permitted approvals within the Council.

4.3 Spend on adult social work services in North Lanarkshire is approximately 80% of the social work budget (and around 20% of the total Council budget). When combined with health spend - subject to what acute hospital monies are included - this could potentially create an organisation that is larger than the functions that would remain within the Council thereafter.

4.4 The document acknowledges that there are significant potential risks that the proposals could, in creating one set of organisational arrangements, create other organisational boundaries and unintentionally fragment key elements of social work (children’s services; justice and a range of cross-cutting services such as homelessness) and council functions (housing, education etc). It is difficult to see how this can be avoided by following either of the two proposed delivery options.

4.5 The document invites views on the proposed legislation not the policy, and takes the form of 20 questions that will require the Council and its partners to frame a considered response, given the scale and implications of the proposals. The full document is available at www.scotland.~ov.uk/Publications/2012/05/6469 The deadline for responses has been extended to 11 September. Partners have agreed that each agency will submit their own response that will address the specific questions posed, and that the North Lanarkshire Partnership will submit a general response.

4.6 The proposed response - attached at Appendix 1 - articulates general support for the intended outcomes of the policy but rejects the proposed organisational arrangements, which are considered to properly be a matter for local determination.

5. Recommendations

Committee is asked to approve the proposed response at Appendix 1.

%buncan Mackay Head of Social Work Development

For further information about this report please contact Duncan Mackay, Head of Social Work Development, tel: 01698 332024.

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Appendix 1

Annex G Consultation Questionnaire

The case for change

Question 1: Is the proposal to focus initially, after legislation is enacted, on improving outcomes for older people, and then to extend our focus to improving integration of all areas of adult health and social care, practical and helpful?

Comments

services that support consistently high which are endorsed by reported local a

It is recognised that different loc evolution and development in positive outcomes. The creati inevitably draws a on each partnersh

starting position or performing

esearch evidence on integration. An

ared the findings to date. Successful partnerships tend to be characterised by strong, embedded partnership working; shared vision; co-terminosity; and committed leadership. Unsuccessful approaches tend to be characterised by top-down imposition; performance regimes; financial pressures; and organisational and financial complexity. The factors that localities say most help integration are local and cultural, the factors that localities say most hinder integration are national and structural. The document as it stands appears to pay little heed to this evidence. ---- ---

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The efficacy of our own approach gained high profile recognition as recently as July 201 1 when the Nuffield Trust published "Integration in Action: Four International Case Studies" featuring North Lanarkshire Health & Care Partnership, Community Care North Carolina (USA), Greater Rochester Independent Practice Association (USA), and Regionale HuisartsenZorg Heuvelland (Netherlands). The desire to be outcomes-focussed is fully supported but the Council has significant concerns that central prescription will not deliver the desired improvements.

The proposals and accompanying questions are conc organisational arangements and are not set out in outcomes for the person are foremost in the Gove

Finally it is simply not appropriate to seek bla questions that reflect often complex issues

Outline of proposed reforms

nse that they do little to

ces. Neither do they address

realisation tha als, however well intended, are unlikely to achieve

The proposals go significantly further than that previously indicated by the Cabinet Secretary in her public announcement in December 201 1. The prescriptive nature of much of what is proposed is surprising given her evidence to the Scottish Parliament Health and Sport Committee on 20 March 201 2, which strongly indicated greater flexibilities for local partnerships (within a core set of principles) than is actually the case in the consultation document.

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National outcomes for adult health and social care

It is not so much a question of whether it mechanism", it is more whether it can ac

influential e.g. the clinical autho

and education

areas of activit

d and potentially dangerous. into well-ordered, age-specific

lessness are cross-cutting.

included in the new arrangements, the ed may be greater than the rest of the

thing approaching the same level of

Question 4: Do you agree that nationally agreed outcomes for adult health and social care should be included within all local Single Outcome Agreements?


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Comments

There clearly needs to be a direct relationship between nationally agreed outcomes for health and social care and Single Outcome Agreements. The latter are intended to be strategic documents and the extent to which they could comfortably accommodate what is proposed would require further exploration.

Governance and joint accountability

e- --=’*-%%**-mw* ~ ~ - ~ ~ - ~ ~ - ~ ~ ~ ~ ~ ~ - ’ - ~ ~ ~ ~ - ~ ~ ~ - ~ ~ ~

Comments

No. This question assumes the same as the local authority in w accountable to their own local a

Scottish Govern me nt

reates a direct

Chief Executive Council Leader.

ntability. This is one of four statutory roles ing Orders with a responsibility to endanger lives or welfare; and to

In terms of acco of Finance of the local authority must be clarified to ensure that arrangements, such as for the establishment of a Joint Accountability Officer, do not conflict with statutory requirements.

ty and governance, the statutory role of the Director

Delegation to the Health and Social Care Partnership, established as a body corporate results in VAT inefficiencies (body corporate is unable to recover any VAT and hence becomes an additional cost). For this reason, it is deemed to be a bad option with the potential to cost the “public purse”.

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Given the significant reductions envisaged in local authority budgets, no consideration has been given to what this means for the financial planning arrangements for a Health & Care Partnership in the longer term.

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Question 6: Should there be scope to establish a Health and Social Care Partnership that covers more than one Local Authority?

Comments

This question implies that the proposed performance management arrangements somehow sit outside a much wider infrastructure of pre- existing inspection and regulation. This includes bodies such as The Care Inspectorate, The Mental Welfare Commission, The Scottish Social Sevices Council, QUEST and the Older Peoples Inspection Proaramme managed by --- * s-*---m--M------% --- -* __l --- "--w*-----M*

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Health Improvement Scotland.

The proposals seek to integrate certain areas of activity but leave the inspection and regulation of those areas of activity to bodies that themselves are not integrated. This creates even more potential than already exists for uncertainty and confusion.

Additionally, as previously stated, the Scottish Government has already assumed powers through “the ladder of support and intervention” that enable it to address where partnerships are not petformin standards .

quired

-*-

to include the budgets for other CHP functio care -within the scope of the Healih and Soci

adult health and social

In general these sh

king a view on excluding. It as “adult health and social o be excluded. For example

rity. Reshaping Care for relevant to the housing function as it is silent on that key role and the

e such as that in North Lanarkshire these functions. In an integrated

al Work

integrated budgets and resourcing

Question 10: Do you think the models described above can successfully deliver our objective to use money to best effect for the patient or service user, whether they need “health” or “social care” sumort?


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Comments

No, not least because parallel legislation on Self-Directed Support creates a duty (supported by this authority) on local authorities to identify an individual budget and provide options for people as to how that may be drawn down. The same legislation imposes no such duty on the NHS yet planned legislation on integration seeks to “make invisible” the from either agency. The two positions are inherently c

Social Work is a targeted service, some elements charging regulations and policies. Health is point of delivery. This brings with it inevitabl integrated working and budgets.

Most public spending on older people is bulk of it is likely to be excluded from the largely futile to include special

authority on dischar always possess the

about a person’s orted by evidence

of the care of older people in by Health Improvement

We have a range of approaches to integrated services that are appropriate to the setting and planned outcomes. It cannot be a ‘one size fits all’ approach. There is already the opportunity to move resources across community health and social work services. This has been used in different ways to suit the purpose e.g integrated day services for older people; integrated addiction teams; integrated equipment and adaptations service etc. More information can be provided on this range of initiatives as rea ui red.


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Independent evidence is cited in the answer to Question I.

Question 12: If Ministers provide direction on the minimum categories of spend that must be included in the integrated budget, will that provide sufficient impetus and sufficient local discretion to achieve the obiectives we have set out?

This should be a matter for local determination.

.--wm--”-isIIl-ll ”~ --v-* mm

Jointly Accountable Officer

autonomy than any public his is not simply about

f outcomes. The level of

overnment targets for delayed

to make major reductions in funding at a time of

Question 14: Have we described an appropriate level of seniority for the Jointly Accou n ta ble Officer?


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This is not the right question. Legislation creates statutory duties for local authorities, the discharge of which is the responsibility of the authority not a single individual.

The reporting arrangements of such a post should be a matter for local partners to decide and not for the Scottish Government to prescribe.

Professionally led locality planning and commissi

No - this must be left to local d has agreed to base its operat major townships in the area.

nd 6 localities i.e. ve a local area

als, including GPs, on how best to put

---- ---*- * -

ion. Legislation imposing duties cannot in itself vance effective arrangements. See response to Question 1 on the

actors that help and hinder legislation.

Question 17: What practical stepskhanges would help to enable clinicians and social care professionals to get involved with and drive planning at local level?


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ere are existing arrangements in North Lanark participation of clinicians and other professionals to assume responsibility to ensure such arrange

Question 18: Should locality planning be organised around clusters of GP practices? If not, how do you think this could be better organised?

That is a matte

n a key factor in achieving ildren in this authority area.

Comments

No. See response to Question 18. This should be a matter for local determination not for the Scottish Government.

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INTEGRATION OF ADULT HEALTH AND SOCIAL CARE

I Do vou have anv further comments reaardina the consultation DroDosals? --- - omments

It is the sincere wish of North Lanarkshire Council that this document is subject of genuine, open consultation where the outcome has not been largely pre-determined and that the significant concerns of local government will be appropriately addressed.

The proposals themselves are substantially flawed. Bef further

Comments

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