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03 Jun 2016
Forth Valley Stronger Together

An early study by the Policy Innovation Research Unit into the development of Health And Social Care Integration in England has found it struggling.   Just as in Scotland, H&SCI started with ambitious visions to transform care for people with multiple long-term conditions and frail older people by shifting services out of hospitals, reducing costs and improving people’s experiences of care

There had been plans to use a wide range of initiatives to meet these objectives including multi-disciplinary teams, improved access to services, rapid response teams to reduce avoidable admissions, telecare and telehealth, increasing the use of community resilience and personal health budgets.

However such ambitions became more limited and focused on “short term, financially driven goals”, mainly around containing hospital admission and discharge costs.   The range of initiatives used had narrowed to setting up multi-disciplinary teams, improving care planning, creating a single point of access for services and using care navigators to provide people with information and advice on accessing care.

Health And Social Care Integration is struggling in England.   Increasing financial constraints on councils and NHS bodies are making it harder to achieve integrated health and social care, government-funded research has warned.   The study also found that engaging frontline staff in initiatives to integrate care was proving challenging in a climate where they were “firefighting” to keep existing services running. 

Health and social care were beset by an “integration paradox” in which the financial environment made it ever more important to integrate care but, at the same time, made it more difficult to make progress in doing so. 

The findings came from an early evaluation of the integrated care and support pioneers programme, a Department of Health initiative set up in late 2013 to test new ways of integrating care for people who needed the support of multiple care services.   The study, by the Policy Innovation Research Unit, assessed the initial 14 pilots from January 2014 to July 2015 and was largely based on interviews with 140 council, clinical commissioning group (CCG), NHS trust and voluntary sector staff involved in pioneers.

 

The pioneers started with ambitious visions to transform care in their areas for people with multiple long-conditions and frail older people by shifting services out of hospitals, reduce costs and improve people’s experiences of care.  They had plans to use a wide range of initiatives to meet these objectives including multi-disciplinary teams, improved access to services, rapid response teams to reduce avoidable admissions, telecare and telehealth, increasing the use of community resilience and personal health budgets.

But the researchers found that over time their ambitions appeared to have become more limited and focused on “short-term, financially driven goals”, mainly around containing hospital admission and discharge costs.   Also, the range of initiatives used had narrowed to setting up multi-disciplinary teams, improving care planning, creating a single point of access for services and using care navigators to provide people with information and advice on accessing care.

Interviewees identified a number of barriers to and enablers of integration. Most of the enablers were local factors. These included the relative simplicity of organisational structures, with the best arrangement perceived to be when a pioneer involved just one council, CCG and NHS trust with similar boundaries. The most important of the enablers was perceived to be staff involvement in integration initiatives and the extent to which they felt ownership over them.

Glasgow City introduced personalisation in 2010 as part of a programme designed to save up to £6.4 million per year.  The first phase of this for people with learning disabilities was rapidly extended to other groups.  As individual budgets became the preferred method of managing support packages the council moved to close a number of day centres arguing that with individual budgets, less people would use these  services.

Actually it seems that less people now use any services in Glasgow.   Official figures from ESAY reports that the number of people with learning disabilities receiving any service from the council fell again in the last year, this time by 104 people  to just 2,306 in 2015.  

Figures produced by the NHS suggest that others have been seeking out NHS help when they cannot get it from the council.    At around the time of the introduction of personalisation in Glasgow the number of “inpatient weeks” rose rapidly as can be seen in the chart.   By 2013, it was costing NHS Greater Glasgow & Clyde an additional £4.5 million per year.  

It seems strange that a policy of that was presented as being about Choice And Control should be connected to less people getting any service and more people using  specialist hospital services.

 

 

In a surprise announcement Glasgow City Council is to close Cordia, the Arms-Length External Organisation (ALEO) which until now has been the preferred provider of social care in the city. Cordia employees will transfer  to the Council, bringing its social care function back in-house.  

As part of the new approach, the Council will overhaul the way that it purchases community-based care services from other providers, including the third sector, in line with their Transformation Strategy, a far reaching reform programme that aims to modernise working practices and deliver required savings of £133m over the next two years.  See this article for more details

Proposals include testing a new purchasing model, which will see a move away from purchasing care services by the hour.  It is unclear at this stage what the new model will look like, however, a further report will be submitted to committee in March 2016 outlining plans, which will include working with a small number of organisations in the coming year to test out new approaches. 

 

The essence of Self Directed Support is meant to be having the freedom to spend an Individual Budget on the support and services that can truly meet your need.  In the early days, videos were produced of people spending their money on holidays abroad or on personal development courses or opportunities.  The argument was if you gave people the freedom to make their own choice, they would be better choices and in many cases would be cheaper.  For example, instead of paying a support worker to take you to a football game as well as buying a tickt, a friend, family member or volunteer could be induced to do this for just the price of the ticket

Over the last few years as SDS has been introduced in Scotland, that has rarely been the case.  Instead the use of Individual Budgets has been constrained by local authorities who have claimed that their duty to ensure the "public pound" is properly spent overrules thing else.  Budgets can only be spent on areas approved by councils.  85 page contracts have been drawn up to support new "freedoms" which set limits on anything creative.  

Now Glasgow City Council is proposing to give "providers" the freedom to do it differently. Read the proposal here  No longer will providers have to provide a fixed number of hours for an Individual Budget instead as long as the needs of the individual are met, then the budget can be used to increase the wages given to staff so they can rise in line with the National Minimum Wage.  

This proposal will be introduced in a pilot scheme for a range of adults in community care groups.  But for people with learning disabilities it will make life much harder.  Glasgow has made a range of reductions in support for peopel with learning disabilities.  They started with a cut in people with learning disabilities budgets of an average 20% with the introduction of personalisation, followed by a 5 year freeze in the value of RAS support packages.  Then a they shut most of the city’s day services.   Now they now propose to make people with learning disabilities pay for the Tory’s National Minimum Wage by cutting their support packages even further while pocketing further savings in the meantime.  

Its not completely clear in the paper but it seems to suggest that the new National Minimum Wage will cost  £21 million  and that this amount should be diverted from social care users support packages into paying the new wage level.  There is then an indication at the , while there would be a further 5% reduction in total spend in support packages to be retained by the council.  However a third set of savings may be generated  “significant” reductions in council “administration and processes”  

The Learning Disability Alliance Scotland views this proposal with some concern.  Support packages for social care users in Glasgow and in particular people with learning disabilities have been severely reduced over the last 6 years.   This proposal takes the good idea of further social integration into the community but ties it to real pressures on social care.  Providers are likely to have little choice but to go along with it.   In the report it does not mention that they asked service users what they think of this process.   Surely SDS is about the service user's choice and decision making.  This appears to be completely absent from the proposal.  We are really disappointed that Glasgow City Council are not turning their focus on the UK government who had introduced this policy of the National Minimum Wage but failed to fund it.