Pick up the pieces

September 22, 2005 in Community Care

The problem of service fragmentation is rife throughout welfare
systems in Europe, and Scotland is certainly no exception. A
comment made during the recent consultation exercise for Better
Outcomes for Older People (1) sums things up tellingly –
“It seems like quite a few people have pieces of the jigsaw,
but no one has the picture on the box.”

In England, the initial response of New Labour to this problem was
to promote the ideal of partnership working, but more recently the
pendulum has swung towards the promotion of choice, whether through
offering a choice of provider or the empowerment said to arise from
individual budgets.

Unlike the English, the Scots are still pinning their colours to
the partnership mast. The recent Kerr report(2) on the NHS in
Scotland, for example, explicitly rejects a choice model in favour
of “a more truly Scottish model… a collective approach in
which we generate strength from integration, and transformation
through unity of purpose”. Indeed, in a speech to the
Scottish NHS annual conference in May, Kerr referred disparagingly
to “English contestability” as compared with
“Scottish collectivism”. Moreover, the focus in
Scotland is no longer on ad hoc service specific partnerships but
on a much more ambitious whole systems model covering services for
both children and adults.

The partnership agenda in Scotland has been brewing for several
years. An agenda for joint working was set out in pre-devolution
days by the Scottish Office, but the new Scottish assembly declared
progress to be uneven and set up the joint future group in the new
Scottish executive to provide a fresh impetus. The subsequent
report of the joint future group(3) required all 32 local
partnerships in Scotland to return a local partnership agreement by
April 2002. In the meantime, the Community Care and Health Act 2002
took joint working to new levels by enabling – and expecting
– local partners to delegate functions and pool budgets,
initially for services for older people but more latterly for all
community care services.

Social work services in Scotland are not being buffeted to the same
extent as in England. There is no formal integration of education
and children’s social services, and no apparent threat to
adult care services through care trusts or other forms of
annexation to the NHS – a degree of stability that will be
the envy of English colleagues, and an environment in which
partnerships are more likely to prosper. The new kids on the block
in Scotland are the embryonic community health partnerships (CHPs),
which arose from the 2003 NHS white paper(4) to replace the
unevenly performing local health care co-operatives.

In the consultation paper introducing CHPs, the then minister for
health and community care described them as “bridging the
divide that has existed for too long between primary and secondary
care, and between health and social care”. The future
relationship between local authorities and CHPs will be
crucial.
One of the problems facing many partnerships in England is that
local efforts to integrate are in conflict with silo-driven central
performance management regimes. This should be less of a problem in
Scotland, where a rather daunting plethora of central bodies and
requirements have been put in place to promote and monitor joint
working. All local partnerships now have to produce extended local
partnership agreements [ELPAs] for all community care groups,
showing progress made against the indicators contained in the joint
performance information and assessment framework [JPIAF].

The JPIAF is not short on ambition, even though in its current
third year the original nine indicators have been reduced to five
in order to shift the focus from process to outcome factors. The
five indicators for 2005-6 relate to joint resourcing, accessing
resources, single shared assessment, local improvement targets and
– ambitiously – whole system working.

The outcomes issue is crucial here, and it is in this respect that
Scotland may have something to learn from England. The recently
published framework, Better Outcomes for Older People,
might be expected to be the definitive source for pinning down the
outcome upon which local partnerships will be judged. In fact the
four national outcomes have been identified as:

* Supporting more people at home.
* Reducing inappropriate admissions to hospital, reducing time
spent inappropriately in hospital and enabling supported and faster
transfers from hospital.
* An improved quality of care through faster access to services and
better quality services.
* Better involvement of, and support for, carers.

Compared with the outcomes identified in England for both
children’s services (in the Every Child Matters
green paper) and adult care services (in the Independence,
Well-being and Choice green paper) these outcomes are
singularly service-based rather than outcome-focused. Indeed, for
the most part they are more like indicators than outcomes, and seem
to imply that the purpose of a joint approach is to solve the
problems of the acute health sector.

By contrast, the recent Scottish consultation paper on
children’s services(5) hits the outcomes spot much better
with an outcomes framework that states children need to be: safe,
nurtured, healthy, achieving, active, respected and responsible,
and included.

As in England, it is not easy to turn these outcomes into aims,
indicators and targets, but this is the challenge that has to be
met.

A further concern is the way in which the notion of a whole systems
approach is being interpreted, with a heavy focus upon addressing
“the balance of care”.

The JPIAF whole systems indicator seeks data on some familiar
matters, such as the number of people receiving single shared
assessments, the number of delayed discharges and emergency
hospital admissions. Again, this seems to put the needs of one part
of the system, the acute sector, at the centre of a whole systems
approach, when in fact the raison d’etre needs to be the
sorts of outcomes identified in Independence, Well-being and
Choice – improved health, improved quality of life,
making a positive contribution, exercise of choice and control,
freedom from discrimination and harassment, economic well-being and
personal dignity.

Where does all this leave the Scottish partnership agenda? On the
one hand there will be much support for an approach that, unlike
England, eschews quasi-markets, choice and contestability –
and the differences in approach certainly offer the opportunity for
a “policy laboratory” comparison between the two
countries. On the other, there will be concern that Scotland may be
heading for a partnership fall, for there is little in the record
of previous partnership achievement to suggest that new heights
will be easily conquered. There is no quick fix for piecing
together the picture on the box.

Bob Hudson is visiting professor of partnership studies, at
the School of Applied Social Sciences, University of Durham. He has
written and researched on partnership issues for the past 20
years.

Training and learning
The author has provided questions about this article to
guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl
and individuals’ learning from the discussion can be
registered on a free, password-protected training log held on the
site. This is a service from Community Care for all GSCC-registered
professionals.

Abstract
Unlike England, the Scottish approach to problems of
service delivery has been to stick with partnership working rather
than engage with the choice agenda. Indeed, the expectation now is
that local partnerships will develop ambitious models for whole
system working. This article examines these policy imperatives and
makes some assessment of the extent to which they can be expected
to succeed.

References
(1) Scottish executive, Better Outcomes for Older
People: Framework for Joint Services, 2005
(2) Scottish executive, Building A Health Service Fit for the
Future, 2005
(3) Scottish executive, Community Care: A Joint Future,
2000
(4) Scottish executive, Partnership for Care: Scotland’s
Health White Paper, 2003
(5) Scottish executive, Getting it Right for Every Child:
Proposals for Action, 2005