The Scottish government today published legislation to fully integrate the commissioning and delivery of adult health and social care. The Public Bodies (Joint Working) (Scotland) Bill is driven by the need to make better use of scarce resources, shift care out of acute settings into the community and deliver better support for the growing number of frail older people and people with long-term conditions.
Unlike proposals for integration south of the border, they will require structural change: councils and health boards would be mandated to set up an “integration authority” in every area which would manage an integrated budget. They would also need to appoint a chief officer, jointly accountable to both partners, to ensure new national outcomes are met.
Integrating health and social care in Scotland: key points
Read more about the plans in the Public Bodies (Joint Working) (Scotland) Bill
Besides these requirements, there will be flexibility, meaning the implications for social care professionals will depend on where they work. Responsibility for the integrated budget could be vested in an “integration joint board”, a new corporate body that would allocate sums to councils and NHS boards to deliver on joint objectives, avoiding service restructuring. Or partners could delegate responsibilities for services and budgets to each other, meaning that council social workers could find themselves working for the NHS, as has already happened in the Highlands.
Social work staff transferred to NHS
In April 2012 1,400 adult community care staff from the Highland Council transferred to NHS Highland, along with an £88m budget for the first financial year, as part of an agreement to make the health board the lead agency for adult care and the council the lead agency for children’s services.
The Highland Partnership is the only one so far in Scotland to have adopted the lead agency model – where there is a wholesale transfer of services – and the agreement was made ahead of the Scottish government’s legislative proposals for integration. But it does give some insight into ways workforce issues may be tackled.
After a long period of intensive negotiation, a TUPE transfer was agreed of social care staff to the NHS, which means there is no impact, initially at least, on terms and conditions for social care professionals coming from the council. Pay, holidays, expenses and pension arrangements remain the same and will apply to new social care professionals joining the partnership.
In addition, the former council workers will gain a greater say in their working conditions from being part of the more formal and inclusive NHS workforce structures, says Adam Palmer, Unison Highland branch secretary, who was involved in the negotiations. They will also now routinely undertake personal development plans under the NHS knowledge and skills framework.
“At NHS Highland 80% of staff have a personal development plan, but before the transfer only 2.5% of social care staff had a PDP, so this is an area for action,” says Palmer.
However, former council social workers may end up working slightly longer hours as the local authority 35 hour week is harmonised with the NHS 37.5 hour week.
A professional leadership structure was introduced to address concerns over management and supervision, particularly where social care staff are line managed by health professionals. Each of the partnership’s three operation units has a lead social worker who acts as a professional advisor to the chief social worker, Bill Alexander, who remains at the council.
Jan Baird, NHS Highland director of adult care and the transitions director for integration, says: “There is a clear line of professional leadership and the social workers who were involved in the transfer said they felt quite secure. We have since surveyed staff on the transfer and some say it is too early to decide [if the move was good for them] others said it is valuable to have more opportunity to be involved with other staff. There’s been a mixed response as some staff have been more engaged in integration than others.”
A key facet of the government’s plans is to strengthen the role of social care professionals in the planning and running of services. Baird says this is beginning to happen as integrated teams, including social workers and district nurses, are established at four test sites, to eventually be implemented in all nine districts. Baird says they will shape the commissioning of care in their areas.
Biggest challenges for social workers
Being part of an integrated team will be the biggest daily change to practice for social workers, says chief social worker Bill Alexander.
“So far most of the change has been structural with little significant change to frontline delivery,” he says. “We have created the means to develop integrated teams and deliver more seamless services. While there has been a significant learning curve for both organisations we are now able to grapple with issues that we couldn’t before as a single service.”
For Alexander, it is having a single governance structure and budget that is the crux of successful integration. “You need to be working to common guidance and objectives to get a consistent vision and seamless pathways. Integration is more than just joint working. That is better than separate working but there is still a lot of bureaucracy and barriers. You don’t get the 100% clarity on objectives that you can only get with single governance.”
Scepticism about Highland-style staff transfer
It appears unlikely, however, that many other areas will opt for such a radical approach to integration. “There is not much enthusiasm in Scotland for replicating the Highland model. The preferred model doesn’t involve any staff transfer,” says Unison Scottish organiser Dave Watson.
Ruth Stark, manager of the Scottish Association of Social Workers (SASW), agrees. “My understanding is that people are not looking for wholesale structural change, but at the point of service delivery,” she says.
Both SASW and Unison have concerns about the reforms. Unison’s key concerns are around the potential loss of democratic accountability if social care services transfer to the NHS; the financial risks involved in joint budgets, and what Watson describes as “poor” consideration of the staffing implications in the government’s proposals. The union is calling for statutory governance and workforce frameworks to be introduced in the legislation to ensure reform is implemented consistently across the country.
Concerns over impact on adults-children’s links within social work
While SASW agrees with the objectives of the reforms, one of its major concerns is that integrating adult health and social care could destabilise a cohesive system of generic social work in Scotland that encompasses adults’ and children’s services. In a letter to deputy first minister Nicola Sturgeon she warned of the potential “unintended consequences” of reform, particularly for families needing to access a range of services.
“The proposals need to be more carefully thought through,” she says. “There has also got to be a cultural shift in the health service to think of complex health problems rather than single health problems. In social work our strength is we are used to seeing a complex set of problems and we are interested in prevention and in helping people to remain in communities.”
This article was amended on 29 May to take account of the publication of the Public Bodies (Joint Working) (Scotland) Bill.