Thursday, August 22, 2013

Another go at health and care integration

Parliament will have another go at health and care integration next month with the Public Bodies (Joint Working) Bill. But will this be any more than moving the managerial deck chairs? 

Proposals for the integration of health and care services go back at least to the 1970‟s when the first joint finance arrangements were introduced. Since then we have had at least eight different initiatives and Acts, plus many reports. Staff who deliver these services could be forgiven for taking a somewhat cynical view of yet another reorganisation.

Almost everyone believes that health and care integration is a good idea in principle. However, the evidence from a range of studies indicates that structural integration in itself, and top down change in particular, does not deliver anticipated levels of service improvement. Petch (2011) states: “Differences in culture and in values and differentials in power tend to distort any blueprint and to undermine any projected model. Moreover major financial and time resources can be absorbed by attempts to implement such structural change without demonstrating effective outcomes”. These studies also show that local implementation is the key to effective service delivery across health and social care and that depends on culture, leadership, local history, context, time and vision.
If local implementation is the key, the apparent flexibility in the Bill for councils and health boards to agree a form of integration that meets local circumstances is to be welcomed. However, it may not be that clear. When you read the Bill, line by line, you are left with the impression that Scottish Ministers are granting themselves an extensive battery of powers to centrally direct their model of integration. Reserve powers of direction are reasonable, but this Bill goes much further and could result in a significant centralisation. 

Ministers can set outcomes that could be prescriptive - notably without any requirement to provide ‘inputs’ i.e. resources.  They must approve integration plans and have wide ranging powers to direct and set out requirements in regulations. Overall these powers reflect the NHS performance management approach that takes little account of local democratic accountability. Lets not forget that some £2.1bn of council spending is involved.
As these services are staff intensive you would have expected some detailed consideration to be given to the staffing aspects of integration. In which case you will be disappointed. The staffing provisions in the Bill are limited to contract protection aspects of TUPE only. There is no staffing framework as UNISON has proposed and this will, at best, lead to reinventing the wheel or at worse disruption. In addition there could be legal confusion over staffing decisions made by integration boards when they are not the employer.
Part 2 of the Bill includes shared services powers for the CSA and the establishment of Joint Ventures. These are enabling provisions, except that in Part 1 of the Bill ministers have powers to approve plans and direct contracts and services.  There is scope here for further privatisation and the Financial Memorandum indicates that regulations could direct third sector involvement. All too often on this issue there is a confusion between community engagement and ‘commercial’ voluntary sector delivery interests. £150k has also been provided to the private sector to support their engagement.
On costs, the Financial Memorandum is somewhat speculative and vague. The big financial gain from integration is supposed to be NHS bed costs from unplanned admissions. This has been estimated at around £1.5bn. However, these savings are only realised if the beds are closed and the Health Minister has put a big question mark over that. Glasgow and Lothian health boards have also recently called for more beds not less. I would also question if VAT will be recoverable by integration boards under the s33 exemption - remember the police and fire debacle on this point. £32m to the Treasury, rather than care services, would be an outrageous waste.

Overall, the powers in the Bill don't  match the rhetoric of local solutions.  There is a real concern that the centralising tendency of government, overrides the strong evidence that top down direction doesn't work. 

Dave Watson

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