Integration of health and social care – predicting the quality, costs and consequences 17.4.2018

1. Health & Social Care Integration in
Scotland 2018
John Gillies OBE FRSE FRCGP
Deputy Director of the Scottish School of Primary Care
Honorary Professor of General Practice
University of Edinburgh
Scottish School of Primary Care

2. Vision: Sustainable and equitable high
quality primary care that meets the
needs of the people of Scotland.
Scottish School of Primary Care
• Inform our key stakeholders by collating relevant evidence,
and actively contributing to the evidence base.
• Support the continuing growth of Academic Primary Care in
Scotland.
• Promote Scottish Academic Primary Care internationally
Stewart Mercer Director, John Gillies Deputy Director

3. With thanks to:
Dr Alison Taylor
Head of Integration, Scottish Government
Dr Gregor Smith, Deputy Chief Medical Officer
Professor Stewart Mercer, SSPC

4. Population 5.4 million
Devolved Parliament
Universal healthcare
Integrated delivery
system
£13.1 billion budget
14 + 8 NHS Health
Boards
31 Integration
Authorities
Free personal care for
65+

5. Projected % change in Scotland’s population
by age group, 2010 - 2035

6. Multimorbidity in Scotland
Lancet 2012; 380: 37–43
Epidemiology of multimorbidity and implications for health
care, research, and medical education: a cross-sectional study
Karen Barnett, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke, Bruce Guthrie

7. People living in more deprived areas in Scotland develop
multimorbidity 10-15 years before those living in the most
affluent areas

10. Public Finances – Fall in Government Expenditure

11. Vision
People should be supported to live well at home or
in the community for as much time as they can
People should have a positive experience of health
and social care when they need it

12. Guiding principle:
“. . . effective services must be designed with and for
people and communities – not delivered ‘top down’ for
administrative convenience”
The Christie Commission Report
Commission on the future delivery of public services, June 2011

13. Key dates
• Consultation – May – October 2012
• Bill introduced to Parliament – May 2013
• Bill passed – unanimously – February 2014
• Royal Assent – April 2014
• Secondary legislation complete – December 2014
• First Integration Schemes approved – February 2015
• First partnerships go live – April 2015
• All partnerships in place – April 2016

15. Our children have the best
start in life and are ready to
succeed
We live longer, healthier
lives
Our people are able to
maintain their
independence as they get
older
Our public services are
high quality, continually
improving, efficient and
responsive
NATIONAL OUTCOMES
Our vision is of general practice and primary care at the heart of the healthcare system.
People who need care will be more informed and empowered,
will access the right professional at the right time and will remain at or near home wherever possible.
Multidisciplinary teams will deliver care in communities and be involved in the strategic planning of our services.
PRIMARY CARE VISION
We are more informed and
empowered when using
primary care
Our primary care workforce is
expanded, more integrated
and better co-ordinated with
community and secondary care
Our primary care services
better contribute to improving
population health
Our experience as patients in
primary care is enhanced
Our primary care infrastructure
– physical and digital – is
improved
Primary care better
addresses health inequalities
PRIMARY CARE OUTCOMES
People can look after
own health
Live at home or
homely setting
Positive Experience
of Services
Services improve
quality of life
Services mitigate
inequalities
Carers supported to
improve health
People using services
safe from harm
Engaged Workforce
Improving Care
Efficient Resource Use
HSCP OUTCOMES
We start well We live well We age well We die well

17. Learning from successful
integrated systems
Four common characteristics:
• Plan for populations, not delivery structures
• Pool resources – money and people
• Embed clinicians and care professionals in service planning,
investment and provision
• Strong local leadership

18. Adult hospital care
• A&E
• Inpatient beds:
• general medicine
• geriatric medicine
• rehabilitation medicine
• respiratory medicine
• psychiatry of learning disability
• palliative care
• palliative care
• addictions and dependencies
• mental health services, except secure
forensic mental health services
• addictions and dependencies
• GP beds
Integration Authorities – minimum functions
Adult primary and community healthcare
• Primary medical services
• Out-of-hours services
• District nursing services
• General dental services
• Public dental service
• Community ophthalmic services
• Community pharmaceutical services
• Community and outpatient AHP services
• Community addiction and dependency services
• Community geriatric medicine
• Community palliative services
• Community learning disability services
• Community mental health services
• Community continence services
• Community dialysis services
• Services provided by health professionals that
promote public health
Adult social care

19. “A focus on supporting
people, rather than single
disease pathways
with a solid foundation of
integrated health
and social care services
based on new
models of community-
based provision.”

20. Challenge
Higher public expectations of the health and care
system as more people live longer and into very old
age, with an increasing prevalence of illness,
particularly chronic conditions, supported by new
medicines and technologies, which together with
inflation make healthcare less financially
sustainable each year.
And not just a sustainability challenge, a quality
challenge.

21. The nature and scale of the challenges facing our NHS - in particular the
challenge of an ageing population - mean that additional money alone will not
equip it properly for the future.
To be blunt, if all we do is fund our NHS to deliver more of the same, it will not
cope with the pressures it faces.
To really protect our NHS, we need to do more than just give it extra money - we
need to use that money to deliver fundamental reform and change the way our
NHS delivers care.
John Swinney, DFM
Budget Speech, 12/15

22. “Let me be clear about the objectives of this programme of reform.
We want to ensure that adult health and social care services are
firmly integrated around the needs of individuals, their carers and
other family members; that the providers of those services are held
to account jointly and effectively for improved delivery; that services
are underpinned by flexible, sustainable financial mechanisms that
give priority to the needs of the people they serve rather than the
needs of the organisations through which they are delivered; and
that those arrangements are characterised by strong and consistent
clinical and professional leadership.”
Nicola Sturgeon, MSP, Deputy First Minister and Cabinet Secretary for Health and
Wellbeing, December 2011

23. Key ingredients
• Nationally agreed outcomes, supported by indicators
• Primary, community and social care together with those
aspects of hospital care linked to unplanned admissions
• New accountable boards that plan and commission
services, with a focus on localities
• Single budget for health and care
• Operational integration of services
Public Bodies (Joint Working) (Scotland) Act 2014

24. High Resource Individuals

27. Realising realistic medicine
• Culture
• Collabora
te
• Connect
• Communic
ate
Relationships

28. Health & social
care delivery
plan 2016
• Better health
• Better care
• Better value
Through:
• Strengthened primary,
community and social care
• Focus on realistic medicine
• Better interfaces between
primary and secondary care

29. Need for
collaborative
leadership!
• Health services and Councils have
very different employment/ HR
policies
• Different & diverse cultures and
leaderships styles
• Where things work well, usually
because of good local leadership
• Leading for Integration programmes
may be effective. e.g: RCGP/ NHS
Education/ Scottish Social Services
Council
• http://www.knowledge.scot.nhs.uk/
home/portals-and-
topics/leadership--
management/programmes/you-as-
a-collaborative-leader.aspx
Type to enter a caption.

30. Improving Together: A National Framework for Quality and GP Clusters in Scotland set out
the intrinsic and extrinsic functions of clusters as follows:
Intrinsic Extrinsic
Learning network, local solutions, peer
Support
Collaboration and practice systems
working with Community MDT and third sector partners
Consider clinical priorities for collective
Population
Participate in and influence priorities and strategic plans
of Integrated Authorities
Transparent use of data, techniques and tools to
drive quality improvement – will, ideas, execution
Provide critical opinion to aid
transparency and oversight of managed services
Improve wellbeing, health and reduce
health inequalities
Ensure relentless focus on improving
clinical outcomes and addressing health inequalities

31. It's about the outcomes, but people often want to talk about the
process…
It's about behaviours…
Everyone wants change, but it's easier when other people have
to do it…
There are some really hard-edged challenges where it has to
work quickly, but change takes time…
It's iterative, we are making large and small gains all the time…

32. Some signs of progress…
From Scottish Government:
• A key focus for integration is to shift away from inappropriate use of
unscheduled inpatient care. this shift has been in unscheduled care. The
SG’s Delivery Plan set a 2017-18 target of reducing the number of occupied
bed-days in acute care by as many as 400,000 through reducing delayed
discharges, avoidable admissions and inappropriately long stays in hospital.
• There are clear on-going improvements being achieved in reducing
unscheduled bed occupancy, in part through on-going improvements in
delayed discharge performance. The latest published data (February
2018) demonstrates that since August 2016, the number of days spent in
hospital by people where discharge was delayed has reduced from just over
45,500 to 38,394, a reduction of over 15%.

33. What’s actually happening?
• National Health and Wellbeing Outcomes
Framework:
http://www.gov.scot/Publications/2015/02/996
6/downloads
• Suite of core indicators:
http://www.gov.scot/Topics/Health/Policy/Adul
t-Health-SocialCare-
Integration/Outcomes/Indicators/Indicators
• Rigorous overview by Audit Scotland:
http://www.audit-
scotland.gov.uk/report/health-and-social-care-