The implementation of health and care integration won’t be achieved on the cheap. While there should be long-term savings and better care from a shift to community services, it will take time to realise that ambition.
The Scottish Parliament’s Health and Sport Committee has been holding an inquiry into the budget for next year. We don’t have much idea how big the pot will be until the UK Autumn Budget and the Scottish Government decides on its own tax policies. However, that still allows some scope for an examination of the principles that underpin the budget.
The Integrated Joint Boards (IJB) are now responsible for some £8.3bn of expenditure – a substantial part of the Scottish budget and supplemented by local taxation. In evidence to the committee the IJB finance officers highlighted that resources are not keeping up with demands. They said:
“There is emerging evidence which indicates that the current level of resources is less than that required to meet current cost and demand pressures. In practical terms this means that the required shift in the balance of care will take longer to achieve. A number of Integration Authorities have modelled the level of additional resources required to meet cost and demand pressures, with estimates between 3% (for 2018/19) and 14% (over two years) of existing budget.”
The clear message to the committee was that increased demand, largely due to demographic change, means that they don’t even receive a standstill budget. Transformational change comes with a much bigger price tag.
Measures to reduce unplanned admissions to hospitals and cut delayed discharges can be successful. A number of IJB performance reports demonstrate progress. Not least in Glasgow, which claims continuing decreases in delayed discharges with acute bed days lost falling from 38,152 (13/14) to 15,557 (16/17). However, the picture continues to vary across the country. As I said while giving oral evidence to the committee; unplanned admissions will continue until a full social care service is in place – hospitals don’t turn patients away.
I did notice a definite pitch from IJB directors and finance leads for direct funding and greater control. We should remember that IJBs don’t employ staff and get their budgets from health boards and councils. Their complaint is that funding ‘doesn’t lose its identity’ in this system and they have matrix performance monitoring. Concerns over double counting of health and care funding are valid, as are the constraints of ring-fencing.
It was entirely predictable when you create a system that co-ordinates services that sooner or later the leaders want to create an empire that they have more control over. This leads to a demand for stand-alone bodies – in effect a whole new set of local quangos.
This demand should be resisted. The change that is required in care cannot be achieved by IJBs in isolation. One of the points I picked up from trade union colleagues in Norway was that separating the management of acute and community services made it that much more difficult to achieve resource transfers. The same applies to councils, who run range of other services that impact on health; like housing, planning, libraries and leisure services. You don’t join up services by fragmenting them even more.
From a staff perspective, such direct control would involve a massive transfer of health and care workers to new organisations. A move that will be resisted by all the trade unions for good reason. Such a transfer would take many years and the harmonisation negotiations would be a complete nightmare. It would require a massive funding pot and divert staff and management effort for years.
It is clear that transformational change in the health and care system requires a significant increase in funding. While there are still some organisational and cultural barriers to integration, more local quangos are not the solution.