Care integration - lessons from Wales

Delivering better health and care integration is a challenge in all parts of the U.K. and internationally. We should try and learn from experiences elsewhere, and I was in Cardiff yesterday contributing to the Cymru/Wales UNISON seminar on the issue.

Wales faces similar challenges to Scotland - austerity and Brexit. The Welsh health minister told the conference that reform should be about better ways of delivering services, not just about saving money. They have had a parliamentary review of care integration that has made recommendations for going forward and a new government plan will be published soon.

The minister was not convinced that big structural change was the way forward, but he was in favour of better partnership working between health and local government. There are good examples of integrated system change locally that can be scaled up nationally. He was strong on the need to engage staff in finding solutions - making it a formal part of the system. As he put it; "Motivated staff are much more likely to do a better job."

Wales has similar problems to Scotland with fragmented domiciliary and residential care, many of which are struggling. The minister said better commissioning and standards had to be part of the solution. He recognised the need to increase funding and they are looking a levy to specifically fund the increasing cost. Something that hasn't really been part of the debate in Scotland.

The research report launched at today's conference highlights a very complex picture of care integration in Wales. Words like 'partnership', 'integration' and 'seamless' service are used, and abused, with means often confused with ends. As in Scotland, the driver is collaboration not competition, but that has its challenges around trust and power. Previous reports have been critical of progress and they have similar problems with short term funding initiatives rather than increasing core funding. 

The core of the report is three case studies on integration. 

The Bridgend approach shows real improvements in outcomes like unscheduled care and long term placements. Anticipatory care is key to preventing inappropriate admissions and building trusted relationships between staff.

Monnow Vale in Monmouthshire is a good example of how locality based health and social care hubs can work. Staff are co-located, they talk to each other and staff are empowered to find solutions that work locally. This is an approach that we should do much more of in Scotland as recommended by the Social Care Commission. It resulted in a more welcoming approach for users and greater continuity of care - creating a relationship with the carers. Trade union involvement in designing services and getting pay and conditions right was important in building trust in working together and redesigning home care.

Ynys Mon (Anglesey) case study is an example of enhanced dementia service using a residential home as a base to integrate services with community health staff. It was obvious that staff had a real sense of ownership, being engaged in service design from the outset.

The parliamentary review, independent of government with a cross-party reference group, pulls some of this together. They recognised the case for change is compelling, but it hasn't always compelled action. Amongst ten key recommendations, it makes the case for co-location of staff, a focus on outcomes (what they call the Quadruple Aim) and a recognition that staff are a key element in service delivery. It is not about restructuring, it's about effective implementation of a seamless service across all services.

In my presentation I set out the lessons from Scotland's experience in health and care integration. Many different models have been tried, but it is still work in progress. Demographic change places additional costs on an already underfunded service, particularly in the local government half of the process. In social care we have a hugely fragmented service that makes workforce planning very difficult. And of course there is always Brexit! We do have decent procurement frameworks, including the living wage, but councils put insufficient weighting on workforce matters and do very little monitoring of the quality of service delivery. 

My colleague from London, outlined developments in England. There is very little action on a national basis in England and just a few local initiatives. In essence it's a mess.

Finally, workforce regulation in Wales is following the Scottish model, with the phased regulation of domiciliary care staff. They have similar challenges in terms of recruitment and retention of social care staff.

Scotland is probably a bit ahead of Wales in terms of legislation and structure. However, the challenges are very similar and they do have some impressive examples of best practice, highlighted in the report. On that basis the research report published today is well worth a read. No one has got integration right yet, so we can all learn from experience elsewhere.

Private Sector Fails and the Public Sector Pays Again

Carillion’s board are accused of presiding over a “rotten corporate culture” in a report by two parliamentary committees. The company collapsed earlier this year with £1.5bn of debt leaving the public sector to pick up various public contracts. Rachel Reeves MP said the directors “drove the company off a cliff.”

The joint report, by the Work and Pensions and the Business, Energy and Industrial Strategy select committees, also criticises the UK government concluding that they lacked the decisiveness or bravery” to address the failures in regulation that allowed Carillion to become a “giant and unsustainable corporate time bomb”.

The bulk of the criticism is pointed at the company’s board who are clearly responsible for the company’s spectacular failure, despite the directors attempt to portray themselves as “victims of a maelstrom of coincidental and unforeseeable mishaps”.

The report calls out the directors’ “recklessness, hubris and greed and describes a business model that was “a relentless dash for cash, driven by acquisitions, rising debt and exploitation of suppliers”. It als suggests that their accounting practices “misrepresented the reality of the business”.
The report also raises questions for the company’s auditors: All of the big four accounting firms (KPMG, Deloitte, Ernst and Young and PWC) had done work for the company and had clearly not provide the degree of independent challenge needed to prevent the problems highlighted in teh report.

The report states that that by failing to question Carillion’s financial judgements and information KPMG complicit in the companies questionable accounting practices. They are accused of “complacently signing off its directors”. “Deloitte was paid over £10m to act as internal auditor but were either ‘unable or unwilling’ to identify ‘terminal failings’. They report also indicates that the lack of completion in the audit market creates conflicts of interests at every turn

This collapse illustrates the risks of outsourcing vital service to the private sector. The risk remains with the public sector who then have to pick up the tab for private sector failures.

Defending devolution in the EU Withdrawal Bill

The Tories and SNP may well be playing with the EU Withdrawal Bill for political reasons, but there are important reasons why those who support devolution should be concerned.

The EU Withdrawal Bill heads back to the House of Commons after some serious mauling in the House of Lords. UK headlines focus on the EEA and customs union amendments, but the Clause 11 issues, relating to devolved powers, remain unresolved. This means that Holyrood is likely to withhold consent for the Bill, leaving the UK Supreme Court to rule on the competency of the Scottish Parliament's Continuity Bill.

The dispute revolves around consent for UK frameworks on powers that come back to the UK from the EU in areas of competence that are devolved. The UK government wants to retain control over 24 areas to create UK frameworks that they claim are necessary to maintain a single UK internal market. The Scottish Government doesn't dispute the need for frameworks, but argues that these must be agreed by consent because a UK veto would undermine the principles of devolution.

The original Clause 11 was opposed by almost everyone, including the Scottish Conservatives. However, they, and others, now argue that the new clause is a reasonable compromise creating a set of procedural hoops the UK government must jump through before it gets the powers it needs to make frameworks. This also means that repatriated powers in devolved areas will go to Holyrood automatically, unless Westminster specifically reserves some for a few years through regulations.

The Welsh government has signed up to this compromise and Lord Hope, who tabled, but didn't push to a vote, some helpful amendments supported by the Scottish Government, appears to partly agree. He argues that the Scotland Act was not designed for a Brexit situation, so a more subtle, pragmatic solution is required. 

The Scottish Government argues that this is a matter of principle, while the UK government argues that the Scottish Parliament cannot have a veto on UK legislation.

I think there is an important principle at stake. This includes a defence of the hugely important Dewar amendment, which embodied the principle that all powers are devolved unless they are specifically reserved. This was not the position in Wales until the 2017 Act, so I appreciate that they may not view this matter in the same way as we do in Scotland.

However, it goes wider than that. The 24 areas that the UK government wants to have its own veto over are already clearly devolved areas. The current Clause 11 would give them the power to interfere, not just with new powers coming from the EU, but existing legislation. A particular concern for me is procurement. Scottish legislation and statutory guidance may be more timid than I would wish, but it's a lot a better than anything the UK government would support. 

If this debate appears to be a bit arcane, let me give a practical example. A care worker in Scotland should receive the Scottish Living Wage thanks to our procurement rules. This could be ended by the UK Government, using Clause 11. A pay cut is not in the slightest bit arcane! 

Then there is the 'veto' argument of the Tories which claims the Scottish Government wants to extend the powers of the Scotland Act to block UK legislation. A line reinforced by the usually more sensible Tory MSP Adam Tompkins in Scotland on Sunday. This is highly misleading. Of course it is the case that s28 of the Scotland Act 1998 gives Westminster the power to legislate on Scottish matters, but the principle in the Sewell Convention, incorporated into the 2016 Act, was that they would not normally do that. 

This is not a veto on UK legislation. It just means that UK legislation would not apply in Scotland without the consent of the Scottish Parliament. That leaves the UK government with the option of amending their legislation to get the Scottish Parliament's consent, or excluding Scotland from the geographical scope of the Bill. 

As a consequence of devolution, we don't have a single market in many areas. If you are a UK firm trading in Scotland, you already have to deal with different rules between England and the devolved administrations. Procurement is again a good example, but there are many others. In fact, some of these pre-date devolution in Scotland. New EU powers may add to these, but it isn't a new challenge. 

So, the nationalists and the unionists may pose on constitutional principles and use the dispute to further their politcal strategies. Those who support a devolved or federal model for the UK should focus on defending the devolution settlement. There is a pragmatic solution to be found that resolves differences over UK frameworks, while respecting both parliaments. What's missing is the political will.

If you want quality you have to pay for it

The Minister for Childcare made a statement to parliament this week about the extra funding for local authorities childcare expansion plans.

Disappointingly she is still boasting about guaranteeing the Living Wage as if this was a reasonable wage for a highly skilled and qualified workforce. As I said when the trade unions met with the Minister: the Living Wage is the bare minimum to live on it's not a wage that will help with the recruitment and retention challenges the sector faces.

The Minister's statement is worth watching. This week's announcement, about agreeing funding with local authorities to pay for the expansion was, I assume, prompted by Audit Scotland's report which highlighted a range of issues with the government's planning. The most headline grabbing being the difference between their and local authorities estimates of the cost. While the agreement has been reached, the funding still seems to be short of what will be needed. Particularly as they still don't seem to have got on top of the staffing issues.

There still seems to be little acknowledgement of the fact that many of the current and new staff will work part-time and that therefore the estimates of staff numbers needed are too low. Even with their own estimates the number of training places the minister states in her answers falls short of the numbers needed.

More significantly this notion that the Living Wage is an acceptable rate of pay for childcare workers is ridiculous. There is constant reference to quality being the key to closing the attainment gap, to a highly qualified workforce but no commitment to appropriate pay for those (mainly women) who they expect to deliver.

It is true that for some outwith the public sector nurseries this will mean a welcome wage rise. This is because they are shockingly underpaid. They deserve a much more substantial pay rise.

In order to deliver the aims of the policy we need a qualified workforce. You cannot expect workers to study for HNCs and then degrees for the promise of £8.75 an hour. The reality is that those who don't pay wages that reflect the skills of workers will continue to lose staff to those who pay more.

Why would you work for £8.75 an hour in a nursery when you can make the same on a supermarket checkout without the responsibility of educating young children, child protection and report writing or Glasgow City Council will pay you approx £19,000 for 38 weeks of the same work?

I know I keep repeating this but we can't have a system that keeps some women on poverty pay in order to create free childcare for others. Done properly lives will be transformed but there is a lot more to do to make sure that the result is reduced poverty and the end of the poverty related attainment gap.