Integration - a Scottish context

Iain Wallace, FMLM Regional Lead for Scotland

In Scotland, the system governing the way healthcare is organised changed radically on 1 April 2015. Through the Public Bodies (Joint Working) (Scotland) Act 2014, community health partnerships, the primary care arm of health boards, were disestablished and were replaced by one of two options. In the first option, an agreed set of functions and resources are delegated by a health board and local authority to an integration joint board (IJB). This is also known as the body corporate model. The second option, a lead agency arrangement, is where a health board or local authority delegates some of its functions and resources to the other body.

Integration schemes have been developed for both options and have been approved by the Scottish Parliament. These describe the functions which have been delegated by the relevant health board and local authority and must include as a minimum adult social care services, adult primary care and community health services and some adult acute services. For IJBs, Chief Officers have been appointed to manage the services delegated by health boards and local authorities. Under both arrangements strategic plans have to be agreed by 31 March 2016.

In the body corporate model, IJB membership comprises an equal number of local authority councillors and health board directors (usually non-executives) as voting members, together with a range of advisory (non-voting) members including a general practitioner and a secondary care medical practitioner.  

The changes brought about by the legislation are designed to bring many local authority and health services closer together and to offer the prospect of more integrated planning and delivery of services, particularly for older people. Integration is not limited to primary care and social care, but also includes a number of secondary care services such as emergency medicine and old age medicine.

For IJBs the potential impact has still to be felt as these remain early in their development. However, the lead agency model, which has been in place in the Highland area since 2012 under previous legislation, is more developed. Both have the potential to drive significant improvements for patients, ensuring that: they are cared for in the most appropriate setting; that where possible they can remain at home or in a homely setting for as long as possible; and that if they do require acute care it is for as short a time as possible and the likelihood of returning to their own home is maximised.

So, what are the implications for medical leaders?

Clearly it is important that medical input to IJBs or lead agencies is strong. Under the legislation doctors in IJBs (unless they are Board members) will not be voting members. On the face of it this may appear disempowering, however, it is unlikely that IJBs will be able to function effectively if they have to resort to making decisions by majority voting. Doctors are well placed to influence the thinking of voting members. Non-executive health board members are used to this but it will be a new experience for local politicians. Similar challenges exist for those working in a lead agency model, particularly if services are delegated to a local authority.

No matter what the model of integration is, medical leaders from primary and secondary care backgrounds should grasp the opportunity to shape local services and develop more appropriate models of care. In positioning doctors to maximise their influence alongside other clinical and non-clinical professionals, they will need to employ a range of skills including collaborative and collective working, negotiation and consensus building. As agencies develop their strategic plans there may be occasions when clinicians have differing views to those held by elected representatives. Working through differences to agree solutions that are safe, effective and person-centred will be challenging and a test of the skills of medical leaders. 

At locality level, medical leaders will be expected to work with a range of services including those from the third, independent and private sectors to integrate service provision and use resources to best effect, including directing expenditure more towards prevention and early intervention. In the current financial climate, with seemingly unlimited pressure placed on the acute end of healthcare, whether in primary or secondary care, this seems like a big ask but it is one which will need to be addressed if society is going to meet the demands placed on it by the shift towards an older population.  

Ultimately, health and social care integration offers a new, and some may say radical, opportunity to reshape services. Medical leaders must play an important role in ensuring the success of these arrangements.  They should equip themselves with the necessary skills to maximise their effectiveness in what is, and will continue to be, a complex and changing environment.