The integration barometer – the state of play of health and social care integration

The integration barometer – the state of play of health and social care integration

The integration barometer – Clare Hammond looks at the state of play of health and social care integration

The integration of health and social care. Currently held as the holy grail of getting public services right. Both England and Scotland have been attempting to integrate these services in various ways for a while now. So, where are we? What have we achieved? This blog looks at what each country is doing and what where they have got to.

So, what’s happening in Scotland?

In Scotland, the Public Bodies (Joint Working) (Scotland) Act 2014 requires NHS and Local Authorities to integrate social care and a proportion of NHS activities. This move is driven by the Scottish Government’s 2020 Vision where everyone in Scotland can ‘live longer, healthier lives at home, or in a homely setting”.

The integrated activity equates to around £8 billion of the nearly £15 billion spent on health and social care across Scotland and covers adult social care services, adult primary care and community health services and a portion of hospital services. The integration of services such as criminal justice social work and children’s services are at the discretion of each area.

The legislation dictates that this integration must cover governance, planning, and resourcing recognition of Joint Bodies as legally separate entities. Since then, 31 Joint Bodies have developed across all 32 Local Authority areas in Scotland (with a slightly different model operating in the Highlands.

A 2016 report by Audit Scotland provided an update on the progress of integration. It acknowledged that new approaches to making health and social care integration really work are springing up across Scotland. However, they also conclude that this integration isn’t occurring fast enough to keep up with the growing service demand resulting from an ageing population and the increasing complexity of need. Audit Scotland are due to report again on the progress of Health and Social Care integration in November 2018.

Institutionally speaking, these organisations are in their infancy. This shift is considered the largest change in services since the creation of the NHS. The integration of two very different organisations, service structures, budget priorities and cultures is going to take a while. And it is probably going to be longer than 4 years for the benefits of integrated governance and decision making to bear substantial and financial fruits. Even one of the most advanced examples of health and social care integration, in Canterbury New Zealand, has failed to achieve a financial saving to their District Health Board despite achieving a large impact against a range of the typical indicators of success (average bed days per admission etc).

And, what about England?

In England, the picture is somewhat more complicated than Scotland. Here, Health and Social Care integration requires coordinated efforts from NHS England, the Department of Health (DoH), the Ministry of Housing, Communities and Local Government (MHCLG), and Local Authorities across England.

Numerous commitments to integration have been made by these organisations over the years. In 1999, the Health Act allowed Local Authorities and the NHS to pool budgets and merge services where appropriate. Very little action occurred in response to the 1999 Act, much of which is put down to Clinical Commissioning Groups and the Health and Social Care Act 2012 complicating integration.

 

English health and social care bodies have made more recent recommitments to integration. In 2013, the Department of Health committed to making health and social care integration ‘the norm’ by 2018. In 2014, NHS England made a commitment to integrate health and social care by 2020.

Various integration approaches have been used. There was the rise (and current slow death) of Health and Wellbeing Boards around 5 years ago. The latest are Sustainability and Transformation Partnerships (STPs) between the NHS and Local Authorities. There are currently 44 of these across England. A national performance system for STPs has been established with a dashboard of measures that STPs will be measured against annually. July 2017 saw the release of the ‘baseline’ performance of STPs.

Some of these STPs have ‘upgraded’ to Integrated Care Systems (ICS) which indicate an even closer integration between health and social care than the STPs. In 2017 there were seven ICS with a limited range of accountabilities around operational and financial performance. In 2018, ICS are expected to gain greater flexibility in financial management.

How integration occurs in England is less specified than in Scotland with local areas able to choose what integration looks like for them with no requirement for that integration to be the creation of a joint institution. For example, integration could include joint commissioning, or joint patient assessments.

Also unlike Scotland, English integration recognised that to reduce the pressures on hospitals means that social care will need to pick up the slack. At a cost. The 2010 Spending Review transferred £2.7 billion from NHS to Local Authorities for the following four years.

Despite the commitments, development of STPs, ICS and a number of integration initiatives, the National Audit Office (NAO) released a fairly scathing report in February 2017. Most of their recommendations were for NHS England, DoH and MHCLG and related to providing national standards, guidance and oversight on progress. However, there were two conclusions that are particularly pertinent in terms of encouraging integration in the future.

As in Scotland, there was recognition that a number of examples of good integration are occurring across England. However, these were yet to be tested at scale, not where they proven to have a sustainable impact on service budgets and outcomes. As with Scotland, comprehensive proof that integration can reduce budgets and improve patient outcomes is yet to be provided.

NAO concluded that attempts at integration are still ‘siloed’, with each ‘side’ having their own mechanisms to encourage integration. The Better Care Fund is seen by most as helping Local Authorities, while the Sustainability and Transformation Planning Process is viewed as an NHS initiative, despite both initiatives’ focus on integration. This siloed view of programmes as either NHS or Local Authority, combined with concern that much of the funding available for integration is being diverted to plug funding gaps in an already struggling NHS, leads the NAO to conclude that much needs to be done for services to see themselves as part of the same team.

 

Clare Hammond is an Associate Director at Rocket Science specialising in health and social care including evaluation, strategy and organisational development, cost modelling and cost benefit analysis.You can check out her profile here.

This blog is part of a wider series on Health and Social Care Integration. Other blogs in this series can be found here

 

Prevention in Action – Invest early in housing advice according to our latest SROI on Legal Aid

Prevention in Action – Invest early in housing advice according to our latest SROI on Legal Aid

Prevention in Action – Invest early in housing advice according to our latest SROI on Legal Aid – Clare Hammond looks at the latest findings

Prevention is heralded as the long-term solution for tackling poverty and disadvantage.

Since featuring as one of the four pillars of public sector reform set out by the Christie Commission in 2011, prevention has been a firm fixture on the Scottish Government’s agenda. However, for many policy makers and service providers, it is a much spoken about ideal that still feels out of reach.

When it is done effectively prevention work can slash the costs of later support provision and reduce the demand for a wide range of pressurised services. Most importantly however, it can lessen the impacts of poverty and improve the health and wellbeing of individuals, families and their communities.

As we have previously discussed, making a decisive shift towards prevention is not without its challenges. These challenges cut across sectors and tend to centre around two areas:

  • Where funding is directed from: insufficient budget flexibility; the potential mismatch between who funds interventions and who gains from the benefits; opportunity costs associated with re-prioritising resources
  •  Evidencing return on investment: risk and uncertainty about future impacts of upfront investment; the timescales for a return on this investment

As a company, we have sought to help our clients, and others, to understand practical and realistic ways to implement prevention in an imperfect world where funding is restricted, and support provision is fragmented across different organisations and policy areas.

Don’t get us wrong, we are working with organisations across the UK to improve the coordinated efforts across policy and budget silos. However, we think that there are also a number of easy wins to implement preventative approaches that aren’t reliant on a fundamental shift in service delivery models.

The Law Society of Scotland have recently published the findings of a study they commissioned our team at Rocket Science to undertake. This study sought to identify and quantify the preventative benefits of legal aid in Scotland, focusing on housing, criminal and family law cases. We used a Social Return on Investment model for this research which measures the social, economic and financial impacts of an activity on all the relevant parties including service users, service providers and other stakeholders.

The analysis of housing cases revealed a particularly interesting finding. Many cases involved providing housing advice, often to those facing eviction as a result of debt or rent arrears. We estimated that for every £1 spent on early provision of legal advice on housing cases, there was a return of £11. This included savings to homelessness services and reductions in temporary accommodation costs, as a result of avoiding eviction and addressing growing housing arrears. It also considered the benefit to individual tenants such as improved mental and physical health and confidence in their ability to maintain their accommodation in the future.

This research provides a clear steer for local authorities, housing associations and the NHS to invest further upstream, ensuring that legal advice around housing debt is available at the earliest opportunity to avoid the higher and longer lasting costs of eviction.

Recognising the benefit of investing upstream to prevent homelessness, the Royal Borough of Kingston upon Thames is piloting a new project focused on early interventions. This project supports its service users with a wider range of issues, such as mental health, which are found to be trigger future housing problems. We are currently working with Kingston and two of their surrounding boroughs to evaluate the effectiveness of this pilot. This work will include a cost benefit analysis of their impact.

We will continue to evidence the value of investing in preventative approaches and research the most effective ways to implement new approaches. We hope that this encourages investment, so that prevention begins to feel less like a long-term ideal and more of a current opportunity.

 

Clare Hammond is an Associate Director at Rocket Science specialising in cost benefit analysis and social return on investment across a range of sectors including employability, health and social care, housing and poverty reduction. You can check out her profile here.

 

The changing face of health and social care

The changing face of health and social care

Health and social care services are changing, and so is the help we provide our clients. Clare explores some of the changing nature of what clients want.

Across the UK health and social care staff are exploring how to work in a more integrated way for the benefit of their clients and patients – who are often those ‘further from work’ and clients of a wide range of services. There is still a need for independent evaluations, but our experience is that clients are seeking help in three other areas.

Supporting service improvement

After almost a decade of budget reductions, services are feeling it. This is not a new story, but the easy efficiency wins have often gone. For services where demand is still increasing (for example those supporting older people), this poses a particular issue: resources are already stretched, and services need to make  more sophisticated, creative and cultural changes if they are to continue to meet demand while managing their budgets.

What has proved helpful here is acting as expert advisor, critical friend, and independent facilitator.

Service change like this requires buy in and change from within. So, we facilitate workshops, oversee the progress of workstreams, and provide a steering hand based on our experience of what works (and what doesn’t) in service delivery and managing change. For a recent client, we have been helping delivery staff to think strategically about their service. This is really about helping the service to find the breathing room to explore the evidence about current delivery in a carefully structured way and develop the solutions themselves.

Reviewing service need and delivery

Health and social care needs are becoming more complex. Policy makers are also shifting their focus on the interaction between health, social care and other outcomes such as housing, education and employment. 

Service providers are responding to this by undertaking reviews of their range of services to answer the questions, “What are the needs of my target group, and is what I am delivering – and the way I’m delivering it – addressing these needs?”

Our work with one Health and Social Care Partnership in Scotland has been typical of this.

Having explored with them the range of employability services they funded, and how they could enhance their impact by connecting these around specific client routes and journeys, they asked us to review their tailored health services for young people.

These are delivered through different models that have grown organically in response to local needs and available resources. These services were one part of a range of services provided by an array of partners. We identified the needs of young people in the area and recommended a service delivery model that would best meet these needs while fitting in with, taking advantage of, and influencing other services. This can feel a bit like three-dimensional chess at times!

Understanding costs and benefits

As Clara and I wrote some months ago, in an environment where every pound comes under the microscope, common sense is not enough to drive decision making. Commissioners are asking themselves, “How do use my resources in a way that supports service users, while generating savings elsewhere”. Clients want to understand how spending can relieve the financial pressures and free up resources to be reinvested elsewhere.

One example is the help we are providing to a Clinical Commissioning Group in England to understand the likely financial return to commissioners from changes to clinical follow up procedures. We are also evidencing and measuring how non-clinical support for patients can lead to tangible savings to clinical services (and therefore commissioners), while improving the service users experience. Another example has been helping The Yard Scotland to articulate how much its service reduces the demand for Local Authority funded respite care for young people with disabilities.

You will gather from this that client support needs in the area of health and social care are fluid and shifting. They need to maintain progress and make significant changes while ensuring that their clients and patients receive high-quality care and support.  Our experience is that there are still improvements to be made against a background of tightening budgets and increasing demands. But it needs evidence, leadership, sustained investment in staff and their development – and great collaboration across the front line.

 

Clare is a Principal Consultant in our Edinburgh Office. She works on health and social care projects across the UK and is trained and experienced in economics and public policy. You can check out her profile here.
When common sense is not enough

When common sense is not enough

Clare Hammond and Clara Mascaro on using Cost Benefit Analysis to justify investing in prevention

The saying goes: “It’s better to build a fence at the top of a cliff than to park an ambulance at the bottom.” And this common-sense notion that it is better to prevent than to cure has in the last decade also become an accepted principle in public policy. This has been helped by the influential work of the Early Action Taskforce and other bodies such as NESTA.

But putting common sense into practice is often easier said than done. Designing a preventative intervention involves important decisions such as when to intervene, and whether the intervention should be universal or targeted at a specific group of people. In particular, making a solid financial case for investing in preventative strategies is proving to be the ‘do or die’ of whether these are implemented at all. This is where cost-benefit analyses (CBAs) have a crucial role to play.

…the costs and benefits of prevention are spread over time…

A major difficulty for financing such interventions is that service providers bear the costs now, for a service that may create benefits in the future – often 5, 10 or 20+ years in the future. Well beyond any service budget or political term. Convincing service providers to divert already limited money from those who need it now, to benefits in the future is a tough one. Particularly with all the uncertainty that goes with things not in the here and now.

… the costs are usually borne by one service and the benefits received by another…

The agency bearing the costs is not always the agency reaping the benefits. For example, a local authority may invest in a programme to facilitate youth transitions from school, but the savings from reduced youth unemployment will accrue to DWP as a result of having fewer out-of-work benefit claimants. In a world of siloed budgets and service pressures and demands for results, moving money across organisations, even within the public sector, is complex.

…the solution is trust and coordination between agencies – and a lot of hard evidence…

To support investment in preventative strategies, co-operation is needed. This could be facilitated by pooling and integrating budgets. For example, this is what happens with Health and Social Care Partnerships, which bring together local authorities and NHS Boards across agencies and institutions.

 

However, when such integration is not an option, strong partnership working, coordination and trust is needed to encourage investment. This can be helped by cost-benefit analyses showing who will benefit from an intervention, by how much and when. On this basis, agreements can be made between agencies to share the costs and benefits of a preventative intervention.

…Cost Benefit Analysis is critical to underpin conversations and agreements between agencies that build this coordination and trust…

CBAs can be used to make a case for investment now for future savings. By clearly showing the expected costs, savings, those who pay, those who benefit and when, decisions about prevention become more tangible. We have been working with a number of Local Authorities and service providers to create CBAs that help them to better understand and articulate the costs and benefits of a range of preventative investments.

A few of these include:

·        Helping the Dundee Partnership to estimate the likely savings to a range of agencies from reducing the incidence and duration of long term unemployment. Our work also identified who to invest in, when, and how to successfully prevent long term unemployment

·        The London Borough of Havering where we created a CBA to estimate the savings to the Local Authority from our recommended interventions to reduce unemployment. These savings were as a result of less demand for council services such as social work, care and housing

·        For a charity called The Yard Scotland, we estimated the savings to the Local Authority of their service through reducing the demand for council funded respite care for children and young people with disabilities by preventing issues from escalating.

In a context of tight budgets, a complicated landscape of provision, and a short-term bias, CBAs can provide the supporting weight to tip the scales in favour of early action. We may all agree that ‘it is better to prevent than to cure’ but, in this case, common sense alone won’t make prevention happen.

 

Clare is a Principal Consultant at Rocket Science based in our Edinburgh office.  You can check out her profile here.

Inclusive Impact – capturing ALL voices

Inclusive Impact – capturing ALL voices

How can you involve vulnerable young people and their families in measuring social impact? Clare Hammond talks about our work for The Yard in Scotland, developing their first Social Return on Investment report.

We have been working with The Yard Scotland and their community since June 2016. The Yard provides safe play spaces and respite for young people with disabilities and their families. During our time with The Yard, we conducted a Social Return on Investment and Cost Benefit Analysis to be able to evidence and quantify the impact their service has on families and how much they save other service providers such as the Local Authority.

For Rocket Science, the voice of the service user should be present, loud and clear, and the central driving force for any impact analysis. Social researchers the world around can talk to you about sampling sizes, interview techniques, and running a great focus group to get that voice. However, social impact research gets slightly more complicated when service users are less able to engage with the more traditional research processes.

Engaging extensively with The Yard’s young people and families as part of this research has been very important to both Rocket Science and The Yard Scotland. To do this we have had to use less conventional methods of social research – and we have learnt a few things along the way: We’ve learnt a few things along the way about how to approach impact analysis using less conventional methods:

Co-design with The Yard of all research activities was vital. As consultants, we brought expertise in evaluation disciplines, analytical processes and robustness. However, it’s The Yard that knows its client group inside and out. Bringing together this expertise was vitally important, particularly in designing and delivering the research activities with their young adventurers.

Abandoning the traditional – for the young adventurers we knew we couldn’t use traditional research techniques. Instead we embraced what made The Yard so great – play! We kept it simple– we had two questions we needed answering.

 

Then we developed a range of play activities that young people could engage with…ever conducted an interview on a go-kart? It’s exhilarating.

Understanding the impact of the service on families was much harder than we expected. Parents and families of these young adventurers are so used to constantly being the advocate for their child. They are some of the most selfless people we have engaged with. For our research – getting parents to think about themselves was difficult. We overcame this in two ways:

We needed to make it clear to parents that this was a space for them to talk about themselves as well as their children. Using colourful post-it notes we put all messages relating to their children on one wall, and messages relating to themselves as individuals on another wall. As expected, the wall of messages about their children filled up fast, while their own wall remained largely empty. We then set them the challenge of filling their wall to be as colourful as the wall about their children. Highlighting their selflessness visually, and colourfully proved to be very effective.

Once again, we embraced The Yard’s motto – fun! We needed to convert outcomes such as friendship and relaxation into monetary values. We chose to use Choice Modelling – which, I promise, is as dull as it sounds if done with no humour. So with fun, laughter and a joke or two we had groups of parents and carers giving us their honest views of what was important to them as individuals as well as their family.

Our time with The Yard has been rewarding, enlightening and a lot of fun. There aren’t many researchers that get to say they got to play with paints, bikes and swings for work! The Yard are now armed with robust evidence of their impact to use with the policy makers and funders. With this information, they intend to influence the design of services and expand their services further across Scotland.

Clare is a Principal Consultant at Rocket Science based in our Edinburgh office.  You can check out her profile here.