Thursday, 27 February 2014

Health and social care sitting in a tree....

(Pic :

Plaid's Shadow Minister for Health & Well-being, Elin Jones AM (Plaid, Ceredigion), launched a second policy consultation on Tuesday (first - Dr Plaid's NHS Treatment Plan – another several hours of voluntary work), outlining proposals to integrate the two services.

The paper is available here (pdf) and the consultation is open until May 30th.

Why integrate health and social care?

Integrating health and social care will hopefully lead
to fewer scenes like this in Welsh hospitals.
(Pic : The Telegraph)
Firstly, it worth distinguishing between "health care" and "social care".

Health care includes diagnostic and treatment facilities provided by hospitals, GPs, allied professionals like physios, pharmacists, dentists and opticians and the ambulance service. These are provided by the NHS or on the NHS's behalf (in the case of dentists etc.)

Social care helps people with physical difficulties to "live their lives comfortably". That includes things like cooking, cleaning, home adaptions and more personal things like managing finances. This can be done in someone's home, or in a full-time residential complex.
These services are provided both by local authorities and private companies.

The paper outlines several problems resulting from keeping the two services separate from each other :

  • "Bureaucratic battles" over which service is responsible for the care, and for whom specifically.
  • Unnecessary hospital admissions and delayed transfers of care ("bed blocking").
  • Lack of sufficient community care through "chronic under-investment".
  • Budgets for health services have generally been protected by the Welsh Government, but there are threats to social care services due to local government cuts.

Older patients in particular are often passed between different organisations – a concern raised by the Older People's Commissioner. It also means some patients with chronic illnesses go to hospital when it's better for them to be treated at home and given support so they can live independently again.

Merging the two services has long been an aspiration in Wales, with a continued focus on partnerships, collaboration and pooled budgets.

During the recent Social Services and Well-being Bill debate, service integration was raised several times and amendments were proposed – including from Elin Jones herself – which would've paved the way towards limited integration.

The issue is even more urgent as a result of the Williams Commission. Echoing what Leanne Wood said during the debate on that, the Commission's proposals go beyond a simple reorganisation of local authorities. Plaid describe the omission of local health board and social care reform from the Commission's remit as a "flaw".

However, in one example – Powys – the Commission recommended Powys Local Health Board (LHB) merge with Powys County Council. That's because no acute services are provided in Powys (they're reliant on Shrewsbury, South Wales and Aberystwyth) making the process easier. The Commission also recommended the new local authorities don't straddle the 7 LHB boundaries.

So although it was outside of the Williams Commission's remit, they "future proofed" things to enable a smooth integration between health and social care in future.

Plaid argue a single Health and Social Care Service, with a single budget, means some services that would otherwise face cuts can be protected, with all staff involved in care working to the same end. This will improve services for those needing care and put less pressure on hospitals.

Learning from Northern Ireland

Northern Ireland has long had a system of integrated health and social care services.
(Pic : South Eastern Health and Social Care Trust)
Northern Ireland, in practice, merged health and social care system in 1973, though a direct merger was delayed until 2009 due to political problems. The driver of change there was also – coincidentally - local government reorganisation, though the advantages of integrated services weren't realised at the time.

In terms of how it works, GPs are at the head of a team of professionals that includes social workers and nurses, services aren't duplicated, people aren't passed between different organisations and care is co-ordinated between the health side and the social care side.

Scotland's currently pursuing integration of services through the Public Bodies (Joint Working) Bill, which, if passed, will offer two options to Scottish local authorities and health boards – joint boards with joint budgets, or functions and budgets being transferred between boards in order to set their respective roles in stone.

England's also experimented with integrated services, with Torbay given as an example, seeing "impressive" falls in bed occupancy rates, emergency bed occupation rates and bed blocking.

Plaid's Challenges

Plaid describe this as a "once in a generation opportunity for Wales to lead the way by fully integrating health and social care". However, they outline the significant challenges standing in the way.

The first is that health services are universally free at the point of use, but social care is means tested by local authorities - with only the poorest receiving free care. There are complications caused by what are described as "bureaucratic battles", where free care is only available depending on which organisation undertook the needs assessment. Governments are therefore reluctant to scrap means testing as it would increase expenditure.

Plaid would prefer to make all social care free at point of use – in line with health services. However, as the budget isn't there do that, they intend to put services into three bands :
  • Free at the point of use – this includes GP appointments, NHS hospital treatment, prescriptions and health information etc.
  • Capped charges with free services or reduced charges for the less well off – dental treatment, opticians, non-residential social care.
  • Charges imposed with means testing available – residential social care and home adaptions.
This is, essentially, how services are provided now. If more money comes in, Plaid say they'll try to make more services free at the point of use.

Plaid also flagged up:
  • Social care affordability – The Dilnot Commission recommended a cap on what a person pays for care, subsequently set by Westminster at £70,000. The Welsh Government hasn't decided whether to bring in a cap or not because of the potential impact on the Barnett Formula.
  • Mental Health Services – A 2008 paper for the Welsh Government recommended the creation of a single body for mental health services in Wales which would "stretch across health and social care". These proposals were rejected by the Welsh Government because there were no links between mental and physical illness, a stand alone body might be subject to cuts they otherwise wouldn't be and there were objections to including learning disabilities within that structure. Plaid propose "revisiting" the idea, and ring-fencing the budget for mental health for the foreseeable future.
  • Third Sector involvement – It's said the third sector has provided both innovation and a voice for service users. An integrated service would allow a review of how contracts are awarded to make it less bureaucratic.

Plaid's Integration Options

Handing control of adult social care to local health boards could result in fewer
hospital admissions and "bed blocking", as services would fall under a single umbrella.
(Pic : BBC Wales)
Option One : Adult Social Care becomes the responsibility of Local Health Boards

The Welsh Government "would retain control over strategic decisions" but the responsibility for commissioning social care and mental health services would be with LHBs, not local authorities. It's possible LHB boundaries could be reviewed too.

For democratic accountability, Plaid propose either nominating local councillors to sit on boards, or direct elections for board seats at the same time as local council elections.

They're not proposing the same for children's social care, because users of adult social care often have health problems, while children's social care is often related to things like child protection - a role for social workers, not the NHS.

One risk here – as experienced in Northern Ireland – is that health could dominate the integrated system, furthering under-investment in social care. Under this choice, the Welsh Government would, therefore, "play a stronger role in budget allocations", possibly ring-fencing social care funding.

Option Two : Local authorities are given control over primary (GP) and community health

This is described as "the radical option", where local authorities (presumably post-reorganisation) would control GP services, community hospitals, patient transport and community medicine (including community mental health). Current local health boards would be scrapped, and it's a similar, but not identical, set-up to Denmark.

Hospital services and things like ambulance services would be run either :
  • directly by the Welsh Government.
  • by a single National Hospital Board.
  • three health boards based on fire and rescue service areas.

It would end problems caused by patients transferring for treatment between LHBs, and allows greater national planning.

Plaid say option two would also ensure "a greater emphasis on preventing ill health and looking after people in the community" with bed blocking reducing over time - as long as there's investment in community hospitals.

A risk is that continuing to have two seperate bodies responsible for health and care could continue arguments over who does what, and see no end to "postcode lotteries". There's also a risk current financial pressures on local authorities will transfer into the health service.

For both options, Plaid say it would take an Assembly term (5 years) to integrate services.


Option two sounds attractive, but after the experience of the old 22 local health boards, foisting responsibilities for primary care onto councils after they go through a very rough reorganisation would be a bad idea.

The first option seems sensible - and has been backed by the Royal College of Nursing. It's best to use existing structures for service delivery, while integrating health and social care makes sense for reasons clearly set out in the paper and in the Senedd chamber.

A similar set up has been argued for ambulance services too, and as regular readers will know, I would prefer services like these (and others) to be provided by a regional tier of government - but that boat's sailed.

What's also pleasing is the constructive response of Health Minister, Mark Drakeford (Lab, Cardiff West), who's quoted as saying he would read the paper "with interest" and that "ministers will look carefully at what the party is saying". That's much better than the nonsense we got last time from Labour.

It's fair to say Plaid are heading in the right direction (again). Shame about "other things".


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