Read the Edinburgh’s Integration Joint Board’s submission below.
Dear Mr Feeley
The Edinburgh Integration Joint Board (EIJB) is pleased to be able to respond to the call for views in relation to the Independent Review of Adult Social Care. This is a significant and important piece of work, being done at a time of real pressure and challenge across our system and in a very short timescale and we hope that the challenges in both of these support an outcome that delivers the best possible outcomes for people to live as independently, in their community as possible.
It’s noted that in inviting views, that the panel has not provided any specific questions or narrative in relation to its work and so we have developed this response based on what we believe are key principles for the review and any future model of adult social care to operate within, as well as from our own ambitions as an Integration Authority (IA) and our strategic transformation plans.
IRASC Terms of Reference
The terms of reference for the review is wide reaching, giving an opportunity to resolve some of the barriers to deliver truly integrated health and care services especially at a time where there are significant demands for health and care services across Scotland.
The EIJB welcomes the inclusive approach to the review, taking account of the importance of housing and education and those other services and partnerships that support people in their communities.
We note from the Terms of Reference that one element under consideration is that of the structures through which social care is delivered however we also believe it important to recognise that structures – and massive organisational restructure – alone do not lead to transformation and that their undertaking can itself detract from driving the change being sought. In that theme therefore, any alternative structural arrangements (as part of the outcome of the review), must be considered through the lens of its achievability and the real impact on people.
The panel is aware that Integration Joint Boards(IJBs) are themselves relatively new, having been brought into formal being in 2016. While there remain challenges with the model which have been set out by Audit Scotland among others, it is the case that the formal integration of health and social care, under legislation, has made a difference and driving improvement across Scotland. This has been seen most recently in the agile response of IJBs and their Health and Social Care Partnerships (HSCPs) in response to the first wave of the Covid19 pandemic and the support they provided in partnership as one of the leading Public Sector Bodies, alongside Councils and NHS Boards.
There is much that can be improved in the integrated landscape by way of its complex relationships, accountabilities and governance but the principle of services, as close to the populations they are designed for and with, with local democratic accountability, and which integrated from planning, decision making and delivery must be a cornerstone of the Panel’s work and we would urge that any consideration of structural reform focusses on strengthening the role of IJBs to be truly responsive to their communities as an accountable Public Body.
Edinburgh IJB Transformation Programme The EIJB is ambitious to transform the way we work and our relationship with the citizens we serve.
We believe that the Panel welcomes learning from innovation happening now in adult social care and that examples from some of the work we are doing in Edinburgh will be of interest and strong relevance to its work. The following sections sets out some of what we are doing, and we would be very happy to discuss any aspect of this directly with the panel.
Over the next few years, the EIJB is focused on four key areas to deliver a caring, healthier, and safer Edinburgh:
- Redefining the Edinburgh Pact
- Embracing the Three Conversations Approach
- Adopting the principle of Home First
- Advancing our Transformation Programme
- Developing a ‘One Edinburgh’ approach to our work with providers of care
The EIJB face some real challenges in delivering a health and care system in Edinburgh, therefore the EIJB need to think differently and the review is timely in supporting the EIJB to boldly shape services. The EIJB’s ambition is to deliver a health and care services in a way that supports people to be well at home and in their community for as long as possible.
Within Edinburgh, through its strategic plan are focusing through its transformation programme to develop both the Edinburgh Pact and Three Conversations model which put people at the centre of decision making.
Previous approaches to delivering adult social care have used triage systems and an allocation process approach, have staff and individuals complete lengthy assessment forms and presumes the need for formal services. Too often this leads to people having to wait as resources have reduced. They must wait for an assessment and then, once assessed, wait for a ‘package’ of formal care. This system is broken and, as resources are put under further demand while need increases, is not sustainable. The EIJB agreed to change the way we work with people – to achieve better outcomes for them, a better and fairer use of resources and a more empowering model for our professionals.
The Three Conversations Approach which we are working on with Partners4Change is about working differently with individuals to achieve good outcomes for them and their families. The model is centred around having a more dynamic and flexible approach to helping and supporting people, recognising the power of connecting people to the strengths and assets of community networks, and work dynamically with people in crisis. The model focuses on what is important to individuals and conversations are person centred, leading to a reduction in support which undermines independence and allows intensive support to be used where there is most need. This model also aligns with the Self-Directed Support (SDS) philosophy where people should have the right to choose how their care needs are met.
This approach will be embedded in everything we do, including the workforce, commissioning approach, and links to other parts of the community which impact on the health and care of individuals, such as housing, third sector and community assets.
We want to support people to live independently in their own homes or in their communities therefore we need to ensure that there is sufficient community infrastructure in place to support this, takes account of best practice and cognizance of local voluntary activity.
Our initial work on this is demonstrating transformational change for people and for our practitioners who report greater empowerment, the ability to do what’s needed and better role satisfaction. Our early evaluation demonstrates fewer people needing a formal service following a conversation than under our previous models and more people able to access either advice or one-off support to address their initial enquiry. There is huge potential in this model in changing how we work and pushing decision making and power to where it is most impactful – our citizens and our frontline professionals.
The Edinburgh Pact aims to reflect a pact made between individuals and providers to prevent crisis and support people to manage their health and personal independent at home as we believe that individuals are experts in their own lives.
The intention is that we will work with individuals to identify what matters most to them and support them to reach their potential. We must also provide clarity to citizens of Edinburgh on what we can provide and redefined what statutory service can contribute.
This can only be achieved through working in collaboration with partners to tackle inequality in communities and having meaningful engagement with citizens so that citizens who find themselves needing our support, know how to engage with us and realistically what to expect from that relationship. Working with the strengths of our citizens and communities to make sure that age, disability, or health conditions are not barriers to living a safe and thriving life in Edinburgh.
Significant work is being undertaken to ensure services are designed with people at the centre of decision making, however there is still more to do in fully implementing Self Directed Support effectively.
It is important that we develop ways to engage with citizens and service users and involve them in the transformational developments and initiatives underway. The EIJB have started that journey with two public engagement sessions running in November to get feedback on health and care services and the citizen experience of using these services.
Experience of people who work in social care The workforce is our key resources and ensuring we have the numbers and skills to meet the increasing service demand remains a priority for the Edinburgh Health and Social Care Partnership (EHSCP). It is vital that we engage with, motivate, and support our workforce, to improve and sustain their knowledge, skills, and experience as we face the challenges and opportunities ahead. The workforce is ageing in several areas and there is a constant struggle to recruit and retain health and social care professionals in the city. Baseline indicators identify across the Partnership that 45% of the total workforce is age 50 and above. Further scrutiny also highlights issues of supply with less than 10% of the workforce below the age of 30. Into this mix, the ageing city population, as well as Edinburgh’s buoyant employment position and the high cost of housing, poses further challenges with recruitment and subsequent service delivery. We also need to encourage individuals to see health and care services as an attractive career path, easily access training with a clear route into a valued, supported, well paid career path.
To meet the increasing demand, the EHSCP workforce planning group has highlighted the need for targeted recruitment, for example offering modern apprenticeships and vocational learning, as well as the need to transform roles and encourage more applicants from ethnic minorities to better reflect modern society, to allow for a step-change in the way our workforce deliver services now and in the future. A workforce strategy is being developed, will form part of our transformation programme, and will be published in the coming months.
Through the integration of health and social care services we have managed to integrate teams successfully across a range of disciplines.
However, there are ongoing challenges around the operation of two difference cultures, systems and processes that still exist between health and social care services. These can hold us back in delivering the kind of agile change we need and force us to remain in traditional professional silos. The review must give consideration to a vision of a future workforce that encompasses new roles and how we train, educate and prepare the workforce for the future and create jobs that support recruitment of highly motivated and skilled people, appropriately and fairly rewarded for the work they do.
A significant focus of the inquiry will focus no doubt on the workforce across our third and independent sector partners who deliver essential, person centred care for many thousands of people across Scotland. This is a crucially important partner workforce, and we encourage the panel to consider models which ensure parity of esteem with the public sector. Consideration must be given to how we value this workforce and these roles in Scotland and how we recruit to them, prepare, train and educate people to undertake them and the career progression and support they can and should expect in their undertaking. We have seen great progress in delivery of the Scottish Living Wage to this workforce, but the panel will recognise that for several IJBs, securing the funding to do this is particularly challenging, despite our commitment. This needs a sustainable solution if we are to aspire to parity with training, pay and conditions, and career progression.
Opportunities to redesign the overall system of social care The review offers a real opportunity to redesign a fit for future system for health and care services. The principle of integrated health and social care is the right approach; however, the current structure of integration (the Body corporate model) is inefficient and clunky and has been slow to evolve. Any further proposed structural changes in the health and care area, could bring considerable uncertainty for staff groups and would have to be managed, and could be more disruptive than positive. It has also introduced additional levels of bureaucracy and not managed to develop a single budget nor single needs assessment.
There are significant strengths in local relationships and interfaces with other service areas and organisations that would be lost should the review lead to the development of a more regional or Scotland wide organisation of adult social care. There is a recognition that there is not enough funding in the system, which stops the ability to do fast and deep redesign at pace. Further development is also needed to identify where the funding opportunities and resourcing is.
Any new system of health and care needs to focus on a culture of learning, evidencing, problem solving, respecting and being accountable. The further developing of relationships with third sector and people with experience of using and delivering services with communities is fundamental to delivering the Edinburgh Pact and any wider redesign of health and care services.
Services needs to take account of the different lifestyles and personal outcomes and design support arrangements to empower people and services should not be designed in a one size fits all approach. It is also important to recognise that family carers are fundamental and provide sufficient support for them to support their families, arrangement for funding, governance, ownership, administration and deliver of social care services.
It is recognised that there needs to be a greater national focus on the distribution of funding and resources across the health and care landscape. Currently there is a varying landscape and resource distribution, which creates a postcode lottery and variability in terms of quality and performance.
Full integration of health and care services should continue. IJBs have managed to achieve this to some degree, however there is further work to do – we’ve touched on some of the work the EIJB is driving and know there will be multiple other examples of this across Scotland. We acknowledge that we have made progress in terms of the challenges facing our budgets, however IJB budgets continue to be complex and further work needs to focus not on how we manage within the complexities as 3 Public Bodies but toward truly understanding what we require to meet the needs of our citizens. We would ask that the review considers the potential to look at placing effective responsibility with the ability to act in one place which would be more effective and take integration further.
Our requests of the Review We would wish to close by setting out the following ‘requests’ of the review – for them to consider as they continue their important, and potentially far reaching work.
We would ask that:
- The panel puts people, and not structures or re-organisation for the sake of it, at the heart of what it does and that in thinking of its final conclusions can answer clearly the question ‘does this make it easier for people to access the advice and support they need to live independently, or when in crisis, or when they require long term care and support?’
- The panel sets what it does against the principles of self-determinism and self-direction and ensures that its recommendations support a drive to embed further self-directed support
- The panel recognises the importance of social care as a distinct entity to the provision of healthcare. It is not just a means to provide care and reduce delayed discharges and social care services should have parity of esteem in a fully integrated system.
- The panel recognise that care services, however organised, has been in the past, and remains sometimes, seen as subordinate to the NHS. There is a very real risk that social care becomes medicalised, a risk that is perhaps heightened with this review being initiated during the worst global pandemic in recent history. While we must learn lessons from working within the pandemic, we must also imagine the future beyond it.
- Given the important opportunity the Independent Review is presented with, we ask that it not focus on how the system might be organised within existing funding levels but seizes the opportunity to question more fundamentally what we are willing, as a society, to pay for these services and that the kind of excellence in care we are ambitious to see in Scotland, will need investment and additionality.
- Finally in relation to finances, we ask the panel to recognise that funding for adult social care is too important for people and the workforce, to be subject to the current significantly challenging and complex one-year processes across 3 organisations. This is not serving us well and it detracts both the EIJB and officers from the important work of delivering its strategic plan ambitions. We urge the panel to consider how to address both the sustainability of adequate funding for social care in Scotland and ensure the mechanisms for its allocation for delivery of these crucial services and supports can be simplified.
Chair – Edinburgh Integration Joint Board