Care and Repair Annual Conference

I’d like to begin by thanking Care and Repair for inviting me to speak at your Annual Conference in Dunblane this morning. You have an excellent programme on delivering better outcomes for older people and disabled people with some really good information sessions around supporting people with dementia living at home, housing adaptations, the transition from hospital to home. I’m looking forward to learning more about these myself and to hearing from the wealth of expertise, experience and professionalism that is in this room.

I’m delighted to have this opportunity to speak about the integration of health and social care, and in particular the vital role that housing services such as Care and Repair will have to play in its successful delivery.

Today’s conference is very timely – following the approval of the Public Bodies (Joint Working) (Scotland) Bill by the on 25 February it was granted Royal Assent on 1st April, becoming an Act. This month the Scottish Government published two sets of draft regulations (the first on 12 May and the second on 27 May) that will underpin the operation of health and social care integration across Scotland. These are currently out to consultation until August and I’d encourage everyone with an interest to respond. Following the consultations, the Orders and Regulations will be reviewed and

1 finalised and then laid in Parliament in September and October 2014 and will come into force by the end of December 2014.

I would like to start by firstly reminding ourselves of the context of the Government’s reforms – why have we legislated for health and social care integration and what is it we are intending to achieve; secondly to say something about the main aspects of the Act and the Parliament’s scrutiny of the legislation; thirdly I want to focus on where housing and housing services fit within our ambitions in helping us to deliver the Act’s key objectives; and finally what I see as some of the key challenges we face in implementing this on the ground and making it a success.

THE CONTEXT:

Why legislate for health and social care integration?

The Christie Commission report of June 2011 set out very clearly the economic and social challenges we face as a result of the demographic changes happening within our society as people live longer and the proportion of the elderly in our total population increases. That more people are living longer is of course to be welcomed unreservedly as a positive development across society, but it is a development that brings with it new types of challenges to which Government, public policy and those working across our voluntary and third sectors must respond. Increasing longevity is bound to result in a higher

2 incidence of complex and long term conditions among our elderly population that have to be addressed.

As the Christie Commission pointed out so forcefully in its report, the fragmentation and disconnect across our public service delivery posed a fundamental obstacle to addressing this challenge. That Commission recommended the Government take urgent action to change the way in which we deliver public services in Scotland in order that it better met the needs of the people and its communities, and was better placed to meet the demographic challenges that lie ahead.

Of course it is not solely the elderly who will benefit from the new legislation. The integration of health and social care will benefit all in our society – the infirm, the vulnerable as well as the elderly – who depend on public services so that they may attain an acceptable quality of life at home, and in their own communities.

The legislation to integrate the provision of health and social care is therefore a key element in the Government’s response to a range of demographic and societal challenges we face today and in the near future. That ultimately is what integration is about. An outcomes based approach where health and social care services are firmly integrated around the needs of individuals, their carers and families – placing people at the centre of service planning and delivery – and where the

3 unhelpful barriers that can get in the way of providing good support to people are removed. This requires a focus on preventative services and a focus on anticipatory care planning to ensure people have access to the right care, at the right time and in the right place.

What are we trying to achieve?

With the integration of adult health and social care we expect to see a shift in the way that care is delivered to people, and further progress towards the Scottish Government’s 2020 vision of seeing more people cared for at home or in a homely setting.

This is what we now term shifting our focus to preventative actions – that is establishing public service delivery systems and policies that reduce the level of demand for acute public health services – services that are frequently not designed for the purposes they are being asked to serve.

For example we know that too often people are admitted to hospital or to a care home when a package of care and support delivered at home, in the community, could achieve vastly better outcomes for them.

All the evidence tells us that treatment at home is far preferable, by virtually every criteria, to treatment in hospital. I was struck by the Healthcare Improvement Scotland report on NHS Lanarkshire published last December which had

4 calculated that up to 30% of all patients in hospital in Lanarkshire at that time did not need to be there in any clinical sense.

In Scotland the average costs of keeping someone for a week in an acute hospital is £4600. To keep someone in a nursing home is on average £600 a week. And on average to keep and treat someone in a home setting is £300 - £400 a week. While it makes economic sense to treat people at home, the really important point is that, where that has been done, peoples’ health outcomes and the quality of their life have improved substantially. One of the worst things we can do is to hospitalise people unnecessarily.

So not only will the integration legislation improve the outcomes and welfare of many of our vulnerable and elderly citizens who do not require clinical treatment, it will release vital NHS resources that are then free to attend to patients who, for clinical reasons, need to be in hospital.

We also know that we can treat many more conditions more successfully in the community through the use of telehealth and telecare such as for example chronic obstructive pulmonary disease (COPD). The Scottish Government is piloting a number of other digital health projects including the Hospital at Home scheme in Lanarkshire which has enabled 80% of patients to stay in their home rather than be admitted to hospital.

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There is a need to upscale our current efforts in this regard and the integration of health and social care provides an opportunity to support independent living and delivery of care in the home setting.

But we need to have the legislation in place to help make this happen.

MAIN ASPECTS OF THE ACT

The new Public Bodies (Joint Working) Scotland Act provides the legislative framework necessary for bringing together the very substantial resources of health and social care. The key aspects of the Act are that:

1. Health Boards and local authorities have a statutory duty to integrate adult health and social care services and can decide whether to include children’s health and social care services into their local integrated arrangements. They must now work together effectively to deliver joined up seamless health and social care provision so that services focus on the whole person and the needs of the community in which they live.

2. Health Boards and local authorities are required to establish local integrated partnership working arrangements. The Act provides for two models – delegation to a body corporate established as a joint board or delegation to each other as a lead agency. So far only the Highlands has followed the lead agency model with the other 31 local authorities looking likely to follow the body corporate model.

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3. Health Boards and local authorities will have integrated budgets for health and social care. They will be required to delegate functions and budgets to the local integrated partnership. These will be as a minimum, adult primary care and community care, adult social care and aspects of acute hospital services.

4. Each local Health and Social Care partnership will be required to establish locality planning arrangements, which will provide a forum for local clinical and professional leadership of service planning and delivery and will encompass an assets-based approach, building on local knowledge and best practice to meet the needs of the local population. These local plans will form a key input to the production of the integrated partnerships joint strategic commissioning plan.

For me the local level is where all the action is going to be and is where I believe we really can make a big difference because it is very much within the localities where service provision in the community is critically important. It is also where we need to ensure we have the voices of housing, GPs, AHPs, carers, disabled people, third and independent sectors, service users etc when it comes to the designing and planning of services locally.

5. The integrated partnership will be required to prepare and implement a strategic commissioning plan which will use all the resources available across health and social care to plan for the health and social care needs of local populations. The development of this plan is fundamental as it is the core work programme and sets out the way forward for every integrated partnership in Scotland.

6. Health Boards and local authorities will therefore be jointly responsible for joint strategic and locality planning in their area. They will also be accountable for delivering the new

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health and wellbeing outcomes that will be nationally agreed and which are now being consulted upon through the recently published set of draft Regulations.

Of course structural reforms alone will not deliver the objective of a more integrated and partnership focus to providing health and social care services.

HOUSING AND HOUSING SUPPORT SERVICES

Crucial to the success of this legislation will be the partnerships forged between the local authorities, health boards, third and independent sectors, housing services and providers and in particular housing related support like Care and Repair and a range of other key stakeholders (GPs, service users, carers, etc).

Such partnership working is essential to ensure that individuals and communities have access to the best possible services to meet their specific needs and circumstances.

Both the Scottish Parliament and the Scottish Government fully recognize the importance of joint partnership working with housing if we are to improve the health and wellbeing outcomes of our citizens. This was clear when the Cabinet Secretary for Health and Wellbeing MSP introduced an amendment at stage 3 of the Bill (“Amendment 13”) which added housing stakeholders to the list of persons whom the Scottish ministers must consult before they prescribe national outcomes for health

8 and wellbeing. And as Alex Neil stated during the stage 3 parliamentary debate: “It is particularly important to ensure a strong role for housing in integration. After all, it is our policy commitment to enable people to be cared for at home or in another homely setting for as long as possible”.

I very much welcome the commitment given to ensuring housing has a key role to play at the heart of health and social care integration and that this is now recognized in the legislation.

Delivering the Government’s 2020 objective – which affirms its view that every individual should have an opportunity of living at home or in a homely setting no matter how complex their requirements – will require central and local government and housing associations to work in partnership to review and update where necessary local housing strategies.

Work is already underway to achieve this through, for example, the Housing Need and Demand Assessment tool to ensure that the needs of older people and disabled people for housing and housing-related services will be better reflected in Local Housing Strategies and Strategic Housing Investment Plans.

Related to this is the development of the Housing Contribution Statement which health and social care partnerships were asked to include within their Joint Strategic Commissioning

9 plans for 2013-14 and the development work for 2014-15 is currently underway.

The role of housing in the protection and promotion of individual wellbeing extends far beyond the provision of housing, central though that is. Equally significant is the added value provided through the range of other services local authorities, housing associations and housing related support like Care and Repair are able to offer to adapt homes to ensure vulnerable individuals are able to continue to live safely in their own environment, reducing the need for care and improving their quality of life. Achieving this requires that different aspects of health, social care and housing services work in a closely coordinated way to the benefit of the individual and the wider community.

Although the new Public Bodies Act marks a statutory watershed in how we ensure better delivery of public services in Scotland, I’m conscious that considerable progress is being made in this respect across the country at local level. For example, Borders Care and Repair is a service provided by Eildon Enterprise Ltd in partnership with Scottish Borders Council. It is essentially a one-stop shop for major adaptations which provides services to all the local RSLs and to the private sector and has been developed collaboratively between the housing sector and the Occupational Therapist service. Another

10 example is the housing provided by Eildon Housing Association for people with dementia designed with the help of Stirling University Dementia Services Development Centre and the Iris Murdoch Centre. This is important as well designed, ‘fit for purpose’ housing can extend the amount of time people with dementia are able to remain living at home, by reducing accidents, falls and burns and delaying the need for residential care or the need for hospital care. The housing services that support them to remain in this environment are key.

Rolling out all this best practice across Scotland that housing bodies have been championing for a long time will require collaboration across health, social care and housing. It is clear that the success of health and social care integration needs the full involvement of housing in planning both at strategic and locality level and I’m therefore very pleased to see that this is now recognized in the draft regulations.

SOME KEY CHALLENGES All of this of course is not without its challenges especially given the diversity of the housing sector and the need for a scaling up of the capacity of the housing sector at both the national and local levels to deliver health and social care services in local communities. However there is a huge

11 opportunity for housing to maximize its contribution to help deliver better outcomes for and with people.

Health Boards and local authorities are required to put in place their local integrated arrangements by April 2015 with the full integration of services across Scotland expected by April 2016. That means many of the shadow health and social care partnership boards are already being established. It is therefore important for Care and Repair to make local connections with your own local NHS and Councils in preparation for health and social care integration. Now is the time to do it and it is absolutely essential to ensure you are involved fully right at the start in the strategic planning and delivery of local services.

There is much that can be done and is being done to support housing to work collaboratively with other housing partners as well as partners in the third sector and with health and social care in the design and delivery of innovative and preventative approaches locally. For example, the £10 million Healthy at Home fund (2015/16) announced by the Scottish Government last October which is designed to support health, social care, housing and third sector partners to explore innovative local programmes that can be scaled up and rolled out across the country. This is part of the additional resource of £100 million to be made available to local partnerships in 2015/16 which is being developed.

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Housing continues to be represented on a number of key Scottish Government working groups including those looking at joint commissioning and developing the draft national health and wellbeing outcomes.

At a practical level the Scottish Government is working with the Joint Improvement Team to look at what further resources can be made available to support the housing sector to engage effectively at the local level with integrated health and social care services. Work is also underway on a housing and integration learning network to both facilitate the exchange of ideas and best practice and to establish a body of evidence around the contribution of housing to successful integration outcomes.

These are all very welcome steps forward in the right direction.

However, implementing health and social care integration on the ground will be a huge challenge for everyone. While integration will not happen without the statutory underpinning which is necessary, we know this in itself is not sufficient to achieve the transformational shift in culture the Christie Commission envisaged for the future delivery of services across the health and social care sectors.

With the creation of 32 integrated partnerships between the health sector and the social care sector using two different models (either the lead agency model or the body corporate

13 model), this requires the bringing together of two different sets of organisations to work in an integrated way, with different cultures, different backgrounds. And even within the health sector there are also different cultures as well as different aspects and sub-sectors within social care.

Getting this right is a priority for Scottish society, and it requires strong leadership, engagement and involvement from everyone working across the whole health and social care sector, in every capacity and at every level. This is a team effort.

The wealth of collective expertise, experience and professionalism that housing and housing support related services like Care and Repair bring to the table are huge assets in helping us to achieve this important policy objective.

I am very much looking forward to continuing to work closely with the sector over the coming months and years to make health and social care integration a reality that really does improve the lives of people across Scotland.

Thank you very much for listening.

Aileen McLeod MSP

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