Chapter 3 Collaborating for health
Development of collaboration and integration in health and social care
Integration of health and social care is not a new phenomenon. Public health departments in local authorities, overseen by Medical Officers of Health (MOsH), provided hospital, primary and community care services from the end of the 19th century. For example, between the first and second world wars public health departments in local authorities had a remit to provide maternal and child welfare services; school medical services; TB clinics and treatment; infectious disease, ear, nose and throat, and VD services; health centres; regional cancer schemes; and to run the old Poor Law hospitals (Lewis 1991).
The MOsH tripartite system of prevention, family practitioners and hospital services was transferred to the NHS in 1974, although local government retained social care and environmental health services. This split is believed by some commentators to have had a long-lasting impact on the ability of health and social care services to work together (McClelland 2003). In addition, allowing general practitioners to remain as independent contractors rather than salaried employees has resulted in the need to introduce complex incentives to ensure service delivery and distribution of staff.
In 1997, The NHS: modern, dependable (Department of Health (DH) 1997) and Designed to care (Scottish Executive 1997) were the English and Scottish White Papers, respectively, which introduced a modernisation programme for the NHS of dismantling the internal market and working towards a system of integrated care. In England, Primary Care Groups were set up not only to commission services but also to have more influence with acute care; their aims included promoting the health of the local population in partnership with other agencies and better integrating primary and community health services. Primary Care Groups were to develop further into freestanding Primary Care Trusts, totally responsible for commissioning and delivering services but remaining accountable to Health Authorities.
In Scotland, primary care was to be delivered through Primary Care Trusts (PCTs) and Local Health Care Co-operatives (LHCCs). Scottish PCTs had fewer budget-holding responsibilities than their English counterparts, but provided staff such as nurses, allied health professionals and health centre management, and were later (from 2002) merged with NHS Boards. LHCCs were to work in association with general practitioners (GPs), dentists, pharmacists and opticians, who remained independent contractors, but were encouraged to be given places on boards of LHCCs. LHCC objectives were described as providing services to patients, working with public health to plan for meeting the defined health needs of the LHCC population, clinical governance and developing population-wide approaches to health improvement and disease prevention (Scottish Executive 1997).
Both sets of polices clearly set out moves towards working in partnership and integration between primary care and both acute and social care services. They also introduced the need for primary care to begin to take a population approach to improving health as well as to deliver services to individual patients.
The move towards integration between health and social services in Scotland was supported by a national collaborative group, called the Joint Future Group. This was set up by the Scottish Office in 1999 (Joint Future Group 2000) to find ways of improving joint working to deliver modern and effective person-centred services, to identify options for charging for home-based care and sharing good practice. The focus was initially to be on older people, but to eventually move onto other client groups, including children. The Group produced a number of recommendations in 2000, including:
A survey of LHCCs across one-third of the Health Boards in Scotland found that local working between LHCCs and social work, particularly in relation to community care, had developed substantially since the introduction of LHCCs, although joint working between primary and secondary care was less developed (LHCC Best Practice Group 2000). Recommendations from this report influenced the objectives of the next re-structuring of LHCCs as they were further developed into Community Health Partnerships.
The process of integration and further reform in Scotland continued in the next NHS White Paper Partnership for care (Scottish Executive 2003a). LHCCs were to evolve into Community Health Partnerships (CHPs), but the new bodies would have statutory underpinnings instead of being voluntary groupings, and would be part of the NHS Boards. CHPs were to establish a substantive partnership with local authorities (social work, housing, education and regeneration this time), patient involvement through establishing Patient Partnership Forums for patients and staff, have more devolved budgetary responsibilities and a duty to promote health improvement (Scottish Executive 2003a). The White Paper also required health boards to work with local authorities to ensure more effective working with social care in appropriate locality arrangements, and to integrate the management of primary and acute services. However, CHPs were expected to play an increasingly central role in integration of services locally as they matured into their partnerships, in order to improve the health of local populations as part of an ongoing programme of development and modernisation in public services (Scottish Executive Health Department 2004a).
Further integration of services
Greater Glasgow NHS and Glasgow City Council took the CHP national guidelines a step further in 2006 in to create fully integrated Community Health and Care Partnerships (CHCPs) (Greater Glasgow NHS 2005). CHCPs brought together primary care and social work services under a single management structure, with associated accountability and governance arrangements, and with similar aims for integration to that of England’s Care Trusts (see below). They also propose substantial involvement of (and credibility with) elected members and intend to develop structured links to housing, regeneration and employment. With these proposals, the Glasgow Scheme of Establishment for CHCPs stated that its aims were to add value to existing programmes for integrating and improving services, particularly children’s services, and was notable as the first integrated NHS and social care services structure for children and families in Scotland.
Integration of services for vulnerable population groups
Following on from the work of the Scottish Joint Futures Group for services for older people, the drive towards integration in Scotland was developed in other services. At first, reform focused on services for people with learning disabil-ities and for people with alcohol and drug problems, with the development of co-located health and social care services including with joint funding and joint management (Joint Future Group 2000).
A similar process was undertaken in England, with the introduction of Care Trusts in the NHS Plan as a mechanism for integration of health and social services. Care Trusts were to be established on a voluntary basis in partnership, with a joint agreement at local level regarded as the best way to offer services, rather than forcing a partnership where no relationships existed. Different models for Care Trusts could be developed, but it was envisaged that they would mostly be based around existing Primary Care Trusts, focusing on commissioning and providing services for older people and mental health services initially. They aimed to bring together existing staff from health and social care services within one local organisation, and were to be governed by a mixture of local councillors, health managers and patient and user representatives (DH 2002).
Children’s Trusts in England
Children’s Trusts, based on similar principles as Care Trusts described above were introduced in England in Every child matters (HM Government 2004). They were to bring together local education authorities, health and social services in order to establish greater strategic coherence, better integration of services and improved access to services. The main driver for this model for children’s services was said to be the Laming inquiry into the death of Victoria Climbie, which made extensive recommendations for raising standards and improving the monitoring of social care staff and services. The Laming inquiry demonstrated that frontline social services staff were working in departments that were struggling with poor management supervision, unfilled posts and substantial underfunding. Commentators at the time of the report being published hoped that the new codes of conduct and the emphasis on evidence-based practice would give social workers greater clarity of their roles and responsibilities in multi-agency working. Concern was also expressed in that the impact of structural reform on a service already very stretched, was thought to have the potential to further undermine the services.
Children’s Trusts were duly created, but using a stepped approach. Thirty-five pathfinder Children’s Trusts were initially set up in 35 of the 150 local author-ities in England, and their early implementation reviewed as part of a national evaluation (University of Anglia and NCB 2004). Most of the pathfinders aimed to achieve all five of the outcomes stated in Every child matters, that is of being healthy, staying safe, enjoying and achieving, making a positive contribution, and economic wellbeing (although the latter had a lower priority). By 2004, most pathfinders had pooled budgets already in place, or planned, along with written partnership agreements; most were establishing processes for sharing information about individual pupils, clients or patients; most had brought together front-line professionals from across health, education and social services sectors; and most had incorporated views of children, young people and their parents and carers in the development of the trusts.
The evaluation reported that integration and collaboration was said to have been facilitated by joint training, maintaining a stable workforce, commitment to integration at all levels and a history of joint working. Barriers were identified where there were complex service interfaces, insufficient funding, lack of time, changes in management personnel and problems recruiting and retaining staff.
Integrated Children’s Services in Scotland: Starting Well
Demonstration projects were first announced in the Scottish Public Health White Paper, Towards a healthier Scotland (Scottish Office 1999) and were designed to develop and demonstrate good practice in the areas of child health, coronary heart disease, sexual health and colorectal cancer. Glasgow won its multi-agency bid for the child health project for £3 million over an initial 3-year period and Starting Well was duly launched in November 2000. Extensions of the funding were later granted and continued until 2006, at which point plans were in place to roll out the model of working throughout Glasgow (Wallis 2006).
Starting Well aimed to demonstrate that child health can be improved by a programme of activities to support families, coupled with access to enhanced community-based resources for parents and their children. It was developed through a multi-agency partnership and assumed a collaborative approach in its design and delivery. The project focused on two of the most deprived areas in Glasgow and drew heavily on the US literature on home visiting, which demonstrated significant impacts on a range of child- and family-health-related outcomes. The main programme for Starting Well in its first phase encompassed an augmented programme of home visiting for all families of newborn babies in the two areas, the development of enhanced local community supports and structures within the areas, and the development of integrated organisational services within the areas and across Glasgow (Mackenzie et al 2004).
In the last year of the project, Starting Well re-focused to target the most vulnerable children in the intervention areas and extended the multi-disciplinary teams drawn initially from health and voluntary sectors to include professionals from social work and education. The approach they took to integrated working was to recognise that it was not just the staff working directly with families who needed to work together, but that the whole system within which services are planned, funded and managed must integrate together to ensure that families health and social care needs are met (Wallis 2006).
Integration of planning for improving health
Health improvement and health inequalities in Scotland
In addition to improved integration of health and social service delivery, the Community Health Partnerships (and Community Health and Care Partnerships) in Scotland also aimed to have stronger roles in health improvement and to reduce health inequalities. Collaboration through partnership working is regarded as an important focus for this work. For example, the Scottish Executive’s Guidance document (Scottish Executive 2004a) for establishing Community Health Partnerships (CHPs) states that the focus for health improvement should be on:
This focus reflects Scottish public health and health improvement policy documents, that is, Towards a healthier Scotland (Scottish Office 1999) and Health improvement – the challenge (Scottish Executive 2003b), and arguably builds on years of public health, health education and health promotion research and practice. It also reflects that health improvement, as a move on from health promotion, is increasingly understood as a partnership activity between health, local authority, voluntary and community sectors, rather than residing only in the ‘health’ domain.
The focus in the CHP guidance for health inequalities is also stated as being to work in partnership to address the needs of the full range of community groups (Scottish Executive 2004a). While partnership is again reinforced as the appropriate approach to take, there is otherwise a lack of clarity as to what is expected of CHPs in relation to addressing health inequalities. However, the Scottish targets for reducing health inequalities are included as a section in the Scottish Executive’s regeneration policy (Scottish Executive 2004b), which is delivered through the mechanism of community planning. CHPs and Community Planning Partnerships (CPPs) are now linked through legislation, policy and emerging practice, and provide an example of where integration within the public sector has become irreversibly established within planning structures.
Community planning
However, their aims are broadly similar, with small differences between countries, such as in accountability mechanisms, and differences between and within countries in the configuration of the structures. Community planning in Scotland is highlighted here as an example of integration of strategic planning.
Community planning in Scotland has two main aims:
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