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Different routes to integration….

A perspective from Scotland

Derek Feeley Director of Healthcare Policy and Strategy

NHS ScotlandNHS Scotland

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NHS Scotland

• c. 5 million population• Spend £1788 per

head• Devolved (since

1999)• 14 Unified Boards• Integrated system

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Deprivation

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Spot the difference….

National Health Service Act 2006

• Secretary of State’s duty to promote health service

• (1) The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—

• (a) in the physical and mental health of the people of England, and

• (b) in the prevention, diagnosis and treatment of illness.

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And this…?

National Health Service (Scotland) Act 1978

General duty of Secretary of State.

(1) It shall continue to be the duty of the Secretary of State to promote in Scotland a comprehensive and integrated health service designed to secure—

(a) improvement in the physical and mental health of the people of Scotland, and,

(b)the prevention, diagnosis and treatment of illness,

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Better Health Better Care

Current view Evolving model of careGeared towards acute conditions

Hospital centredDoctor dependent

Episodic careDisjointed careReactive care

Patient as passive recipientSelf care infrequent Carers undervalued

Low tech

Geared towards long-term conditionsEmbedded in communitiesTeam basedContinuous careIntegrated carePreventive care Patient as partnerSelf care encouraged and facilitatedCarers supported as partnersHigh tech

The future model of health care – shifting the balance

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Towards a Mutual NHS

• Strengthen public ownership by strengthening rights to participate

–Public Partnership Forums–Patient experience–Patient Rights–Board elections –Participation standard / ownership

report / independent scrutiny

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Mutuality and Integration

“We intend to ensure that NHS Scotland is based on a mutual ethos. This will not involve changes to the financial arrangements of the NHS. Neither will it require structural change. On the contrary, it is entirely consistent with our existing approach of integrated care, based on the values of co-operation and collaboration through unified Boards.”

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4 ways to deliver public services (LeGrand 2007)

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Rationale for integration

• Consistency with;

• political requirements• patient centred approach• values/ (equity, universality)• mutuality• emphasis on professional networks• need to position healthcare as part of

wider public service reform.

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Glasgow City

Inverclyde

West Dunbartonshire

All cause death rates, M 0-64, 2001

30%

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Integration at a number of levels• System• Community• Clinical• Financial• Culture and ethos

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System Integration• Unitary Health Boards• No purchaser/ provider split• Clear and consistent accountabilities• Duty to collaborate

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Community Integration• Community Planning• Community Health Partnerships• Shared Budgets• Single Outcome Agreements• Elected Boards• Participation standard

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Clinical Integration• Managed Clinical Networks• Community Resource Hubs• Team Based care• eHealth• Health and Healthcare

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Financial Integration• Unhypothecated budgets• Independent budget allocation formula• Freedom to shift resource• Contractual alignment• Collaborative contracts• Managed Service Networks

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Culture and ethos• Clear and shared vision• Going with the flow• Values professionalism• Challenges appropriately• Transparent

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Benefits of integration

• Buy in/ Shared goals• Easier for patient to navigate and for

the public to participate• Aligned incentives• Whole system approaches enabled

(resources for innovation and collaboration)

• Easier to work across boundaries

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Lessons learned• Integration is a means to an end• Beware of silos• Integration is not the “soft option” – it

has to work as well as the alternatives• People are the key – policy only

creates the right environment