Posted by: ayrshirehealth | August 14, 2013

Integration – one year on by @garrycoutts

Last year the Highland Council and NHS Highland entered into an historic agreement to integrate health and social care. We developed “The Lead Agency Model” under which the council has become responsible for children’s services including health care and the health board for adult services including social care.  It saw around 250 NHS employees such as school nurses and health visitors transfer to council employment and around 2000 social workers and social care staff transfer to the Health Board.NHS Boards

Underpinning this move is a “partnership agreement” that runs to hundreds of pages of legal stuff that is boring and technical but necessary to allow the move to take place. What was important during the process however was that councillors and board members did not get bogged down in the minutiae of the process and remained focussed on what we wanted to achieve for patients and service users.

We did it because we believed that we were not delivering the quality of service to which we aspired, or that we thought we should be. Despite a huge amount of effort and commitment to joint futures, single shared assessment, joint community care plans, shifting the balance and community planning etc we felt that there were still fundamental blockages in delivering properly joined up services.

Islands of excellence

Don’t get me wrong there was fantastic work in Highland. We could point to numerous examples of first class service delivery and we were developing new services that were leading to improvements for patients, service users their carers and families. But it was not consistent. While there were islands of excellence there were also areas where the level of care we were delivering was just not good enough.

ECCF NetworkHaving looked at the reasons for this patchy performance we concluded that where front line staff and managers agreed a way ahead they could develop and implement great services. But where one partner, team or individual did not prioritise the plan or was resistant to change then no matter what we did we could not implement. With separate budgets, management and governance there were always many opportunities for people to veto a proposal or simply not co-operate.

Single budgets, single management and single governance became our mantra. We were not so naive to believe this would be a magic wand to cure all of the problems we faced but we were clear it would take away the excuse that it was someone else holding us back.  We would, in effect, become masters of our own destiny and not at the mercy of other people’s decision making.

So how has it all turned out?

We were very clear that in our first year we would not be embarking on major change. The staff who were running care homes would continue to manage them. The staff who ran the care at home service would continue to manage that. Their clients should see no change to their services.

Behind the scenes however we were starting to look at ways of devolving centralised budgets to local management, creating new integrated teams and giving people the chance to learn the business of their colleagues across the services. This was all vital preparation for a major programme of service redesign that will be undertaken over the next 4 years.

screening 2Having said that, staff on the ground have been encouraged to “fix” things where they see obvious service improvements they can make. For example in one area care home staff who would have phoned NHS24 when one of their clients took ill out of hours worked with the local community hospital and community nursing teams to get direct support where appropriate. Residents who had become dehydrated for example would have invariably ended up as an emergency admission to hospital (and at risk to infection, falls, deterioration of cognitive function and perhaps becoming a delayed discharge) now get the medical and nursing care they need in the care home.

They also recognised that in one care home any of around a dozen nurses from 3 separate community teams could have been attending clients during the week. This has now become the responsibility of a single team who have better in-depth knowledge of each resident and the care they need. They work much more closely with the care staff, GPs and other health professionals to help keep people well and avoid hospital admissions. In this home admissions to hospital have dropped dramatically.

Access to care

Another team comprising an adult care centre, day hospital and a community hospital realised that they were working largely with the same group of people. It transpired that where people were referred had little to do with their condition or the care they needed and more to do with custom and practice and the level of knowledge the referrer had about the services provided in each. They saw a huge number of people being referred to the day hospital who actually required very limited clinical input. There were also people who were delayed in the community hospital because of difficulty getting a package of home care arranged.


Use with permission from

By instigating a joint triage of each referral people were referred to the correct setting. Now, instead of sitting in a hospital waiting for a very brief clinical intervention and then waiting for transport home people can be in the day centre, being engaged in a wide variety of social activities and get their clinical care there. Or people can be discharged from hospital home and get transport to the day centre for their meals and social activities until such time as the home care package can be put in place.

Hospital length of stay has been reduced, 15 hours direct nursing time a week has been freed up, waiting for access to care in the day hospital has been cut from 6 weeks to zero and people are receiving more of their care in a homely setting where they can socialise and develop a network of friends.

Now I know some of you will be thinking “so what, we have already done that” or “surely you don’t need the complex and disruptive process of integration to make such simple and obvious changes”. And of course that is right. The powers to deliver services in this way exist and have done for years but the truth is that this has not become “the way we work”. We are still too often stuck in silos and blocked from making changes because partners do not cooperate. Integration removes these blockages.

Next phase

Now we are moving to the next phase. There will be planned programmes of improvement looking at every aspect of our service from anticipatory care, supported self care and reablement through to support for independent living, home care, care homes and all aspects of clinical care including all acute services. We will focus on the whole system. We won’t look at any aspect of care without having experts (including patients and service users) from both upstream and downstream asking what could we have done to prevent this presentation and how can we support someone to become as independent as possible as quickly as possible.

This is integration. It’s not about how committees are formed or jointly accountable officers are appointed. As long as we are able to stay focussed on patients and service users integration could be fantastic. It could even be fun.

This week’s blog was by @garrycoutts Chairman of NHS Highland

Next week’s blog is by @davidgarbutt Chairman of the Scottish Ambulance Service


  1. […] Integration – one year on by @garrycoutts. […]

  2. […] Integration – one year on by @garrycoutts. […]

  3. […] I started in post some three years ago our CEO Elaine Mead (@nhshem) and Chair Garry Coutts (@GarryCoutts) wanted to see more pro-active communications and lots more involvement with patients […]

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