Problem: Ageing population with complex care needs; suboptimal service delivery due to fragmented health and social sectors.
Solution highlights: A lead organization model was introduced in Highland to promote greater integration between health care and social services. This new management structure united previously fragmented professional groups, serving to streamline service delivery and improve working relationships; broad political support for integrated care created a favourable environment for change; strong support from local senior management drove the initiative forward; extensive local engagement across all care levels ensured widespread buy-in for the initiative and reduced resistance to change across stakeholder groups; design and implementation of the initiative was iterative and not every detail was worked out prior to its launch; leaders stressed the need for “balance between diligence and good enough”.
Description of practice
In Scotland, increasing chronicity in an ageing population has expanded health and social care needs. With the aim of improving care for patients, a broad government agenda to support increased integration between health and social sectors was put in place across Scotland; however, meaningful integration was limited in practice. In Highland, for example, management of care services was divided between NHS Highland (health services) and the Highland Council (community and social services), resulting in fragmentation and suboptimal service delivery, including reports of overlapping service provision and weak cooperation across sectors.
In 2010, Highland embarked on a mission to accelerate local integration of health and social services. There was strong managerial support for the initiative from the outset and extensive stakeholder engagement generated widespread buy-in across all stakeholder groups, including trade unions, care providers and the general public. After careful consideration, a lead agency model was selected as the means to help drive integration, whereby NHS Highland was appointed as the lead agency for all health and social care for adults and the Highland Council was established as the lead agency for children. In this way, the unique needs of adult and child populations could be addressed holistically, without separation of health and social systems. Change activities advanced at a rapid pace and the lead agency model was officially launched in 2012. Now, NHS Highland and the Highland Council share responsibility for allocating budgets and setting joint objectives according to terms laid out in a five-year partnership agreement that runs until 2017. While services at the public interface remain largely unchanged, the organization and management of service delivery has become more coordinated and streamlined. Professional relationships have improved and team-working has increased as a result of the new shared vision and organizational culture. The relationship between NHS Highland and the Highland Council remains strong and the partnership agreement is expected to be renewed. In line with the Highland initiative’s aims, recent legislation passed by the Government of Scotland requires that all districts adopt integrated delivery models.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
The initiative benefitted from strong support at the highest level within both NHS Highland and the Highland Council, with these organizations jointly driving the change effort. By adopting a lead agency model, NHS Highland and the Highland Council developed a new single governance, financing and management structure for health and social care. As part of the new arrangement, some 1500 staff transferred between NHS Highland and the Highland Council and over £90 million moved between budgets. All adult social care previously delivered by the Highland Council was transferred to NHS Highland, which now oversees planning and delivery for both health and social services (as the lead agency for adult care) according to jointly agreed outcomes and budgets. Likewise, the Highland Council now oversees planning and delivery of health and social care for children.
The direct impact of the initiative is difficult to quantify, but leaders informally report improvements in professional culture and patient engagement. The initiative is focusing on improving the quality of services, building the concept of people-centred care, and increasing community-based care.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Elaine Meade and Jan Baird
- NHS Highland