Productivity and Value for Money in Integrated Health and Social Care- Dr Alastair Noble
Both Health and Social Care are service industries. This means that their main preoccupation should be the individual and their community. They are not there to bring glory to the service providers or temples to their grandeur!
If we accept that the clinical decision is the purchasing decision, we must look at the outcomes for each individual and the optimum pattern of care from each locality integrated team and their integrated relationship with specialist care – both in and in many ways more importantly out-back into their own community care team.
The major users of our service industry is care of the frail elderly and mostly in the last year of their life. The best example is a frail elderly woman and what we have found is where she is put at the centre of the care package and given the best local community care, she does best. This is supported by all the evidence from for example Torbay and all the Multi Agency Inspection for Services for Older People in Scotland (MAISOP)
Given the choice of being well supported in her own home, local nursing home, Community Hospital/Hospice or being the dreaded delayed discharge in a specialist bed or spending an extra 2-3 years in a nursing home it is no surprise that most individuals will choose the community-based model. Unfortunately, the model on offer in the big cities like Glasgow does not offer that choice. In Scotland we have a range of occupied bed days for the over 75 age group ranging from over 60% being in their own local GP led Community Hospital bed in Aberdeenshire to none in Glasgow. In simple terms where we have allowed the domination of the big teaching hospital e.g. The Queen Elizabeth we have not given the choice to the individual of what is seen to be best clinical care. They are forced to be the square peg in the round hole.
Covid has surely taught us that the big hospital model does not always work. The Italian Government’s response to the failure of the big hospital model with Covid is to build 3-400 Community Hospitals.
What is best for Scotland going forward?
The best Scottish Traditions has always been based on productivity and value for money. There is ample experience that both private and public services can be well managed and run or alternatively badly managed and trade in insolvency/go broke!
So, this is not a sterile argument about Public or Private Ownership or Management – it is about putting the quality-of-care for each individual at the centre of the process and using locality based clinical and financial DATA to quality control care and as a big bonus give value for money.
“Looking after old people well is better value than looking after them badly” has long been the clarion call from Dr Colin Currie.
What then are the benefits I see in prioritising integrated Community Care including GP led Community beds in all localities in Scotland.
The first and most obvious is that it allows the individual person a choice with their integrated health and social care team to choose what is best option for them at this moment in time. It also allows that decision to change as necessary depending on the individuals current clinical need.
The second major benefit is to each locality in having properly trained, housed, equipped, and maintained community teams – with all the benefits that brings to each locality.
The third major benefit is to the specialist team who can then concentrate on what they do best. In all my discussion with many excellent consultants and GPs the simple main message is please keep them out of my specialist bed unless I, as a Specialist, have a specific role or treatment which will benefit them. As soon as that has been done, they should be moved back into the care of their Integrated Locality Based Community Team. It also means that the specialist hospital will have no blocked beds. This allows for maximum efficiency in elective care in the specialist setting.
The fourth benefit is around this rather “annoying problem” that very few of these elderly patients are only suffering from one specialist condition. The evidence is all in favour of continuity of care. The better the community care team is – the more confidence the individual, their family and their locality has in that team – the better the outcomes will be. As an added bonus the Consultant Team will be even more confident in transferring the patients care back to an excellent locality team.
The fifth benefit is around recognising and supporting the essential difference between the “Generalist “ and “Specialist”. We need both but a massive mistake has been in trying to staff “specialist “ units when there is not the total infrastructure available on the site. This means we will have a lot more community based team and fewer, but properly staffed and functioning, “specialist” units doing the job they are trained and equipped to do. It also means a lot more “generalists “ in all professions.
The sixth benefit will be in educating and training the workforce for all the professions. You cannot train generalist in a specialist unit. All professionals will benefit from training in both.
The seventh benefit will be to social and home care staff. They will be seen as essential and equal members of the same Integrated Team. This will mean better pay and working conditions for them.
Lastly on the thorny issue of mean’s testing – all the evidence I have seen would support the position that within the existing Fair Share Health and Social Care Budgets we can afford this Integrated Model of Care. It means each locality would receive their Fair Share Budget and would have to stay within that budget. It clearly means fewer staff working in “specialist” care and more working in “generalist “care. This is exactly what all our need’s assessment tells us is optimal care. If clinically and financially it is best for the individual and our communities, then we can afford it. There is no doubt in my mind that we are wasting a lot of money in areas such as delayed discharges in “specialist” beds and underfunding community and social care. Value for money means exactly that – we make sure we manage the whole system for what is clinically best for each patient. The fairest way of paying for health and social care is by taxation. In committing to continuing that model we must optimise the correct clinical care for each individual, prioritise Integrated Community Teams and make optimum use of Specialist Care.
To echo Professor Gray and Reform Scotland’s position – now is not just the time for a National Conversation it is the time to deliver the best health and social care in the world to our Scottish population.
Dr Alastair Noble worked as a GP in Nairn and was awarded an MBE for his work in integrating Health and Social Care in Nairnshire
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