H.M. TREASURY

Project 28: Towards a Seamless Service for Health and Social Care

Description

1 This is a partnership project between Perth and Kinross Council, Tayside Health Board and Tayside Primary Care NHS Trust. The project is investigating how the partner organisations might be able to create a fully integrated and flexible Health and Social Care Service for the whole of the adult population of Perth and Kinross. Research is being worked up into a series of options for delivery and a pilot project will be undertaken. ISB support of Ł1m has been received, with Ł100,000 committed by each of the three partner bodies, though they expect their final out turn contribution (including contributions in kind, for example in staff costs) to be twice this. Based on current levels of commitment, ISB will be contributing over 75% of the project costs.

2 The purpose of the pilot and its main objectives are outlined below, as are the key risks that were anticipated for the project.

Purpose of the project ‘Towards a Seamless Service for Health and Social Care’

n To address client concerns about fragmentation of delivery of health and social care services at the local level by testing a fully integrated form of delivery.

Objectives

§                  a single visible identity for health and social care services within communities so that users are clear about where to go to access the support they need

§                  a one stop reception/assessment service that integrates access to health and social support

§                  an integrated and flexible range of services that will encourage service users to live in their own homes and which will be quickly responsive to their changing needs

§                  complete joint working between all disciplines and staff involved and full sharing of resources including pooling of budgets

§                  identification of the financial capacity at revenue and capital levels to develop the infrastructure and service range necessary to secure these primary objectives This will require integration:

§                  at the planning, commissioning and financial level, bringing together the present responsibilities of the Health Board and the Council under a Joint Commissioning Body, and

§                  at the service delivery level amalgamating the Primary Health Care Trust services and the Council’s Adult Care services.

Key risks

Deviation from main purpose; emphasis on structures over quality of service; professional jealousies; poor communications with staff and clients; legislative difficulties.

Project initiation, design and specification

3                     Prior to the ISB submission, research had already been commissioned by the partner organisations into client views on the services provided for older people.   The research was undertaken by Strathclyde University. A strong message came over that that there was confusion in the minds of clients about who delivered which service and concern about being passed from one organisation to another. There was also significant support for the development of single reception and assessment points as part of the answer to the problems which people faced. The partners considered these messages and took the view that they were unlikely to be confined to issues affecting older people and that there was a need to consider integration of services, in some form, throughout the delivery of health and social care.

4                     Some initial work to take the research forward was undertaken. The Scottish Office (as was) was aware of the work going on and suggested that it could be enhanced if funding from ISB could be attracted. The partner organisations therefore submitted a bid. The Council took the lead in this though the other partners were consulted in the process of preparing the bid.

5                     There was no direct contact between the project implementers and HMT (it was all through the Scottish Office) and those involved in putting the bid together were not clear about HMT’s criteria for project selection.   HMT made no changes to the bid and there was no comment or feedback from them.   Scottish Office themselves commented on the difficulties imposed by the compressed timescale for getting bids in.

Management of the project

6 The project is now established and led by a Steering Group with over 20 members, which meets quarterly. It is jointly chaired by the Chief Executive of the Council and the General Manager of the Health Board. The Chief Executive of the Primary Healthcare Trust is also on the Group. All the main Directors of the three organisations are represented, as is the Scottish Executive. The view of those we consulted was that although the Group may be somewhat unwieldy, the very high level of representation is a testament to how seriously the project is being taken by the partner organisations.

7 There are seven Sub Groups covering detailed aspects of implementation, namely:

§ legal implications

§ human resource implications (for example harmonisation of working terms and conditions, and a ‘sub sub group’ looking at the job description of a ‘generic worker’)

§ finance

§ single assessment

§ IT MIS

§ communications/public relations

§ organisational development and training.

8                     The breadth of this subject matter gives some indication of the root and branch view which is being undertaken in this project. It is also possible that the Sub Groups, with their wide membership, might be one means of promoting the change in attitude which lies behind this project.

9                     The ‘engine room’ of the project is a dedicated team of secondees consisting of a senior official from each of the three main partner organisations. This is led by the representative from the Council and is based in the Council’s premises. The Project Team is charged with the actual implementation of the project. It is expected to produce options for testing and then to specify and test a pilot. Should the pilot be successful, the Team will be responsible for leading the effort to implement the pilot model within the partner organisations. The Team has the clear responsibility to direct and draw into the process the work of the Sub Groups.

10                 The salaries of the secondees are paid from the project budget, the lion’s share of which is covered by ISB. However, the partners are making a financial contribution of their own and, as was noted earlier, there may be further in kind contributions by way of staff time. There is thus likely to have been some displacement by diverting staff time from other activities of the partner organisations. This was not raised with us as an important issue. The view of the participants was that the importance of the project was such that it would outweigh any minor negative displacement effect in other activities.

11                 The methodology set out in the PRINCE project management system is used by the Team and is considered to work well.

Project outcomes, including contingency and monitoring

12                 This is clearly an ambitious project which has required its own management structure to be set up. Our consultations with the project managers and the Scottish Office/Executive suggested that primary outcomes at this stage should relate to the establishment of the structure, that is, the Steering Group, the Sub Groups and the Project Team. The targets for activity therefore relate to the establishment of this structure and the working up of the project by the Team (examining options, developing and implementing the pilot etc).

13                 More precise indicators for outputs and outcomes will be determined once the pilot is closer to implementation and this has some way to go yet. This should, however, be relatively straightforward, given the nature of the project and the ‘baseline’ information which will be available from the Strathclyde University research. The approved budget for the project contains Ł50,000 for evaluation costs. Consultants are about to be appointed to put in place the first steps of the framework for evaluating the project.

14                 The current timetable for implementation is:

§ create a model for a joined up approach by October 2000

§ pilot the model by April 2001

§ roll out the model for wider implementation by April 2002, providing the stakeholders sign up.

15 The Team itself was established and in operation by July 1999. This was somewhat behind schedule mainly because of delays resulting from the reorganisation of Primary Health Care Trusts. They are on schedule, however, to have a preferred model approved by October this year, as the revised programme specifies.

16 Monitoring which is undertaken at present relates to:

§ progress on getting the structures in place and the pilot specified

§ spend on the project.

17 This takes the form of reports to each quarterly Steering Group and is based on the PRINCE format report method.

Additionality, longer term effects and value for money

18                 There are two views on additionality. The Scottish Office consultee reckoned that it was 100% since there would have been no alternative funding available. However, those responsible for implementation on the ground (who are better informed) believed additionality to be partial – the project would have still gone ahead without ISB funding (recalling that it had already been partially researched prior to ISB intervention) but on a much smaller scale. It would also in their view have been much later and much less effective. There would have been at least a 12-month delay.

19                 Most importantly, the ISB funding is more likely to ensure that the prospect of real integration is achieved, rather than more partnerships or joint working which are happening anyway. Given the radical nature of the project, it is hard to see how its ambitious aims could be achieved except through the dedication of the level of resources which has been possible through the ISB contribution. Additionality is in our view almost certainly high.

20                 This is a radical initiative. As currently specified, it is aiming to merge health and social care provision at the local level, even possibly to the extent of creating a new single organisation. Much will depend on the outcome of the pilot. It is the intention, however, to assess the effects of the pilot and, if judged successful, mainstream it within the partner organisations. It is notable that the Scottish Executive Minister for Health has been presented to on the project and is taking a keen interest in it. Both local consultees and the Scottish Executive consultee commented on this. Should the pilot work and be extended within this area, it is quite possible that it will be taken up in other areas.

21                 It is hard to comment on value for money at this stage since so much is still to be done. Much has been achieved so far in terms of getting the structures in place, but it is only when a pilot has been tried out that a more informed view of what has been achieved, and how this relates to the resources, dedicated will be able to be formed.

Administrative issues

22                 The partners bidding for ISB support for this project found no difficulty in putting the bid document together. As we noted, however, they had little idea what criteria HMT would use to make decisions on bids. It appears that HMT guidance did not get beyond the intermediary government department, in this case, the Scottish Office. Additionally, there was little if any feedback to the bidding organisations from either the Treasury or the Scottish Office on the quality or shape of their bid.

23                 The project implementers are happy with HMT's monitoring requirements for the project which seem appropriate for their purpose. There has been only one minor irritation in that while they have had no contact whatsoever with HMT, they have received many calls from applicants for second round ISB funding looking for guidance on how to prepare a bid.

24                 The project itself has been well-publicised within the partner organisations and wider afield in Scotland. There have been presentations to representative professional organisations as well as to the Scottish Executive Minister.

25                 The Council holds the single pot of money for the project into which the contributions of all the partners are put. The Council’s Director of Social Work is the accounting officer for this project. None of the three partners, or the Scottish Executive, saw this as in any way problematic. There were some initial issues to do with the flow of money and recharging between organisations, but they were resolved relatively early in the life of the project. There have been no major problems since. It should be borne in mind that any such difficulties would be referred to and handled by the Steering Group, on which all three main partner organisations are represented at the most senior level possible.

Conclusions

26 This is a radical project which, if it works and if it is repeated elsewhere will involve major change to delivery of services at the local level. The level of seniority on the Steering Group and the Project team demonstrates a positive attitude to the re-examination of current forms of delivery, which surveys of clients have shown to be sub-optimal. The ultimate success of the project will depend on the outcome of the pilot which is still to be implemented, but steps are about to be taken:

§ first in getting approval from partners for a pilot to be implemented later this year, and

§ second to put in place a system for external monitoring of the pilot through the use of consultants.

27                 Only time will tell whether the pilot will work and whether, if so, the commitment is there to roll it out wider within the partner bodies. It is therefore too early yet to judge if this ISB funded project will be a success or a failure but it cannot be faulted for lack of ambition, nor the seriousness with which it is being taken by the organisations taking part.28                 Would it have gone ahead at all without ISB support? We noted above that additionality, though partial, seems to be very high. The extra resources made available by HMT appear to have allowed a much more substantial effort to be undertaken.

29                 The question follows, however, that if the project is so important, why should the Scottish Executive and the partners not be funding it in any event? We cannot answer this question, but what can be said is that the partner organisations believe that sufficient funds would simply not have been available other than through ISB. Thus, if the project does proceed to a successful outcome (and though risky, there is a chance that it will), much of the ‘credit’ will be attributable to ISB for supporting a radical venture that would not otherwise have attracted the necessary resources. Where it can be seen to be supporting radical, experimental and risky projects such as this one, ISB should therefore have a future.

30                 The implementers of the project believe that there are some good aspects in the implementation so far that would be worthwhile considering as good practice, that is:

§ the Steering Group/Sub Group approach has been effective in bringing together top down and bottom up views

§ the multi-disciplinary groups have been very effective

§ since staffing issues are central to this project, bringing the unions in at an early stage (they were invited on to all of the Sub Groups and participate in six of them) has helped to bring them on board

§ look for an early win - in this case linking the e-mail systems of the partner organisations together.

31                 Monitoring the outputs and impacts of the project will need further consideration; targets currently relate to creation of structures rather than outcomes or outputs. This is appropriate since the final shape of the project for implementation is not yet specified. HMT might wish to consider how it specifies the development of indicators and targets for future projects such as this one which have a relatively long-term time frame. It might be possible to define project targets related to structures in early stages with those for outputs and outcomes identified later. Once the specification for the actual project to be carried out on the ground is drawn up, a further report to HMT could spell out the actual indicators for outputs and outcomes, targets and how they will be measured.

32                 There has clearly been an issue, though not a major one, with the presence of an intermediary government department. This will be less true in Scotland in the future as the Scottish Executive will be taking over ISB to produce an equivalent, but in England and Wales it will be necessary to ensure that applicants are familiar with the criteria and requirements of the initiative in future.

33                 Last, HMT might wish to consider one comment made in that external organisations are suffering from ‘initiative overload’, given the number of challenge type funds in existence (apparently over 60 in Scotland). Before taking ISB forward, a review of challenge funds might be valuable to see how far rationalisation or mainstreaming of some might be appropriate.