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Almost 10 years after legislation was introduced to integrate health and social care services staff, those accessing services and citizens in general are benefiting from one of the biggest reform programmes since the creation of the NHS.
The integration agenda was driven by shrinking budgets, a smaller working population and growing demands for services from an increasingly ageing population with complex care requirements. The new model of working puts consumers at the centre of services and focuses on their needs and desired outcomes.
The challenge was to involve everyone in the process, from people who use services and service staff to the community, creating a shared vision and values. Buy-in from the chief executive and managers down to care support workers and carers was essential. Staff were reassured that people not jobs would be protected. It was about having the right skills, attitudes and behaviours, values and experiences. Staff became movers, leavers or enablers – the latter staying in the same role but delivering services differently.
Today in 2025, person-centred locally based care delivered by a flexible and multi-skilled, mixed economy workforce is a reality. Synergies between health and social care and other care providers, and the consequent lack of duplication and better use of resources, has led to cost savings and more efficient working practices.
Multi-disciplinary teams work in collaboration with the voluntary and independent sector as well as carers to make sure those accessing services get the right care in the right place at the right time. The community is the centre of care activity and the people providing services are defined by their skills and competencies from digital literacy to communication rather than by job titles.
These days health and social care staff require not only the technical skills for the care they provide but also emotional intelligence – from an appreciative mindset to being able to develop collaborative relationships and managing uncertainty. Adaptability is key.
Today generalists and specialists work together and nurses, pharmacists and physician/practitioner assistants undertake many roles previously the domain of hospital doctors and GPs as everyone works at the ‘top end of their licence’.
Service redesign and other new roles, such as flexible hybrid workers who offer general support, as well as some medical assistance in hospitals and the community, have led to improved patient care and greater satisfaction from those accessing services and their families.
Everyone, including those with disabilities, long-term conditions and the frail, is living longer healthier lives. Significantly, the large elderly population is now much more able to remain independent at home or in a ‘homely’ setting in the community.
Hospital admissions and delayed discharges among this group have fallen dramatically. This follows innovations such as the introduction of named community and hospital coordinators who get to know patients’ wants and needs.
Better access to patient records and relevant patient information, along with greater data sharing between health and social care workers, has transformed communication among team members and between care providers and those accessing services.
Job satisfaction is also rising as a result of the increased support from joint working and more rewarding roles now available to health and social care staff. Significant numbers are enjoying second careers as mentors, trainers and service planners.
There has been a significant fall in the numbers leaving the service or taking early retirement due to low morale, disillusionment or burn-out. Consequently the health and social care service has been able to retain valuable expertise and experience. This continues to inform service development and workforce planning which is now ‘intelligence’ led. Improved retention has also led to significant savings on temporary cover and retraining, as well as better continuity of care and higher levels of morale.
Creativity and resilience are the bywords of the more productive workforce. This includes health and social services staff, freelance personal assistants employed by those accessing services, the flourishing third and independent sector and a huge unpaid army of volunteers and carers, many of whom are retirees with time and valuable life experience to offer. Reflecting demographics, the workforce is older and octogenarians have now joined a growing number of pensioners working for agencies providing part-time support in people’s homes.
The 2015 Community Empowerment (Scotland) Act led to an upsurge in community groups taking over facilities and running services in collaboration with the Health and Social Care Partnerships. Carers’ hubs have also been established to provide support for people looking after friends and loved ones.
As well as mutual support, these hubs offer access to health and social services’ staff to ensure carers’ own health and wellbeing are supported and that their voice is heard. Each hub has an evaluation and review group, which has the confidence of the wider public as well as formal qualifications to scrutinise the health and care service. Each hub publishes an annual report with a series of recommendations on areas that carers feel need improvement.
The journey began with Health and Social Care Partnerships, governed by joint integration boards consisting of community representatives and staff from the local authority and health board. To fully embrace integrated working, professionals have had to give up some of their authority and status to allow others to play their part in the ‘new normal’ world where everyone – professional and non-professional – has a role to play. The new order has required a new mindset. It is based on shared values and a shared vision, devolved decision making, managed risk taking and constant reinforcement by service leaders in the form of consistent messaging and communication and proactive support for change.
Blurring the lines between health and social care and introducing new flexible working patterns, particularly in rural areas, has challenged traditional boundaries and approaches and has resulted in novel solutions to provide localised services. New options include offering staff opportunities to take their careers in different directions by learning new skills to fill shortages and staff working from home or co-working in different localities.
Most frontline staff spend their time seeing people in the community rather than in offices. They generally meet managers only on a monthly basis for updates and performance development reviews or appraisals. Advances in technology and comprehensive training in digital literacy for all health and social care staff means they can make operational decisions on the move. They have a constant link to colleagues with key information available at the touch of a button. Enhanced training, confidence in their professional skills and tacit support of managers means staff no longer need to ask managers to make decisions for them, and now more explicitly use their professional expertise.
Creating trust and accountability have been key in making these changes work. Some managers and senior leaders in particular have struggled with the concept and the perceived loss of control while frontline staff have embraced their new freedom and responsibilities and feel more empowered.
Although there have been challenges as a result of the greater autonomy enjoyed by staff, enlightened partnerships have moved away from a ‘blame culture’ approach when things go wrong, understanding that they needed to explore what went wrong in the system rather than trying to blame individuals’ They have adopted a no blame culture to reflect their focus on being a ‘learning’ organisation. Political realities requiring bosses to be accountable means this is not always possible, but where it is, more progress is made. In areas where there is still a blame culture a fear of risk taking remains setting progress back substantially. These areas also suffer from high sickness rates and high turnover.
Significant time and effort has been spent equipping staff and the wider workforce with the necessary skills to adapt to working in new ways. There has been a subtle shift away from training to learning, with greater emphasis placed on peer learning, the extent to which workers learn from people using social services, and many shared learning experiences involving workers and people who use services learning together.
Staff share their expertise, skills and knowledge at events such as ‘lunch and learn’ sessions and job swap days, and success is celebrated. Colleges and universities are closely connected with the communities they serve. They are involved in community based research and support work-based learning. They also support the co-production of qualifying professional programmes with other professionals and people who use services, so that students are work ready, with practical experience, up to date relevant knowledge and core skills. Personal ownership of records and relevant patient information plus greater data sharing between health and social care workers has transformed communication among team members and between care providers and those accessing services.
Some staff are involved in more work-based learning and receive support for the transition into work after achieving professional qualifications. Ongoing work and discussions with professional and service regulators have ensured that staff are accountable and operate within the guidelines of their area of practice. Guidelines and registration is changing and adapting to take into account the new hybrid roles, and enabling innovative ways of working while ensuring that the public is protected.
Continual professional learning is not only available to health and social care staff but also to personal assistants to ensure those accessing services are benefiting from the latest thinking. Carers also have access to community courses on caring and disease management.
A skilled and motivated workforce has been critical in ensuring the success of these far reaching reforms set in motion in 2016. Cultural change doesn’t happen overnight or even over a decade but promoting a shared understanding of integrated working, combined with collective effort is having a cumulative effect. The most successful integration has been in areas where HR and organisational development teams have actively involved staff in focus and feedback groups, on issues from the partnership’s values to innovation, harnessing their wisdom, experience and expertise and galvanising their goodwill.
Employee engagement has become a key focus for HR departments who have been through a steep learning curve of their own, taking part in ‘train the trainer’ sessions on careers and resilience. They are adopting more employee-friendly practices as they work hard to make the organisation an employer of choice in today’s increasingly competitive labour market. These include involving staff in key decision making such as on the strategic direction of the partnership and the organisation’s values.
Many hold annual ‘values days’ which reinforce the primary purpose and develop a common culture among staff, while slogans such as ‘Enhance Every Life We Touch’ and ‘Together We Are Greater Than The Sum of Our Parts’ appear on screensavers and payslips as a constant reminder of shared goals. Some HR departments run regular happiness surveys and hold drop-in clinics as well as exit interviews when someone leaves to help with recruitment and retention.
An increasing number of staff recognition programmes and new career pathways have resulted in significant reductions in turnover in a number of areas where posts have traditionally been hard to fill. This reflects the success of integration and good organisational development. The result is a valued and ambitious workforce.
Recruitment and retention is a key issue for everyone involved in providing care. Improved learning aims to ensure prospective employees have the necessary values and attributes for the job to save time and money re-recruiting.
The impact of organisational change and people’s responses to it cannot be underestimated. The integration journey hasn’t been easy – old habits die hard. There have been and still are culture clashes between health and social care workers keen to protect old fiefdoms and traditional boundaries and thinking. However, regular educational and social events run by the most successful partnerships to bring health and social work teams together are breaking down barriers.
Team newsletters and the intranet keep staff abreast of new developments and in touch with each other. A lot of effort has been made in these organisations to use a common language that unites people. More cultural integration is happening thanks to lots of small steps taken in partnerships and a constant drip feed of positive messaging.
Professional leaders have played a critical role in collaborative activities such as masterclasses, action learning sets and enquiry skills development sessions, acting as coaches, facilitators and mentors. Leaders engage in dialogue rather than prescribe solutions. Change events for staff and leaders have been crucial in preparing for new ways of working with chief executives and managers leading conversations within organisations.
The new working practices are constantly measured, monitored and reviewed internally and externally to keep apace of changes to budgets, demographics, new demands or learning needs. Some are measuring cultural integration with the ‘lanyard test’ – to see if partnership staff attending meetings choose the integration joint board badge over their health board or local authority one. Most do.
Planning for the future by the Scottish Social Services Council is licensed under a Creative Commons Attribution 4.0 International License. Based on a work at http://learn.sssc.uk.com.