As the Scottish Government consults on proposals to integrate health and social care, Holyrood visits Orkney where it has already begun to happen. 

One side of the courtyard is lined by cheerful cottages, each with its own brightly coloured front door. On the other, a stone-fronted building houses six further properties, including a respite flat, staff base and a shared social space – where a thoughtfully positioned picture window with a prospect down to the bustling port and village below, allows residents to observe the comings and goings.

There is much to see inside as out, however. The Braeburn extra care housing facility is not long open and is a hive of activity. Staff are settling in to their new premises and care managers dot in checking finer details such as the strength of mobile signal for prospective tenants. Some final touches remain and I’m implored to imagine that the planters in the courtyard are already blooming with tumbling plants and shrubs. The £2.3m facility was designed by drawing on the expertise from health, social care and housing professionals in Orkney, as well as further afield, and will support people with a wide range of care and respite needs to live independently with the added reassurance of access to 24-hour personal and social support. The facility held an open day in April to allow the local community to see for themselves, and the reaction to what they saw was overwhelmingly positive, says Gillian Coghill who manages the facility.

Each property is light and spacious and comes with its own garden, a fully fitted kitchen, bathroom and built-in storage. But otherwise, they are blank canvases. Rather than generically fitting out each property for all eventualities, which might be off-putting for some people, each property can be adapted to suit particular individual needs, such as by setting up tracking hoists or lowering kitchen worktops, explains Coghill. They can also be personalised as tenants can bring their own furniture and treasured items, even pets, so that the whole look and feel will be homely, rather than institutional. The different sized properties, which have all been designed following dementia-friendly principles, will also lend themselves to a range of tenants of differing ages and needs – from families to elderly couples – and so when full, Braeburn will be much more reflective of what a community is, says Coghill.

The facility has been designed to be as flexible as possible, continues Caroline Sinclair, head of health and community care with Orkney Health and Care .

“We recognise that for some conditions you might want to come in sooner rather than later so you can become orientated to where you are or get used to accepting support.

“So maybe for somebody with dementia, it would be more appropriate if they came in earlier on while they can still get used to new surroundings rather than wait until they are more far progressed and it might be disorientating. Or somebody with a physical condition that we know is going to be deteriorating might come in earlier on to get settled in, knowing that their support needs are probably going to grow as time goes on.

“So it is a bit more need level than the idea of sheltered housing where you have just got a warden and a bell, but it is not so much that it is residential care.”

A key aim of the facility is to support reablement. Environment can have a huge impact on people’s ability to manage, says Sinclair, and so within the facility staff will support individuals to live as independently as they can and work with them to help them regain their confidence and ability in daily living skills.

The facility, which has been informed by people from different disciplines, is a good example of how joined-up working can deliver well thought-out services for our local community, she says. It will also serve as a trial for the extra care housing model in Orkney. At present, ambitious plans are afoot on the island for a purpose-built joint health and care campus in Kirkwall, which will include a new hospital, dental and doctor practices, residential care and, if found to be successful, extra care housing, all brought together on one site. The joint campus, which is expected by around 2016, will be a very physical manifestation of Orkney’s efforts to fully integrate its health and social care services.

The integration of these services is also a priority for the Scottish Government. In May, the Government launched its consultation on the integration of adult health and social care, which will run until September. The consultation sets out proposals to inform and change the way the NHS and local authorities work together in partnership with the third and independent sectors, and the responses will also inform legislation that the Government intends to bring forward to help to create the type of working environment that professionals and staff within the current health and social care system, and users of it, say is needed.

“Separate – and sometimes disjointed – systems of health and social care can no longer adequately meet the needs and expectations of increasing numbers of people who are living into older age, often with multiple, complex, long-term conditions and who need joined-up, integrated services,” The introduction to the consultation states.

“Addressing these challenges will demand commitment, innovation, stamina and collaboration from all of us who are involved, in different ways, in planning, managing, delivering, using and supporting health and social care services.”

While there is wide agreement that this is the appropriate direction of travel, for some this will come more naturally than others. In Orkney, helped no doubt by its petite proportions and coterminous boundaries, this has been happening organically for a number of years, explains Cathie Cowan, chief executive, NHS Orkney.

“I suppose in Orkney it is a microcosm of the bigger boards, so it is easier to think about a whole, what we would call, health and social care economy,” says Cowan.

“We fundamentally feel that if we can join-up things we can reinvest our money into different services, because we won’t have the people falling between the gaps and being admitted to hospital and having to get discharged.”

Orkney Health and Care, a partnership between Orkney Islands Council and NHS Orkney, was already in its infancy when Cowan arrived in Orkney to take up the chief executive post. She agreed to take up the role of interim director, which Cowan says reinforced to her the importance of integrated working.

“Having a joint person means that you do wear two hats and you need to actually say to yourself, ‘If I do that what is the impact on social work? If I do that, what is the impact on health?’ So, it is about what is the best for the client or the patient…”

The partnership’s vision is that wherever possible, individuals can be maintained in their own homes, she says.

“So, people in their own homes, carers supported in their own homes, are beginning to think about working very closely together so that we share information, joint resources and we cut through the bureaucracy so that any waste in our system, any variation, we are beginning to look at that, to try to take that out and reinvest in front-line services – that is our raison d’être.”

For those who can’t be cared for at home, there are wrap-around services, she continues.

“That is where we’ve looked to, if it is not at home, could it be extra care housing? Could it be still your front door, still your furniture, still your bits and pieces but it is as near to your community and your family as possible with staff 24/7 so there is that protection around that. I think Orkney Island Council and NHS Orkney, who have invested in Braeburn, have demonstrated a really high quality capital investment.”

Another important player in the partnership has been the third sector, she says, adding that the strength of that relationship was emphasised in the decision to give 40 per cent of its Change Fund money to the sector.

Gail Anderson, chief executive, Voluntary Action Orkney, says there has been a tradition of working together in Orkney that they have been able to build on in seeking to make these more formal partnerships, adding that the experience so far has been a “fairly positive” one.

“We have a seat in community planning, we are members of the Orkney Health and Care Committee, we have been very positive in terms of the Change Fund work, we’ve worked very collaboratively with our colleagues in Orkney Health and Care and have had, I think, 40 per cent of the funding allocated to Orkney. So all of these informal partnerships and relationships have helped us to move forward into the more formal partnerships and be able to build on that.”

However, she adds that the sector also values its independence.

“We are very different in the third sector in the way that we operate and that is our strength. So that independence in a sense is precious. But we do want to build and develop and see where the third sector can support statutory colleagues in this way forward.”

In order to move ahead, however, she says that people have to be open to looking at things in new ways.

“Change is always challenging and certainly where you have put a lot of effort and your heart into developing something in a diff erent way to see that potentially challenged, you have to recognise that that is potentially very difficult. But we also have to be open to change. We can’t respond to new challenges using old tools and I think it is about being aware and being open, and also in terms of [the] third sector recognising the skill and the professionalism that [the] third sector can bring to the table and that is often underestimated.”

These close links are also evident at another facility I visit. The Selbro independent living resource centre and community equipment store brings together the health board, council and voluntary sector under one roof, creating a one-stop-shop for advice and information for those who have difficulty managing in their home environment.

John Ross Scott, chairman of NHS Orkney, proudly boasted of its achievements following a visit by the Health Secretary last year.

“It is not a high cost activity, but an excellent example of how a relatively small amount of money can be used creatively to make a significant difference,” he said, adding that: “It demonstrates, once again, just how inherent close partnership working is in Orkney.”

Conveniently, the space chosen was a former plumber’s merchant and so they inherited a fitted-kitchen showroom and rooms that easily lent themselves to become bedrooms and bathrooms to display some of the products available. Public open afternoons are held once a week, although private sessions can also be requested, where service users and family members can come for advice or to see and even try some of the adaptations, assistive equipment and products for themselves, such as stair lifts, level access showers, hoists, sensory impairment equipment and telecare products.

Before the centre existed, individuals could go along to a local shop and hope to see the right thing or have an occupational therapy referral where they could be talked through some of the options available, explains Pam Marwick, acting occupational therapy team manager.

“But if we wanted to try a stairlift or a fancy toilet it would be, can we squeeze into that respite flat when nobody is using it to try it or who is quite nice who hasn’t had a visit from us for a while who would let someone come in and try out the stairlift.”

Letting people see for themselves and spend time with the products can help them make a more informed choice, she adds.

“People have in their minds that something might be the very thing but it is not until they have actually tried it that they realise, ‘Oh, well, ok, I’m willing to listen to what other options are, maybe that is not the only option. So it just opens people’s eyes to the options.”

Selbro pre-dates the current ethos and national drive towards re-ablement and maintaining independence, continues Lynda Bradford, service manager for older people’s services.

“This plays a huge part in enabling people still to be in their own homes and do as much for themselves as they possibly can. That is the way we really want to care for people, that they are completely involved in their own care and we support them as opposed to doing care to them, to help them feel confident about the choices they are making because they’ve got the space and the time to actually see some of the things that are being recommended.

“It’s also been very useful from the point of other staff groups,” she says.

“We’ve had home carers here seeing bits of kit being demonstrated. Community nurses too. There are lots of staff that can come and go here and everything is here under the one roof and it is just that bit more efficient.”

More roof-sharing is on display at the Peedie Sea Children’s Centre, which adjoins the local school. Here, the aim of the staff is to help the children reach their full physical potential and independence. The centre consists of physiotherapy and occupational therapy rooms, as well as a very popular hydrotherapy pool and, of course, lots and lots of toys.

Sometimes children arrive at the centre a little apprehensive about their therapy, explains paediatric physiotherapist Penny Martin, and then they see the colourful pile of toys in the corner – or better yet, the cupboard full of them down the corridor – and they can usually be cajoled.

“One of the little boys I was working with said to me, ‘You’ve got a lovely job, all you do all day is play’” jokes Martin.

The team works with a wide range of children, from very small babies all the way up to the age of 19 when they leave education, she explains.

“We tend to be quite flexible at the top end because basically, we don’t like it when everything changes at once and if we can stagger it, it works much better and often the physiotherapy side of it for a child with complex difficulties, we’ve been actually a constant all the way through their life and also, we are really quite significant in the transition to adult services and we would rather keep them on until everything else is sorted out because if you suddenly change everything it can be complicated.”

While the other facilities I visited have demonstrated the forging links between health, social care and the third sector, here at the children’s centre, the connection with education – where an adjoining door allows staff to easily traverse between the centre and school – is impossible to miss.

It is a link that is much valued, explains Martin.

“It is so important because most of, definitely the therapy work is in the schools. Speech and language work is mainly in the schools. It is such an obvious link because we are doing it already. It is just not as formal as we would like it to be. Well, we don’t want it to be formal; we just want everyone to think this is the best for the children.”

The centre is also a demonstration of Orkney’s bigger ambitions to travel further still along the road to full integration.

“Health and social care is about what do we do in our everyday life. So employment, housing, safety, leisure, transport – you begin to think how do you join all this up, and whilst it is a great start with health and social care when we formally joined it up, we also have brilliant links with education,” Cowan says.

While the Scottish Government’s consultation focuses, for now, on the integration of adult services – mindful, perhaps, of not wanting to overwhelm areas by attempting to tackle too much reform in one go – the decision was taken in Orkney to press ahead with the integration of children’s services at the same time.

“We feel that to do it in piecemeal, for us, it is different in other places and I absolutely recognise that, for us, we wanted to do it as an integrated programme of work,” says Cowan.

“For other big boards where it is big, big services, maybe a phased approach suits them better because it is maybe too much to do. But we’ve said, no, integration is integration. How do you deal with children who are in transition to that adult world if you don’t have integrated services?”

She recognises, however, that Orkney is in a fortunate position in that the numbers involved are much smaller. But nevertheless, she says it has come across, and overcome, many of the same barriers that other boards are grappling with.

“I suppose the question for me to be posed to the areas that are struggling is why are you struggling? What are the barriers? Because the same barriers are in place here. So people will say there are legal barriers, there are VAT barriers, there are HR employment barriers, and my challenge to people is: sort them out,” she says.

However, while Cowan and many of the staff I meet are clearly enthused about the direction and pace of change in Orkney, others advise caution.

“There is no doubt that the plans for health and social care integration in Orkney have been developed in response to local circumstances, which is what is expected of local authorities and health boards in every location across Scotland. However, we do have concerns about some specific elements of the plans for Orkney and how they could impact on safe and effective patient care,” says Theresa Fyffe, director of Royal College of Nursing (RCN) Scotland.

“For example, the integration of care is not ultimately about where organisational lines are drawn and re-drawn. We believe successful integration is all about people with different expertise and experience working together equally to meet the needs of individuals, families and communities. The potential for the blurring of professional boundaries between nursing and social care and resulting dilution of their respective expertise could mean that vulnerable people will fall through any gaps that emerge. This is the type of issue that all organisations planning to integrate services must consider carefully, particularly as care at home is becoming ever more and more complex.”

Cowan insists, however, that the staff are up for the challenges ahead.

“Katie, you’ve met the staff. I would love to say I’m driving this, but they are brilliant staff. They are absolutely up for it and willing. And they are able. They are confident. So for goodness’ sake, let them do it and let them celebrate their success.”

She welcomes the Scottish Government’s consultation for the direction it provides, but also for the space it leaves for areas like Orkney to continue carving out its own path towards integration.

“It allows people to build on what they have achieved already. It allows people who maybe are that wee bit further out in front, for whatever reason, to get on with it and not hold back. So there is flexibility in it but there is also direction; whilst it is fluid it is directive. There is a clear message that we have to do this. If we are going to reform our public services then integration is the name in town. We need to join up our people, our services, our resources to actually make a difference.”