A critical friend
“None of us is as smart as all of us,” reads the quote on the office wall in St Andrew’s House. It’s an ethos that is embodied in the newly formed Joint Improvement Partnership Board – a partnership between NHSScotland, the Scottish Government, COSLA, the Third, and Independent sectors, which was launched in April. The intention was to strengthen the position of the Joint Improvement Team (JIT) – the lead improvement partner in health, housing and care reform – to work with others to accelerate transformational change and support the delivery of integrated health and care.
The new board is chaired by Professor Jim McGoldrick, who previously experienced the work of JIT from the other side as the former chair of NHS Fife, where they engaged in issues about delayed discharges, and also as part of his work with the Ministerial Strategic Group on Health and Community Care. Previously, McGoldrick served as Vice Principal of the University of Abertay and explains he “accidentally” moved into the NHS after a position on a working party led to his appointment to a board in crisis: “There are certain people who hear the sound of gunfire and walk towards it,” he says, laughing.
The board is expected to “encourage greater ownership of the joint improvement and integration agenda by all national partners, and a greater willingness by local partnerships to engage as a matter of course with the important improvement capacity and resource that the JIT represents. “It’s a ‘unique arrangement’ in Scotland and is capitalising on the momentum for change in Scotland,” says McGoldrick, adding that it got off to a good start at its first meeting where it was agreed that all those around the table had equal status as members.
“The ethos we are trying to get in is we are a corporate body and there is no difference in membership status between our statutory body and non-statutory members. And that was pretty good in the first meeting because people felt there wasn’t a two-tier membership.”
Working alongside McGoldrick is JIT Director, Dr Margaret Whoriskey, who also has a background working in Fife. She began her career there as a clinical psychologist and worked for many years heading up services for people with learning disabilities in the 80s and early 90s, at which time she says there was a shift from an institutional to a more community-based model of care with a greater focus on improving outcomes for people. There, she saw that working in an integrated way made change happen, and Whoriskey says that focus has stayed with her and continues to inform her current work.
JIT has been a consistent “champion” of integrated, partnership working, she says, and has a “vital” role to play in assisting those in the design and delivery of public services. It has also been “quite fleet of foot” in terms of working outwith traditional boundaries, and has adopted a “critical friend” approach – providing support or constructive challenge when required.
And she points out that it has positive progress to report. Its 2012/13 annual report lists highlights such as the rate of emergency bed days for people aged 75+ falling by 7.2 per cent in two years and points out that delayed hospital discharges over four weeks are now at an all-time low. On an average day in 2011/12, there were 486 fewer patients over 65 in hospital following an emergency admission compared to 2008/09. While a focus on a reablement approach to care at home has also seen 12 partnerships report a median 40 per cent reduction in home care hours.
“I think the data does tell a story,” says Whoriskey.
“Again, it sometimes poses questions rather than answers. But I think we’ve certainly seen really good progress being made in people whose discharge is delayed in hospital. So that has been a really strong policy driver as JIT was almost set up to have that as one of its main priorities in 2004/05 because of the significant problems there has been with delayed discharge.”
While she says there is still a way to go, and more ambitious targets ahead, she adds that with the introduction of the Public Bodies (Joint Working) (Scotland) Bill there is a renewed impetus to pick up the pace, and scale, of change in Scotland’s public services, which means the role and contribution of JIT is “more in profile than ever”.
Partnership working has come a long way since JIT was established in 2004 to work directly with local health and social care partnerships across Scotland. Whoriskey observes that whereas partnership working was perceived as being in the “nice to do box” a decade ago, it is now recognised as essential. And with its new partnership board, she explains that JIT is modelling at a national level what has been promoted at a local level.
“Clearly the richness of bringing together people outwith your immediate ken in terms of the other sectors, I think, brings with it different conversations. I would certainly observe, and I’m sure others would agree, that as we’ve been supporting the work on the Reshaping Care partnerships and the Change Fund, it has allowed different people to come to the table and different conversations to be had.”
That has not been without some challenges in terms of people working out how they work together, she notes. However, that, she says, is “inevitable”, adding: “And I think if you don’t have a bit of grit in the oyster it can be a bit passive.”
If we are serious about prevention then it is obvious that health and local government can not achieve that on their own, she says, and so there is a need to also think more holistically around working with individuals and communities. Achieving this “decisive” shift towards prevention is one of JIT’s “Big Six” priorities that are set out in its new three-year strategy, alongside supporting integration, partnership and collaboration; enabling individuals to live at home and among their ‘ain folk’ for as long as they want; a focus on person-centred outcomes; continually improving practice and performance; and building capability.
The strategy is deliberately ambitious, says Whoriskey.
“I guess you could cut your cloth and keep a fairly conservative approach to what you can do. So I think the strategy itself is quite ambitious in terms of where we would like to be in three years’ time, in terms of building that capacity and capability with partnerships and stakeholders. But the challenge for us will be the pace and scale and how we ensure we don’t dilute our resource to such an extent that you lose the focus. So that is the balance for everyone now: how you do more with less.”
The strategy will also help shape the work of the board, explains McGoldrick.
“One of the ways we plan to get the development and dialogue within the board is to take one of these key themes at each board meeting and have a discussion so we can draw on the talent of those people who are in the room and not come just saying we’ve done it all, please approve it as a board. We’ve got a great opportunity to use the talent that is there and that is the natural way of organising it,” he says.
The kind of workforce developments that will be required to support the effective delivery is another key interest, he says.
“This is something that the ministerial strategy group has got an eye on as well, which is, what kinds of skills do we need in the workforce to live in the world that is changing this way? That takes you into some big thinking around the undergraduate curriculum for some of the professions, in a sense, that they are still trained very much in the way the job is being done now. And the idea is to say early on they should be thinking about how the job will change over time – whether it is nursing, social care, etc. And I think that is very important and there is some very interesting work being done between NES and the SSSC looking at how do you support these changes in care by developing the workforce in different ways.”
The board was established to help create the conditions to make some of these changes happen. However, as Whoriskey points out, people have been working in integrated ways for a number of years and so she is keen that we don’t forget these early experiences when considering the new legislation.
“The legislation is going to bring with it a more robust framework to ensure a degree of consistency across the country predicated on the outcomes we are aspiring to achieve. But I think it is really important that we hold on to the story.
“There is a story around this and we learn from some of the bad experiences as well as the good experiences. And it is how we capture that to shape and support.”
While discussions around integration are not new, Whoriskey is feeling optimistic about the current efforts and says it is her sense that the partnerships are “really up for this”.
“I feel quite excited about the agenda going forward. I think I have a fantastic team here, a great board. So it is a huge opportunity to work with partners nationally and locally on the journey towards better outcomes,” she says, adding: “We probably haven’t had as good a time as this before with all the different elements coming together.”