A testing year ahead for Scotland's Integration Authorities

 Nurse speaking with elderly woman

George Black, Visiting Professor, IPPI

George Black
Visiting Professor, International Public Policy Insititute

23 January 2017 

2016/17 may have been a testing year for Integration Authorities but 2017/18 looks like being even tougher. I have previously identified that Integration Authorities face five key challenges relating to – the political landscape, governance, service redesign, financial management and staff management. So, what progress has been made in this first year of operation and what do the next twelve months hold in store?

Political Landscape

The new structures came into being just before the 2016 Scottish Parliament elections and their first full year of operation will come to a close just before the 2017 Local Government elections. This has undoubtedly been a period of heightened political tension, particularly with the unexpected outcome of the European Referendum. Although the next cycle of elections is not scheduled to start until 2020 with a UK General Election, the combination of the current financial climate, the uncertainty surrounding Brexit, and the prospect of a second Independence referendum will ensure that heightened political tensions will remain with us over the next twelve months and beyond.

Although political support for the principle of integrating health and social care is most likely to continue, there will be fierce political debate over the success, or otherwise, of its implementation.


The complexity of the governance arrangements has been highlighted by Audit Scotland as an ongoing concern, in particular the lack of clarity about decision making. Tensions have arisen between Council and Health Board appointees, voting and non-voting members, and Integration Authorities and their parent bodies (Councils and Health Boards). Uncertainty has also been caused by the prospect of significant changes to Council appointees as a result of the local government elections this coming May.

The overriding view from Integration Authorities has been that Councils and Health Boards “need to let go” and trust Integration Authorities to make the right decisions. Indeed, some views have been expressed that Integration Authorities should be directly funded by the Scottish Government rather than by Councils and Health Boards, thus strengthening their independence.

If Integration Authorities are to gain more independence they will need to be able to clearly demonstrate their ability to manage major redesign of services in an environment of scarce financial resources.

Service Redesign

A major challenge for Integration Authorities is to shift the balance of care away from hospitals and into community settings. The scale of this challenge was recently highlighted by Audit Scotland which reported that, although there has been a policy to shift the balance of care for over the past  decade, NHS funding has not changed course. Information gathered by the Scottish Parliament Information Centre (Spice) shows little evidence of this situation having changed in 2016/17.

This is perhaps understandable, as 2016/17 was the first full year of operation for Integration Authorities. However, more progress will be expected in 2017/18 with there being a particular focus on reducing delayed discharges, reducing unscheduled hospital care and shifting resources into primary and community care. Integration Authorities will need to move quickly to put Action Plans in place if there is to be any meaningful shift in the balance of care in 2017/18.

Financial Management

The biggest single challenge facing Integration Authorities remains managing services against a background of a severe reduction in financial resources, coupled with growing cost pressures and the demands of an ageing population. For 2016/17 the majority of Integration Authorities inherited budgets developed separately by Councils and Health Boards. The challenge in this last year has been simply to managing these resources effectively, an outcome achieved by many, but not all.

2017/18 will be a much more challenging year for Integration Authorities as existing services will need to be maintained at the same time as new models of care are introduced. Those Integration Authorities that go into 2017/18 with an underlying financial deficit will find the going extremely tough.

Staff Management

As there has been limited service redesign over the past year it is not surprising that major staff management issues have not arisen. However, 2017/18 could be different if transformational change programmes get underway, something which is essential if a significant shift in the balance of care is to be achieved. The different terms and conditions of staff, Council and Health Board, can be expected to become more of an issue, particularly with regard to the policies of “no compulsory redundancy” and “lifetime protection of earnings”.