Agenda:

The Scottish Government is committed to shifting the balance of care from hospital to the community and has made it a priority in its 2020 vision and its Quality Strategy. Despite this, we are still a long way from completing the journey. This has been highlighted in recent Audit Scotland reports, which have indicated a lack of headway being made, particularly in shifting financial resources from hospitals to the community.

We need to get this right now, as the burden on services is only going to grow and the risk is that as pressure grows, vital hospital services will become unsustainable.

The pressure is principally coming from Scotland's ageing population, which is increasing rapidly. As more people live longer they develop more long-term and chronic conditions, such as heart disease, diabetes and dementia. The vast majority of older people have more than one of these conditions, making their care complex. This changing demographic will bring more demands on health and social care services, which will simply not be possible or appropriate to meet in hospital. Scotland currently spends £4.5 billion on health and social care services for those over 65, and one- third of that is on emergency hospital admissions.

The vast majority of people who need care want to receive it at home or as close to home as possible. Most people only want to go to hospital when it is absolutely necessary. Unfortunately, far too many are still finding themselves there when they could be getting that care at home or in a community setting.

Many of these problems can be seen in the care of people who are terminally ill, who often wish to spend as much time as possible in their home over the last months of their life, as well as having the choice to die there. Close to 60 per cent of the 55,000 people who die each year die in hospital.

Research from the Nuffield Trust has shown the cost of receiving care at home in the last days of life is actually notably less than in hospital, delivering significant savings. Although the study was carried out in England, there is no reason to suggest this would not be true in Scotland too.

Hospital services are expensive to deliver, but relatively small reductions in spending on those services could release much-needed money for community services, which could make a big difference. A significant part of the problem is that those making budget decisions for acute services are not identifying areas to make savings. This is unsurprising when all services are already facing increasing financial pressure combined with increasing demand. For many, looking beyond the short-term is impossible. There is also the added political pressure that comes when decisions are made to reduce or cut services in hospitals. As a result, the balance of spend between hospital and community services has remained broadly the same over the last 10 years despite warm words for change.

Putting people at the heart of service planning and delivery, reflecting their wishes and the outcomes they want to see for their care, will help ensure a shift in resources to the community where they want to be. This has to be the guiding principle when looking at the allocation of resources for the long term.

There are still opportunities for faster and lasting change. The integration of health and social care that starts in earnest from next April could be the catalyst. The integration of budgets, shared planning based on local need and a focus on outcomes for people will give the new integrated authorities the chance to shift resources. To achieve this we need to support the integration agenda and give authorities the opportunity to lead and develop a new culture in health and social care.