Moving towards integrated working in health and social care in Scotland: from maze to matrix.

The development of integrated working across health and social care has featured strongly in recent policy directives in both England and Scotland. This is part of a wider agenda of partnership and collaboration, with a range of options from the creation of unified structures as in the care trusts in England to localised arrangements for joint working between individual professionals. This article presents a detailed matrix of drivers and barriers to integrated working which has been developed through a number of case studies of community care practice pursued as part of work undertaken for the Joint Future Group of the Scottish Executive. Drivers and barriers in three key areas are highlighted: national policy frameworks, the local planning context, and operational factors. It is anticipated that the matrix should provide a useful framework for the detailed scrutiny and operationalisation of integrated working.

The domiciliary care market in Scotland: quasi-markets revisited.

By offering people the choice of care at home, the policy of encouraging local authorities to purchase domiciliary care services from voluntary and private providers was intended to achieve a key part of the community care agenda. A study to establish the extent to which there was a mixed economy in the purchase and provision of domiciliary care in Scotland in 1996 revealed reluctance by local authority managers to divest the provision of domiciliary care to voluntary and private agencies. In a telephone survey of purchasers, some social work respondents noted a preference for voluntary over private providers and expressed concern as to whether either could take over the bulk of domiciliary care provision. These attitudes were reflected in the pattern of market development observed. Five hundred and ninety providers were identified, but a postal survey of a random sample of one in two providers (response rate 66%) found that the independent sector's share of the market, measured as the proportion of weekly care hours provided, was small compared with the position in England and Wales at that time (15 : 36%). It is concluded that understanding of the development of the quasi-market in domiciliary care in the UK must now take account of slower development in Scotland. Explanation for the difference may lie in the level of state regulation, for in Scotland there was no compulsion on local authorities to purchase from the independent sector. Paradoxically, the quasi-market in England developed through strong state regulation, whereas in Scotland the strength of policy networks may account for the persistence of a more traditional welfare state model. The paper questions whether the incentives for change were sufficient in Scotland under the quasi-market. If local partnerships do not deliver these results the government may have to take a more active role to modernise domiciliary care services.