The imminent integration of health and social care could lead to conflict between health boards and councils with no clear plan over who will be accountable if something goes wrong, the public spending watchdog has warned.
Thirty-one new health and care integration authorities (IAs) will go live in five months but just six of them have submitted strategic plans, with many still arguing over budgets.
The Accounts Commission said there is a “pressing need” for integration to succeed as the current divided system has become unsustainable.
Last year, 625,000 hospital beds were blocked by people ready for discharge but with no appropriate care, support or accommodation to go to.
The proportion of people living past 75 is expected to rise by nearly two-thirds in 20 years, and as more people live longer into infirmity more will need help washing, dressing and eating.
The limited efforts to create community and preventative services to date means things are going to have to change fast and significantly, auditors said.
However, they found the Integration Joint Boards (IJBs) designed to bring services together contain inherent potential for “real or perceived conflicts of interest”.
Board members, senior managers and lawyers will all still be part of separate NHS boards and councils.
Each side could guard their separate organisations and budgets if disagreements arise, and it is also unclear who will be accountable if there is a service failure, auditors said.
The Accounts Commission found a consensus amongst people involved in the integration that it should be the council or NHS board delivering the service that should be held accountable for failure.
But auditors say the ultimate responsibility may also lie with the IJB that commissioned the service.
And some people will be responsible for both commissioning the service through IJB and delivering it through their health board.
Auditors also found “significant concerns about funding”, with councils and NHS boards “having great difficulty in agreeing budgets for the new IAs”.
NHS boards may decide cash set aside for integration remains their own separate money, while unsynchronised budget cycles could make joined-up financial planning difficult.
Councils may be disproportionately hit by budget cuts and rising costs as they have a more flexible approach to staff cuts and private sector outsourcing than the NHS, auditors said.
Integration is also expected to lead to increased workload for GPs, who are already under pressure due to poor recruitment and retention.
If GPs have any doubts about the quality of social care they may just send patients to hospital, auditors said.
The Scottish Government expects integration to save £138- £157 million a year, but auditors found no clear method for tracking performance meaning it will not know if integration has freed up resources or achieved its purpose.
Ministers issued strategic guidance in July, but this was found to be “too late” as most authorities had already begun their strategic planning, auditors said.
The Accounts Commission has recommended the Scottish Government develops a clear performance monitoring system, resolves tensions, publicly reports progress on cost-cutting and results, promotes leadership development and shared good practice and provides clear and strategic leadership.
Integration authorities must develop clear guidance on how to manage disagreements, confusing lines of accountability and conflicts of interest and ensure constructive working relationships, it added.
IAs must also be rigorous and transparent about decision-making and actions, develop detailed strategic, financial, workforce and resource plans and recognise the risks associated with their complex accountability arrangements.
Just 100,000 people – roughly 2% of the population – use up half the NHS hospital and medication budget and account for three quarters of unplanned hospital visits, according to Government estimates.
People using the services are not expected to see any front-line changes at first, and will still contact their GP or social worker if they need help.
But the new authorities are expected to join up their health and care needs behind the scenes, to ensure they are well cared for at home and to keep them out of costly taxpayer-funded hospitals.