SPICE takes the heat out of merging health and social care

FOR YEARS SCOTLAND HAS PURSUED the merger of health and social care as a structural reform. The aim has been simple: people – particularly older adults with complex needs – should experience care that feels coordinated, responsive and continuous rather than fragmented across organisational boundaries.

Yet structural mergers and governance reforms have often delivered less transformation than expected. Administrative integration rarely translates into better care at the bedside, in the care home, or in the patient’s own home. Many countries have tried and failed.

I see this every day working in A&E up and down Britain. The same problems pop up in England and Wales as well as in Scotland. It is simply too complicated to co-ordinate these at scale for three reasons.

The first is that unlike health, diagnoses are discrete and subjective, the second is that funding for social care is means tested, even in Scotland, and health care is not. The third is that social care is heavily linked to housing which means it makes far more sense to keep it in the hands of local authorities. Health is episodic, social care rarely is.

A concept such as SPICE – Single Person Integration of Care and Escalation – offers a different route to the same goal. Rather than merging institutions, SPICE integrates care around the individual patient, using clear clinical responsibility, shared information systems and structured escalation pathways. In doing so it could provide a practical alternative to further structural reform in systems such as NHS Scotland and the social care sector overseen by the Scottish Government.

The integration agenda focuses on top down organisational architecture: joint boards, pooled budgets, and shared planning structures between health services and local authorities. These reforms have improved communication and strategic alignment in some areas. However, they often come with a significant “change premium”: years of administrative transition, cultural negotiation and governance redesign.

integration too often happens on paper but not in practice

Meanwhile the day-to-day experience of care can remain largely unchanged. A nurse in a care home may still struggle to reach the right clinician when a resident deteriorates. Information may still be fragmented across records. Responsibility for clinical decisions may remain ambiguous. In other words, integration may exist at the level of committees and policy frameworks while frontline staff continue to navigate complex systems that may look integrated on paper but not in practice.

This gap between structural integration and clinical integration is where SPICE becomes relevant.

The central insight of SPICE is that the true unit of integration is not the organisation but the individual receiving care. Each person – particularly those living in care homes or with multiple long-term conditions – should have a single, clearly defined framework for care coordination and escalation.

In practice this means three key components.

First, a shared integrated care record that functions as a live clinical tool rather than a passive archive. Observations, care plans, ceilings of treatment and clinical notes are accessible to relevant professionals. Trends in a patient’s condition can be recognised quickly, allowing earlier intervention and reducing unnecessary hospital admissions.

Second, explicit escalation ladders. When a patient deteriorates, staff know exactly who to contact and in what sequence. Instead of uncertainty about whether to call a GP, out-of-hours service or emergency ambulance, the pathway is predefined. This clarity reduces delays and supports staff who may otherwise feel exposed when making difficult decisions. This could be done now as I hinted at previously on corridor care. Care providers could be given direct access rights to Same Day Emergency Care, clinics and GP appointments so vulnerable people receive the care they actually need, when they need it.

Third, direct clinical supervision for care settings outside hospitals, particularly care homes. Under SPICE, a hospital or clinical team provides structured oversight for a defined group of patients or facilities. Each care home then effectively functions as a virtual ward, with named clinicians responsible for guidance, escalation and clinical governance.

Care homes represent one of the most important test cases for integration. Residents often have high levels of medical complexity, yet clinical oversight is fragmented. Carers may hold responsibility for recognising deterioration but have limited access to rapid clinical advice.
Treating care homes as virtual wards addresses this gap. Residents remain in familiar surroundings while benefiting from structured clinical supervision linked to a base hospital or community team. Observations and assessments feed into the integrated record, and escalation pathways connect staff directly with clinicians who know the patient population.

This model also supports care staff themselves. Rather than feeling isolated when faced with complex clinical situations, they operate within a framework of support and accountability. Provide NHS nurses to nursing homes with base hospital support and staff rotation – and let them do the rest.

The old cottage hospital has largely gone but it served a purpose. Many people with complex health and social care needs benefit from a halfway house. Elderly patients leaving A&E after a fall or a young adult with a chaotic lifestyle needing several clinic appointments benefit from a one stop shop to co-ordinate this and their own home often isn’t suitable. Much of this is now done on expensive, intensive hospital wards, with alarm buzzers and crash calls punctuating the silence. Hospital at home only works when the home is suitable and safe. Often it isn’t.

A major advantage of SPICE is that it does not require wholesale structural reform. Instead of reorganising institutions, it introduces operational tools. Pilot programmes could begin with a small number of care homes linked to a hospital team, expanding as systems and workflows mature.

SPICE emphasises named clinical responsibility for defined populations

This approach dramatically reduces the change premium associated with large organisational mergers. Resources can be directed toward information systems, clinical leadership and training rather than governance restructuring.

Change is expensive. The valley of despair is well recognised in management speak – the idea that effort put into shake ups and redeployments is money not spent on delivery.

Another benefit of SPICE is improved accountability. In many integrated systems responsibility can become diffuse: multiple organisations share roles but no single clinician or team clearly owns the outcome. By contrast, SPICE emphasises named clinical responsibility for defined populations.

This does not replace the role of social care professionals or diminish the importance of person-centred support. Instead it ensures that when medical issues arise – such as infections, falls or deterioration – there is an unambiguous clinical pathway with someone clearly in charge.

Scotland has long been a leader in policy thinking about integrated care. However, experience across many health systems suggests that structural reform alone rarely produces the improvements hoped for. Integration must ultimately be experienced by patients and staff in the moment when care is delivered.

SPICE offers a pragmatic complement – or even an alternative – to structural merger. By focusing on the single person, linking care settings through shared records, and establishing clear escalation pathways with clinical supervision, it targets integration where it matters most: at the point of need.

In a system facing growing demand, workforce pressures and constrained resources, solutions that are practical, scalable and clinically grounded are particularly valuable. Rather than pursuing ever more complex organisational arrangements, SPICE suggests that the most effective integration may begin with something simpler: ensuring that every individual has a clear, connected and accountable pathway of care.

And yes – if hospitals can arrange step-down beds in the community, care homes should also be able to arrange urgent and planned admissions, rather than defaulting to A&E at four in the morning.

The question for new parties is not whether integration of health and social care should happen but where, how and now.