Integration of Adult Health and Social Care in Scotland: Consultation on Proposals

Chapter 4 Governance and joint accountability

What do we want to achieve?

4.1. In order to ensure successful delivery of the nationally agreed outcomes that are proposed across adult health and social care, we must ensure that arrangements are in place to assure the appropriate governance and joint accountability of the statutory partners - Health Boards and Local Authorities - for achieving these outcomes. Just as the statutory partners will under these proposals be jointly and equally responsible for delivering the outcomes, they must also be held to account jointly and equally for performance.

4.2. Community Health Partnerships have taken the integration agenda as far as they can within the current legislative framework. They have demonstrated how integration can work and have provided an invaluable source of knowledge and experience in developing our integration proposals. These proposals introduce a model of integration that is based upon joint and equal governance and accountability between Health Boards and Local Authorities. This is a step change forwards from the Community Health Partnership model, in which Community Health Partnership Committees are sub-Committees of Health Boards, albeit with strong Local Authority representation.

4.3. In this chapter, we give some consideration to how governance and accountability arrangements could be organised in Health and Social Care Partnerships. Inevitably, this takes us into the territory of, for example, Committee arrangements. In keeping with the underlying theme of these proposals, it is important that, as we examine these details a little more closely, we remain focussed on the outcomes we want to achieve. A Partnership Committee is a mechanism for governing a Partnership; it is not an end in itself.

How will we go about achieving this change - what will change in legislation?

4.4. Health and Social Care Partnerships will replace Community Health Partnership Committees, which will be taken off the statute book. Health Boards and Local Authorities will jointly be required to set up a Health and Social Care Partnership. Each Partnership will cover one Local Authority area, and will replace current Community Health Partnership arrangements. Health Boards, with their partners, will have flexibility regarding whether to include the responsibilities of Community Health Partnerships that extend beyond services for adults; further detail is provided below.

4.5. The Health Board and Local Authority, via the Health Board Chief Executive and the Local Authority Chief Executive, will be required to devolve budgets made up from primary and community health, adult social care and some acute hospital spend to the Health and Social Care Partnership. These will become integrated budgets, in which the resource will effectively lose its identity - those working with it to plan and deliver services will cease to view it in constituent "health" and "social care" parts.

4.6. A duty will be placed on Health Boards and Local Authorities to appoint a senior Jointly Accountable Officer for the Health and Social Care Partnership. The Jointly Accountable Officer will report to the two Chief Executives, and through them to the Partnership Committee, which will be a Committee of the Health Board and the Local Authority.

4.7. The Jointly Accountable Officer will be responsible for commissioning and managing services to deliver the nationally agreed outcomes using the integrated budget. The Jointly Accountable Officer will have a level of delegated authority from the Health Board and Local Authority that enables them to make decisions about use of the integrated budget without needing to refer back up the line within either partner organisation (for example, by using what was previously "health" money to invest in home care services). Further information on the post of Jointly Accountable Officer is provided in Chapter 6.

4.8. A Partnership Agreement between the Health Board and the Local Authority will establish services to be delivered and outcomes to be achieved, within the context of the nationally agreed outcomes, and the financial input of each partner to an integrated budget to achieve those services. The Partnership Agreement will also describe the mechanisms to effect integration of budgets locally. A governance Committee will oversee the running of the Health and Social Care Partnership.

Accountability

4.9. The Cabinet Secretary for Health, Wellbeing and Cities Strategy, the Local Authority Leader and the Health Board Chair will together hold the Chair and Vice Chair of the Health and Social Care Partnership, and the Health Board Chief Executive and Local Authority Chief Executive, to account for the delivery of the nationally agreed adult health and social care outcomes, the integrated budget and the development of community health and social care services.

4.10. Each of these leaders will bring their own perspective and overview to ensure that the localism delivered by Health and Social Care Partnerships is intertwined with the delivery of other NHS Scotland and Local Authority services, and supports the delivery of the National Performance Framework, HEAT and Single Outcome Agreements.

4.11. The NHS Chair and Local Authority Leader will form a "community of governance" overseeing the effectiveness of the Partnership. The NHS Chair and Local Authority Leader will also ensure that the Health and Social Care Partnership delivers services that support wider community planning processes, particularly in relation to promoting early intervention and prevention, and that appropriate stakeholders have been engaged by the Health and Social Care Partnership in the planning and delivery of services.

4.12. Each Health and Social Care Partnership will be expected to produce joint commissioning strategies and delivery plans over the medium and long-term, which will be reviewed as part of the process of ongoing assurance. Further information on what we mean by "commissioning" is provided in Chapter 7. Reporting meetings to Ministers, Health Board Chairs and Local Authority Leaders, will be established and will use an agreed set of measures to support monitoring of progress towards outcomes. These meetings will build on the current regime of accountability reviews for Health Boards. Accountability to the public will be via publication of local performance data.

Composition of the Health and Social Care Partnership Committee

4.13. The Health and Social Care Partnership Committee will ensure the efficient, effective and accountable governance of the Partnerships. Our proposals for the composition and role of members of the Committee are described below.

Chair of the Committee/Casting Vote

4.14. The Health Board and Local Authority will nominate a Chair and a Vice Chair for the Health and Social Care Partnership Committee, which will rotate on an annual basis. The two roles together will form a "team" providing integrated governance for the Partnership on behalf of the Health Board and Local Authority, rather than "representing" the individual interests of their respective statutory partner organisations.

4.15. The Chair and Vice Chair roles will be taken by one of the NHS Non-Executive Directors (not the Chair of the Health Board), and one of the local elected members (not the Local Authority Leader). The reason for these exclusions is that both the Chair of the Health Board and the Local Authority Leader will play a governance role alongside the Cabinet Secretary - and they cannot hold themselves to account.

4.16. The Chair of the Health and Social Care Partnership Committee will have a casting vote were the Committee unable to reach a majority decision. We would hope that the circumstances in which a casting vote were needed could be kept to a minimum; guidance will be developed for good use of a casting vote by the Scottish Government, NHS Scotland and COSLA.

Voting Members

4.17. Voting members of the Health and Social Care Partnership Committee will be made up of an equal number of Health Board Non-Executive Directors and local elected members. A minimum of three representatives from each statutory partner will have a mandate to act on behalf of their parent statutory bodies. Local Partnerships will be able to increase the number of non-executive directors and local elected members where there is joint local agreement to do so, but will need to retain an equal number of each.

Non-voting members

4.18. Voting members of the Committee will be supported on the Health and Social Care Partnership Committee by a number of non-voting members. These members will represent the professional and service user perspective on the pathway of care, and will include:

• The jointly accountable officer;
• Professional advisers. A minimum requirement would be an Associate Medical Director or the Clinical Director of the Partnership, and the Chief Social Work Officer. From the health perspective, it will be important to ensure that the interests of both the primary and secondary aspects of the integrated budget and care pathways are represented by the clinical adviser;
• Patient/service users' representation; and
• Third sector representation of the service user and carer experience of care

Performance Management, Performance Improvement and Scrutiny

4.19. A sliding scale of improvement and performance support will be put in place to assure the delivery of national outcomes by Health and Social Care Partnerships. Improvement support will be offered to all Health and Social Care Partnerships to ensure sharing of good practice, benchmarking, leadership and organisational development, development of commissioning skills and other priority areas. Where Health and Social Care Partnerships fail to deliver nationally agreed targets, performance support will be offered and, where critical, put in place to assure the delivery of targets.

4.20. We recognise that effective collaborative working with external scrutiny partners will be important, and will work with the Care Inspectorate and Healthcare Improvement Scotland to ensure an appropriately integrated approach to reviewing the quality of service and outcomes achieved.

Other Community Health Partnership functions

4.21. Community Health Partnerships currently have responsibility for services that sit outwith the scope of these proposals; for example, they are also responsible for the delivery of children's community health services. It is important that we consider the implications for governance arrangements of "other" services as well as for adult health and social care.

4.22. We anticipate that different partnerships of Health Boards and Local Authorities may prefer to handle governance of other Community Health Partnership functions in different ways. For example, partners in some places may wish to include the budget for other services along with the budget for adult health and social care, and to apply the Health and Social Care Partnership governance arrangements to the full range of current Community Health Partnership budgets and service delivery.

4.23. Partnerships may choose not to integrate the budgets for other services along with adult health and social care, in which case the governance for other services might be provided by another Committee arrangement. Other options, and permutations on these options, are also possible; at this stage, it is our proposal that decisions about managing other areas of what are currently Community Health Partnership functions should be left to local determination. Community Health Partnerships themselves will be taken off the statute book.

4.24. It is important to note that, whether or not other Community Health Partnership functions are managed within the Health and Social Care Partnership, our proposals for accountability to Ministers and Leaders apply only to adult health and social care services, and the nationally agreed outcomes relating to those. The delivery of 'other' national targets that fall within the integrated budget will be the responsibility of the Jointly Accountable Officer who will report direct to the NHS and Local Authority Chief Executives for these areas.

Community Planning

4.25. A review of Community Planning is underway as part of Ministers' response to the findings of the Christie Commission. It will be important to ensure effective interaction between and across the functions of Community Planning and the functions of Health and Social Care Partnerships, in order to ensure that local planning and delivery arrangements are robust, joined up and driving forward performance improvement. Governance and accountability arrangements for Community Planning will complement the current accountability relationship between Health Boards and Ministers, which will continue.

How will this approach be different from current arrangements?

4.26. The main differences between Community Health Partnerships arrangements and the new Health and Social Care Partnerships will be:

• Health and Social Care Partnerships will be the joint and equal responsibility of the NHS and local government. Community Health Partnerships are sub-Committees of Health Boards, albeit with strong requirements for Local Authority membership. The new Health and Social Care Partnership Committees will be Committees of Health Boards and Local Authorities.
• Financial authority for achieving outcomes, and the requirement to demonstrate value for money, will be delegated to Health and Social Care Partnerships by the Health Board and the Local Authority. Currently Community Health Partnerships have no delegated financial authority beyond managing Health Board community health budgets. Local Authorities are not required to delegate budgets to Community Health Partnerships.
• Decision making authority in relation to delivering outcomes will also rest with the new Health and Social Care Partnerships, without the need to refer decisions back "up the line" to Committees within the statutory partners.
• Health Boards and Local Authorities will be jointly held to account for performance.

4.27. There are currently 34 Community Health Partnerships. New legislation will streamline those arrangements significantly, with at most one Health and Social Care Partnership per local authority area (32). This will remove the need for partners to have Community Health Partnership Committees; partners may also find that other strategic forums or Committees are no longer required.

4.28. These proposals will also for the first time draw together performance management arrangements for teams working together across the NHS and local authorities.

What do we want to know from you?

Question 5: Will joint accountability to Ministers and Local Authority Leaders provide the right balance of local democratic accountability and accountability to central government, for health and social care services?

Question 6: Should there be scope to establish a Health and Social Care Partnership that covers more than one Local Authority?

Question 7: Are the proposed Committee arrangements appropriate to ensure governance of the Health and Social Care Partnership?

Question 8: Are the performance management arrangements described above sufficiently robust to provide public confidence that effective action will be taken if local services are failing to deliver appropriately?

Question 9: Should Health Boards and Local Authorities be free to choose whether to include the budgets for other CHP functions - apart from adult health and social care - within the scope of the Health and Social Care Partnership?