Integration of Adult Health and Social Care in Scotland Consultation: Scottish Government Response

Governance and joint accountability

37. We asked for your views on arrangements for governance and joint accountability of Health and Social Care Partnerships.

What we heard

38. There was general support for the principle of joint and equal accountability, although we heard from many people that competing organisational and political priorities could create obstacles to improved delivery. Many people noted that effective dispute resolution mechanisms would be important, as would improvement support arrangements.

39. A number of responses highlighted the need for co-ordinated external scrutiny of the new arrangements to ensure that they deliver the expected improvement in outcomes, and to provide transparency in terms of the way outcomes are reported and compared.

40. Some respondents noted that the proposed committee arrangements for Health and Social Care Partnerships were dominated by the statutory partners, and did not provide for sufficient involvement from the third and independent sectors, or from carer, user and public representative groups. In particular, some respondents felt that the proposed committee arrangements should allow for voting by non-statutory members.

41. Some respondents asked for greater flexibility in terms of the number of committee members that could be appointed. This was particularly the case where respondents were providing views from larger Local Authorities.

42. Some respondents noted that it should be possible for more than one Local Authority to be part of a single Health and Social Care Partnership with a Health Board.

43. Many respondents noted that accountability for the effectiveness of the Health and Social Care Partnership should be to the full Council and Health Board, not to the Council Leader, Health Board Chair and Ministers.

44. We were asked whether, when the delegation to a body corporate model of financial integration is used, the new Health and Social Care Partnerships would in fact be 'third bodies' in addition to Health Boards and Local Authorities, to what extent they would operate autonomously from their parent bodies, and whether they would be employers of staff.

45. We were asked whether, when the delegation to a body corporate model of financial integration is used, the Scottish Government would distribute funding directly to Health and Social Care Partnerships, or whether it would flow via the Health Board and Local Authority.

46. We were not asked many questions about the delegation between partners model. We have, however, provided some further information here on this approach.

47. We were also asked about the relationship between Health and Social Care Partnerships and Community Planning Partnerships. Would one hold sway over the over?

The Scottish Government Response

48. In some areas, competing organisational and political priorities currently have a negative impact on effective delivery of services, and outcomes for people. Representatives of the third sector, users and carers, in particular, highlighted examples of this over the course of the consultation, and Audit Scotland note such tensions in a number of reports^[4]. Statutory partners are also aware of the difficulties that exist within current configurations of service provision, and report experience of struggling to overcome them.

49. We recognise the very valuable role that is played by the third and independent sectors in providing good quality support to people, working in partnership with other partners. We believe that, by legislating to place Health Boards and Local Authorities under a duty to work together effectively and in collaboration with key stakeholders, such as the third, independent and housing sectors, to deliver nationally agreed outcomes, we can establish a public sector environment where there is the correct expectation that public bodies will overcome such difficulties in order to deliver better outcomes for individuals.

50. We agree that it will be important to ensure effective improvement support and dispute resolution mechanisms are in place. It is our intention to build these on the good groundwork that already exists, and on the role of Local Authorities, Health Boards, and Scottish Government itself, to ensure that difficulties are addressed and local leaders work together to resolve challenges.

51. An essential part of this process will be the role of external scrutiny. We are committed to working with statutory partners to ensure that co-ordinated scrutiny arrangements are in place to assure effective delivery of services, and to identify areas where improvements to outcomes should be made.

52. Effective, appropriate, joint governance of Health and Social Care Partnerships will be of key importance regardless of which model of integration is used. Work is ongoing with partners and stakeholders regarding the detail of how committee arrangements should work in each of the two models of integration described in the consultation, in order to ensure an appropriate balance of consistency and local flexibility. We are clear on a number of points at this stage, and these are described in greater detail below.

53. In terms of voting rights on the Health and Social Care Partnership Committee, we remain mindful of the significant statutory and budgetary responsibilities of the Local Authority and Health Board. It is also of particular importance that Health Boards and Local Authorities together devolve planning and decision-making for adult health and social care into the integrated Health and Social Care Partnerships. We believe that decision- making will only be effectively delegated to Health and Social Care Partnerships if Local Authorities and Health Boards remain confident that all voting Committee members are publicly accountable for their decisions.

54. Having said that, we do not want to confuse accountability with influence, or, indeed, insight and innovation. We recognise that current, effective integrated arrangements tend to see very few votes actually taken 'in committee'. In general, where there is strong local leadership and commitment to effective involvement of individuals and communities working across health and social care, agreement is reached via discussion and consensus, rather than by putting individual matters to a vote. We recognise that good discussion, and effective, positive consensus, will only be achieved where it is informed by the local expertise of professional, carer, user and public representatives.

55. It is therefore our intention to legislate for committee arrangements that confer voting rights on statutory members of the Health and Social Care Partnership Committee, and to strengthen these arrangements by legislating to require additional membership of the committee covering professional, carer, user and public interests.

56. Locality planning arrangements are also important in this context, and are covered later in this response.

57. In terms of numbers of committee members, we recognise the concerns of larger Local Authorities in particular about assuring appropriate breadth of membership, not least considering the sizeable proportion of their resources that are committed to the delivery of adult social care. We are also aware, however, that evidence^[5] suggests that the size of committees is an important consideration in terms of ensuring their effectiveness. We intend to legislate for the principle that Local Authorities and Health Boards will have parity of voting power on Health and Social Care Partnership Committees. Further work is underway with COSLA, Local Authorities and Health Boards to consider how we can best ensure that Health and Social Care Partnership Committees are organised to optimise their effectiveness and efficiency, particularly in terms of numbers of members.

58. In terms of more than one Local Authority forming a Health and Social Care Partnership with a Health Board, we note again that the purpose of these reforms is not to undo effective arrangements agreed locally, or already in place. It is our intention to legislate on the basis that a Health and Social Care Partnership will be formed between one Local Authority and one Health Board, but to make provision for Ministers to consider applications for more than one Local Authority to form a single Health and Social Care Partnership with the same Health Board.

59. We agree that accountability for the effectiveness of Health and Social Care Partnerships should be to the full Council and Health Board, and not to the Council Leader, Health Board Chair and Ministers, as stated in the consultation. Legislation will reflect this position.

60. Where a Health Board and Local Authority agree to use the delegation to a body corporate model of financial integration, the new Health and Social Care Partnerships will be new bodies in law. In these circumstances, the Partnership will be a joint Board of the Local Authority and NHS Board and will not be operating separately from the governance or influence of the two parent bodies. The parent bodies will also exercise influence over the Health and Social Care Partnership through a Partnership Agreement and joint strategic commissioning plan, which will set out the Partnership's plans to deliver the agreed services using the integrated budget.

61. Where a Health Board and Local Authority agree to put in place a delegation between partners arrangement, there will also be a Partnership Agreement and joint strategic commissioning plan. No new body is created in this situation however.

62. Where the delegation to a body corporate model is used, the body corporate will not employ staff in its own right. Staff will be employed by the parent bodies - the Health Board and Local Authority.

63. Where a delegation between partners arrangement is used, staff may transfer employment between the Health Board and Local Authority. Transfer of employment is not prescribed in this arrangement, though it may be decided locally that transfer of some staff may help to facilitate a truly integrated model of service planning and delivery.

64. Where the delegation to a body corporate model is used, funding will not be distributed to the Partnerships directly from the Scottish Government. It will flow via the Health Board and Local Authority, as per the terms of the Partnership Agreement.

65. Where a delegation between partners arrangement is used, funding is delegated from one partner organisation to the other to support delivery of delegated functions.

66. Whichever model of integration is used (delegation to a body corporate or delegation between partners), the Partnership Agreement will define the functions that the Health and Social Care Partnership will deliver, the outcomes to be achieved and the financial input of each parent body to the integrated budget to deliver those outcomes. It will also set out the mechanisms that will apply locally to enable effective day-to-day working of the integrated budget, and local arrangements to assure accountability to the full Council and Health Board.

67. Guidance on establishing the Partnership Agreement will be provided. Work is already underway to introduce joint strategic commissioning plans in local partnerships, based on a single, integrated budget, building on the work of the Change Fund for Older People.

68. It is important to remember that the purpose of establishing these new arrangements is to deliver better, different outcomes. The imperative for change and improvement, and a shift in the balance of care, applies equally to both models of integration.

69. The relationship between Community Planning Partnerships and Health and Social Care Partnerships will not be hierarchical. Community Planning Partnerships provide a mechanism via which the different partners in public service delivery in a community come together to plan effective co-ordinated provision. Health and Social Care Partnerships, whose function will be to plan for and deliver, as a minimum, adult health and social care services, will be partners in the process of community planning. These different responsibilities must be acted upon so that they are complementary to one another in order for the improvements sought to be achieved.