National Care Service: consultation analysis

6. Reformed Integration Joint Boards: Community Health and Social Care Boards

Chapter overview

This section of the report considers the proposals for reforming current Integration Joint Boards (IJBs) into Community Health and Social Care Boards (CHSCBs) which would act as the local delivery bodies for the NCS, funded directly by the Scottish Government.

Governance model

Around three quarters of the 435 respondents to this question agreed that Community Health and Social Care Boards (CHSCB) should be the sole model for local delivery of community health and social care in Scotland, with individuals (212 of 277 respondents to this question (77%)) and organisations (115 of 158 respondents to this question (73%)) broadly similar in terms of levels of agreement.

Benefits mentioned included greater standardisation across Scotland, as well as helping to improve equality of access to services, although some were concerned about the potential lack of local decision making and that a "one size fits all" approach would not work. The majority of respondents also agreed that CHSCBs should also be aligned to Local Authority boundaries.

Membership of Community Health and Social Care Boards

A range of roles were suggested as potential members of the Boards, including people with lived experience and frontline workers. There was a view that their involvement should be meaningful and that they should not be included in a tokenistic way. In line with this, there was a strong majority in support of the proposal that all Board members should have voting rights (358 of 405 responses overall and 90% of individuals and 86% of organisations that answered this question).

Community Health and Social Care Boards as employers

A large proportion (283 of 362 respondents (78%)) agreed that the Boards should employ Chief Officers and their strategic planning staff directly. Other comments in relation to this question referenced the need to avoid unnecessary bureaucracy and for strong leadership.

Introduction

This section of the report considers responses in relation to reforming Integration Joint Boards (IJB). It sets out the level of agreement with the proposals for reforming current Integration Joint Boards (IJBs) into Community Health and Social Care Boards (CHSCBs) which would act as the local delivery bodies for the NCS, funded directly by the Scottish Government. This would be the sole model for local delivery of community health and social care in Scotland to ensure the ambition for consistent, quality delivery across services.

Governance model

There were 435 responses to the question on whether "one model of integration" should be used throughout Scotland and the majority of individuals (212 out of the 277 respondents

(77%)) and organisations (115 out of the 158 respondents (73%)) agreed that Community Health and Social Care Boards (CHSCBs) should be the sole model for local delivery of Community Health and Social Care in Scotland (Q58a).

Q58. "One model of integration... should be used throughout the country." (Independent Review of Adult Social Care, p43). Do you agree that the Community Health and Social Care Boards should be the sole model for local delivery of community health and social care in Scotland?

	Individuals	Organisations
Yes	212 (77%)	115 (73%)
No	65 (24%)	43 (27%)
Total	277 (100%)	158 (100%)

For individuals, there was a difference in response between the social workers and frontline care workers who responded to the consultation : with the latter more in favour of the proposal (76 out of the 87 frontline care workers (87%) that responded to this question compared to 44 out of the 64 social workers (69%)). People accessing care and support who responded to this question were also more likely to be positive (with 37 of the 45 (82%)). Private and third sector providers were also in favour with 56 out of the 68 providers who responded to this question in favour.

There were 314 free text responses provided to this question. Those who agreed with the proposals tended to reference:

• The current fragmentation created by the use of different IJB models
• Standardisation would help equality of access to care services across Scotland
• Greater integration will result in better communication

Some comments also referenced the need for simplicity and efficiency, reducing the perceived complexity in the current system, and the perception that integration had not really been achieved.

"It makes sense to have a consistent approach across the country which is helpful as people often move around between different geographical areas." (Self Directed Support Scotland)

"There is a lack of connection between health boards, councils, social care and public health. No joined up thinking." (Unpaid carer)

There were also some comments about the need to respect the context of remote and rural areas, including the Islands.

Those that disagreed suggested:

• Local areas should be able to set their own priorities
• There should not be a "one size fits all" approach
• There were some concerns that integration has not worked in all circumstances

"Better integration of care offers the potential for improved outcomes for people receiving care and support and more effective use of resources but the importance of the community-based aspects of care need to be recognised." (The Homecare Association)

" Whilst we can see the benefits of a consistent approach to integration across the country, there will undoubtedly be examples of various local configurations that are very different but equally effective for their local communities. Strategic planning, service design and delivery, that effectively meets the needs of communities, requires to be done as close to those communities as possible and, just as importantly, in conjunction with those communities. This has remained an aspiration for all Integration Joint Boards and should continue to be the case with Community Health and Social Care Boards. Continuing to align these Boards with local authority boundaries keeps the proximity of decision-making appropriately local and manageable." (Orkney Island Council)

Q59. Do you agree that the Community Health and Social Care Boards should be aligned with local authority boundaries unless agreed otherwise at local level?

	Individuals	Organisations
Yes	216 (78%)	141 (88%)
No	62 (22%)	20 (12%)
Total	278 (100%)	161 (100%)

There were 440 responses to Q59 with regards to Local Authority alignment with the majority of individuals (216 out of 278 respondents (78%)) and organisations (141 out of 161 respondents (88%)) agreeing that Community Health and Social Care Boards should be aligned with local authority boundaries.

Of the respondents who used the Easy Read format, 23 out of the 38 (61%) agreed that the Community Health and Social Care Boards should cover the same areas as councils (Q14).

Q60. What (if any) alternative alignments could improve things for service users?

There were 250 responses to the question on what, if any, alternative alignments could improve things for people accessing care and support (Q60). Some suggested the alignment should be with health boards and some suggested that there should be flexibility in approach depending on the area. Some degree of alignment with education and housing were also referenced by a small number of respondents.

In this context, some also noted: the need for a national approach; a review of public administration in general in Scotland; and the need to include people accessing care and support in any decision-making. Some suggested, as can be seen below, that there may need to be different arrangements to meet the needs of people accessing care and support (perhaps with complex needs) in rural and remote areas. Specific comments in relation to Q60 on alternative alignments included:

"The Health and Social Care should [be] one for the whole of Scotland not separated out into regions as at present. The present system creates an unfair system with different authorities supplying different services." (Unpaid carer)

"Whilst the overall alignment should be within local authority boundaries, it will be appropriate to allow further breakdowns within that arrangement for local authorities having a large geographic area, e.g. the Highlands, Argyll and Perthshire, or with local authorities having small populations and being grouped with others, e.g. Stirling and Clackmannanshire, East Renfrewshire and Glasgow." (Person accessing care and support)

"There was overwhelming support in the SASW survey (84%) in question 58 for the CHSCBs to be aligned to local authority areas. Questions were raised about whether the 32 local authority areas should remain or if they need to be reduced. Reductions in numbers of local areas might bring reduced inconsistencies and improvements in implementation. There was some thought that the CHSCBs could be aligned to the 14 health board areas giving hospital-based services and community-based services in each health board area which could be renamed to reflect the inclusion of social care. Irrespective of what is agreed, it is important that people who need support get the best support/service possible to meet their needs with decision making as close to them as possible and the staff who work in the organisation(s) providing support are recognised, valued and appropriately rewarded for the work they do." (Scottish Association of Social Work)

Q61 Would the change to Community Health and Social Care Boards have any impact on the work of Adult Protection Committees?

When respondents were asked whether the change to Community Health and Social Care Boards would have any impact on the work of Adult Protection Committees (Q61), there were 209 responses to this question. There were mixed views and a degree of uncertainty over whether there would be any impact on the Committees. Some suggested that Adult Protection Committees should be independent, others suggested that more integration is required. Some suggested that child protection should also be considered. There were also several comments to the effect that more information is required to allow respondents to contribute in more detail.

"There is no explicit mention of [the Chief Officers Groups] within the consultation or their relationship with Community Health and Social Care Boards. As the Boards will potentially have responsibilities for activities beyond Adult Services it may be helpful to consider overall impact upon Public Protection. Current arrangements work well and ensure clear focus on local protection activity. Additional clarity would be required regarding the role of COG and relationship with Community Health and Social Care Boards before being able to comment further." (West Lothian Council)

"Adult Protection Committee (APC) are now reasonably well established and a current round of inspection activity is currently underway across Scotland to provide a level of assurance to the Scottish Government relating to key operational activity and strategic leadership… Where concerns may arise is where any separation of social work functions may take place as this would introduce risk to the coherence of the overall public protection agenda. The potential impact on APC will relate to the scope of responsibility given to CHSCB and how relationships develop beyond the current arrangements. There are strong links across adult services and children and families services through the Inverclyde Chief Officers group currently. These can and should be retained." (Inverclyde Council Health & Social Care Partnership)

Membership of Community Health and Social Care Boards

Q62 The Community Health and Social Care Boards will have members that will represent the local population, including people with lived and living experience and carers, and will include professional group representatives as well as local elected members. Who else should be represented on the Community Health and Social Care Boards?

Q62 in the consultation addressed the membership of the planned Community Health and Social Care Boards. It stated that the Community Health and Social Care Boards will have members that will represent the local population, including people with lived and living experience of accessing health and social care and carers, and will include professional group representatives as well as local elected members. It then asked whether there is anyone else who should be represented on the Community Health and Social Care Boards. There were 319 responses to this question which included the following suggestions:

• People with lived experience
• Frontline workers
• Funders
• GPs
• Community nurses
• Teachers
• Policing
• The third sector

There were also comments around the balance of representation, ensuring that the inclusion of people with lived experience was not a token gesture, and creating a balance between including disparate voices and keeping decision-making focused on a pragmatic number of people so that the board size was reasonable.

"Equality and diversity of representation will be essential in any proposed Board." (NHS Tayside Nursing, Midwifery and Allied Health Professions Response)

In relation to representation on the Boards (Q15), respondents to the Easy Read consultation suggested:

• People accessing care and support (people with lived experience)
• Frontline staff and key workers
• Relatives of people in care homes
• Other practitioners

It was noted by a few respondents to the Easy Read questionnaire that there needs to be a "shift in power" from the previous system and that these groups of people should be supported to help their participation.

Q63. "Every member of the Integration Joint Board should have a vote" (Independent Review of Adult Social Care, p52). Should all Community Health and Social Care Boards members have voting rights?

	Individuals	Organisations
Yes	227 (90%)	131 (86%)
No	26 (10%)	21 (14%)
Total	253 (100%)	152 (100%)

There were 405 responses to Q63 with regards to voting rights. The vast majority of individuals (227 out of 253 respondents (90%)) and organisations (131 out of 152 respondents (86%)) agreed that all Community Health and Social Care Board members should have voting rights.

Q64 Are there other changes that should be made to the membership of Community Health and Social Care Boards to improve the experience of service users?

Respondents were asked whether there were other changes that should be made to the membership of Community Health and Social Care Boards to improve the experience of people accessing care and support (Q64). There were 260 responses to this question. Common themes included:

• The need for the Boards to be people-focused
• The need for users to have support to represent themselves, perhaps through an advocate
• The need to ensure that Boards are accessible and inclusive, including consideration to timing and location of meetings and provision of accessible papers and materials
• The inclusion of frontline staff
• The need for transparency and accountability e.g. through the regular publication of board minutes
• A focus on co-design

"The commitment to engaging people who access support and families must be real. The Boards should demonstrate a commitment to co-production and ensure that their involvement does not become tokenistic." (Community Integrated Care)

Community Health and Social Care Boards as employers

Currently, the Integration Joint Boards' chief officers, and the staff who plan and commission services, are employed either by the local authority or Health Board. The Independent Review of Adult Social Care proposed that these staff should be employed by the Community Health and Social Care Boards, and that the Chief Executive should report directly to the Chief Executive of the National Care Service. This section of the report considers responses in relation to the Community Health and Social Care Boards as employers.

Q65. Should Community Health and Social Care Boards employ Chief Officers and their strategic planning staff directly?

	Individuals	Organisations
Yes	189 (78%)	94 (78%)
No	52 (22%)	26 (22%)
Total	241 (100%)	120 (100%)

The majority of individual respondents (189 out of 241 respondents (78%)) to this question agreed that the CHSCBs should employ Chief Officers and strategic planning staff directly. A similar proportion of organisations were also in favour of this.

There were 232 responses to the question on whether there are any other staff the Community Health and Social Care Boards should employ directly (Q66). Respondents provided comments and suggestions on:

• Technology and IT staff to support the digital infrastructure
• Administrative staff
• Social work and social care staff
• Representation from each relevant professional body
• Representation from nurses and carers

"Lead nurse, lead social worker, lead medical officer. To ensure professional standards including the need for staff governance are met." (A friend or family member of mine receives, or has received, social care or support)

Other comments in response to this question tended to relate to:

• The need to avoid additional bureaucracy and layers of management
• The need for visible and strong leadership
• Consistent terms and conditions, given the disparity between terms and conditions between those employed by the NHS and those employed by Local Authorities.
• The need for clarity on the role of local authorities before this could be finalised
• The need for more detail on the proposals in general

"There must be careful consideration of issues of local decision-making, accountability and proportionately. Any case for change must be linked to a demonstrable public interest justification and must deliver improvements for the end users of social care services." (Law Society of Scotland)

"Someone needs to be accountable and responsible for delivering the local strategy and achieving the mission of the local CHSC Board. They must have the authority and must have the resources to go and make it happen, BUT again within an appropriate national redesign and commissioning framework." (Blue Triangle)

There were several comments to the effect that further details would be required before a full discussion of the issues took place.

"For both Questions 65 and 66 there are fundamental issues which first need to be worked through… If a CHSCB was to be an employer, what terms & conditions of employment would it use? Would existing staff be transferred from the NHS Board and the local authority? Has any analysis been made of the impact of this proposal on the NHS Board and the local authority and their capability to carry out their functions? …There needs to be clarity on the implications of the proposals in the consultation on what functions and services local authorities and NHS Boards will be responsible for… By focusing on just senior management and strategic planning roles, this appears to be limiting the scope of what CHSCBs will do." (NHS Lothian)

"We have not ticked yes or no to this question as the issue is complex and requires careful consideration of detail which is not presented in the consultation paper." (UNISON - South Ayrshire Local Government Branch)