National Care Service consultation: discussion events summaries

10 September 2021

• Theme of discussion: community health and social care boards
• Time: 14:00-16:00
• Discussions leader(s): Angie Wood

Introduction

This is a summary of the key points raised by attendees at this session.  None of the points have been attributed to individuals as the purpose was to encourage broad and open discussion.  The summaries for all the national events will be provided to the independent contractor undertaking the consultation analysis.

Points raised at event

• Accountability for social care will shift to Scottish Ministers as well as remain with LA – where is ultimate accountability of new boards? If to Ministers does that not mean they Chair the appointment and authorise appointment of CE and be able to remove them?
• Will there be a statutory requirement to include people with dementia – and therefore requirement for procedures to be dementia friendly.
• Participation needs to ensure that people with lived experience are involved at the earliest stages. Voice of lived experience important but how do we provide coherence across these many voices?
• Relationship with accountability to local people through local authorities – how will this be achieved – response: through elections and making sure that people are involved in NCS at all levels continuously e.g. overhauling commissioning/ procurement to ensure services are not procured based on price
• Relationship with acute services – helpful aspiration of IJBs has been to have influence over acute care delivery – how will proposals affect this- response subject to consultation – aspects will come under the community health and care board
• Inhibitors for IJBs to work effectively are the levels of funding and control in hands of Chief Officers – would shift to this make governance more effective? How will new boards connect to existing structures e.g. housing, education, community planning – IJBs connected to a much broader system and keen to see these referenced.
• Keen to explore current arrangements and see what is possible to deliver within that rather than seek to resolve issues in new arrangements.
• With all members having voting rights how will representatives act effectively as advocates for their sector when having to take accountability for decisions
• Concern over top down approach – with IJBs trying to change from top down to localities – how do we ensure that in future we maintain a bottom up culture – what individual localities need rather than political direction.
• As well as people who have lived experience and carers, 3rd sector orgs should also be well represented given the huge role they play in service delivery in Scotland. Agree that community council members should also be involved in any new CHSC Board
• We could go further and faster with change within current structures if we invested in development of locality working. Integrated care is intensely relational.
• Issues with third sector reps having voting rights on procurement of services they deliver.  I was not questioning legitimacy of any TSI per se and understand your point on any conflict of interest, simply hoping that there would be the opportunity for other third sector orgs to be involved in a helpful way in the process
• Social Care primarily a community process although we talk about it in relationship to acute – sitting on NLC IJB as non-voting member – what is proposed is expanding to all representative to have a vote – concerned about accountability in this regard – none are accountable to the community – all are accountable to the Minister – in reality the power then lies with the officer and minister – real danger with diminishment of LA role and option to remove councillors – how does the proposed system improve local accountability?
• Loss of local democratic accountability has been raised and is important to consider. Great point on who holds the knowledge, and perhaps power. We can be experts on our own health and care needs and work in partnership with specialists when their particular skills are required.
• Some advantage in retaining the LA boundaries in terms of continuity/transition rather than moving to something on regional scale.
• CHSCBs could follow HB area e.g. all three Ayrshires share one HB. However, this is likely to multiply the issues with setting up CHSCBs. There are some LAs that straddle HB areas and are therefore required to work with more than one HB. Need to be mindful of geographical differences. Could three IJBs in Tayside area not be amalgamated, for example?
• There is very little mention of the CSWO role in the consultation document which is surprising given their specific statutory role in relation to social work and social care.

Membership of CHSCBs            

• Need to be careful about different roles at the moment. Some have votes and others don’t. Perhaps some members should feed-in in another way rather than sitting on the board and being accountable to themselves. Boards are currently cliquey and must be more transparent about how people get a seat at the table.
• Don’t want less of breadth of representation than we have at the moment. Need to know if CHSCBs will include some/all/how much of health and SC service. Need to consider extent to which elected members should be involved as they are democratically elected and represent community. People with lived experience should be included in an open/transparent manner as membership can be cliquey.
• Will the third sector have membership on the boards? But how do we decide who should be represented?
• There needs to be those who understand what rights-based approaches and meaningful participation actually look like or involvement of those with lived experience can end up being inaccessible and tokenistic.
• Non-voting members currently feel like they are a token gesture i.e. it looks good but they have no influence on final decisions.
• Need to consider accountability and where it sits in governance structure.
• We can learn how not to do it by looking at IJBs – look at what hasn’t worked and try not to replicate it.
• Conversely, find out where there are examples of good practice and share.
• Opening up the voting will counteract the current party political / NHS block voting.
• Whilst I'm sure some social workers are closest to most vulnerable, I would argue that vol sector orgs are also pillars of our communities who know people very well as part of our relationships and service delivery
• Too big is dysfunctional but a forum feeding in isn't good enough because lived experience is locked out of decision making
• Our current Self-directed Support legislation ensures the supported person, through a good conversation with a Social Worker, has a voice (without being on a Board) and choses how they want their support to be organised in order to have a life that matters to them. Choice and control.
• Risk of equal votes is that needs of the majority are addressed, but the needs of the complex don't get the attention, support and service needed. It’s the professionals and support organisations with the knowledge who would be voted down.
• How will CHSCB link to Community Planning Partnerships and align with Community Empowerment (Scotland) Act?
• Under current proposals reformed boards will be funded direct from Scottish Government
• People who have accountability need to evidence that they have taken views on board but ultimately have authority to make decisions – not sure that there has been a proper review of what is currently not working in present system
• In favour of changing voices – reminded that we are voting as board members regardless of representation – does not happen – broadening of the base will minimise the NHS/LA dominance
• Currently budget is a major concern when anyone with a learning disability needs a service - due to the lack of funds the council has adopted a stance of only addressing critical need - how would this change address the lack of funds and allow a service to meet the assessed needs of every individual

Employment

• Focus on bureaucracy and not front line services during set up and additional cost of infrastructure to act as employers – HR/Finance teams
• No clear benefits of moving employers - It is not clear what the benefit of moving all those staff to a new employer would be and there would be protracted process to transfer staff and harmonise terms and conditions. The energy, time and cost of that process could be better spent on delivering services
• I think the T's and C's mismatch between NHS and Council employed staff is an big issue to be addressed in some way, whether via direct employment by the new boards or via another mechanism.
• Focus should be on delivering outcomes not on employment conditions and structures
• Current system is where people report to 2 masters – if we want efficient well run service need to have people responsible running the service, owning the developing the people – different working conditions across NHS and council – gets in the way of true integration – need to have them working in the same organisation and the Director have this in his accountability.
• ​Getting everyone onto same terms and conditions will likely take longer than 5 years or an awful lot of money!
• The people running the services are in a thousand employers in the private, third and public sectors. What is being discussed here is the commissioning and procurement staff moving from NHS and Council to a third body, each losing the connection and knowledge of their current teams and networks. 
• There has to be a better way of doing it but one option is if they had one employer - but this would mean we do not need a third organisation (i.e. CHSCBs).
• One (existing) group/body should employ everybody.
• Cannot pretend CHSCBs are delivery arms unless they employ the staff.
• How does SG see it working with three CEXs all with vested interests; some holding staff; others finance etc? Need more detail on how SG thinks it will work to enable us to share opinion.
• We need to make sure we don't add another layer .

General comments

• Recognise need for reform but loss of focus on  the person – CI has been looking at integration and difference across Scotland – need for reform and funding – need to focus on what problem we are needing to fix –bringing the cost, money and effort, time and energy into a single model carries risk -  needs to be put into existing structures is the loss of social care in the midst of health needs – bringing social care into health needs thinking through and are we keeping the people at the centre and focusing on the best use of time and energy – feels huge in terms of scope and structural change – will not necessarily result in improvement in integration
• Know that social care costs money, fundamental question is that there is money that leaves the system in the form of profit and often goes abroad – if we are short of money why do we allow this –not been addressed in the review or features in the proposals – advised that good to raise in commissioning and procurement section.
• No uplift in healthcare provision for having 3 prisons in the IJB area – by making HSCBs provide that – will increase our costs significantly – where is resource coming for this – clear in England and Wales – how much will this cost Scotland wide.
• if only all that enormous effort could be put into fixing the glitches in the current arrangements, using the experience we have., and best current practice.
• Mental Health services – important not to get caught up in bureaucracy of this – in social care people get classified into brackets due to lack of funding and resource – don’t want to see money getting misspent in new structures and management – currently people having to get admitted to care homes because there are no carers – don’t waste money when it can be better spent
• My reading of Feeley was that he reckoned there should be one model rather than a variety. No clear evidence to justify this position
• It is imperative that we have a unified workforce. Only then can we have a slimmed down efficient management structure by eliminating duplication of management positions. This and empowering our workforce will mean that more funding will become available for services
• Concerned that loss of focus on person as referenced in Christie by focusing on structure and governance – Community Planning focus ensures bottom up and not top down. One of Christie's principles was local integration and joint working not centralising control and accountability to central government. That has been lost.
• We need to ensure we're protecting the social model approach, and not moving back to a medical model.
• Were there to be additional investment locally in HB or LA services what would that look like in comparison to the NCS?
• How can we be assured of cooperation between NHS and NCS and what is the likelihood of getting that consensus across Scotland?
• How can we really support the people whose lives are most affected by these decisions?
• Provider workforce engagement: SG might not hear their voices as strongly due to the crisis we are currently in. Providers are on their knees in terms of staffing. Recruitment was an issue pre-pandemic and now worse. Pay, terms and conditions in Social Care means we are haemorrhaging staff.
• Much longer is needed to give responses beyond knee-jerk reactions to headlines (especially as lots of ifs/maybes; more information needed to respond properly).
• Disappointed that none of Children’s or Justice sector involved in what is now part of proposals. How do we ensure lived experience across the whole system is properly involved?
• There will be a huge ‘unpicking exercise’ to establish new boardsLots of things in the consultation are very good but the reality is that there is a limited financial envelope and not confident that the money is there to deliver on these within the timescale. There is the added issue of where the money comes from and what other areas might be hit e.g. housing (that relates to health outcomes).
• I'd like to understand how it is imagined that local authorities would continue to deliver services that they have no control over the budget for and no statutory responsibility for?
• Size something to consider – what we have seen is that smaller IJBs have better chances with agility, but multiple IJBs to one NHS Board can work against integration. 
• Alignment with local authorities will be really important – but that could still be achieved with alignment to NHS Boards and then localities at a LA level.
• We need partnership working without doubt – why do we keep acute services on the outside of these services? (Assumption being made that the acute services will remain with the NHS)
• Consider going back to regional boards that combine health and local authorities and consider patients who require cross boundary care e.g. residential but GP in other authority area
• Things definitely need to change but fear is that the new structure won't solve the current core issue of poor joint working between LAs and heath boards.
• One of our challenges will be to strike a balance between national direction and local accountability, democracy and priorities.
• The continued relationship with the NHS Board will be very important
• Some NHS boards are so far away from social work colleagues, for example Argyll and Bute come under Highland Health board but it is hundreds of miles away.
• For children and young people with disabilities there is a need also to consider education services being linked to health and care – statement of fear that SG will remove Educational Services from LAs next?
• Totally agree with the need for smaller areas and more local community decision making and governance – how do we achieve this if the CHSCBs are over larger areas?
• Need to look at community councils – closer to people in their areas
• Ideal size of a CHSCB Board would not be beyond 30 people.
• There must be opportunities for front line staff to share their experiences and not have it go through various layer to ‘sanitise’ the view
• How do we create a structure around the board so that they can contribute to the board and decision making - constrained to only having good conversations?
• Diversity on the Board will be very important and vested interested should be left at the door.
• Those people on the board who are not employed should receive remuneration – as they do for the NHS and other Boards
• The Chair post should be open to anyone on the Board, they should be paid – what same terms and conditions of NHS
• It is too simple to get distracted by structure, the money used for setting up a big agency and changing local services would be better in supporting the existing structure to overcome obstacles.
• Most people do not know that the IJBs exist – most people don’t know what NHS Boards are directed by IJBs for planning and delivery of non-acute services.
• Establishment of local third sector and independent sector provider representation groups to encourage collaboration within sector rep should sit on each community board. The sector can contribute solutions to the challenges we face
• Would prefer if the consultation could move away from the language of 'voting rights' - all should be equal partners with an equal voice - with the aim to reach a consensus - rather than needing to vote on issues
• Great point on who holds the knowledge, and perhaps power. We can be experts on our own health and care needs and work in partnership with specialists when their particular skills are required
• Front line staff and service users need to be part of the new Boards.
• Our current Self-directed Support legislation ensures the supported person, through a good conversation with a Social Worker, has a voice (without being on a Board) and choses how they want their support to be organised in order to have a life that matters to them. Choice and control.
• Risk of equal votes is that needs of the majority are addressed, but the needs of the complex don't get the attention, support and service needed. It’s the professionals and support organisations with the knowledge who would be voted down
• Good carer recruitment will rely on speedy solutions on fair work agenda - recruitment now moved from a problem to crisis - valuing and paying the workforce is at the heart
• I think the T's and C's mismatch between NHS and Council employed staff is an big issue to be addressed in some way, whether via direct employment by the new boards or via another mechanism. If we are going to get health and LAs working properly together, then the key staff need to be in the pay of the local Boards and not one or other services ....otherwise those conflicts of interest will always trip up progress
• A lot of back office functions are sole reliant on the body corporate of the NHS board or local authority and HSCPs are they currently stand are not funded for this nor do they necessarily have the skilled staff to support these functions - could these more specialist and essential support structures come directly to all new boards via the NCS. This could also apply to planning functions etc. which are then drawn down into local areas but with very much a national vision.