NHS public protection accountability and assurance framework

Introduction

Public protection is the prevention of harm to children (including unborn babies), and adults. In Scotland, the rights and responsibilities in the United Nations Convention on the Rights of the Child ('UNCRC') should underpin the provision of all services. In addition, public authorities have a legal duty under the Human Rights Act 1998 to act compatibly with the rights enshrined in the European Convention on Human Rights ('ECHR').

Public protection requires effective joint working between statutory and non-statutory agencies, as well as with staff with different roles and expertise. To achieve effective joint working, there must be constructive relationships at all levels, with a strong executive lead at Health Board level in respect of its statutory duties, and shared Health Board member accountability. These arrangements should also facilitate clear oversight of the Board's corporate parenting duties and responsibilities as set out in the Children and Young People (Scotland) Act 2014. Moreover, where requested by a local authority, the Board must provide mutual assistance with the exercise of that authority's functions under the Children's Hearings (Scotland) Act 2011. As an employer and contractor of services, Health Boards are required to support staff to uphold professional standards and guidance outlined by their governing bodies.

Under Section 5 of the Adult Support and Protection (Scotland) Act 2007, Health Boards, along with other named public bodies, must, so far as consistent with the proper exercise of their functions, co-operate with the relevant council and each other where they know or believe a person is an adult at risk (in the meaning of that Act).

Health Boards are also Responsible Authorities for the purposes of Multi-Agency Public Protection Arrangements (MAPPA) in Scotland. The Management of Offenders etc. (Scotland) Act 2005 places a statutory duty on Responsible Authorities to jointly establish arrangements for assessing and managing the risks posed by registered sex offenders, restricted patients and other "risk of serious harm" individuals. Health Boards are Responsible Authorities in relation to the management and care of restricted patients.

In addition, Health Boards have a duty to cooperate with other agencies about all individuals who are subject to MAPPA. This statutory duty to cooperate includes the provision and sharing of information relevant to the assessment and management of the risks posed by these individuals. All Health Boards should have robust reporting and escalation mechanisms in place to identify and report on MAPPA activity.

While inspections, Significant Case Reviews, and Learning Reviews have highlighted strong and effective health partnership working in some areas, they have also identified unwarranted variation and inconsistencies in public protection roles and accountability arrangements across the country. Issues identified include:

• A lack of clarity of role in multi-agency planning processes resulting in insufficient join-up and health involvement in risk assessment processes, including lack of representation at key meetings arising from child or adult protection activity.
• Lack of resources and capacity to meet the demands of attending a number of critical protection meetings.
• Communication and information sharing within and between services, including at points of transition between healthcare services and settings, and in transition between other services.
• Cultural issues which impact on shared ownership of case responsibility and in establishing the lead agency.
• The importance of a coordinated approach to the work of the National Child Death Review Hub and local Child Protection Committee requirements to conduct reviews whilst avoiding duplicity of effort in parallel processes.
• A lack of co-ordination and oversight across the range of staff working in different clinical settings, including inconsistent multi-disciplinary approach to protection of adults and children that promotes all individuals feeling their contributions are valued.
• In a few but important number of cases, a lack of health involvement in assessments, including a lack of medical examinations in a small, but again, important number of child protection cases.
• A lack of clarity about the role of capacity in adult protection activity, and inconsistent understanding of the interface between child and adult protection, Adults with Incapacity legislation, the Mental Health (Care and Treatment) (Scotland) Act, and the revised child protection guidance (up to the age of 18).
• A need to consider whether there are any indicators of abuse or assault, including trafficking, as part of pre-birth assessment and planning.
• Inconsistency in the level of Health Board engagement with MAPPA in relation to individuals who are not restricted patients.
• Variation in the level of seniority of the Health Board liaison role and the contribution they make to MAPPA meetings about specific individuals. This can be limited to factual information about the individual's access to health services rather than information supporting multi-agency management of risk and the sharing of expertise in risk management.
• Variation in appropriate and consistent Health Board representation on MAPPA Strategic Oversight Groups (which is the overarching governance forum in each of the 10 MAPPA regions in Scotland). As a result, representatives do not always have the authority to take decisions.

In addition, variations have been highlighted in Health Board designated roles, functions, resourcing, and governance arrangements for public protection. This has led to inconsistencies in lines of accountability, shared understanding of governance, and support for public protection services. Key designated health roles for child protection (including unborn babies) in Scotland are non-statutory, unlike comparative roles in other parts of the UK. This places an even greater responsibility on all agencies to have in place robust and rigorous processes to support staff in carrying out their professional roles.

Furthermore, the establishment of Integration Joint Boards (IJBs) and delegation of functions and budgets has led to more integrated arrangements in adult services (and children's services for those IJBs with strategic planning, commissioning, and oversight of children's services responsibilities), which has impacted on a number of aspects of accountability and assurance arrangements across Scotland. This is apparent at a strategic level, in terms of the role of Chief Officers and members of the Health Board and the Integration Joint Board. It is also the case in relation to operational responsibility, with variation in the responsibilities and reporting lines for Child Health Commissioners, Child Protection Advisors, public protection leads, and lead officers in paediatric and community teams.

While the responsibilities of Chief Officers are set out in national guidance, given the range of factors that impact on public protection responsibilities and the breadth of legislative, policy and practice changes in recent years, there is a strong case for a restatement of critical accountabilities within Health Boards and Integration Joint Boards.