NHS Scotland Executive Group: terms of reference

This proposal sets out a new approach to the system leadership of NHS Scotland. It advocates a shift away from existing engagement structures and a move to provide collective leadership, strategic decision making, prioritisation and assurance of delivery through performance and accountability. It will be a collaborative and purposeful construct that supports the implementation of one service model across more than one NHS board, excluding services that individual boards are doing themselves and will create an important pillar of our NHS Scotland Executive.

The NHS Scotland Executive Group aims to enhance the effectiveness and efficiency of healthcare services, improving patient outcomes, by:

• improving co-ordination: allowing multiple health boards to work together, to enhance coordination and streamline services across different regions
• improving how we use resources: combining efforts which may lead to improved efficiency and productivity, for example, sharing of resources such as specialised medical equipment and staff, which might be underutilised if confined to a single health board
• standardising Practices: enabling a more standardised approach to healthcare practices and policies, reducing variability in patient care
• innovation and Best Practice: fostering an environment where best practices and innovative solutions are shared and implemented more widely, benefiting a larger population

The focus of the NHS Scotland Executive Group will cover productivity and efficiency, as well as enabling the recovery and reform work through the Care and Wellbeing Portfolio, that is pivotal to the sustainability of the NHS. It signals an intent, not simply to maintain an effective NHS, but to ensure it thrives.

The recent review of the planning and delivery arrangements through the NHS Scotland Planning and Delivery Board has set out the value of planning at a national level. While NHS boards are discrete legal entities and accountable and responsible for how they carry out their functions and services - and the various duties and responsibilities that arise from this (permitting local decision-making to respond to local circumstances) - we need a new approach to support boards and our senior leaders to work cooperatively both regionally and nationally.

Central to this approach will be the continued understanding that the NHS boards cannot, on their own, drive the pace of recovery and momentum of reform that is required across the health system. A renewed focus on implementation will be required in all that we are doing, including prevention and population health improvement; our continued work to support integration of health and social care; and the implementation of our national strategies and policies.

Taking a new approach, that involves our most senior leaders, is a mechanism that can be used to support these ambitions. As Accountable Officers for their health boards, Chief Executives have a personal responsibility for the propriety and regularity of the public finances of their board, and ensuring that the resources of the board are used economically, efficiently, and effectively. 

This new approach also supports the measures in the 1978 Act which relate to co-operation and assistance in the context of planning and providing health services, health boards must cooperate with each other, as well as with special health boards, NSS and Integration Joint Boards to promote and enhance the health of the people of Scotland. Under Section 12(J) of the NHS Scotland Act 1978 Arrangements for Service Provision:

• a health board may undertake to provide or secure services in the area of another health board
• health boards can jointly provide or secure services across their respective areas
• health boards undertaking such services can enter into arrangements with other health boards, Special Health Boards or the agency 

NHS Scotland Executive Group terms of reference

Purpose

The NHS and the communities it serves have changed. The NHS Scotland Executive Group will develop and agree proposals that will be recommended to NHS boards, recognising that boards remain responsible for the exercising of functions on behalf of Scottish ministers. This will support the DG Health and Social Care and Chief Executive NHS Scotland to:

• jointly lead the development of national strategy and policy development
• demonstrate delivery and implementation of NHS Recovery and Reform priorities, including productivity and the duty of best value, on an all-Scotland basis
• discuss and agree the prioritisation and implementation of Scottish Government national policies
• collaborate on regional and national delivery of reform and recovery, where services are not sustainable or can be delivered more effectively and efficiently
• create capacity of our senior leaders, freeing up time by establishing a clear reporting system and limiting the number of ‘discussion groups’
• develop strong collective leadership with NHS Chief Executives, working to strengthen services locally, regionally and nationally
• promote and enable a co-ordinated approach (Once for Scotland) to achieve better outcomes, eliminating unwarranted variation and enable Chief Executives as Accountable Officers to deliver their general and specific responsibilities, which includes making arrangements to secure best value
• collaborative working with the NHS Board Chairs Group to ensure alignment across NHS leaders

Reform will be a key theme throughout all agenda items. Standing items will include: 

• quality and safety
• performance – for example, planned care, unscheduled care, cancer waiting times – led by the system leaders with issues taken for decision, not for information
• finance – for example, fifteen box grid (requiring development to cover all boards), quarterly updates, budget and allocation prioritisation discussions
• workforce – including our culture, values, and wellbeing of our colleagues

Approach

The meetings are conducted in an atmosphere of respect. The following guidelines provide ground rules to support this environment:

• a single shared space where discussion and decision take place. A subcommittee structure will be created to support this but there will be a single, protected, space where system leaders come together
• no surprises – this is the NHS Scotland Executive Group of NHS Scotland, which will focus discussions on the priorities for our health and care system, within the scope of Ministerial priorities
• recognise, respect, and optimise the collective roles of boards, their Accountable Officers, ministers and civil servants and their respective responsibilities for the health and care system
• maintain confidentiality of discussion – enabling a free and open exchange of views before agreeing a collective approach. A culture of openness and engagement will underpin this, as set out in the sponsorship model framework
• minutes of meetings and an action log of decisions will be maintained by the Secretariat, with minutes published on the SG web pages (as currently happens for CE meetings)

Scheme of delegation 

NHS Scotland Executive Group (NHSEG) is a key lever to deliver transformation at a national level. The group will make decisions and recommendations on what should be delivered at a national level across relevant health boards. 

Once a decision is made on a recommendation at the executive group, there are two ways this work can be taken forward. Either it requires further development and a commission is agreed to be taken forward through the supporting substructure and working groups or it is agreed that the recommendation should be communicated to boards for consideration. 

Recommendations to health boards

Recommendations to health boards are communicated through the distribution of the minutes of the NHSEG and Action letter but also through each Chief Executive ensuring their Chair and board are aware of the group’s recommendations and discuss the implementation of proposals. 

Timescales for consideration at board level are set through the NHSEG action letter. If a board is rejecting a recommendation, the health board must clearly outline why that decision has been reached and what risks they require to be addressed in order for the board to accept the recommendation. The Chief Executives, as a representative of their board, will be expected to bring this back to the NHSEG for discussion. This process should continue until all boards can accept a recommendation and implement appropriately. Where necessary, a Ministerial Direction may also be considered.

Commissions to supporting substructure

Commissions to the supporting substructure of the NHSEG will be agreed by the NHSEG and communicated to the lead CE representative on the subgroup. They will then take the action to the group for further work and a timescale will be agreed for the action to come back to NHSEG. This will be communicated formally through the minutes of the NHSEG and action letter and informally through the lead representative as appropriate. 

A diagram setting out the flow of recommendations and decisions is included in annex A.

Membership

The NHS Scotland Executive Group is jointly Chaired by the Director General/Chief Executive for NHS Scotland or Chief Operating Officer and the Chair or Vice Chair of the NHS Chief Executives Group, with deputies to cover absence. 

SG membership will be the Chief People Officer, the Director of Finance, Director of Social Care, Chief Medical Officer and Chief Nursing Officer and Director of Population Health. Other Directors/Officials may be invited, as required.

All NHS board Chief Executives attend the meeting. Other professional groupings may be invited but it will be important that outside these meetings, board CEs are working with the full range of professional leads within the NHS, so that decisions reflect the critical input from the broad director cohort. 

The principle is to minimise attendance and build the appropriate space to support our system leaders.

Full membership can be found in annex B.

Roles and responsibilities

The NHS Scotland Executive Group is operationally focused and about implementing changes that have undergone substantial national engagement on agreed priority areas. It is the responsibility of Chief Executives at the meeting to ensure their boards are aware of the discussions taking place and the pipeline of recommendations that will be coming to boards for agreement. 

The meeting minutes and action letter will be shared with NHS Chief Executives and NHS Chairs for knowledge. This is to ensure NHS Chairs are aware of the business being discussed at the executive group. 

NHS Chairs will continue to engage with the Cabinet Secretary on strategic issues and will be updated by their Chief Executive on the operational matters that are under consideration by the NHS Scotland Executive Group. As appropriate, NHS Chairs may also be asked to input to the development work taking place through sub-committees. 

Meetings

The meeting schedule will be controlled by the board but will initially be scheduled at six weekly intervals. 

The venue for NHS Scotland Executive Group meetings is to be agreed but the preference that these will be in-person, with hybrid arrangements for island boards and others, when necessary.

These will be supported by an appropriate sub-committee programme, that will also provide an opportunity for any deep dives into issues.

The sub-committees will be co-chaired by a Chief Executive and SG Director/Deputy Director, with wider membership still to be confirmed, but should include individuals who can take work forward and provide relevant briefings as requested by the NHS Scotland Executive Group. 

The NHS Scotland Executive Group will commission the relevant Sub-Committee to take forward work and will advise the Sub-Committee Chair of any relevant briefings/papers required. Sub-committees will take place at least two weeks prior to the NHS Scotland Executive Group meeting, to ensure that there is sufficient time for the committee to consider and approve papers before they are submitted to the NHS Scotland Executive Group.

These new committees will replace the work that was being taken forward under the portfolio structure set up under the Chief Executives Group and will bring together clinical leaders from multi-disciplinary teams. This is not an additional layer of groups/committees for our senior leaders to attend, instead these will be the only key committees and other groups will be stood down or become sub-committees as appropriate. 

We will also undertake work to look at the range of groups established across SG which CEs attend and remove any duplication. A simplified structure with clear reporting lines will be created. This will enable senior leaders to focus on what we do collectively to drive forward improvements.

These are subject to review but will come together to establish a coherent and cohesive framework of governance. 

The sub-committee structure will ensure space to consider: 

• Planning and Delivery Board (planning and resources)
• Planned Care Programme Board
• Unplanned Care Programme Board
• quality and safety
• finance and risk
• digital and innovation
• population health/care and wellbeing portfolio
• integrated care
• people and workforce

Under development - a proposed structure outlining the scope of each committee is in development. 

These mirror broadly what is in place for our largest territorial boards and will support better alignment between SG and NHS boards. 

Agenda items

The guiding principles and process for requesting items for the agenda is as follows:

• where practicable, the agenda items will be aligned to implementation of the agreed strategic priorities for the group, Programme for Government and keeping with the principles set out within the group’s terms of reference
• agenda items should be agreed during planning meetings with DGHSC/CE NHS Scotland and Chair/Vice Chair of Chief Executives
• agenda items must have a clear aim, objective and outcome which can be articulated to members and stated within supporting documentation. For information and update issues will be by correspondence
• this will be a decision-making board, supporting the DG/CE and all members would attend with appropriate delegated authority

Accountable officer meetings

These meetings will continue in any month where the NHSEG does not meet and will continue to be supported by NSS secretariat. 

Quorum and attenadance at meetings

It is expected that each NHS board will be represented by the Chief Executive or nominated deputy at each meeting. The nominated deputy will act on behalf of the person they are representing during attendance at the NHS Scotland Executive Group.

Secretariat

Agendas, associated papers, and previous minutes will be distributed at least three clear days prior to each meeting, in line with Model Standing Orders used by NHS boards. An action log will be created to ensure momentum is maintained.

Secretariat for the NHS Scotland Executive Group will be provided by the Office of the Chief Operating Officer within the SG. They will work closely with NSS Executive Support Team colleagues on ensuring effective meeting scheduling and development of the required sub-committee structure. This will ensure that work is commissioned to the appropriate committee and that actions are progressed and reported back to the NHS Scotland Executive Group within the required timescale.

Document preparation

Standard templates will be used, similar to those currently used by boards. Papers will be quality assured by the Secretariat and Joint Chairs, where necessary. 

Annual cycle of business

Dates for the NHS Scotland Executive Group are set out below and the Planning and Delivery Board will be aligned with these.

These are: 

• 22 January 2025
• 5 March 2025
• 16 April 2025
• 28 May 2025
• 9 July 2025
• 20 August 2025
• 1 October 2025
• 12 November 2025

The NHS Scotland Executive Group will be reviewed after the first 12 months of operation.

Flow of recommendations and decision making (annex A)

Director General for Health and Social Care/Chief Executive NHS Scotland

• Portfolio Accountable Officer

Chief Operating Officer’s NHS Scotland Executive

• focus on the delivery function with Health and Social Care Directorates

NHS Scotland Executive Group

• agrees recommendations for boards
  • recommendations sent to NHS boards affected
    • NHS board accepts recommendation; Implementation with SRO
    • NHS board rejects recommendation; returns to NHS Scotland Executive Group for clarification/further work
  • commissions work through supporting substructure (under development)

Supporting substructure

• submits proposals to NHS Scotland Executive Group from working groups

Annex B

NHS representatives:

• Chief Executive, NHS Ayrshire and Arran
• Chief Executive, NHS Borders
• Chief Executive, NHS Dumfries and Galloway
• Chief Executive, NHS Fife
• Chief Executive, NHS Forth Valley
• Chief Executive, NHS Grampian
• Chief Executive, NHS Greater Glasgow and Clyde
• Chief Executive, NHS Highland
• Chief Executive, NHS Lanarkshire
• Chief Executive, NHS Lothian
• Chief Executive, NHS Orkney
• Chief Executive, NHS Shetland
• Chief Executive, NHS Tayside
• Chief Executive, NHS Western Isles
• Chief Executive, Healthcare Improvement Scotland
• Chief Executive, NHS Education for Scotland
• Chief Executive, NHS Golden Jubilee
• Chief Executive, NHS 24
• Chief Executive, Public Health Scotland
• Chief Executive, NHS National Services Scotland
• Chief Executive, Scottish Ambulance Service
• Chief Executive, State Hospitals Board

Scottish Government representatives: 

• DG/CE NHS Scotland, Health and Social Care Directorates
• Chief Operating Officer NHS Scotland, Chief Operating Officer Directorate
• Director of Health and Social Care Finance, Directorate for Health Finance
• Chief People Officer, Directorate for Health Workforce
• Director of Social Care Resilience and Improvement, Directorate for Social Care Resilience and Improvement
• Co-Director of Population Health, Directorate of Population Health
• Chief Medical Officer, Directorate for Chief Medical Officer 
• Interim Chief Nursing Officer, Directorate for Chief Nursing Officer

Additional Scottish Government attendees as required:

• Deputy Chief Operating Officer – Planning and Sponsorship, Chief Operating Officer Directorate
• Deputy Chief Operating Officer – Performance and Delivery, Chief Operating Officer Directorate
• National Clinical Lead for Quality and Safety, Directorate for Healthcare Quality and Improvement
• Director of Health Workforce, Directorate for Health Workforce
• Director of Social Care and NCS Development, Directorate for Social Care and NCS Development
• Co-Director of Population Health, Directorate for Population Health
• Director of Primary Care, Directorate for Primary Care
• Director of Mental Health, Directorate for Digital Health and Care
• Chief Pharmaceutical Officer, Directorate for Chief Medical Officer
• Chief Dental Officer, Directorate for Primary Care
• Director for Children and Families, Directorate for Children and Families

Additional service representatives as required:

Can be drawn from NHS Director cohort – but can include the following e.g.:

• Medical Director/Co-Chair of SAMD, NHS Highland
• Medical Director/Co-Chair of SAMD, NHS Golden Jubilee
• Executive Nurse Director/Chair of SEND, NHS Grampian
• Chair, Directors of Finance (DoFs), Scottish Ambulance Service
• Chair, Directors of HR (HRDs) , NHS Lanarkshire
• Chair, Directors of Planning (DoPs), NHS Ayrshire and Arran
• Directors of Public Health (DPH), NHS Grampian

Other representatives:

• OCENHS Team, Scottish Government
• Executive Support Team, NHS NSS