Health and social care - Planning with People: community engagement and participation guidance

Part 5 – Governance and decision-making

NHS Boards, Local Authorities and Integration Joint Boards are required to make decisions about how any proposed service changes and developments should be taken forward.

Although there are separate processes each must follow, they are the public bodies that must decide on proposed service changes and developments. Overall, the decision-making process must be transparent and clearly demonstrate that the views of communities have been taken into account. Organisations should ensure that they have evidence to assure these principles as practically embedded and effectively implemented in practice.

Healthcare Improvement Scotland (along with the Care Inspectorate) has statutory responsibilities to assure and support improvement in the quality of care services.

Additionally (and as outlined earlier in this guidance), Healthcare Improvement Scotland – Community Engagement ensures people and communities are engaged in shaping health and care services. It has a legal duty to support, ensure and monitor the discharge of health bodies’ duties in respect of public involvement, including quality assurance of changes being made by Integration Joint Boards and in primary and community health services. This legal duty has been operationalised by the establishment of the Scottish Health Council, within the corporate governance structure of HIS, as a sub-committee of the HIS Board.^[10]

When an NHS Board or Integration Joint Board proposes a service change, it should work with Healthcare Improvement Scotland – Community Engagement, to ensure that people and communities potentially affected have the information and support they need to play a full part in the consultation process. Where appropriate, they should collaborate in the delivery of these duties.

Where a proposed service change will have a major impact on a patient or carer group (including where changes are proposed by Integration Joint Boards), members of equalities communities or on a geographical community, Healthcare Improvement Scotland – Community Engagement can advise on this. Where a proposed service change being considered by an Integration Joint Board has a clearly identifiable health component that is being provided under delegated authority from an NHS Board, Healthcare Improvement Scotland-Community Engagement has a duty to undertake quality assurance of engagement.

This approach reflects the requirements of guidance and advice supporting the implementation of the Public Bodies (Joint Working) (Scotland) 2014 Act and in particular, the expectations on partners across the health and social care landscape, and their stakeholders to focus together on their joint responsibility to improve outcomes for people.

This approach is also recommended as best practice in corporate governance as outlined in Scottish Government: The Blueprint for Good Governance in NHS Scotland (second edition)(sections 4.26 and 4.27) in recognition of the key role of Healthcare Improvement Scotland – Community Engagement, in supporting NHS Boards and Integration Joint Boards to meaningfully engage with people and communities to shape national policies and health and social care services; and the requirement on NHS Boards to collaborate with Healthcare Improvement Scotland in support of the statutory duty to review existing services and planning new services or care pathways, ensuring appropriate engagement with local communities throughout changes to services.

NHS Boards should be assured that actions and decision-making in respect of changes to services (proposed by them or as a consequence of changes proposed by stakeholders) reflect the requirements of the ‘Engaging Stakeholders’ section of The Blueprint for Good Governance in NHS Scotland (Second Edition).

The decision-making process for NHS major service change is unchanged. Scottish Ministers will continue to make the final decision regarding whether to approve proposed service changes by NHS Boards that will have a major impact on people and communities.

NHS Boards will continue to make most decisions about how health services should be delivered locally. The outcome of community engagement and other relevant information must inform these decisions.

Integration Authorities were established under the Public Bodies (Joint Working) (Scotland) 2014 Act and include Integration Joint Boards and, in the case of Highland, lead agency partnership agreements. The Act does not identify a process for engagement that must be adhered to for community engagement. It recognises that Integration Joint Boards will have the local knowledge to undertake engagement that best suits their local population.

Local Authorities are responsible for the provision of a wide range of public services. There is no requirement for these bodies, led by elected councils, to adopt a particular decision-making and scrutiny structure. Each council decides the most appropriate structure suited to its particular circumstances and must be transparent about decisions made and the quality of services provided.

While different organisations have different ways of working, and have different statutory functions to fulfil, the Community Empowerment (Scotland) Act 2015 requires equal opportunities duties to be met when it comes to participation.

Local authorities work with other public bodies to deliver services and are required by law to deliver an integrated approach, along with care providers, through Health and Social Care Partnerships They are expected to work together to develop common engagement approaches.

5.1 The Quality Framework for Community Engagement and Participation

Healthcare Improvement Scotland – Community Engagement and the Care Inspectorate have developed a Quality Framework for Community Engagement and Participation. The Quality Framework is aligned with ‘Planning with People’ and supports NHS Boards, Integration Joint Boards and Local Authorities to meet their statutory responsibilities to engage, and to continually improve their engagement practices.

The Quality Framework is designed to support self-evaluation and improvement activity in relation to routine engagement; specific engagement activities; and organisations’ internal governance systems for community engagement activity.

The Quality Framework should be used to identify and support improvement in community engagement practice, as well as identify and share good practice.

The Quality Framework supports self-evaluation in three areas:

• Ongoing engagement and service user involvement
• Involvement of people in service planning and design
• Governance/Organisational Culture and Leadership

The Quality Framework should be used as a guide for improving the quality of engagement. It will help NHS Boards, Local Authorities and Integration Joint Boards to understand what good engagement involves and how it can be evaluated and demonstrated.

The Quality Framework is an improvement tool, developed in collaboration with, and for the use of health and social care providers. It has been designed to support reflection and self-evaluation, which is an important first stage in any quality improvement journey.

Organisational self-evaluation

It is important to understand how well your organisation is currently engaging. Senior leaders within the organisation should support the use of the Quality Framework’s self-evaluation tool, to provide assurance to their Board members on the quality of their community engagement activity. Health and care services should complete a self-evaluation, which should focus on outcomes rather than activities. This could include a description of the impact of engagement, changes made as a result of feedback, or information on how potential impact is being monitored.

That can be done systematically, efficiently, and quickly using a range of methods.

You might want to know:

• What role do communities have in your organisational structures? How do people respond when you communicate with them? Are levels of public satisfaction and trust, high or low?
• How does your organisation view engagement? Is it regarded as important and is there a shared view of what it means? Has there been a culture of tokenism?
• Has engagement influenced decisions?

Assessing the view of all stakeholders is essential and to understand the quality of your engagement activity you need to know the views of the people who participate or have participated. Feedback should be sought from patients, the public, service users, family, carers, staff, communities, third sector and wider stakeholders. This can be done via surveys and interviews, or data reviews and reference to good practice. Following the self-evaluation process will help to identify good practice and show where improvement is required.

Healthcare Improvement Scotland- Community Engagement can discuss how best to apply the framework to an organisation. Further information on the Quality Framework for Community Engagement and Participation, as well as a Guide to self-evaluation can be found in the supporting information section at the end of this section.

5.2 Service change

NHS boards and Integration Joint Boards have a statutory duty to involve people and communities in the planning and development of care services, and in decisions that will significantly affect how services are run.

It is essential that all planned service change or design, including temporary arrangements, must be communicated clearly and demonstrably influence engagement at the earliest opportunity, to the people who may be affected by the proposal.

Healthcare Improvement Scotland – Community Engagement has produced guidance to help NHS Boards to identify major service change, as well as a flowchart to support the service change process HIS-CE service change resources-flowchart .

Further detailed information on major service change, including links to previous reports can also be found on the Healthcare Improvement Scotland – Community Engagement website, HIS-CE Major service change reports

Healthcare Improvement Scotland – Community Engagement can provide a view on proposed major service changes by NHS Boards, and also on proposed major service changes by Integration Joint Boards, but only when the service change has a clearly identifiable health component that is being provided by the Integration Joint Board under delegated authority from an NHS Board.

Other service change, including temporary change

Services delivered by general practitioners (GPs) etc, through Primary and Community Care are delegated services to Integration Joint Boards. While services are provided by independent contractor GPs, dentists, optometrists and pharmacists, Boards are still required to adhere to 'Planning with People’ when they are considering changes to the contractual, and other, arrangements for primary care services.

While independent contractors are responsible for running their own practices they are also expected to engage in a proportionate way with their patients and relevant community groups, when planning any changes to the way they deliver services.

Temporary service change

Some changes are made on a long-term or permanent basis, while others are provided on a temporary basis, due to the need to take immediate short-term action to deliver services, for example:

• Infection prevention and control measures (environmental concern, outbreak of infection/virus, either within a limited or confined space such as a ward or wider community outbreak)
• Interim changes, as a result of staffing pressures that could have an impact on the configuration of services.
• Pilot projects where patients have an expectation that this is part of service (patients do not differentiate between pilot projects and day to day service delivery, they just see that a service has been withdrawn)

Temporary changes also need to be implemented with due regard to ‘Planning with People’ and should take account of the following:

Understanding impact: Identify those people who currently use, or could potentially use, the service(s) that have undergone urgent change, and ask them about potential impacts and potential mitigations moving forward. This information will support understanding and response to unintended consequential impacts of change.

Communicating clearly: Ensure that communications are clear, transparent, and accessible, and include information on how to access services and the support available to people remotely or in person. Communications may give an indication of how the service is being evaluated and indicative timescales for the temporary arrangement being in place. It may be helpful to consider that communication can be undertaken with service users and their carers face-to-face when they interact with the service, as well as digitally or by post with others.

Using feedback: Seek on-going feedback from people and communities on the interim and urgent changes and consider how this can be used to inform current practice and future service design. Feedback may be gathered from people when using services, at the point of service delivery, through surveys (postal or digital) or via Care Opinion Care Opinion, what's your story?

Agree the approach: For those changes that were introduced on a temporary basis, due to service pressures (such as part of the response to the COVID-19 pandemic), NHS Boards or Integrated Joint Boards should contact Healthcare Improvement Scotland – Community Engagement to discuss the approach to move forward in line with national guidance and policy on community engagement and participation. The period of temporary change may have enabled the collection of valuable service user experience and evidence to support a case for change.

5.3 NHS Boards and Major Service Change

The established principles and requirements for major service change decision-making process for NHS Boards, remain unchanged from those outlined in CEL 4 (2010).

There are specific requirements for public consultation on proposals that will have a major impact on people and communities, and Healthcare Improvement Scotland – Community Engagement is required to quality assure this process. For any service changes that are considered to be major, NHS boards should not start the consultation stage until HIS-CE has confirmed that their engagement to that point has been in accordance with ‘Planning with People’.

Scottish Ministers will continue to make the final decision regarding whether to approve proposed service changes by NHS Boards that will have a major impact on people and communities. NHS Boards will continue to make most decisions about how health services should be delivered locally. The outcome of community engagement and other relevant information must inform these decisions.

An inclusive process should encourage and stimulate discussion and debate. While it may not result in agreement and support for a proposal from all individuals and groups, it should demonstrate that the NHS listens, is supportive and genuinely takes account of views and suggestions. Ultimately, Boards should demonstrate that there has been a wide-ranging consultation, which has taken all reasonable steps to take account of differences of view.

Responsibility for identifying a major service change

NHS boards have responsibility for identifying if a potential service change or design proposal should be considered ‘major service change’.

Healthcare Improvement Scotland – Community Engagement has developed guidance to help identify major service change. HIS-CE: Guidance, Identifying 'major' health service changes

Identifying a major service change:

• NHS boards can categorise proposals as major service change themselves, as informed by Healthcare Improvement Scotland – Community Engagement guidance.
• NHS Boards are advised to contact Healthcare Improvement Scotland-Community Engagement at the outset for preliminary discussions on approach.
• NHS Boards should consider a range of issues to help identify major service change, (see box below). As a general rule, the more issues that apply, the more likely it is that a service change should be considered major.
• Healthcare Improvement Scotland – Community Engagement can offer a view on the categorisation of proposals. In the absence of an agreed consensus, the NHS Board should seek a final decision from the Scottish Government.
• A proportionate approach may include a form of consultation for proposals not considered to be major.

There are other factors that NHS boards will consider to be important drivers for change, including workforce issues and clinical standards. However, the key issues listed must be taken into account when identifying if a proposed service change might be classed as major:

• The impact on patients and carers
• Changes in the accessibility of services
• Emergency and unscheduled care
• Public or political concern
• Alignment with national policy or professional recommendations
• Changes in the method of service delivery
• Financial implications and consequences for other services

The process for identifying a major service change is the same for all service change, whether driven by local decisions or national policies.

If considered major service change:

There is a specific requirement for NHS Boards to consult formally on issues which are considered to be major service change.

For any service changes that are considered to be major, NHS Boards should not start the consultation stage until Healthcare Improvement Scotland – Community Engagement has confirmed that their engagement to that point, has been in accordance with ‘Planning with People’.

Following the public consultation, a full meeting of the NHS Board will then consider the proposals and make a decision. A range of information, including responses to the consultation and a report from Healthcare Improvement Scotland – Community Engagement, will help to inform the Board's decision.

Healthcare Improvement Scotland – Community Engagement is required to quality assure the process and can provide advice on the nature and extent of the process being considered. The final decision on the way forward, following a consultation, requires Ministerial approval.

Proposed change affecting two or more NHS Boards

Where a proposed service change would impact on the public in another area, the Board proposing the change should lead the public involvement process. The Board, and any other affected Board(s), should aim to maximise the involvement of affected individuals and communities in the process.

Proposed changes to regional or national services

Proposed changes to regional or national services should follow the principles set out in this guidance and, as above, the Board proposing the change should lead the involvement process, ensuring that it engages with the public and its wider stakeholders.

Regional Planning Groups are made up of NHS board staff from across the region, who are working on behalf of the constituent NHS boards. All proposals and decisions must be referred to individual NHS boards for consideration and approval.

This means there is a clear responsibility on the Planning Groups to make sure there is effective engagement in the planning and development of service models. The statutory duty to involve people and local communities in the planning and development of services, and in the decision-making process for regional services rests with NHS Boards. Each NHS Board should consider the differential impact of the proposed changes in their local area.

The practical implications of service changes that reflect national policy or regional planning still require engagement at a Board level. NHS Boards operate within a wider national policy context set by Ministers and will seek to ensure that there is a close alignment between local plans and the objectives of Scottish Government.

In developing the policy options, Scottish Government will, of course, ensure meaningful and active engagement with the people of Scotland as per the Scottish Government’s ‘Participation Framework’ published in February 2023. Boards must then undertake engagement with communities in their Board area about the local impact of implementing the policy. Healthcare Improvement Scotland-Community Engagement will provide advice on the engagement required by the Board, taking a proportionate approach which takes into account any earlier engagement undertaken at a national or regional level.

5.4 Major Service Change – process

Proposals for major service change in the NHS must be subject to at least three months of public consultation and, ultimately, Ministerial approval.

For any service changes considered to be major, NHS Boards should not move to the consultation stage until they have confirmation from Healthcare Improvement Scotland – Community Engagement that their engagement up to that point has been in accordance with Planning with People.

Healthcare Improvement Scotland - Community Engagement does not comment on clinical or financial issues or the effectiveness of an organisation's engagement with its own staff. It will, however, look to the organisation to provide evidence that the views of potentially affected people and communities have been sought, listened to and acted on, and treated with the same priority (unless in exceptional circumstances) as clinical standards and financial performance.

Healthcare Improvement Scotland – Community Engagement will set out its views in its report as to whether the relevant NHS Board has appropriately involved local patients, carers and communities in line with this guidance. Further detailed information on major service change, including links to previous reports can also be found on the Healthcare Improvement Scotland-Community Engagement website, HIS-CE Major service change reports

Following the public consultation, a full meeting of the NHS Board will then consider the proposals and make a decision. A range of information, including responses to the consultation and a report from Healthcare Improvement Scotland-Community Engagement, will help to inform the Board's decision.

Following the Board decision, the major service change proposal must be submitted to Scottish Ministers for final approval. Ministers will take all the available information and representations into account, including the report of Healthcare Improvement Scotland – Community Engagement.

The proposals may ultimately be approved or rejected by Scottish Ministers. Where appropriate, they may also instruct the relevant NHS Board to carry out further engagement activity.

5.5 Integration Joint Board decision-making

Specific requirements (known as Planning Principles) are laid out for involvement and participation of a range of stakeholders. Integration Joint Boards are required to have as members a carer representative, a person using social care services, a patient using health care services and third sector representatives.

Healthcare Improvement Scotland-Community Engagement (HIS-CE) major service change guidance may be helpful when Integration Joint Boards are considering the potential impact on people and communities of any proposed changes to delegated services to help inform their engagement process.

Each Integration Joint Board should have its own strategy for community engagement and participation, which should be taking place on a regular and routine basis and not just at time of change. Strategies must take this guidance into account.

Strategic Commissioning Planning

Decision-making by Integration Joint Boards takes place within the context of strategic commissioning, and so it is important that community engagement is part of this process.

Strategic commissioning is the term used for all activities involved in assessing and forecasting needs, linking investment to agreed outcomes, considering options, planning the nature, range and quality of future services, and working in partnership to put these in place.

There is a duty on Integration Joint Boards to create strategic commissioning plans for the functions and budgets they control, which must be reviewed at least every three years with the involvement of the Strategic Planning Group. This requires close working with professionals and local communities to deliver sustainable models of care and support that are focused on improving outcomes for people.

A key principle of the commissioning process is that it should be equitable and transparent. Therefore, it must be open to influence from all stakeholders, including the community, via ongoing dialogue with people who use services, their carers and service providers.

During the development of their strategic plan, each Integration Joint Board is required to run consultations on various drafts of the document.

The role and minimum composition of a Strategic Planning Group can be found in Strategic Commissioning Plans: Guidance. The Strategic Commissioning Plans Guidance is currently under review and updated guidance is expected to be published in 2023.

It is important that Integration Joint Boards develop agreed communication and engagement plans at an early stage to suit the needs and makeup of their community. Boards should use ‘Planning with People’ to help develop their approach to engagement.

Strategic Commissioning Plans must be published and it is best practice for Integration Joint Boards to also publish the Strategic Commissioning Plan in easy-read format.

Localities

Another important route for community engagement is through locality arrangements. Each Integration Joint Board divides its geographical area into at least two localities, and the views of people who live there must be taken into account as part of the strategic commissioning process to inform strategic thinking.

Many Integration Joint Boards have well established locality planning forums that bring together professionals and local community representatives involved in strategic commissioning planning.

Further information can be found in Scottish Government: Health and social care integration - localities: guidance.

Significant decisions out-with the Strategic Commissioning Plan

Sometimes, an Integration Joint Board must make a decision that would have a significant effect on the provision of an integrated service, out-with the context of the strategic planning cycle. It must then involve and consult its Strategic Planning Group, along with users (or potential users) of the service.

Decisions for specific services and functions

While the Strategic Commissioning Plan provides the direction of travel and ambition for the Integration Joint Board, decisions about service change, service redesign, and investment and disinvestment may be made at regular meetings. These are open to members of the public who may attend but not participate, with papers and minutes available online.

Alongside this, Integration Joint Boards are required to undertake ongoing engagement and feedback with the local community, so that the views of service users, their carers, and service providers are taken into account in this continuous process of decision-making. The form of this engagement will vary between Boards and should reflect the makeup of the local community.

5.6 Local Authority decision-making

A full council meeting is the key governing body of a Local Authority, where councillors debate and take key decisions. The Local Government (Scotland) Act 1973 allows Local Authorities to devolve most decision-making to committees, sub-committees or council officers. Individual councils set out their arrangements for delegation to committees in their internal governance documents.

Legislation has been introduced to give communities a stronger say in how public services are planned and provided and to allow communities to have a greater say in local decisions and in scrutinising local services.

The Local Government (Scotland) Act 2003 gave a statutory basis to partnership working between all agencies responsible for delivering public services in an area, including Health Boards. This Act established the role of councils in facilitating the community planning process, at the heart of which is 'making sure people and communities are genuinely engaged in decisions made on public services which will affect them'.

The duty to involve people in the design and delivery of services has increased since the publication of The Christie Commission on the future delivery of public services (2011) and subsequently the enactment of The Community Empowerment (Scotland) Act 2015.

Community Planning Partnerships

There are 32 Community Planning Partnerships across Scotland, one for each council area, which represent all the services that come together to take part in community planning. Each focuses on where partners' collective efforts and resources can add the most value to their local communities, with particular emphasis on reducing inequality.