Health & Social Care Integration – Governance and the Integration Model
Introduction
1.
The Public Bodies (Joint Working) (Scotland) Bill 2013 has now received Royal
Assent. Detailed regulations and guidance on various aspects of the Act will be
issued over the summer.
2.
There is an expectation that partnerships will implement shadow arrangements
during 2014/15. Proposals for shadow arrangements and an options appraisal on
an integration model for Shetland will be presented for decision to the Council and
NHS Shetland in June 2014. The preferred model and shadow arrangements as
agreed by the Council and Shetland NHS Board will be set out in Shetland’s Joint
Commissioning Strategy and Integration Plan 2014-2017. This will replace
Shetland’s CHCP Agreement.
3.
If the Council and NHS Shetland fail to reach an agreement on the model for
Shetland, then the Scottish Government will, under the terms of the Act, be able to
impose a solution
Governance
4.
Work to explore the options for governance at committee/board level has included
five workshops for Councillors, Health Board members, representatives from
partner agencies and managers. The last two workshops provided opportunities to
hear from other partnership areas regarding their experiences of joint working, the
challenges they face and their plans for the future.
5.
East Renfrew have worked with a “concurrent model” for community health and
social care services for some time including children’s services. In a “concurrent
model”, the local authority and health board each retain responsibility and authority
for all decisions affecting their service areas however the appropriate committee of
the local authority and the CHP or CHCP Committee of the health board are
combined so that discussions on community health and social care services take
place at the same time and in the same place.
East Renfrew are looking at the Body Corporate model as the next logical step for
them.
6.
Orkney also have a concurrent governance model, however, they are currently
leaning towards a delegated model with adult and children’s social services in
separate directorates.
7.
Both presentations from East Renfrew and Orkney emphasised the need to look at
what would suit the local context and advocated taking steps during the coming
year, 2014/15, to begin to move towards integration.
8.
On 21 March we had the opportunity to hear from Highland regarding their
experiences and also from JIT, the national Joint Improvement Team who
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Health & Social Care Integration – Governance and the Integration Model
continue to support partnerships as they work towards implementation of the terms
of the Act.
9.
Highland implemented a delegated model in April 2012 whereby the local
authority delegated responsibility for all adult community care services to NHS
Highland and NHS Highland delegated responsibility for community health
services for children to the Highland Council. Bill Alexander, Director of Health
and Social Care for Highland Council, explained how in their model of integration
staff had transferred across to the lead agency for either adult or children’s
services under TUPE to create integrated services. He said that on 1April 2012
when they went live, “everything changed and nothing changed”. He went on to
explain that staff continued in their substantive roles however, the move paved the
way for real joint working with better outcomes for service users. There had been
some anxiety among staff regarding the move to another employer however, the
agreement that all transfers would be done under TUPE had made this acceptable
and now they would not want to go back as they feel the benefits of being in a
single structure for their service areas.
10.
The slides from the presentations made by Orkney, Highland and JIT are available
separately.
11.
The information from the seminars, the emerging guidance and previous papers
presented to the Social Services Committee and CHP Committee have informed
an options appraisal of governance models for Shetland. The current situation is
presented below. There is still more work to do and part of the activity in April and
May will be to gather the views of a wide range of stakeholders, staff and
community representatives.
Options Appraisal – An Integrated Governance Model for Shetland
12.
The Act identifies two main models for integration:1. Body Corporate
2. Delegation between partners
13.
Within the second model there are 3 ‘sub-models’.
a. Delegation of functions by the local authority to the Health Board;
b. Delegation of functions by the Health Board to the local authority;
c. Delegation of functions by the local authority to the Health Board and
delegation of functions by the Health Board to the local authority i.e. a mixed
model of delegation between both partners; “the Highland model”.
14.
Previous reports and discussions recommended that the options for integration of
children’s services in the terms of the Bill should be considered separately at a
later date. Consequently the options considered here are concerned with
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Health & Social Care Integration – Governance and the Integration Model
creating an integrated governance model for predominantly adult health and social
care services whilst recognising that for some services this will also include
services for children e.g. GP services.
It is standard practice in an options appraisal to consider the “Do Nothing/Status
Quo” option. As the proposals in this report are concerned with implementing
requirements under new legislation, to “Do Nothing” is not an option or rather if the
Council and the Health Board do nothing, an integration model will be imposed by
the Scottish Government.
Three options are considered in this report:
15.
1. Option 1 – Body Corporate;
2. Option 2 – Delegation of functions for adult social care services
by Shetland Islands Council to Shetland NHS Board;
3. Option 3 – Delegation of functions for community health care for adults
by Shetland NHS Board to Shetland Islands Council;
16.
Whichever option is chosen, it is proposed that the following service areas and
functions are included in the integrated service:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
xiv.
xv.
xvi.
xvii.
Primary medical services
Dental services
Community pharmacy
Community nursing
Optometry
Podiatry
Allied health professions – OT, Speech and Language Therapy,
Physiotherapy, Orthotics, Dietetics
Telehealthcare
Mental health – psychiatry and psychological services, child and adolescent
mental health (CAMHS)
Learning disability services
Community health and care services for older people
Community based rehabilitation, reablement and palliative care
Delayed discharges
Community health and care services purchased from the third sector
Substance misuse services through the Shetland Alcohol and Drugs
Partnership
Adult social work services including adult protection
Community health and wellbeing
The following areas may be included
i.
Health promotion
ii.
Housing and homelessness
iii.
Criminal Justice
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Health & Social Care Integration – Governance and the Integration Model
iv.
v.
vi.
Poverty
Community safety
Sport and leisure services
17.
This is compatible with the Act which requires Health Boards and Local Authorities
to integrate health and social care services for all adults and allows Partnerships to
include other service areas e.g. services for children and young people, housing
and criminal justice.
18.
Separate briefing papers are being prepared on a range of topics to explore further
what service areas should ideally be included in an integration model for Shetland.
19.
Within any of the three options identified above, it is possible that staff could be
transferred to another organisation. This is most likely if a delegated model is
chosen as in Highland, however, the body corporate can also employ staff so it
would be possible to transfer the staff for integrated service areas to the body
corporate if this option were chosen. Therefore a separate briefing paper has
been prepared on TUPE. TUPE would apply to any staff transferred to another
agency. The paper looks at the requirements of TUPE and includes short case
studies of service areas in Shetland. These include
i) the TUPE transfer of staff from Sodexho to NHS Shetland in 2012; and
ii) the experiences of the joint OT service where staff have stayed with their
original agency and work together as one team.
20.
There is a separate paper setting out the three options and forms that can be used
to comment on the 3 options and score these against eligibility criteria drawn from
our current CHCP Agreement. These will be used to gather views on the options.
Interim Arrangements 2014/15
21.
In response to the Scottish Government’s Consultation on the “Integration of Adult
Health and Social Care in Scotland” the Health and Social Care Integration Project
Board considered options for combining the CHP and Social Services committees
into a single, more streamlined governance arrangement. The proposals were
presented to the Council’s Social Services Committee and the CHP Committee in
May 2013 but were not supported by both agencies at that time.
22.
The proposed combined committee was based on a model known as a
“Concurrent Partnership Body”. This model has been used successfully for a
number of years in other parts of Scotland including Orkney and East
Renfrewshire and has been introduced in other areas to create shadow
governance arrangements in advance of the legislation being introduced.
23.
A combined partnership committee would bring together the CHP Committee
which is a sub-committee of Shetland NHS Board and the Social Services
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Health & Social Care Integration – Governance and the Integration Model
Committee of Shetland Islands Council. There would be agreed delegated
authority to the relevant committee from each statutory partner. The
committees/sub-committees would meet together at the same time and in the
same place under the banner of “Shetland Health and Social Care Partnership
Committee” (the “Partnership Committee”).
24.
Essentially the committees of the statutory agencies would be aligned reducing
duplication for officers and members and speeding up the decision making
process. It is proposed that a combined committee is put in place by August
2014. This would save time for officers and members and speed up decision
making during the last few months before full integration in April 2015. The
combined committee would give good experience and an appropriate interim
model leading to either the body corporate or lead agency model. In the former it
would act as a precursor to the Joint Board and in the latter would become the
Joint Integration Monitoring Committee
25.
Decisions would remain the responsibility of each statutory agency within the
combined committee arrangement. However, the expectation is that decisions
would generally be reached by consensus. If a decision could not be achieved
by consensus, the separate committees would each take a decision on their remit
and would refer decisions to their respective parent bodies in circumstances where
they did not have delegated authority.
26.
There would be equal numbers of members of each of the committees brought
together in the Partnership Committee and it is recommended that there should be
no more than seven members from either agency. For the Health Board, this
would comprise both non-executive and executive members of Shetland NHS
Board. There would in addition be representatives of the third sector, carers, the
Public Partnership Forum and professional advisors in attendance at meetings of
the Partnership Committee.
Management and the Single Management Model
27.
Shetland is among a small number of partnerships who have had a senior jointly
appointed and jointly accountable officer for some time. The role of Director of
Community Health and Social Care has evolved from the creation of a joint
Community Care Manager post in 2002 and now has responsibility for a wide
range of health care services locally and for all community care.
28.
There are currently a number of vacancies at Executive Manager level in the
Council’s Community Care Service and a review has started to look at the options
for increasing capacity at this level.
Service Delivery and Multi-disciplinary Teams in Localities
29.
The strand of work to develop integrated multidisciplinary locality service teams is
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being taken forward through the CHCP Management Team.
Work in this area
has been formalized through the development of a PID specific to this work
stream. The objective is for closer and aligned working with advantages
including:






Better experiences and outcomes for the individual receiving care & support.
More effective & efficient use of resources. Reducing duplication etc.
Meeting potential resource issues in more remote/rural communities.
Supports the ethos and principles around Self Directed Support – in terms of
being able to respond to challenges of ‘deep’ personalisation.
Supporting preventative and proactive care rather than crisis intervention.
Supports the reablement philosophy and minimises dependency.
30.
Project outcomes are defined as:
 Improved service delivery to individuals
 More efficient and effective use of existing resources
 Support for considered change in use of resources including disinvestment
 Support Third Sector Partners to deliver appropriate services instead of
statutory provision or to enhance provision
 Break down actual or perceived barriers of integrated working
 Continue to promote enablement/reablement
 Support for the Joint Commissioning Strategy
 Support for implementation and the ethos of Self Direct Support legislation.
 Full engagement with individuals and other key stakeholders
31.
In order to move towards further integration via locality based service design and
provision the following activities have been identified;
 Identifying localities
 Mapping out current resources, both in situ and uptake of visiting services.
 Potential ability to use assistive technology for both health and social aspects
of care and support.
 Engagement & Consultation events with current services within each locality to
ascertain thinking around improved working and resource management.
 Locality Plan(s) designed and agreed.
 Pilot Project initiated – with 6 month review.
 Learning & Sharing event from the pilot site.
 Plan to roll out across other localities.
32.
Work on the clinical and professional governance arrangements in
multidisciplinary teams is being taken forward as part of the localities project.
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