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 Plan2014-2017. 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 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
  1. Delegation between partners

13.Within the second model there are 3 ‘sub-models’.

  1. Delegation of functions by the local authority to the Health Board;
  2. Delegation of functions by the Health Board to the local authority;
  3. 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 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.

15.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:

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:

  1. Primary medical services
  2. Dental services
  3. Community pharmacy
  4. Community nursing
  5. Optometry
  6. Podiatry
  7. Allied health professions – OT, Speech and Language Therapy, Physiotherapy, Orthotics, Dietetics
  8. Telehealthcare
  9. Mental health – psychiatry and psychological services, child and adolescent mental health (CAMHS)
  10. Learning disability services
  11. Community health and care services for older people
  12. Community based rehabilitation, reablement and palliative care
  13. Delayed discharges
  14. Community health and care services purchased from the third sector
  15. Substance misuse services through the Shetland Alcohol and Drugs Partnership
  16. Adult social work services including adult protection
  17. Community health and wellbeing

The following areas may be included

  1. Health promotion
  2. Housing and homelessness
  3. Criminal Justice
  4. Poverty
  5. Community safety
  6. 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 2013but 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 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 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.

CF 22 April 2014