Chapter 2: Overview of the new model for public health in Scotland
1. The Scottish Government and COSLA have worked with a wide range of stakeholders and partners to develop a model for Public Health Scotland. We have engaged across national and local government, the NHS, local partnerships, the public health workforce and their representatives, the third sector and the private sector.
2. We are committed to a model of shared leadership and shared accountability between Scottish Ministers and local authority leaders. This will be achieved through a combination of legislative and non-legislative mechanisms. Public health reform is not about any one organisation solving the problems we face – it is about working together across organisational boundaries and within our communities to deliver change. Public Health Scotland is being designed to support a whole system approach to improving and protecting the public’s health and wellbeing, by providing leadership and enabling change across all parts of the system that affect it. This is an increasingly complex landscape involving many sectors with competing priorities and resource pressures so future success will require co-ordinated action and integration to bring about change, including health, social care, planning, housing and business. For significant improvements to be made, we need to look at not just the individual contributions of each organisation but also how the whole system works together.
3. The key design principles for Public Health Scotland are:
3.1 That it should, as far as possible, be jointly accountable to Scottish Ministers and Local Government for the delivery of its strategic objectives. Joint accountability may need to be achieved administratively via cooperation, consultation and agreements, rather than defined in legislation.
3.2 Continually and proactively seeking opportunities to undertake processes jointly between national and local government. This should be the preferred approach at all times. Examples may include the appointment of the Chief Executive and Chair roles, the final agreement of Public Health Scotland’s strategic objectives and the performance review process. Where processes, such as appointments, are attached to a Ministerial power and sit with Scottish Ministers in a legal sense, this should not preclude making joint decisions on a non-legislative basis with local government around how those powers are exercised.
3.3 Partnership working must sit at the very heart of Public Health Scotland, recognising its role in supporting the multi‑dimensional system of public health. In other words, Public Health Scotland’s primary focus should be on enabling the whole system to deliver better public health and wellbeing outcomes and that it is able to work with partners to coalesce around the new Public Health Priorities as they relate to community planning across Scotland.
3.4 Public Health Scotland should co-design its strategic objectives with relevant partners from across the whole system. This principle conceives of the public health system in its widest sense, and so is multi-dimensional and underpinned by transparency and collaboration.
3.5 Performance reporting for Public Health Scotland should link with existing frameworks and serve to improve transparency and strengthen relationships with communities. This will require some re-orientating of performance reporting to ensure it is more local-facing.
3.6 Public Health Scotland must have a clear and distinct identity. This should include stand-alone branding and an overt focus on establishing a unique culture and identity as a vehicle for public sector partnership in the widest sense, as part of a multi-dimensional system of public health.
3.7 It would be desirable for the Executive Team to include cross-sector expertise, including representation from the third sector.
3.8 We would like Public Health Scotland staff to be located and deployed in a way that helps re-orient the public health system to be more local-facing, engages communities and supports collaboration across the wider system. We are investigating whether, over the medium-term, this could include at least a partial move from NHS premises and the identification of co‑location collaborative spaces at community, local and national levels, comprised of Public Health Scotland staff and relevant partners from other parts of the wider public health system.
3.9 We would like Public Health Scotland to be able to share services with both NHS and non-NHS public bodies and this needs to be done in a way that embraces the whole of the public sector and beyond i.e. the third sector.
3.10 Public Health Scotland should support innovation by identifying and promoting national and international best practice both within and beyond Scotland, including within the fields of data science and behavioural science.
3.11 Public Health Scotland should be a distinct organisation with the autonomy to advise and support government, local authorities and the NHS in a professionally independent manner. These freedoms and obligations should be described in the Memorandum of Understanding and will protect the independence of Public Health Scotland to advise and provide challenge where necessary.
4. As legislation will be required to establish the new body in line with these design principles, the focus in this consultation is on describing the role, structure and expected functions of Public Health Scotland, with some discussion of its interface with other statutory frameworks. As referred to above, proposed legislation will be subject to parliamentary scrutiny. However, the success of the new model for public health in Scotland lies also in the non-legislative improvements that will need to be made within local partnerships.
The national body – Public Health Scotland
5. The new national body - Public Health Scotland - will be a public body, established in statute as a national Special Health Board within NHS Scotland. We want to ensure the body is designed in the best possible way to allow it to contribute to the whole public health system, both nationally and locally. This means co-production with those who will provide services and those who should benefit from them, along with a strong focus on supporting the whole system and local delivery. Rather than focusing on the consequences of ill‑health, its unique brand offering and related approach will reflect action on all the social determinants of health, sometimes referred to as working ‘upstream’ of the wider health system.
6. Both the Public Health Reform Oversight Board and the Programme Board concluded by consensus that the best way forward was to establish Public Health Scotland as an NHS Special Health Board. This view was supported by Local Authority representatives, COSLA and the Scottish Government.
7. The national body will be directed by its Board. It is our hope that the Board will consist of individuals with professional experience in public health and other relevant sectors and perspectives across Scotland (see Chapter 8 for more information on the composition of the board).
8. We want to embed a human rights based approach to health and wellbeing in the body and so would expect that the relevant lived experience would also be reflected on the Board. Taking a human rights based approach is about using international human rights standards to ensure that people’s human rights are put at the very centre of policies and practice. This approach empowers people to know and claim their rights. It increases the ability of organisations, public bodies and businesses to fulfil their human rights obligations.
9. At the highest level, the national body will be responsible for:
- Providing national, professional and strategic leadership for the public’s health and wellbeing in Scotland;
- Offering independent expert advice to Scottish Ministers and COSLA on the basis of the best available evidence;
- Providing oversight of the delivery of the Public Health Priorities, in the context of the National Performance Framework, in relation to the public’s health and wellbeing in Scotland;
- Identifying and advising on how health and other resources can be better aligned to improve outcomes for the public’s health and wellbeing;
- Management of any services which have been identified and agreed as being best delivered on a national basis by the national body, including services currently provided by Health Protection Scotland, Information Services Division and NHS Health Scotland.
10. Public Health Scotland will also work with delivery partners and stakeholders to agree a long term strategic and co-ordinated approach to planning and delivering public health services in Scotland. Where benefits are recognised at the national, regional and local level for shared services or collective and collaborative undertakings, organisations will be expected to work in partnership to establish these.
Community planning and partnership arrangements
11. A community focus and partnership approach lies at the heart of this new model and the new body will have a role to enable, contribute to and support local strategic planning and the delivery of local services. We want to create a climate and culture where local public health groups, organisations and partnerships feel confident that they have autonomy and authorisation to decide how to best respond to the specific public health needs of their communities. Successful partnerships are clear about goals and purpose; aware of partners' roles and responsibilities; and have a clear strategic overview of performance through robust monitoring and evaluation. However, their success is entirely dependent on the willingness of partners to commit information and resources to the partnership, with sufficient ambition and drive. Active and engaged partners are crucial to successfully lead on, shape and deliver progress against local priorities. They must be clear about the purpose, deliverables and capacities of the partnership. This will require all partners involved to take a constructive and engaged approach, making the most of the strengths and assets of each of their organisations and sectors and combining them in such a way that they are able to make a real difference.
12. Local outcomes for public health are planned and delivered by a range of partners - local authorities, NHS boards, the third sector and many more – working both individually and in partnership at a local level. This is in line with expectations on delivery of a range of key national outcomes set out in the National Performance Framework.
13. Local partners should decide how they work together in ways that in their view best suit local conditions. Community planning provides a space in which they can do this. The Community Empowerment (Scotland) Act 2015 introduced a statutory purpose for community planning, which is about a defined set of public sector bodies working together and with community bodies to improve outcomes, and in particular to reduce outcome inequalities, on themes they agree are local priorities. These bodies do this within a Community Planning Partnership (CPP) that covers a local authority area.
14. Each CPP is required to set out its priorities and ambitions in a plan for its area (called a Local Outcomes Improvement Plan) and at least one locality plan, which focuses on a smaller area with a community experiencing poor outcomes. In order to identify local priorities, each CPP needs to develop an understanding of needs and opportunities based on local evidence. Its partners need to secure participation from local community bodies and commit resources in order to deliver expected improvements on the CPP’s agreed priority outcomes. We are investigating whether Public Health Scotland can be listed in schedule 1 of the Community Empowerment (Scotland) Act and therefore become subject to statutory duties to participate in community planning locally.
15. The Public Bodies (Joint Working) (Scotland) Act 2014 created Integration Authorities for the purpose of integrating health and social care services. Each Integration Authority is responsible for ensuring that services are well integrated with people receiving the care that they need at the right time and in the right setting, with a focus on community based preventative care. Integration Authorities have a duty to take into account reducing health inequalities as one of the National Health and Wellbeing Outcomes, when planning and operating integrated services. Community planning and Health and Social Care Partnerships, together with other local partnerships, are key enablers of change. They will increasingly work with public health teams and communities to realise the reform ambitions for whole system working to improve the public's health and wellbeing, by developing local solutions to local public health challenges. Scotland’s Public Health Priorities will be key to supporting this collaboration.
16. We would like Public Health Scotland to support organisations that are responsible for tackling inequalities and improving health and wellbeing outcomes, including through their partnership activity in CPPs, Health and Social Care Partnerships and elsewhere. Public Health Scotland will aim to increase community participation in decisions that impact on community health and wellbeing, as well as supporting communities to develop innovative solutions to significant challenges. We want people to have more of a say and more control over the decisions and factors that shape their health and wellbeing. The work of the new body will recognise that communities are independently able and often wish to organise themselves and use their inherent assets and resources to improve the health and wellbeing of those who live within them.
17. Addressing the broader determinants of health and wellbeing depends on more than health and social care services, e.g. factors such as feeling safe, having access to amenities and social contact are just as important. It is also through community planning and local partnership working that communities can work together to prevent vulnerability, making it easier for people to continue to live active lives and to maintain physical and mental wellbeing for as long as possible. As well as making a positive difference to people’s lives, the involvement of local partnerships in this way can help to avert future demand for acute health and social care services. Community planning partners are working with local communities to find solutions to local challenges and to increase the opportunities for local communities to genuinely participate in decisions that impact on their health and wellbeing.
18. These local arrangements are considered in more detail in Chapter 3.
Specific local arrangements
19. We want to create a culture of mutual collaboration, regard and trust between Public Health Scotland and all of its local partners, across sectors. Delivering an effective and integrated service together involves careful planning, oversight and support until working practices are established. It is crucial to avoid duplication, address gaps and tackle problems, particularly when a new development has impact across sectors. We want to support local authorities, the NHS, third sector and other partners to work ever more closely together to address the social determinants of health, improving and protecting the health and wellbeing of individuals and the communities in which they live.
20. Local arrangements for the strategic planning and delivery of services for public health will be taken forward at local discretion, in line with existing statutory duties. We will work collaboratively to consider what jointly developed guidance should be produced to assist local and regional partnerships in strengthening these arrangements in conjunction with Public Health Scotland.
21. Other partners, such as colleges and universities, will also be involved according to local needs and circumstances.
New public health model
22. The new public health model seeks to deliver better outcomes for communities by promoting a collaborative approach to planning and delivery based on local public health needs. To support this aim, there will be new arrangements at national level through the creation of Public Health Scotland to provide strategic leadership; enhanced opportunities for innovation, research, learning and development; and support for the delivery of improved outcomes. Locally, Public Health Scotland will contribute to the Community Planning Partnership leadership effort by collecting relevant data and intelligence, identifying best practice and considering service improvements and innovative approaches. Under these new national and local arrangements, the existing bodies Health Protection Scotland (a division of NHS National Services Scotland), Information Services Division (also a division of NSS) and NHS Health Scotland (a Special Health Board) will cease to exist. Public Health Scotland will take over the relevant functions and services. The main features of the model are:
22.1 A national Special Health Board, with the name Public Health Scotland, established to provide national public health functions and independent professional assurance to Scottish Ministers on the collective achievement of public health outcomes across Scotland;
22.2 Support for local strategic planning as part of community planning arrangements, including community planning partnerships;
22.3 Public Health Scotland to consult and cooperate with a defined set of public health partners, including local authority leaders (COSLA), both broadly and in specific circumstances such as preparing Public Health Scotland’s strategic plan and annual report;
22.4 Collective or collaborative arrangements for public health services which may be best arranged, managed, researched, evaluated or delivered nationally; and
22.5 A mechanism, reflecting national and local democratic responsibilities, to afford discussion and agreements as necessary, on aspects of mutual concern. The principles, purpose and values guiding this mechanism will be described in a Memorandum of Understanding.
23. At a national level, Scotland’s National Performance Framework will be used to measure progress against the Public Health Priorities, including the specific contribution of Public Health Scotland. The new body will contribute to the delivery of the National Outcomes.
24. The following chapters provide further detail on the new model for public health in Scotland, setting out the governance and accountability relationships and the roles and responsibilities of each of the constituent parts of the model.
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