Reformed Integration Joint Boards: Community Health and Social Care Boards
The case for change
If we want a better system, we need to do things differently. For too long the current system has operated with multiple complex processes. It has been affected by inflexible supplier contracts, local supplier limitations, and the perception that resources are scarce.
We need to improve local discretion and decision making. We need to focus on people who need support and care, and people who currently receive support and care. To do that we must design focused services based on need. These must be produced together with people who need these services, and with those who support them, whether paid or unpaid. National standards must be clear and consistent, with robust performance monitoring of local systems through regulation, and a commitment to continuous improvement. New local structures would be funded by – and accountable to – the National Care Service (NCS) and Scottish Ministers. These clear lines of accountability will ensure that we can best address future concerns and challenges raised by the people we serve.
In this chapter we set out the plan for reforming current Integration Joint Boards (IJBs) to ensure the ambition for consistent, quality delivery across services.
How it works now
The Public Bodies (Joint Working) (Scotland) Act 2014 (PBJWSA) requires Health Boards and local authorities to work together to form integration authorities, which are responsible for ensuring that health and social care services are well integrated.
There are a total of 31 integration authorities in Scotland; Highland is the only area to adopt the lead agency arrangement, in which the local authority takes responsibility for children's health and social care services and the Health Board has responsibility for adult health and social care. Other areas have adopted the body corporate model of an Integration Joint Board (IJB). Clackmannanshire and Stirling local authorities have combined to establish a single IJB across their two council areas.
The PBJWSA sets out the governance and financial arrangements for these integration authorities, and sets out requirements about the membership of an IJB. This includes minimum required membership, and provision for additional members to be appointed. IJB membership consists of voting members, who are representatives of the local authority and the Health Board, and non-voting members representing various professional groups, social care providers, people who receive social care support, and unpaid carers.
The local authority and Health Board are required to delegate functions (and budgets) to the integration authority. The integration authority then plans what care is needed in its area and directs (and provides funding to) the Health Board and the local authority to deliver it. As a separate legal entity an IJB has full autonomy and capacity to act on its own behalf. IJBs retain strategic responsibility and "operational oversight", but not operational responsibility which remains with Health Boards and local authorities.
The PBJWSA identifies the services for which integration authorities must be responsible, and also identifies some services that, with local agreement, integration authorities may take responsibility for.
Issues and problems
The Independent Review of Adult Social Care (IRASC) identified that a lack of collaborative leadership in both health and social care has affected the progress of integrated health and social care support for people in some areas. There is also a lack of strategic capacity and a high turnover of integration authority staff to support planning, commissioning and delivery.
Financial planning is not integrated, long-term, or focused on providing the best outcomes for people who need support. This limits the ability of integration authorities to improve the health and social care system.
There is flexibility available in the procurement legislation for social care services, however commissioning and procurement through local authorities are inconsistent in their approach. Using this flexibility has resulted in an implementation gap, and negatively impacted on their ability to support commissioning decisions and truly meet people's needs.
Relevant Independent Review of Adult Social Care Recommendations
Recommendation 17: The National Care Service should oversee local commissioning and procurement of social care and support by reformed Integration Joint Boards, with services procured from local authorities and third and independent sector providers. Integration Joint Boards should manage GPs' contractual arrangements…
Recommendation 23: Integration Joint Boards should be reformed to take responsibility for planning, commissioning and procurement and should employ Chief Officers and other relevant staff. They should be funded directly by the Scottish Government.
The IRASC also suggested that all members of the strategic planning group should be included as full voting members of reformed IJBs.
What we propose
In line with the relevant IRASC Recommendations, we propose that IJBs will become Community Health and Social Care Boards (CHSCBs) and will be the local delivery body for the NCS, funded directly by the Scottish Government. This will be the sole model for local delivery of community health and social care in Scotland. The functions of CHSCBs will be consistent across the country and will include all community health and social care support and services that the Scottish population requires.
CHSCBs will be accountable to Ministers and will have members who will represent the local population, including people with lived and living experience, and carers. We expect that CHSCBs will be aligned with local authority boundaries, unless otherwise agreed at local level. The members will include local elected members to preserve local democratic accountability. CHSCBs will employ their own chief executives and staff who plan, commission and procure care and support. Consideration will be given to employing other relevant staff to discharge their duties, such as chief finance officers. The chief executive of each CHSCB will report to the chief executive of the NCS.
CHSCBs will oversee the delivery of all community health and social care services and support within their local area, monitoring and improving impact, performance and outcomes for people. Their work will be guided by the strategic direction, quality standards and operational framework set out by the NCS.
CHSCBs will work together across Scotland, across local boundaries, and as part of the NCS and with the NHS, local authorities, and the third and independent sectors, to improve support for people at a regional and national level. In their local areas they will work with other public, third, and independent sector partners to ensure that support and services for people are safe, effective, seamless, and person centred. Local people will be embedded in the design, development, and delivery of support and services.
CHSCBs will have responsibility and authority for planning, commissioning, and procurement of community health and social care and other relevant support, and for the management of GP contractual arrangements. They will be able to commission services from local authorities, the NHS and the third and independent sectors. CHSCBs will commission and procure support and services based on people's needs and quality of service, and will apply the core requirements for ethical commissioning, once established.
It will still be necessary for the services overseen by the NCS to link closely to services provided by other organisations at the local level. CHSCBs will be members of community planning partnerships, taking the place of IJBs on those groups. This will support the wider integration and co-ordination of community health and social care services with other public services to improve local outcomes and reduce inequality. Similarly they will be members of other local partnerships which co-ordinate services to improve outcomes for people, such as Alcohol and Drugs Partnerships and Adult Protection Committees.
We will consider how best to ensure effective joint working with other services such as housing, education, and policing. One way to achieve this may be to make the CHSCB a statutory consultee for strategic planning on various issues. We also expect that CHSCBs will also be involved in joined up planning to tackle homelessness, and will be subject to the shared prevention duty that we are committed to develop under the Ending Homelessness Together Action Plan.
Q58. "One model of integration… should be used throughout the country." (Independent Review of Adult Social Care, p43). Do you agree that the Community Health and Social Care Boards should be the sole model for local delivery of community health and social care in Scotland?
Please say why.
Q59. Do you agree that the Community Health and Social Care Boards should be aligned with local authority boundaries unless agreed otherwise at local level?
Q60. What (if any) alternative alignments could improve things for service users?
Q61. Would the change to Community Health and Social Care Boards have any impact on the work of Adult Protection Committees?
Membership of Community Health and Social Care Boards
Q62. The Community Health and Social Care Boards will have members that will represent the local population, including people with lived and living experience and carers, and will include professional group representatives as well as local elected members. Who else should be represented on the Community Health and Social Care Boards?
Q63. "Every member of the Integration Joint Board should have a vote" (Independent Review of Adult Social Care, p52). Should all Community Health and Social Care Boards members have voting rights?
Q64. Are there other changes that should be made to the membership of Community Health and Social Care Boards to improve the experience of service users?
Community Health and Social Care Boards as employers
"[Integration Joint Boards] should employ Chief Officers and relevant other staff." (Independent Review of Adult Social Care, p53). Currently, the Integration Joint Boards' chief officers, and the staff who plan and commission services, are all employed either by the local authority or Health Board. The Independent Review of Adult Social Care proposes that these staff should be employed by the Community Health and Social Care Boards, and the chief executive should report directly to the chief executive of the National Care Service.
Q65. Should Community Health and Social Care Boards employ Chief Officers and their strategic planning staff directly?
Q66. Are there any other staff the Community Health and Social Care Boards should employ directly? Please explain your reasons.
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