Minutes of the Special Joint Meeting of the Highland Council and the Highland NHS Board held in the Council Chamber, Council Headquarters, Glenurquhart Road, Inverness on Thursday, 23 June 2011 at 10.00am.

 

Present: Highland Council

 

Mr G Farlow, Ms L Munro, Mr R Rowantree, Mr J Rosie, Lady M Thurso, Mr B Fernie, Ms G Ross, Mr G Smith, Mr D Bremner, Mr D Flear, Mrs D Mackay, Mr J McGillivray, Mr I Ross, Mrs I Campbell, Dr A Sinclair, Mr M Finlayson, Mr M Rattray, Ms M Smith, Mrs C Wilson, Mr R Durham, Mr A Rhind, Mr P Cairns, Mrs A MacLean, Dr D Alston, Mr B Barclay, Mr C Fraser, Mrs I McCallum, Mr H Fraser, Mr J Laing, Mr D Millar, Mr I Renwick, Mr B Clark, Mr A Henderson, Mr E Hunter, Mrs M Davidson, Mr D Hendry, Mr H Wood, Mr A Graham, Mr A Christie, Miss J Campbell, Mr P Corbett, Mr D Kerr, Mrs B McAllister, Mr N Donald, Mr D Henderson, Mr F Parr, Mr I Brown, Mr J Gray, Mr K MacLeod, Mr J Ford, Mrs G Sinclair, Mr R Wynd, Mr L Fraser, Mrs L MacDonald, Mr G Marsden, Mr A S Park, Mr J Crawford, Mr J Holden, Mr R Pedersen, Mr T Prag, Mr S Black, Ms J Douglas, Mr D Fallows, Mr G Rimell, Mr D Cameron, Dr M Foxley, Mr B Gormley, Mr B Murphy.


Present: Highland NHS Board


Mr G Coutts, Mrs G McCreath, Mr C Punler, Ms S Wedgwood, Mr I Gibson, Dr I Bashford, Mr M Iredale, Mr Q Cox, Ms A Gent, Dr V Shelley (videoconference), Ms E Mead, Mr M Evans, Mr O McLennan, Ms E Robertson, Dr M Somerville, Mr B Brackenridge (videoconference), Mr R Creelman, Mr R Stewart.

 

In Attendance: Highland Council

  
Chief Executive
Depute Chief Executive 
Director of Education, Culture and Sport
Director of Housing and Property 
Assistant Chief Executive
Director of Planning and Development
Director of TEC Services
Director of Social Work
 

Mr A S Park and Mr G Coutts jointly chaired the meeting

 

1. Apologies for Absence

 

Apologies for absence were intimated on behalf of Mr D MacKay, Mr R Coghill, Mr W MacKay, Mr R Greene, Mrs J Urquhart, Mrs F Robertson, Mr D Chisholm, Mrs M Paterson, Mrs H Carmichael, Mrs P Munro, Mr J Finnie, Mr R Balfour, Ms P Courcha and Ms H May.     
 

2. Declaration of Interest

 

Mr I Brown (Highland Council) declared a non financial interest in Item 3 on the grounds of being employed as an electrician by NHS Highland but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that his interest could not reasonably be taken to fall within the objective test and remained in the room.   
 

3. Planning for Integration – Development of a Lead Agency Model in Highland for Care Services

 

There had been circulated Joint Report No. HC-NHS-2-11 (149kb pdf) dated 16 June 2011 by the Chief Executive, Highland Council, and Chief Executive, NHS Highland, which confirmed that the Highland Council had agreed to develop a Lead Agency Model for the delivery of aspects of services to children and families and adults and set out further detail behind these models and a proposed Governance framework which included some guidance as to how commissioning would be developed.

 

During a summary of the report, it was confirmed that the proposed model involved single Lead Agency arrangements which left both organisations jointly accountable for determining outcomes and the resources to be committed. The Lead Agency would assume responsibility for all aspects of business delivery, strategy, internal governance and operational delivery or commissioning of services and would be fully accountable for the delivery of agreed outcomes and that this would include training requirements to ensure quality services were maintained. These arrangements were supported by a comprehensive form of pooled budgets in which the total resources for the care of a defined population were integrated in one organisation to either commission and/or provide the care for that population.

 

The Lead Agency arrangement would achieve the same degree of integration of resources as the pooling of resources but had the attraction of using existing transactional relationships between partners. This would make the financial governance and performance management of the integrated resource more straightforward than was the case with examples of limited pooling or where a separate organisation was charged with overseeing the pooled resource.

 

In this regard, the Lead Agency service models for Children and Adults had been scoped with involvement from the Programme Board and the Staff Partnership Forum as well as information gathered at the staff workshops and meetings.

 

Within the Highland context, the model of integration was the Lead Agency and the skills and behaviours required to progress this model were described as ‘commissioning’ which allowed consideration of all of the resource available and the options for service delivery. In this respect, it was recognised that, as organisations and communities, there was a need to develop the ability to analyse need, to plan and to review capacity plans as well as understanding costs.

 

As such, commissioning was defined by the NHS Improvement Service as ‘the process of securing and managing appropriate healthcare services for relevant populations at value for money for taxpayers. More explicitly, the Social Work Inspection Agency defined it as ‘the term used for all the activities involved in assessing and forecasting needs, agreeing desired outcomes, considering options, planning the nature, range and quality of future services and working in partnership to put these in place’.

 

It was clear therefore that commissioning for improved outcomes was a complex and multi-faceted process which involved a wide range of skill sets and that this was made even more complex where the outcomes for the population of interest e.g. adult and/or children’s services, were dependent on care services accessed from a wide range of interdependent providers commissioned separately. In these cases, the evidence suggested that partnerships between commissioners designed to integrate the commissioning process could result in more effective and efficient commissioning with one of the key benefits being that it brought together all of the service costs within a single commissioning process and promoted greater efficiency in the allocation and utilisation of the resource.

 

Delivering the public health function would therefore require close working between several agencies as well as the voluntary sector and the commissioning process needed to ensure that the fully integrated service which the Lead Agency Model supported and enabled took account of these boundaries and explicitly set out the roles and responsibilities for all those involved in delivering the integrated service and not just those directly employed by the provider Lead Agency. As such, the commissioning model described four categories of activity in the commissioning cycle, namely ‘analyse’, ‘plan’, ‘do’ and ‘review’. Work continued with the Scottish Government to refine guidance on commissioning but it was recommended that, in developing the commissioning documentation to support the development of integrated services, this process was adopted. In this regard, the Highland Partnership expected the following groups to be engaged in the process – services users, carers and advocacy groups; services providers from all sectors, including in-house, private and independent sectors; staff responsible for agreeing placements; services planners and policy officers, including public health; regulators and finance and contracting staff.

 

In terms of Children’s Services, it was confirmed that planning for integration was predicated on Highland Education, Health and Social Work developing an integrated approach to the commissioning of services and pooling budgets to deliver strategically commissioned services. This would require a more extensive approach to the planning of services than had been undertaken in the past and represented a once in a lifetime opportunity to reconfigure services and address some of the acknowledged challenges of delivering children’s services across the Highlands. In addition, it would allow a greater focus on the delivery of front line services, support for professionals in delivering a service to children and young people within the scope of their expertise and a reduction in management costs to better support the delivery of front line care. Also, third sector partners could also be involved in the commissioning process which would add further potential for improved service alignment and improved care for children and young people.

 

It was also advised that the Lead Agency Model for Children’s Services had been informed by consideration of the literature on integrating Children’s Services and, in addition, the external drivers which informed the scope of health elements in the Lead Agency Model in Highland and these principles had been considered alongside the views of users, carers and staff.

 

In this regard, details were provided within the report of the proposed scope of service which could constitute an Integrated Children’s Service to be delivered by the Highland Council on behalf of the Partnership and accountable to NHS Highland and Highland Council. Whilst this was not considered to be a definitive list at this stage, it was confirmed that discussions to date had indicated that approximately 230 staff in NHS Highland were currently directly associated with the functions which had been included and could be expected to carry out these functions in Highland Council from 1 April 2012 if the Lead Agency Model was approved.

 

In regard to Adult Services, it was confirmed that effective partnership working between the NHS and Local Authorities was widely recognised as a prerequisite for achieving good health and social care outcomes. In this respect, recent work to develop and test an Integrated Resource Framework for health and social care services had responded to the observation made by many of those working in health and social care that they could deliver better outcomes for people if resources could be moved around the health and social care system more effectively to support shifts I the balance of care. A further argument for integration lay in the inter-dependence of the respective and shared objectives of service providers. It was also pointed out that integration of patient level commissioning of services was an increasingly important issue, particularly for Local Authorities, and also needed to be taken into consideration.

 

The role of the third sector in terms of service provision also need to be thoroughly explored, especially in the context of new types of provider organisations such as co-operatives, community businesses and co-production models and this was something which had been actively progressed through the development of the Change Fund application – Reshaping Care for Older People.

 

A number of services had been proposed as necessary for integration if outcomes in Adult Community Care were to be improved and efficiencies maximised and these were highlighted within the report. In this regard, it was confirmed that discussions to date had indicated that approximately 1400 staff within the Highland Council were currently directly associated with these functions and could be expected to carry them out in NHS Highland from 1 April 2012 if the Lead Agency Model was approved. It was however advised that this was not necessarily a definitive list and further work in this respect was ongoing.

 

In terms of Support Services, it was confirmed that it was widely recognised that, in order to meet the needs of the Highland population, a wide range of skills and expertise were required. Although some of this expertise was less visible in regard to front line delivery, it was nonetheless essential and in scoping out at a local level consideration required to be given to business support, corporate services and management.

 

In regard to Human Resource Issues, the Lead Agency Model raised a number of significant issues and these were clearly of interest and concern to staff within both organisations. In this respect, it had previously been reported that the Staff Partnership Forum and its Sub Group had developed an employment model which was consistent with the overall objectives of Planning for Integration, provided clarity with regard to pay and conditions and ensured best value. Based on these principles, the Programme Board had approved a way forward and had confirmed that pay and conditions of employment and pensions would required to be protected for staff who transferred. However, this was a complex issue and as such a ‘Frequently Answered Questions’ document had been issued to staff in June and staff side representatives were continuing to involve staff in the work of the Human Resources Sub Group.

 

In terms of Governance and Management Structures, the basic principle of the Lead Agency Model was for the Highland Council and NHS Highland to joint agree ‘commissions’ for both children’s and adult services and these would essentially be an agreement detailing the outcomes which each partner would deliver for respective care groups with accountability staying with the statutory agency. As such, the partner organisations would trust each partner to deliver and demonstrate successful delivery of the commission for which they were the lead agent.

 

In this regard, there was a recognition of the unique responsibility held by Elected Members in that, as well as ensuring the efficient and effective management of services for which they were accountable, they were also the general advocates on behalf of their constituents in relation to a wide range of issues impacting on their communities. It was confirmed that NHS Highland would respect this role by establishing, in partnership with the Council, a series of locality/district forums which would meet to discuss the performance of the Partnership and would involve Elected Members, relevant Managers, Community Representatives and representatives for Professional Groups, including Social Work, Nursing, GP’s etc.

 

Following the review of Community Health Partnerships by Audit Scotland and the commitment of the Scottish Government to integration, there was a need to ensure that developing governance systems were able to both influence and comply with anticipated Scottish Government guidance during 2012. It had also been recognised and agreed that the Partnership required to develop a commission which would span 3-5 years, was based on the outcomes to be achieved in Adult and Children’s Services and which would detail the performance management framework.

 

A commitment had therefore been given to defining and establishing new management structures for the two integrated services which could be operational from 1 April 2012 on the basis that it was likely that interim management arrangements would need to be established to support the existing Community Health Partnerships.

 

It was confirmed that a single budget and management structure for the Lead Agencies would enable the establishment of pooled transactional budgets which would be devolved as part of the new management arrangements, single management of services for adults and children, development of the requirements for Lead Agency operation in enabling work such as Human Resources, Finance, etc, development of local integrated teams, opportunistic testing of the model of integrated local teams, creation and support of local partnerships and further discussions with the Scottish Government on the basis that it was the Partnership’s belief that the model being put in place would allow alignment to meet any emerging model of Community Health Partnerships or their successors as anticipated during 2012. In this regard, details of the proposed model, which ensured routes for scrutiny and performance management and appropriate representation of Health Board and Elected Members on the governance committees, were provided within the report.

 

In summary, it was confirmed that further work had been progressed in Planning for Integration but much was still required to be completed to enable implementation of Integrated Services in a Lead Agency Model. Much of the focus was on working with the public and communities through Ward Forums and Stakeholder Events with reporting arrangements through the Programme Board and the Leadership and Performance Group.  

 

During discussion, the following issues were raised:-

  • the reassurances which had been given in relation to the ongoing levels of care for vulnerable adults and children and families in the Highlands were welcomed;
  • positive feedback had been received from the Stakeholder Events which had already taken place and this was encouraging;
  • a step change in practice in terms of children’s services had already taken place with the introduction of Getting It Right For Every Child (GIRFEC) and this now needed to be taken further through the pooling of budgets, getting the right service (within that pooling of budgets) and shared management;
  • there was a need to work towards establishing a proper integrated system for families in that no-one should require to know who held the budget or who the manager was for the service;
  • there was a need to ensure that the opportunity was taken to eradicate duplication in management structures as this would be welcomed by the general public;
  • there was a need to set outcomes and quality indicators which were measurable and ensure that the data infrastructure was in place in order to be able to assess the difference which was going to be made;
  • there was a need to engage in dialogue with professional staff in both organisations in order to address any areas of concern as they arose;
  • it would be helpful to enter into further liaison with staff and trader union representatives from North East Lincolnshire in order to identify issues which had previously arisen in their area with their own particular model;
  • in terms of adult care, consideration needed to be given to the issue of patient transport which had not been mentioned or addressed in the report;
  • there was a need to recognise the possibility of service improvements coming up from the front line and for the people involved in service delivery to be given the opportunity to provide their own contributions to the process;
  • it was vital that communities across the Highlands had confidence in the process and that the locality/district partnership forums should be a formal part of the decision making structure with action points from these meetings being taken forward as necessary;
  • there was a need for assurances to be given in terms of involving the third sector in the commissioning as well as the delivery processes;
  • there was a need to preserve current best practice and take forward improvements in this regard;
  • it was reassuring to note that the Partnership remained open to the consideration of evidence and would not implement the Lead Agency Model if there was not a case for such change;
  • understanding patient level activity and cost was critical to the developing Self Directed Support agenda in terms of the allocation of funding to individuals and the consequential planning for investment and disinvestment;
  • there was a need to campaign for the primary legislation in this regard to be reconsidered in order to ensure that it was streamlined and fit for purpose;
  • the proposals would result in service improvements and enhanced outcomes for the people of the Highlands;
  • in terms of the locality/district partnership forums, there was a need for them to demonstrate enhanced local accessibility and accountability with effective communication, substance and influence and the opportunity needed to be available for constructive challenge and scrutiny;
  • it was vital that arrangements were put in place to encourage and resource the third sector in taking forward the proposals, especially in rural areas;
  • there was a need to recognise the role of the Trade Unions in terms of their continuing involvement in taking the proposals forward; and
  • full and ongoing engagement with staff at all levels and service users was imperative in order to ensure that the best care possible was provided for the people of the Highlands.                                   

Decision

 

Highland Council and the Highland NHS Board AGREED:-

 

(i) the development of an Integrated Children’s Service with the Highland
    Council as the Lead Agency;
(ii) the development of an Integrated Adult Service with NHS Highland as the
     Lead Agency;
(iii) the proposed model of Governance;
(iv) the approach to Commissioning;
(v) that the outcome agreements and commissioning documentation should
     be the subject of further reports to the Board and the Council; and
(vi) to continue to support the programme of implementation.

  

The meeting ended at 11.30am.