Leadership is key to the successful integration of health and social care services in Scotland. The legislative framework needs to be strengthened to ensure this
The Public Bodies (Joint Working) (Scotland) Act was passed earlier this year, and provides a legislative framework intended to drive the integration of health and social care in Scotland. The Act provides for two potential models of integration: either a ‘body corporate’ model or a ‘lead agency’ model.
The Scottish Government is currently considering secondary legislation, which will determine the details of how this framework, and the two proposed models, will operate in practice.
CIPFA has previously highlighted that leadership is a key ingredient for the success of integrated service delivery, and concluded that efforts to empower local leadership would be a stronger instrument of change than legislation or particular models of delivery. The importance of leadership was also recognised in the Scottish Government’s policy memorandum accompanying the original Bill, which stated ‘Leadership is key, locally and nationally, to achieve the changes in working practices, culture and behaviour that are required.’
Therefore, it follows that the legislative framework should promote and support such leadership to drive the cultural and behavioural changes which will be essential for successful integration.
However, in testing the draft regulations to underpin the Act, CIPFA has identified a number of areas where the regulations could be strengthened. In particular, in the ‘body corporate’ model, the proposed alternation of the Chair between partner authorities, and the provision for the Chair to have a casting vote creates a challenge around the clarity of leadership.
The main issue centres around the fact that in the ‘body corporate’ model there is ambiguity as to whether the integration authority would be acting in the role of ‘agent’, where it is regarded as acting on behalf of the partners, or ‘principal’, where it is acting in its own right. Not only does this impact on leadership, but it also creates a number of accounting issues for the ‘body corporate’ model, in terms of how it is defined.
In order to ensure that leadership is clearly vested in the participating partners, and to clarify the related accounting issues, CIPFA has recommended that arrangements for both the proposed models achieve equivalent results in the same way. This would better support a stable, long-term transition towards integrated service delivery and better outcomes for the people of Scotland.
While delivery of outcomes, and not the production of huge amounts of performance data, is the ultimate objective of public services, appropriate collection and use of performance management information is necessary. CIPFA believes that the provision of such information should be embedded from the start of this transformation.
The draft regulations also prescribe a set of national health and well-being outcomes and provide for the production of an annual performance report. However, the incorporation of a national level performance management framework underpinning these outcomes would support consistent and comparable data to be collected across Scotland, and allow for the identification of best practice and an understanding of the reasons for any local variations.
Such information would be central to demonstrating best value for the public purse. As the draft regulations stand, the performance report focuses on the stewardship of finances in relation to under- or over-spends. It is essential that the report also incorporates evidence of the achievement of best value in service delivery.
Finally, the draft regulations propose the governance arrangements to be adopted by both models of integration authority. CIPFA recommend that the Chair of the integration authority should be accountable to, and subject to scrutiny by, both partner authorities. To ensure that scrutiny is well informed, the role of the performance report in scrutiny and accountability should also be clarified.
Dr Eleanor Roy is research consultant for CIPFA Scotland
