Coproduction is a much used/misused term. The Christie Commission made a very strong case for service user involvement and for trust to be a key part of public service delivery. The arguments made by Christie have strong application to the integration of health and social care where it is vital that approaches in service delivery are “grounded in people’s lives”. These services must be valued because they help people “… contribute socially and economically and to be who they want to be.”[i]
This clear and compelling vision for public services must be our starting point in relation to these regulations.
The Health and Social Care Alliance points out that the evidence base for true co-production is getting stronger[ii]. As health and social care are some of the most significant services to interact with our day to day lives, it is vital that these regulations send a clear message – tokenistic consultation in creating integrated services is simply not good enough. Where we can, we must give the strongest possible voice to service users, carers and their families as equal partners in care. This must be about shifting power from professionals to people themselves – expanding the spirit within the Self Directed Support Act across health and social care.
The third sector can be a strong voice for some groups, and so brings expertise and knowledge of what works to planning tables. The sector provides critical services which help people to remain well, less isolated and therefore less likely to need hospital or institutional care. As such, it must also be seen as an equal and not just a “key” partner at all levels of representation.[iii]
Achieving effective representation and involvement will require investment in structures and support mechanisms – in response to the Set 1 regulations; we argued that there should be parity of support for allinvolved in integration boards/committees[iv] and in strategic planning and locality groups.
Non-voting members and all key stakeholders including the sector, service users and carers have much to offer in ensuring the policy outcomes for integration are achieved. They must be able to contribute on a level playing field.
Prescribed groups and prescribed consultees: Integration Schemes; strategic and locality planning
A focus on engagement within this set of regulations is welcome, but there is a wider challenge.
We must see a culture of co-production being built into integration from the very start. The level and depth of consultation and involvement should be appropriate and supported. Consider Audit Scotland’s findings on commissioning social care, where the critical nature of co-production was strongly emphasised:
“For users and carers, poor-quality commissioning of social care services can have a significant impact. These services can be very personal, and people may take time to build trusting relationships and settle into a routine. This means any changes in the timing, quality or people involved can cause considerable concern to users and their carers if they are not consulted or involved in decisions.”
Audit Scotland recommended that service users and carers should be “involved at all stages of commissioning to make sure the commissioning process results in services that meet their needs and preferences and make a difference to their independence and quality of life.”
This important report also highlighted where and how service users and carers might get involved, where local authorities and the NHS were:
- “..identifying needs and what the services should achieve
- identifying what services need to be in place
- considering how to ensure that the right range of services are available
- working with providers to develop the services people will need in future
- developing procurement strategies and plans
- undertaking procurement exercises
- monitoring and reviewing the services”[v]
Regulations and guidance must reflect these recommendations and seek to encourage statutory bodies in the strongest way possible to maximise the input and influence of those affected by decisions taken as integration is implemented.
Wider communication of integration planning, delivery and monitoring is needed as many who access services may only do so, on an irregular basis. They will however, still be affected by potential developments. In addition, working with the wider third sector is necessary[vi] to ensure that those who may not use statutory services are consulted given spending decisions and service planning may still impact on them, especially where funding for third sector provision and supports are being considered. We must ensure the widest possible reach in relation to consultation, planning, delivery and review of integrated services. A clear and thoughtful communication and involvement strategy must feature in integration planning in each partnership area.
Lastly, we would question why the second draft of the strategic plan is only being shared with prescribed consultees. If there is to be a true spirit of co-production, appropriate involvement from the beginning of the process to create the strategic plan is required. Indeed, some of this activity may already be happening through RCOP partnerships, where stakeholders such as the third and independent sectors and carer/service user representatives may already be involved in strategic commissioning discussions. The regulations and planned guidance must not have the effect of weakening good partnerships.
Geographical boundaries are increasingly challenging for families providing care when they live apart. Integrated services will need to plan for this complexity in people’s lives – a focus on geographical boundaries within the regulations may not help to challenge some of the bureaucracy which families face when people they care for move to another area, or they themselves move closer to support a loved one. Some face significant waiting lists when a care plan is being transferred including the risk of losing existing support. This is not helped by how services are planned for and procured.
The journey towards integration must recognise our changing lives, communities and demography and every avenue must be sought to reduce the bureaucracy that families face when accessing the right support. Language and tone are again important in this regard. Geographical boundaries must not create actual boundaries and barriers for families as they navigate through health and social care services.
Consultation on decisions which affect service provision
Emphasising involvement in decisions which may affect service provision is important and welcome; how boards/committees agree on these decisions is worth some further consideration.
Boards/Committees may argue that some decisions won’t affect service provision – for example, contracting out of an existing service to another provider does not mean that this service stops, so technically the service might be seen to be unaffected. But from the perspective of families, their experience may be very different.
It could lead to, for example, new care and support workers who have no understanding of the families’ situations however well trained they may be. We refer back to the Audit Scotland review of commissioning, covered earlier in this submission.
Our argument is that co-production and involvement at every stage are necessary – ultimately, this ensures that the decisions made are robust and based on effective involvement of all key groups. Many of the services and interventions covered by the Act are a lifeline for people – even the slightest change can have a significant and perhaps detrimental impact.
Voting and non-voting members – Third Sector capacity
We are disappointed that the good practice developed in Reshaping Care which gave the third sector the right to sign off Change Fund plans may be lost. The “sign off” requirement does not seem to exist in relation to integration schemes, with third sector and users/carers representatives perhaps at risk of being viewed as “less equal” than voting members. This concern was mirrored by many third sector partners at an event held by the Alliance on 1 July:
“Delegates highlighted that the lack of voting rights on joint integration boards remains a key issue. For many third sector organisations there may be little incentive to engage in strategic consultation if they have no direct ability to influence decisions.”[vii]
Many third sector organisations provide support and services which lead to positive health and wellbeing outcomes – they are an essential part of the health and social care landscape e.g. peer support, lunch clubs, food/shopping projects, older people’s social groups, community transport, support for vulnerable adults, carer support etc. Their work is largely preventative in nature and can enable people to be less dependent on statutory services.
As with the Set 1 regulations, Set 2 must be couched in the strongest possible terms, to help create the right culture and conditions which in turn enable honest and impactful involvement of the third sector, service users and carers in shaping integration. Without that involvement, strategic and locality planning and board/committee decisions will be less well informed, as there may not be a full understanding of the totality of resource available or of any potential concerns, service gaps etc..[viii] Important learning will be gained from SCVO’s with community groups and charities in East Dunbartonshire, where the sector is taking the lead in identifying community based services and supports which help people to stay well and as independent as possible[ix].
We would suggest that there may need to be more than one third sector and more than one carer/service user representative on boards/monitoring committees to ensure a stronger voice for all stakeholders. However, we recognise that effective participation which can be seen to impact on decisions made is far more important than representation alone. [x]
Already stretched by welfare reform, the sector’s role and contribution must be effectively supported.
Where good practice is identified in non-voting member and key stakeholder involvement, we must find effective ways of sharing this across all partnerships.
Being able to report on increased investment in community support means that partnerships must understand the nature of the support available.
Again, we emphasise the importance of third sector involvement to ensure that partners can gain a full understanding of services and supports available. As outlined in previous briefings, this includes services which help with wellbeing and independence in the widest sense. The link with Community Planning is critical too as changes made in relation to other local services, the impact of local economic development activity and the development and regeneration of communities, transport decisions, etc., directly affect wellbeing and the ability to remain at home.
We welcome reporting on the outcomes, and would want to see feedback from service users and carers on what they think matters/what works or doesn’t. A journey towards outcomes is needed, but that must filter down to the experiences of service users and carers at the front line.
Performance reporting might provide an opportunity to share consultation and engagement practice both with partnerships’ wider stakeholders and with service users and carers. The trend of public NHS board meetings might be something which extends to meetings of health and social care partnership boards and could form part of their review/monitoring processes.
The third sector does not underestimate the challenges involved in seeking to consult with such a wide range of partners and stakeholders. The most important of these ‘voices’ must be carers and service users. Very often, what will be needed by families will not always be costly; the support required may be not always be provided by statutory partners.
Integration provides partnerships with a unique opportunity to take stock of health and social care provision. This must be done with all key voices “at the table” and with every effort made to involve those who do not have the loudest voices in relation to the planning and delivery of public services.[xi]
The ongoing ‘technical’ focus in the Public Bodies Act and now in both sets of regulations has weakened the “message” about why integration and supporting legislation were driven forward by the Scottish Government in the first place.
We would therefore ask the Scottish Government to ensure that a very clear message is sent in this and in the previous set of regulations. That message is this – the services affected in bringing health and social care together are a central part of many people’s lives; they are the difference between isolation and being a full part of your local community and to contributing to the economy. This must be at the heart of integration planning and delivery.
Health and social care interventions must give people choice and control. Let’s set the scene for that with clear regulations and guidance which place people at the heart of shaping integrated services. The tone, language and “direction of travel” of the regulations are vitally important.
Scottish Council for Voluntary Organisations
Mansfield Traquair Centre
15 Mansfield Place
Edinburgh EH3 6BB
[ii] DRAFT: Consultation Response: Draft Regulations Relating to Public Bodies (Joint Working) (Scotland) Act 2014 – Set 2 – Health and Social Care Alliance, August 2014
[iii] SCVO response- Public Bodies (Scotland) Act, 2014 – Set 1 regulations response, August 2014
[iv] SCVO response to Public Bodies Act regulations, Set 1, August 2014
[vi] SCVO response- Public Bodies (Scotland) Act, 2014 – Set 1 regulations response, August 2014
[vii] Integration – What Next? Note of event on 1 July, Health and Social Care Alliance, July 2014
[viii] SCVO response- Public Bodies (Scotland) Act, 2014 – Set 1 regulations response, August 2014
[x] Integration – What next? Note of event on 1 July, Health and Social Care Alliance, July 2014
[xi] DRAFT: Consultation Response: Draft Regulations Relating to Public Bodies (Joint Working) (Scotland) Act 2014 – Set 2 – Health and Social Care Alliance, August 2014