Health and Community Care. Study of Community Health Partnerships

Transcription

1 Health and Community Care Study of Community Health Partnerships

2 STUDY OF COMMUNITY HEALTH PARTNERSHIPS Glenys Watt, Onyema Ibe and Nicola McLelland, Blake Stevenson Ltd Scottish Government Social Research 2010

3 This report is available on the Scottish Government Social Research website only The views expressed in this report are those of the researcher and do not necessarily represent those of the Scottish Government or Scottish Ministers. Crown Copyright 2010 Limited extracts from the text may be produced provided the source is acknowledged. For more extensive reproduction, please contact the Queens Printers of Scotland, Admail, ADM 4058, Edinburgh EH1 1NG.

4 Acknowledgements We would like to thank everyone who gave their time to participate in the interviews during Stage 1 and Stage 2 of this study, the participants who attended the workshop sessions in Stage 3 and the Research Advisory Group for their advice, guidance and support throughout. In addition to the three authors identified in the title page we would like to acknowledge the other members of the research team: Sophie Ellison, James Mahon and Alasdair Stuart.

5 Table of Contents EXECUTIVE SUMMARY 2 1 INTRODUCTION 1 RESEARCH AIM 1 STAGE 1 RESEARCH - APRIL TO AUGUST STAGE 2 RESEARCH SEPTEMBER TO DECEMBER CONTEXT 5 STATUTORY GUIDANCE FOR COMMUNITY HEALTH PARTNERSHIPS 5 SCHEMES OF ESTABLISHMENT 7 FACTUAL INFORMATION ABOUT THE CHPS 7 IMPACT OF NATIONAL AND LOCAL ELECTIONS DEVELOPMENTS IN HEALTH POLICY 11 IMPACT OF SINGLE OUTCOME AGREEMENTS (SOA) 12 3 PERCEPTIONS OF PURPOSE, STRUCTURES AND RELATIONSHIPS 14 PURPOSE 14 STRUCTURES AND RELATIONSHIPS 14 OTHER RELATIONSHIPS 18 4 CHP PROGRESS AND ACHIEVEMENT 22 SHIFTING THE BALANCE OF CARE 22 IMPROVING HEALTH AND TACKLING INEQUALITIES 26 CHPS KEY ACHIEVEMENTS 28 5 FACILITATORS, CHALLENGES AND BARRIERS 31 FACILITATORS 31 CHALLENGES AND BARRIERS 33 6 MAXIMISING THE CHPS POTENTIAL 42 SUMMARY OF SUGGESTIONS MADE DURING STAGE CONCLUSIONS 48 APPENDIX 1 RESEARCH ADVISORY GROUP MEMBERS 52 APPENDIX 2: STAKEHOLDERS INTERVIEWED DURING STAGE 1 53 APPENDIX 3: STAKEHOLDERS INTERVIEWED DURING STAGE 2 60 APPENDIX 4: LINKS TO KEY POLICY DOCUMENTS 62 APPENDIX 5: INTERVIEWEES PERCEPTIONS OF THE DEVELOPMENT OF THE CHPS 64 APPENDIX 6: EXAMPLES OF PRACTICE FROM THE STUDY 66 LIST OF TABLES TABLE 1.1: NUMBER OF INTERVIEWS CONDUCTED IN STAGE 1 2 TABLE 2.1: TYPES OF CHP STRUCTURES IN RELATION TO HEALTH BOARD AND LOCAL AUTHORITIES 8 TABLE 7.1: IDEAS FOR FURTHER CONSIDERATION 50

6 Executive summary Introduction Community Health Partnerships (CHPs) are the key mechanism through which all primary and community based services are planned and delivered. They have a central role with their partners in improving health and reducing health inequalities. Scottish Ministers have reaffirmed the central role of CHPs in shifting the balance of care which is a prerequisite for the delivery of many HEAT targets and joint outcomes with Local Authorities. This report presents the findings of a study of the early progress of Community Health Partnerships (CHPs) carried out by Blake Stevenson for the Scottish Government between February 2009 and March The research aims were to consider the early progress CHPs had made in relation to key areas of responsibility, identify the factors which had facilitated or possibly hindered progress and to identify ways in which the CHPs capacity and capability could be improved to maximise their potential. Background The National Health Service Reform (Scotland) Act 2004 provided for each Health Board to establish CHPs. Health Boards were required to produce Schemes of Establishment for the CHPs which came into operational existence in 2005 (with the exception of Orkney and Western Isles which came into existence in 2006 and 2007 respectively). The Scottish Government issued statutory guidance to assist in the establishment of the CHPs. The guidance made it very clear that the Scottish Government did not expect all the CHPs to be the same: there is no one size fits all. However it stipulated that in order to allow Health Boards to devolve functions and powers, all CHPs would be either committees, or sub-committees, of a Health Board. Since the establishment of CHPs in 2005 there have been significant changes within the national and local context. As well as the change in administration after the 2007 Scottish Parliament elections, there were also significant changes in the majority of the local elections held in that year. One of the key changes which took place in late 2007 was the Concordat between the Scottish Government and COSLA, which established the agreement of local authorities to work towards national priorities through the mechanism of locally-led Single Outcome Agreements (SOAs). The second round of SOAs were submitted in 2009 by the Community Planning Partnerships (CPPs). Since 2007 there have been significant health policy developments and several key policies introduced which have impacted on the role of CHPs in service planning and delivery.

7 Methodology The study was conducted in three stages: the first stage involved all 40 CHPs and built a picture of the perceptions of a number of stakeholders about how CHPs have progressed; the second stage involved six CHPs and examined in more depth how CHPs are operating and how they have addressed a number of key responsibilities and functions. The final stage engaged a range of stakeholders to discuss and validate the study s findings and contribute to developing the way forward. The CHPs The 40 CHPs vary considerably in terms of population size served (from ,000). The majority of CHPs are co-terminous with one local authority but in some areas (Fife, Glasgow, Highland) there are several CHPs within the local authority boundary. Whilst all CHPs are committees or subcommittees of the Health Board, there are variations to the model, with eight Community Health and Care Partnerships (CHCPs) and three Community Health and Social Care Partnerships (CHSCPs) all of which incorporate care and health services. In contrast, other CHPs, such as West Lothian and Edinburgh City, also have responsibility for social care services but have not changed their name to reflect this. Most CHPs have a central CHP management team but some areas have developed a different model: in Dumfries and Galloway there are four Local Health Partnerships and in Ayrshire and Arran there are three CHP Facilitators. CHPs use a range of different management systems to capture performance including Balanced Scorecards, Citystats and traffic light systems. There is varied interaction with the CPPs in each area ranging from very close involvement where the CHP is the Health and Wellbeing arm of the CPP to a few CHPs where the link is still evolving. Key findings The picture that emerges is one of variation across the 40 CHPs with a complexity of relationships and structures. The no one size fits all described in the statutory guidance has proved to be the case and the opportunity to develop a local approach has been broadly welcomed. The CHPs have successfully developed at a time of significant change in terms of policies and new ways of working. In particular the advent of the SOAs has changed the relationship between local authorities and national government and has led to a greater emphasis on the role of CPPs. CHPs operate in a changing context and cover a complexity of areas of work from improving relationships between primary and secondary care to engaging with the local authority and other partners on linking health and social care as well as working jointly on other services for vulnerable people (older people, children, those with learning disabilities and those with mental health problems).

8 Given this changing context it is not surprising that several of the CHPs have made revisions to their original Schemes of Establishment and that others are considering changes. The CHPs are continually evolving in each local area. Purpose of CHPs There was a variety of perceptions as to the purpose of the CHPs with views ranging from service delivery, health improvement to acting as a partnership working facilitator. There was also variation in the Health Boards perceptions of the CHPs role with some focusing on the operational/service delivery side, while others see both a delivery and strategic role that more clearly reflects the original guidance for CHPs. One description of the role CHPs play was as adaptors or linking agents between the different organisations, departments and sectors involved. This linking role facilitated better understanding between the different organisations and can be visualised as acting horizontally across different areas of vertical service provision to help broker joint working and, where appropriate, integration. Relationships Relationships are central to the way in which each CHP has developed. These include relationships with the Health Board, the local authority and the CPP. The CHCPs and CHSCPs are formalised examples of close working between the Health Board and local authority to manage the CHP jointly. In other CHP areas there are similar levels of close working and devolved responsibility and accountability although these have not been formalised into a CHCP or CHSCP. In some areas the need for formal structures to reflect strategic joint decision making between the Health Board and local authority has led to the development of a Health and Social Care (or similarly named) Partnership Board. The other relationships that are important in how the CHPs conduct their work are with the voluntary sector, the public, secondary care and with independent contractors, especially GPs. CHP Progress The CHPs have made significant progress to shift the balance of care and improve health. In relation to Shifting the Balance of Care, there were examples of shifting to more preventive work, for example in the development of long-term conditions strategies and anticipatory care initiatives. There were also examples of shifting who delivers services in terms of: providing more care at home through the use of Home from Hospital initiatives and new posts such as health and social care assistants; undertaking more treatment locally to avoid hospital admission, for example by paramedics and GPs; undertaking treatment within hospitals by non-consultant staff, such as physiotherapists, where this was appropriate. Finally there was evidence of shifting the balance of care through shifting the location of services including work to provide better access to services. The focus here has been on more local services and on developing multi-agency facilities.

9 While there were many specific examples of activities to improve health, for example around smoking cessation, obesity, tackling alcohol and drug misuse there was a sense from those interviewed that there was still a lot to do in this area. In terms of reducing health inequalities some CHPs were working well with other agencies to tackle the wider social determinants of health and such as employability, housing and homelessness. In other areas there were examples of multi-agency work to tackle inequalities for specific sections of the community such as work with young people to address anti-social behaviour. Overall however, the research participants felt there was much further work to do in this area. Achievements The most commonly reported achievement was working with other bodies and building good working relationships across the health family and externally. Another achievement in some CHPs was linking health and social care, although it was recognised that this had been challenging at the start due to differences in culture and staff. The CHPs in many areas have made the health service more understandable and accessible for local people, facilitating a level of engagement that was not seen previously. For most CHPs the Public Partnership Forum has been central to this engagement. The range of people involved in the CHP Committee was seen as assisting in the service redesign that has taken place, for example around long term care provision, care at home and community nursing. This service redesign has in turn improved access and availability for service users. Facilitators of CHP Progress The key issues that have assisted CHPs to deliver against their areas of responsibility, as identified in the interviews with stakeholders, are the qualities of the CHP management team, the tradition of close partnership working with the local authority and the leadership from key individuals such as the Health Board Chief Executive and Chair of the CHP Committee. Other facilitators included: co-terminosity with local authority locality boundaries as well as with other agencies boundaries; co-location of staff; being an integral part of the CPP; political buy-in from elected members; positive engagement with GPs; and strong links with the voluntary and community sectors. Challenges and barriers to CHP Progress In terms of challenges and barriers facing CHPs, some were specific to the local context and others were common across groups of CHPs. These related to: the relationships with health colleagues, the local authority and the Health Board; engaging effectively with GPs was commonly acknowledged as a challenge for CHPs; the differing perceptions about the role of the CHP;

10 CHP structures (including size of the Committee) and governance arrangements ; organisational differences between the NHS and local authorities; and capacity and financial resources to deliver their work. Conclusions and suggestions for forward action Suggestions to help maximise the potential of the CHPs included: that CHPs have a key role in acting as adaptors, the links between the various agencies involved to help promote and develop further joint working and, where appropriate, integration of services for vulnerable people across the community, primary and secondary care pathway. This role was referred to as managing the horizontal care pathway across the various vertical providers. In addition, the challenge that CHPs face in terms of tackling health inequalities was recognises as was the importance of CHP engagement across the CPP themes if a real difference is to be made in this area. Specific suggestions for further development were considered under three headings: governance and structures; the role of CHPs; the horizontal pathway process. It was concluded that further work was needed to review and strengthen some aspects of CHP governance and structures and some partners had already started this work. In addition, the CHP s role in managing the patient pathway between community care and primary and secondary care needed to be strengthened and the position of CHPs in relation to CPPs needed to be made more explicit. There was a role for all partners (health boards, local authorities, CPPs, CHPs and national level organisations such as COSLA and the Scottish Government) in some or all of these areas of work. The overall sense was that despite the challenges identified during the study, many of those interviewed thought that the CHP in their area was working well and that they would continue to build on the progress that has been made so far. CHPs are now ready to move onto the next chapter of their development.

11 1 INTRODUCTION Research aim 1.1 In February 2009, the Scottish Government s Health Analytical Services Division commissioned Blake Stevenson to undertake a research study on Community Health Partnerships (CHPs). 1.2 The research aims were to consider the early progress CHPs have made in relation to key areas of responsibility, identify the factors which have facilitated or possibly hindered progress and identify ways in which the CHPs capacity and capability can be improved to maximise their potential. 1.3 There are three stages to this study: the first involved all CHPs and built a picture of the perceptions of a number of stakeholders about how CHPs have progressed; the second stage involved six CHPs and examined in more depth how CHPs are operating and how they have addressed a number of key responsibilities and functions. The final stage engaged a range of stakeholders to discuss and validate the study s findings and contribute to developing the way forward. 1.4 A research advisory group has guided the work of the study. A list of the group s members is given in Appendix 1. Stage 1 Research - April to August The main purpose of the first research phase was to produce a high level picture of CHPs overall progress and gather the perceptions of a range of stakeholders as to the purpose, aims and objectives of the CHPs. This was achieved in two ways through desk research and interviews with representatives from each CHP, local authority and Health Board as well as national stakeholders. 1.6 The desk research examined the Schemes of Establishment 1, looked at the minutes from CHP Committee meetings and reviewed other relevant research reports and guidance materials. This provided the context and background for each CHP and helped to shape the areas for exploration during the interviews. 1.7 During this first phase the research team aimed to interview: the General Manager of each CHP; the Clinical Lead of each CHP; the CHP Committee Chair of each CHP (14 of which were local elected members); a senior local authority officer who works with the CHP; the Chair of each NHS Board; and the Chief Executive or Chief Operating Officer of each NHS Board. 1 the document that describes the role and responsibility of CHPs 1

12 1.8 In addition to these interviews, the views of representatives from seven national stakeholder bodies 2 were also explored through a series of face to face interviews. Table 1.1 summarises the number and type of interviews undertaken and Appendix 2 provides a more detailed breakdown. Table 1.1: Number of interviews conducted in Stage 1 Number of interviews CHPs (including Chairs) Local Authority Officers NHS Health Boards National Stakeholders The discussions with interviewees explored a range of themes around: CHP structures and partnership arrangements; the effectiveness of CHPs and considered aspects like performance management, progress against priorities, achievements and challenges; and the future operation of the CHPs and strategies to assist future effectiveness. Stage 2 Research September to December The second phase involved more in depth work with six CHPs to explore how they were operating and discharging certain key responsibilities and functions. The CHPs selected for Stage 2 were: Dunfermline and West Fife; Edinburgh City; Mid Highland; Renfrewshire; Scottish Borders; and South Lanarkshire The research advisory group selected these CHPs against criteria covering different structures, a mix of urban and rural areas, different pre-existing joint arrangements and different relationships with local authorities Stage 2 involved a wider range of stakeholders than Stage 1 and included: the CHP General Manager and the wider CHP team; secondary care professionals and staff; voluntary sector/public partnership forum representatives; local authority elected members; CHP committee members; and the Community Planning Partnership (CPP) manager. 2 Representatives from the NHS Boards Chairs Group, Scottish Ambulance Service, Scottish Government, Volunteer Health Scotland, the Association of CHPs, NHS Health Scotland, COSLA Health & Wellbeing Executive Group 2

13 1.13 Stage 3 comprised four Findings and Reflection events held in Edinburgh, Perth, Stirling and Clydebank. These were attended by 133 participants most of whom had been involved in the earlier stages of the study. An overview of findings were fed back to participants and then, at each event, participants were asked to consider four key questions: How can the role and effectiveness of CHPs be further enhanced through their relationships with the wider health family? How can the role and effectiveness of CHPs be enhanced through their relationships with the local authority and the community planning partnership? What should the balance be between local flexibility and national direction? How can CHPs play a realistic role in how they contribute to addressing health inequalities? 1.14 This report draws together the desk research and the views of the 203 interviewees from Stage 1 and the 66 interviewees from Stage 2 of this study and summarises the views of participants in Stage 3. We recognise in doing this that there are wide ranging and multiple views and experiences of the CHPs and that people s perceptions within a CHP area as well as between areas are hugely varied. We have carefully analysed all the responses in order to present this picture and recognise that there will always be exceptions to the points being made The overarching findings from this study are that there is huge variety across the CHPs, in terms of size, structures, relationships and progress, and that these elements are constantly evolving. This is in line with expectations as CHPs were intended to reflect local circumstances. The report will demonstrate these points in detail The remainder of the report is structured as follows: Chapter 2 provides an overview of the CHPs and the context in which they are operating and identifies the national changes and developments that have taken place since they were established; Chapter 3 sets out the perceptions of those interviewed during the study on the purpose of the CHPs and their relationships; Chapter 4 reports on the perceptions of progress made by CHPs, provides specific examples of services and developments in some CHP areas to illustrate this progress, and explores the tangible benefits and key achievements identified by interviewees; Chapter 5 sets out the perceived facilitators to the progress made by CHPs, along with the perceived challenges and barriers they have faced; Chapter 6 captures the suggestions made at Stage 3 for the future effectiveness of CHPs; and Chapter 7 provides our conclusions from the three stages of the study together with areas for further consideration The report is set out to show the journey of how we arrived at the research findings and final conclusions. Inevitably there are some issues that appear 3

14 more than once but we hope that this allows the reader to see how the different views contributed to the overall review. 4

15 2 CONTEXT 2.1 This chapter starts by describing the history and development of the CHPs with factual information, and finishes by placing them in the national policy context. Some of the information gathered during Stage 1 (e.g. organisational arrangements) had changed by the time we conducted Stage 2 and illustrates the evolving nature of the CHPs. 2.2 The chapter covers the following: the statutory guidance that accompanied the Act that provided for the establishment of the CHPs in 2004; the Schemes of Establishment and changes to them; factual information about the CHPs; impact of local elections; developments in health policy ; and the Single Outcome Agreements. Statutory guidance for Community Health Partnerships 2.3 The National Health Service Reform (Scotland) Act 2004 came into force in September 2004, providing for each Health Board to establish Community Health Partnerships (CHPs). To assist in their establishment the Scottish Government published statutory guidance in October The Guidance document set out the aims for the CHPs. They will be expected to: deliver services more innovatively and effectively by bringing together those who provide community based health and social care; shape services to meet local needs by directly influencing Health Board planning, priority setting and resource allocation; integrate health services, both within the community and with specialist services, underpinned by service redesign, clinical networks, and by appropriate contractual, financial and planning mechanisms; improve the health of local communities, tackle inequalities and promote policies that address poverty and deprivation by working within community planning frameworks; be the main NHS agent through which the Joint Future agenda is delivered in partnership with local authorities and the voluntary sector; be the main NHS agent through which the recommendations of For Scotland s Children are implemented in partnership with local authorities; be the principal NHS partner in Integrated Community and Health Promoting Schools; lead the implementation and monitoring of child health surveillance and relevant aspects of screening of children; 3 Community Health Partnerships, Statutory Guidance, Scottish Executive, October

16 promote involvement of, and partnership with, staff whether employed by or contracted to the NHS; secure effective public, patient and carer involvement by building on existing, or developing new mechanisms. 2.4 Health Boards were charged with preparing a Scheme of Establishment for the CHP(s) in their area. The Scheme of Establishment was expected to define the intended outcomes for each CHP and to describe the range of services it would offer. 2.5 The Guidance made it very clear that it did not expect all the CHPs to be the same: there is no one size fits all. However it was stipulated that in order to allow Health Boards to devolve functions and powers, all CHPs would be either committees, or sub-committees, of a Health Board. The Guidance gave a suggested list of potential members, to include at least one representative from: a general medical practitioner; a general manager who will be an officer of the Health Board; a nurse; a medical practitioner who does not provide primary medical services; a councillor or officer of the local authority; a representative of staff (nominated by the area partnership forum); a member of the public partnership forum; a community pharmacist; an allied health professional; a dentist; an optometrist; and a member of the voluntary sector carrying out services similar or related to the Health Board. 2.6 In particular, it was anticipated that Local Authority membership should be commensurate with their substantive partnership arrangement with the CHP. 2.7 The Guidance stated that CHPs should build on the success of LHCCs and Joint Futures work and should also be involved in other areas of developing joint outcomes across the range of care groups, in particular: CHPs will be expected to be a core component of local arrangements for translating joint planning of children s services at a strategic level into better integrated service delivery on the ground and improved outcomes for children and young people. 6

17 Schemes of Establishment 2.8 Section 10 of the Community Health Partnerships (Scotland) Regulations (2004) set out the prerequisite for a Scheme of Establishment to be submitted which outlined the following: size of population and geographical coverage of each CHP; membership; the services they will provide and co-ordinate; financial arrangements; organisational and accountability arrangements; development plan; and arrangements for partnership working including the local authority, NHS Board, Officers of the Board, members of the public and voluntary organisations. 2.9 Each Health Board was required to submit their Schemes of Establishment for approval by Scottish Ministers by December 2004 with a view to CHPs being operational by April Both Orkney and Western Isles were granted extensions to finalise their Schemes of Establishment and formally came into being in November 2006 and March 2007 respectively. Orkney evolved their CHP arrangements further in Factual information about the CHPs CHP by population size 2.11 Across the 40 CHPs Edinburgh City CHP covers the area with the largest population with 496,732, followed by North Lanarkshire with 321,100 and South Lanarkshire with 303, The biggest group of CHPs (17 in total) in terms of population size covers areas with a population of between 100,000 and 200, Five CHPs have populations of less than 50,000 - Clackmannanshire 4, North Highland 5, the Western Isles 6, Shetland Islands 7 and the smallest, the Orkney Islands covering 19,245. Structures of CHPs 2.14 CHPs have been formed as committees or sub-committees of NHS Boards. There are a total of 40 CHPs across the 14 territorial Health Board areas and four types of configuration between the CHP, local authority and Health Board have been identified as shown in Table , , , ,000 7

18 Table 2.1: Types of CHP structures in relation to Health Board and local authorities Model Health Board No. of Local Authorities No. of CHPs Borders 1 1 Dumfries & Galloway 1 1 A Shetland 1 1 Orkney 1 1 Western Isles 1 1 B Fife 1 3 C Greater Glasgow & Clyde 6 10 Highland 2 4 Ayrshire and Arran 3 3 Grampian 3 3 D Forth Valley 3 3 Lanarkshire* 2 2 Lothian^ 4 4 Tayside 3 3 *A small area of Lanarkshire receives clinical services from Greater Glasgow & Clyde NHS Board area. ^ East Lothian and Midlothian are currently managed by one General Manager Type A consists of NHS Boards which are co-terminous with one local authority boundary and have a single CHP, for example NHS Borders NHS Fife (Type B) is co-terminous with Fife Council but the geographical area contains three CHPs which together are co-terminous with the local authority boundary With Type C the Health Board covers more than one local authority for example NHS Greater Glasgow and Clyde covers six local authority areas, five of which have one CHP but Glasgow City Council has five Community Health and Care Partnerships (CHCPs) Lastly Type D where the NHS Board has more than one local authority each with one CHP that is co-terminous with its local authority for example NHS Forth Valley has three local authority areas each with one CHP A total of 29 CHPs are co-terminous as single entities with their local authority. The remaining 11 CHPs are collectively co-terminous with their local authority boundaries Whilst all CHPs are committees or subcommittees of the Health Board, there are variations to the model, with eight Community Health and Care Partnerships (CHCPs) and three Community Health and Social Care Partnerships (CHSCPs) all of which incorporate care and health services. It should be noted that other CHPs such as West Lothian and Edinburgh City also have responsibility for social care services but have not changed their name NHS Dumfries and Galloway has developed a slightly different model with four Local Health Partnerships (LHPs) rather than a CHP management team 8

19 as such. There is a CHP Committee which, until recently when it was reviewed, met once a year. All CHPs have locality structures in place. Evolving contexts and structures 2.22 Both the contexts in which CHPs operate and the structures of CHPs are continually evolving For example in April 2006, following the Ministerial decision to dissolve NHS Argyll & Clyde, NHS Highland took responsibility for Argyll & Bute CHP, while Renfrewshire CHP, East Dunbartonshire CHP and West Dunbartonshire CHP became accountable to NHS Greater Glasgow and Clyde. This resulted in revised Schemes of Establishment being submitted to Scottish Ministers to reflect these changes In Glasgow City a revised city-wide Scheme of Establishment introduced a new Joint Partnership Board where the CHCPs in Glasgow City have delegated authority for Council resources as is already in place for NHS resources. This is similar to other areas such as West Lothian and Edinburgh City who have similar arrangements in place In Edinburgh, following a review of local management arrangements, North Edinburgh and South Edinburgh CHPs were consolidated to create Edinburgh City CHP. This recommendation was approved by the Minister and Edinburgh City CHP came into being in April NHS Ayrshire and Arran has recently carried out a reorganisation of the structure of the CHPs within Ayrshire in order to strengthen joint working arrangements with the local authorities and to achieve better clinical integration across primary and secondary care. In November 2008 Ministers approved the strengthened arrangements for the CHP structures in Ayrshire Each of the three CHP committees within Ayrshire now reports directly to the Health Board and has a CHP Locality Officers Group, where the NHS and local authority officers consider strategic and operational issues, and a CHP Forum, which consists of the membership of the previous CHP committees such as GPs, health professionals and voluntary groups. Each CHP has a Facilitator. The CHP Facilitator is jointly funded by Health and the Local Authority, and as such, their role is to ensure local partnership arrangements, in the widest sense, are functional, productive, focused and integrated into other relevant local authority, health and community planning structures. Essentially the Facilitator is in place to ensure the partnerships add value and produce better outcomes, not least those within the Single Outcome Agreements In the Scottish Borders there was a review in 2008 leading to a restructuring with Ministerial approval for a CHCP Board and a CHCP Planning and Development Committee with joint commissioning teams beneath this covering community care and adults, mental health, learning disabilities and a children and young people s planning partnership. 9

20 CHP Committees 2.29 All CHPs have a Committee. The majority of CHP Committees meet six times during the course of the year with an average of 20 committee members including representatives from, for example, voluntary organisations, Public Partnership Forum (PPF), Staff Partnership Forum (SPF) and Professionals. Committee Chairs are non-executive directors of the NHS Boards (although not all five CHP chairs in Glasgow City sit on the Board) and fourteen Committee Chairs are also local councillors The role of the CHP Committee varies but the most commonly reported primary functions were planning, monitoring performance, advising the CHP team, noting information on actions taken and taking decisions on service development. CHP management teams 2.31 CHP management teams are led by a General Manager or a Director. There was no obvious difference in the title as Directors were not all members of the NHS Board. The majority of CHPs (22) have a General Manager and 14 have a Director. Two areas, East Lothian CHP and Midlothian CHP, are being managed by one General Manager. East Ayrshire CHP, North Ayrshire CHP and South Ayrshire CHP have CHP committees which now report directly to the Health Board following reorganisation, with CHP Locality Officers leading the management team. The Executive Director for Integrated Care and Partner Services is accountable to the Health Board Just over half of CHP General Managers or Directors (23) report directly to the Chief Executive of the NHS Board. The rest are accountable to the Chief Executive through the Chief Operating Officer/Chief Executive of the Delivery Unit, and in one case to the Health Care Director for Integrated Care and Partner Services. In one CHP (Scottish Borders) the CHP General Manager is also the Health Board s Chief Operating Officer There are variations in the levels of pay between the CHP General Managers and Directors and in the remuneration of the CHP Committee Chairs. This variation reflects the differing size and level of responsibility across these roles. Performance Management reporting 2.34 CHPs use a range of different management systems to capture performance All CHPs report locally on relevant HEAT targets set by the Scottish Government and there are also some more local performance monitoring systems such as Citystats, Balanced Scorecards and traffic light systems Two fifths of CHPs use a Balanced Scorecard to measure performance and a third use Citystats or a similar system. Several CHPs report on a combination of HEAT and SOA targets through systems developed locally. 10

21 Links with community planning partnerships 2.37 There is varied interaction with the Community Planning Partnerships amongst CHPs. In nine the CHP is the health and wellbeing arm of the CPP; in 18 CHP staff attend the CPP meetings or have close working relationships. In ten CHPs the relationship with the CPP is less well developed usually because the CPP deals directly with the Health Board rather than the individual CHPs and in three the CHP s links with the local CPP are still evolving at this stage. Impact of national and local elections As well as the impact of the change in administration after the 2007 Scottish Parliamentary elections, there were also local elections in 2007 which saw significant changes to the overall control of 29 out of the 32 local authorities in Scotland. This in turn affected thirty three CHPs to varying degrees. For some CHPs this meant that there was a complete change of all the elected members on the CHP committee and the knowledge and experience held with the former councillors was replaced by first time councillors who were adjusting to their new political roles as well as getting up to speed with health related matters. In other CHPs the change in political administration resulted in the development of new working relationships with political leaders and a new dialogue about the role of the CHP and its involvement with the local authority. Developments in health policy 2.39 The policy context in which CHPs operate has evolved since they first became fully operational in April 2005 or the effect of these policies only began to be felt after the CHPs came into being. Below is a summary of some of the key policies that have been introduced and have impacted on the role CHPs have in service planning and delivery (links to all of these can be found at Appendix 3): National Strategy for the Development of the Social Service Workforce in Scotland: a plan for action (Scottish Executive, 2005); Changing Lives: Report of the 21st Century Social Work Review (Scottish Executive, 2006); Better Health, Better Care: Action Plan (Scottish Government, 2007); Mental Health in Scotland: closing the gaps making a difference (Scottish Government, 2007); Towards a Mentally Flourishing Scotland: the future of mental health improvement in Scotland (Scottish Government, 2008); A Force for Improvement: The Workforce Response to Better Health, Better Care (Scottish Government, 2009) Since 2008 the Scottish Government has produced three inter-linked frameworks that are essential to its focus on reducing health inequalities: Achieving our Potential: A Framework to tackle poverty and income inequality in Scotland (Scottish Government, 2008); 11

22 Equally Well: Report of the Ministerial Task Force on Health Inequalities (Scottish Government, June 2008); Early Years and Early Intervention: A Scottish Government and COSLA policy statement (March, 2008) There have also been papers that touch on the CHPs role in health improvement including the following: The Potential Contribution of the Voluntary Sector to the Scottish Government s Health Improvement Performance Management Framework (NHS Health Scotland, October 2008); and Health Improvement and Community Health Partnerships- Advice Note (CHP Health Improvement Group, June 2009) There are also policy and research papers that relate directly to the CHPs priority areas: Shifting the Balance of Care - Overview of Evidence Relating to Shifting the Balance of Care: A Contribution to the Knowledge Base. (Scottish Government, September 2008); Long Term Conditions - Improving the Health and Wellbeing of People with Long Term Conditions in Scotland: A National Action Plan (Scottish Government, June 2009); and Community Care outcomes - National Outcomes For Community Care (Scottish Government, April 2007) In December 2009, Sir John Arbuthnott produced the findings of the Clyde Valley Review, in which he was asked by the eight Councils in the Clyde Valley to carry out a review of the potential for providing shared services through joint working across the Councils and two Health Boards in that area. Among other areas this report identified the need for an accelerated joint working between the individual Councils and the two Health Boards to deliver a single integrated health and social care service..which should evolve from the community health and care partnership model The Clyde Valley Councils instigated the Clyde Valley Review process because of an awareness of the growing financial constraints on the public resources available to them. This is an issue that is a key part of the context for CHPs in the coming years together with the demographic challenges posed by an increasingly older population which in turn hold implications for workforce planning Other contextual issues of relevance to the CHPs include the ongoing test site work on Integrated Resource Framework, the pilot elections to Health Boards and the national work programme on reshaping care for the elderly. Impact of Single Outcome Agreements (SOA) 2.46 In November 2007 the Scottish Government signed a Concordat with COSLA which ensured the commitment of local government to supporting progress at national level through agreeing strategic priorities and outcomes for each local 12

23 authority area. Each priority area relates to a set of 15 National Outcomes outlined in the National Performance Framework Scotland Performs 8 and progress towards these outcomes is measured using a set of 45 performance indicators In order to achieve this, each of the 32 local authorities reached their first SOA with the Scottish Government during 2008, setting out priority areas in their local area which would be delivered either individually or in partnership with CHPs, CPPs or third sector organisations. During 2009 the second SOAs were developed, this time submitted by CPPs. The three social policy frameworks identified in Para have been identified as priorities for all SOAs together with economic recovery CHPs along with other community planning partners are expected to contribute to the national indicators including both health and other indicators. Some of the relevant indicators are: reducing the proportion of people aged 65 and over admitted as emergency patients two or more time in a single year; reducing the mortality from coronary heart disease among under 75s in deprived areas; increasing the percentage of people aged 65 and over with high levels of care needs who are cared for at home; improving the quality of the healthcare experience; increasing healthy life expectancy at birth in the most deprived areas; and increasing the average score of adults on the Warwick-Edinburgh mental well-being scale by CHPs were established to work as part of an integrated system of service planning and delivery and to deliver agreed outcomes set by the NHS Board and joint outcomes agreed by the local authority and NHS Board. The SOA does not replace the existing performance targets set by the NHS Boards although in some areas these arrangements are evolving to reflect the SOA This chapter has described the development of the CHPs and the national context in which they are operating. The next chapter begins to feedback the findings from the research with a focus on perceptions of purpose, structures and relationships

24 3 PERCEPTIONS OF PURPOSE, STRUCTURES AND RELATIONSHIPS 3.1 This chapter presents the perceptions of the CHPs purpose structures and relationships given by those interviewed in Stage 1 with illustrations drawn from Stage 2 where appropriate. We also gathered interviewees perceptions of the development of the CHPs, both prior to establishment and since establishment and these are contained in Appendix 4. Purpose 3.2 In Stage 1 of the study we asked interviewees what they saw as the purpose of the CHP. The responses from the CHP General Manager, the Clinical Lead, the Chair and the local authority contacts to this particular question were broadly similar, but with nuances between each group. 3.3 The responses tended to fall into three main categories: those who described purpose in terms of the working process, either around partnership working with the local authority or a broader range of partners or around achieving greater effectiveness and efficiency; those who described it as a form of service delivery, either in terms of delivering primary care services or in terms of better integrating health and social care services; and those who described it in terms of outcomes for patients, either as improving pathways for patients or more generally improving the health for the local population. 3.4 There were noticeable differences in responses from the various types of people interviewed. Clinical Leads were more likely to focus on the patient and outcomes for patients whereas local authority interviewees tended to focus more on the process of partnership working and service integration. Structures and relationships 3.5 The structure and development of CHPs are constantly evolving to respond to local changes and need. As indicated in Chapter 2 of this report some have been involved in major redesign since establishment, others are amending and developing more gradually: for example Dumfries and Galloway has recently revised its CHP Committee to reduce its size and make its meetings more meaningful; Aberdeenshire has reviewed and revised its committee structure also to reduce its size. 3.6 While all the CHPs are committees or sub-committees of their Health Board, in reality the CHP structures vary as has been shown in Chapter 2. In addition to the development issues outlined above, the main factors determining CHP structure and activities appear to be the relationship between the NHS Health Board; the local authority; and the Community Planning Partnership. 14

25 Relationship with Health Board 3.7 The critical element in this relationship appears to be the level of involvement in strategic planning and decision-taking, the level of devolved decisionmaking and resources and the perceived role and effectiveness of the CHP at a Board level. 3.8 For some, the CHP is perceived as being primarily the operational delivery arm of primary care health services at local level (for example in Borders Health Board the CHP is managed by the Chief Operating Officer and in Tayside the CHPs and the acute hospital division form the Health Board s Delivery Unit). For others the CHP is perceived as having a dual role: an operational local delivery function but also input at a strategic level to the Health Board. A clear example of this latter form of relationship is in NHS Lanarkshire where the Chief Executive and all staff interviewed talked about the x and y function of the CHPs : x is the operational local delivery and y is the strategic pan-lanarkshire responsibility. 3.9 The perceived lack of strategic influence at Board level was mentioned by a number of interviewees as a concern as they thought that the wealth of information and experience that the CHP has was not feeding into strategic planning strongly enough. There was a perception that secondary/acute care had greater influence in some Health Boards than primary and community care and that this imbalance was not helpful for overall strategic planning. General Managers in some CHPs were keen to examine how to redress this balance of influence There were examples of how CHPs were influencing Board level activity and decisions. This was normally in the larger CHPs for example in Edinburgh where the CHP had provided evidence that significant resource was tied up in acute length of stay compared to other parts of Scotland. The CHP has committed to reducing the patient s length of stay in a hospital in North Edinburgh by piloting a new service which will reduce the demand for beds. The 600k saving will be reinvested in an enhanced geriatric orthopaedic rehabilitation service in the community. If the success of this service can be evidenced then it might influence a Board-wide approach The views of Health Board Chairs and Chief Executives about CHPs influence on the strategic direction echoed the findings from the CHP staff interviewees: at one end of the spectrum a small number did not consider it is the role of the CHP to have strategic influence on the Board but is rather to deliver the Board s strategy whereas some stated very clearly the importance of the CHP s strategic influence at Health Board level. In between are those who see the CHP as having influenced particular issues significantly. (The regulations covering CHPs make it a requirement for NHS Boards to involve every CHP in its area in planning, developing and making decisions which will significantly affect the operation of services for which the Board is responsible ). 15

26 Relationship with the local authority 3.12 The relationship with the local authority again lies along a spectrum of very close to varying degrees of distance Examples of close local authority relationships include: Moray CHSCP where the management of the CHSCP from the local authority and from the Health Board is co-located; Angus CHP where the local authority and CHP are co-located, report a better multi-agency response which is aided by shared training and protocols for information sharing, greater involvement of innovative approaches at a community level, improved implementation of case management plans and service delivery and improved potential for effective targeting of resources; Clackmannanshire CHP where previous close working with the local authority and the delivery of a joint mental health service has been built on and now a joint approach has been taken to setting objectives, targets and delivering many aspects of social care and health services; and West Lothian CHCP and Edinburgh CHP where the Directors role covers both organisations and includes the management of key activities of senior managers in the local authority and the devolved health and social care budgets The majority of local authority interviewees reported good joint working between the CHP and the local authority, often around particular services such as mental health, learning disabilities and older people. There was some mention of involvement in integration of children s services but our sense is that this area of work is being led by Integrated Children s Services Partnerships and similar structures rather than by the CHPs. There is significant co-location on the ground in many CHPs or moves towards putting this in place/increasing what is already there Where the relationship is more distant this appears to be due to a number of factors for example: the local authority has undergone major restructuring or a difficult period following an adverse audit report; there is an unproductive working relationship between staff in the CHP and local authority; there were existing relationship problems between the Health Board and the local authority and the CHP was caught in the middle ; conversely, close working between the local authority and the Health Board that did not include the CHPs; and the existence of other formal structures between the local authority and the Health Board, particularly the Health and Social Care Partnership, that provided an accountable separate structure for addressing joint issues around community care Some interviewees reported that the relationship worked well on the ground but that at a more strategic level there had been difficulties. At Stage 2 we 16

27 found an example of a local authority that realised it had no formal mechanisms for the CHP to report into the Council s own committee structures although individual Councillors were involved in CHP work There is concern from those we interviewed in both Stages 1 and 2 that structures like the Health and Social Care Partnership, the Health and Wellbeing arm of the CPP or the good working relationship between the local authority and the Health Board may lead to duplication of effort as individuals have to attend several meetings where similar issues are discussed. This may result in a low profile of the CHPs leaving some to suggest the need to clarify and streamline the relationship between the CHP structure in relation to the CPP structures in some areas. This is more apparent in areas where there is one Health Board and one local authority and the relationship between them is already close. Relationship with the CPP 3.18 The CHP relationship with the CPP also varies. This may be partly due to how well developed the CPP itself is as well as to the partners perceived role of the CHP Again the relationships cover the full spectrum. For example, in the Borders and Clackmannanshire the CHP is the Health and Wellbeing arm of the CPP and is responsible for delivery of the appropriate parts of the SOA. In North and South Lanarkshire the Directors of the CHPs sit on the CPP Board and are able to play a key role. Therefore the size of the CHP is not the key factor affecting the ability of CHPs to be at the centre of planning discussions regarding health and well being In other areas the General Manager/Director chairs the Health Improvement or Health and Wellbeing Group as in Angus CHP and West Dunbartonshire CHP In contrast, some areas have reported that they are still struggling to build a relationship with the CPP or work out what that relationship should be and so have limited or no direct involvement with the CPP. This is the case for seven CHPs This can occur for a number of reasons: where there is a close working relationship between the local authority and the Health Board thus limiting the direct relationship between the CHP and the CPP; where the CPP itself has had problems and these have impinged on the development of a relationship with the CHP. 17

28 Other relationships 3.23 In addition to the key relationships with Health Board, local authority and CPP, there are other important relationships that the interviewees in Stages 1 and 2 commented on. These relate to relationships with: the voluntary sector and the public; the acute/secondary sector; and GPs. Relationship with the voluntary sector and the public 3.24 Although we were asked not to explore the relationship with the voluntary sector in depth (due to other research in this area) it was inevitably mentioned in interviews during Stage 1 of the study. In general, while the CHPs recognise the importance of working with the voluntary sector, it was some of the challenges of effectively doing this that have been reported. Over the past two years Meeting the Shared Challenge, a Scottish Government initiative, has brought CHPs and third sector closer together to improve the capacity of each to form productive working relationships Issues raised included: the difficulty of knowing who to approach in the voluntary sector because of the perception of a lack of a single body, recognising that one or two representatives from voluntary sector organisations could not represent the voluntary sector as a whole; concerns about the long term sustainability of certain organisations; recognition of the time needed to invest in developing relationships with the sector; and expectations amongst voluntary sector organisations about their formal role, contribution and recompense, e.g. service level agreements Where the work with the voluntary sector was explored, despite individual examples of close working, some CHPs acknowledged that there was much to be done to develop effective relationships In Stage 2 of the study, the opportunity to gather the views of the voluntary sector and public partnership forum (PPF) representatives provided an insight into the relationship between those CHPs, the public and the voluntary sector. Again the level of interaction and engagement varied dramatically. From one CHP area where the voluntary sector relationship had not sufficiently developed to have representation at the committee to another where as well as voluntary sector representatives, a carer-led advocacy group has a dedicated seat on the CHP committee in recognition of the importance of unpaid carers in supporting health and social care. In another CHP, the active voluntary sector representatives, whilst drawn from a wide range of organisations from the forum, were a small and committed number of people. They were given the opportunity to contribute and be involved in key areas of the CHP s planned and actual work but often lacked the time and capacity to do this. The representatives recognised the need for more involvement from 18

29 other voluntary sector organisations but were realistic about the limited time and resources for their peers to become more involved In terms of working with the public, some CHPs had invested significant time and effort in establishing a strong PPF and providing training and support to PPF representatives so that they could engage effectively with CHP issues In both the above examples, the CHPs have worked hard to ensure their PPF fulfils the main roles 9 outlined within the statutory Guidance and Advice Note A national voluntary sector stakeholder spoke of the diversity of engagement with the CHPs. They reported the nature of the engagement often comes down to the individual CHP s approach to the voluntary sector and that where there is one local authority/one CHP engagement appears to be easier. Relationship with the secondary/acute sector 3.31 During Stage 1, interviewees often raised the relationship between primary and secondary care as a cause for concern and many interviewees stated that they needed to find a way to work more closely with the acute sector, in particular if shifting the balance of care was to be effective There were a set of complex reasons across the CHPs for the varying relationship with their health colleagues in secondary care. These included: tensions over competing for resources and the feeling that acute is still king ; issues of trust and confidence amongst health colleagues across primary and secondary care about who is best placed to take the clinical risk in providing patient services; and perception of the role, effectiveness and influence of the CHPs amongst secondary colleagues and independent contractors In the interviews with Health Board Chief Executives, the systems and processes in place to support close working between the CHPs and secondary and specialist services were explored. As might be expected responses to this question varied according to the structures and relationships in each area Most of the Chief Executives identified Health Board level systems that supported close working for example a person, like the Chief Operating Officer, or a structure, like a Single Operating Division or an operational management group There was acknowledgement of the challenges in some relationships across the health family and in some areas there were planned or actual redesigns (for example in Borders, Ayrshire) in CHP structures or in the interface between primary, secondary and the CHPs. This was in recognition of the 9 To inform local people about the range and location of services, engage local service users and the public in discussions about how to improve health services, support wider public involvement in the planning and decision making and to make services more responsive and accountable to local communities. 19

30 fault line between primary and secondary and acknowledgment that the CHPs position within the Health Board did not provide them with the influence and levers to significantly influence behaviour within primary and secondary care. In one example it was stated that the Chief Operating Officer rather than the CHP was better placed to be responsible for this clinical integration to ensure the pathway between primary and secondary care worked effectively The Stage 2 in depth studies, reinforced some of the challenges identified in the relationship with secondary care but it also highlighted examples where progress was being made. In fact in two of the selected six areas, interviewees commented that building closer relationships between primary and secondary care was the main achievement of the CHP Examples of cross-working between secondary and primary care tended however to be piecemeal, for example done by type of illness or speciality, or in only one locality. There are exceptions to this: in one of the in depth study CHPs, the systems are designed so that secondary and primary care work together from the Board level downwards and all service improvement planning involves both secondary and primary care staff working together. Relationship with GPs 3.38 As with other relationships there is a spectrum of perceptions of how well the relationship between the CHPs and the independent contractors, in particular GPs, is working. This ranges from areas where there is close involvement with GPs for example in one CHP, 16 of the 17 GP practices are involved in GP forums, to other areas where the relationship is seen as more distant. For example in one CHP the relationship with GPs is strongly influenced by the CHP s role in influencing capital spend, e.g. building developments relating to GP practices. In others, there is recognition from GPs and the CHPs that the interaction and relationship is minimal and the GPs do not see the relevance of the CHP s role in supporting their day-to-day work because the CHP has limited influence on budget-holding and contracting Many of those interviewed (both CHP staff and GPs) referred to the fact that prior to the CHP there had been an LHCC in their area with close GP involvement and that GPs felt less close to the CHP now mainly because they felt they had less control than previously One comment made by a CHP Clinical Lead illustrates the sense of difficulty that some CHPs have found in working with GPs: GPs have their own agenda and have always worked more in isolation and have had more autonomy than other groups Many CHPs recognised that this relationship is one that requires further work and there is evidence of attempts to improve GP involvement through establishing new GP networks, CHP staff visiting each GP surgery and budget provision for GP learning time. 20

31 3.42 There was little mention of other independent contractors throughout the research with the main concerns all relating to GPs Chapter 5 describes in more detail the facilitators and challenges of all these relationships. It is clear that the nature of these relationships determine the character of the CHP. 21

32 4 CHP PROGRESS AND ACHIEVEMENT 4.1 This chapter reports on CHP progress and achievements from the perspectives of the interviewees in Stages 1 and 2 of the study. 4.2 The statutory guidance highlights the important role that CHPs have in improving outcomes and the quality of local services. The Cabinet Secretary reaffirmed 10 the central role of CHPs in improving the health of local communities and in delivering better services and identified the three policy areas that the nine CHP priorities would address: a shifting of the balance of care to more local settings; reducing health inequalities; and improvement in the health of local people. 4.3 In Stage 1, the interviews focused on assessing progress against the original nine priorities 11 and providing examples of service developments. These priorities have clear links with each other and interviewees often referred to similar examples in responding to progress against particular priorities, for example the work to address long term conditions often linked closely with anticipatory care services. 4.4 In Stage 2, some of these priorities were further explored and this chapter brings together the views provided by interviewees from both stages as well as illustrations from the Stage 2 in depth work. Examples of best practice collected during the course of the study can be found in Appendix In presenting this information, it must be acknowledged that these are the perceptions of interviewees may be affected by a range of factors from their experience of working with or in a specific CHP to their level of awareness of the CHP s role and activities. 4.6 The perceptions of progress and detail of service delivery are discussed under the following main headings: shifting the balance of care and addressing community care outcomes; and improving specific health outcomes and improving health and tackling inequalities. Shifting the balance of care 4.7 Shifting the balance of care (SBC) captures changes across the health and care system that are aimed at producing better outcomes for people, reducing health inequalities and providing care and support closer to home. 10 Keynote speech to the Association of CHPs, September Better access to primary care services, taking a systematic approach to long term conditions, anticipatory care, supporting people at home, preventing avoidable hospital admissions, more local diagnosis and treatment, enabling discharge and rehabilitation, improving specific health outcomes and improving health and tackling inequalities 22

33 4.8 This approach aims to shift towards prevention and may involve shifts in who delivers care and shifts in the location of services. NHS Boards and their Local Authority partners are responsible for shifting the balance of care in order to improve outcomes for local people and to deliver strategic priorities and targets. CHPs are considered critical players in driving forward these changes and improvements in the level and range of services, care and support required at a local level. 4.9 In undertaking Stages 1 and 2 of the research, it appears that there are different elements involved in shifting the balance of care, including: shifting services from secondary to primary, from primary to community settings, from community services to home; shifting resources to underpin the changes; shifting where decisions are made between different kinds of professionals (from consultants to GPs/other allied health professionals; from GPs to nurses etc); shifting the responsibility of care (where appropriate) for example from professionals to greater self-management by patients; and shifting skill sets, behaviour and attitudes amongst health professionals In examining the ways in which CHPs have helped to shift the balance of care we consider the changes under the following three areas: shifting towards prevention by looking at how anticipatory care is provided, how long term conditions are tackled, how hospital discharge and rehabilitation are enabled; shifting who delivers by examining how avoidable hospital admissions are addressed and how people are supported at home; and shifting the location of services by considering how access to primary care services is improved and the ways in which more local diagnosis and treatment are increased. Shifting towards prevention 4.11 Across all Health Boards the development of a long term conditions (LTC) strategy and action plan, supported by the national LTC collaborative programme, has set the strategic direction for CHPs whilst providing the flexibility to develop services that best meet local needs The CHPs approach to LTC differed markedly but the study identified that service developments, often supported by Scottish Government funding or informed by the SEHD LTC toolkit 12, had progressed well across some CHPs and in others there was, at the very least, development work around self management or self-care This priority was considered by the majority of interviewees to be a huge task but there were many examples of good progress with LTC strategies having been developed or LTC co-ordinators in place across Board/CHP areas. 12 HDL (2007)10, Long Term Conditions Toolkit 23

34 4.14 Many of the health professionals interviewed as part of the study assessed the work of the CHPs in this area as progressing well with one remarking that the Long Term Conditions agenda has meant high risk patients are much better looked after compared to a year ago. Another interviewee said long term conditions are core to what they do and there were others who stated that the work on LTC built on the previous work of the LHCCs Some areas have locally-driven anticipatory care initiatives such as, Dundee s Hearty Dundee and Clackmannanshire s Healthier Lives. These focus on helping people to make changes that will improve their health and wellbeing by either focusing on particular health conditions, e.g. those at risk of heart disease or wider determinants of health, e.g. looking at health and employability There were also examples of pilots or developmental anticipatory care teams that supported GP practices to work with patients to manage their care and reduce the risk of admissions to hospital. These anticipatory care teams are discussed in more detail in the next Chapter Some interviewees expressed concerns about progress against this priority with the main issue relating to financial resources. One interviewee said they were not sure that there is the money for this and another said that clarity was needed about resourcing and added that shifting resources is always a struggle but it is really important. Shifting who delivers services 4.18 Across the CHP and local authority interviewees, supporting people at home was a priority and many considered good progress had been made in this area, particularly amongst local authority respondents. Many CHPs and local authorities had improved social care services and referral processes and were working in joint teams to support people at home rather than in a nursing home or hospital Approaches included using tele-health touch screens in the homes of patients, developing rapid response carer services, Community Older People s Team, 24/7 intensive support services, Home from Hospital initiatives that provide time-limited augmented care and support at home following hospital discharge or introduced re-ablement and home care teams or new posts like health and social care assistants, which all provided some form of support to people in their homes A few interviewees recognised the positive impact of other related priority areas such as their LTC work, long term conditions work is starting to impact on case management. This can be through more efficient early supported discharge or advance care planning, and condition specific activity which has led to service developments and improved patient care, for example, outcomes for diabetes patients Some CHP areas were using information and data to reduce avoidable hospital admissions. Some CHPs worked with GP practices and provided 24

35 them with information about referral data and prevalence of activities, e.g. emergency admissions to help improve referral behaviour and variability. A few CHPs used Meteorological Office weather forecasting to warn patients (by telephone and ) with respiratory problems of impending adverse weather conditions so that they could either stay indoors or take appropriate medication with them if they went out In terms of enabling discharge and rehabilitation, the interviewees focused on the achievement of zero delayed discharge targets and the range of joint teams working to achieve them. One interviewee said there was huge effort on managing delayed discharge which has been zero over the past few years, a view that was echoed across the majority of CHPs. Some local authority interviewees however said that moving patients from acute into the community was well established prior to the CHP although significant and sustained reductions in delayed discharges had only happened since the existence of CHPs Many CHPs said they had good rehabilitation services and there were examples of work to develop new strategies for example local authorities and CHPs had introduced rapid response teams, discharge co-ordinators or discharge nurses and had increased community rehabilitation services with Allied Health Professionals and community nurses Many interviewees expressed concerns about their ability to cope in the future with the ageing population and the steep rise in current population projection for the over 65s. The impact of this in terms of financial resources to support service delivery and the number of carers required was consequently an area of concern with one interviewee saying we need to plan how to sustain support for the future In discussing the work to prevent avoidable hospital admissions, a large number of interviewees related progress in this area to the work they were doing to support people at home, address LTC and their anticipatory care programmes. Others identified services like See & Treat where the paramedic determines the need for a patient to go to hospital and, where possible, treats the patient directly One issue raised by a small number of interviewees was that influence still lies with GPs where patients are normally admitted by referral or out of hours but most CHPs reported that there had been significant work with GP Practices and using the Scottish Patients at Risk of Readmission and Admission (SPARRA) data to try and predict some admissions. There were several examples of anticipatory care teams that focused on improving the care of individual patients and reducing the risk of them being admitted unnecessarily to hospital. This was often delivered through a combination of using the SPARRA data and liaising closely with community nursing teams and GP practices to identify patients, and work closely with them to manage their care Interviewees in some areas recognised the increased role of hospitals. One described how community hospitals are now involved in the provision of care 25

36 which had taken the load off and another interviewee described how they now had an interface with the acute and secondary care services. Shifting the location of services 4.28 Overall, CHPs had made progress in achieving better access to primary care services and providing more local diagnosis and treatment. The majority of interviewees reported a range of improvements including new facilities or service redesigns in the form of health centres, community hospitals or hubs with multi-agency facilities, the development of diagnostic and treatment centres, minor injury surgeries, upskilling nurses, e.g. to provide dermatology services or provide anti-coagulation treatment, to work in the community and an increase in the number of specialist GPs The new multi-agency facilities were often praised, an interviewee from one CHP described how they now had a range of services in one centre a GP, dentist and a diagnosis and treatment centre. Another interviewee in a multi- CHP area said hubs and one stop settings have meant people can walk in directly to receive services CHPs in more rural areas provided examples of investments in ultrasound and laboratory testing in the community hospitals and x-ray facilities in local clinics. In more urban areas there was a move towards outreach services and clinics rather than hospital-only services for diabetes and anti-coagulant monitoring for example. One interviewee from a city-based CHP had new facilities for GP practices enabling podiatry and dentistry more locally Some respondents considered that better access, in particular to GP services was not a direct influence of the CHPs, one interviewee commented that it was not in the gift of the CHP, enhanced access was due to the GP contract, with no opportunity to look at it locally Whilst there were many examples of the shift in the balance of care across CHP areas, the interviewees flagged up a range of challenges and frustrations about the pace and way in which the agenda was moving forward, and the next chapter explores these views in more detail. Improving health and tackling inequalities 4.33 The statutory guidance makes clear that CHPs should be well-positioned to play an important role in improving the health of local communities together with health practitioners and local partners like voluntary sector agencies and CPPs. However, as the earlier chapters have discussed, CHPs have varying levels of involvement with community planning some are at the heart of CPPs and others are on the periphery which can limit their ability to contribute to the health inequalities and health improvement agendas In many areas, the CHP perceives that the Board leads on health improvement (through for example the Director of Public Health taking responsibility for this area of work at CPP level) and works closely and directly with local partners such as the local authority. This together with other 26

37 situational factors in addressing these priorities has meant that most CHPs have a perception that they have yet to effectively tackle these issues The Health Improvement Advice Note 13 to CHPs re-emphasises the central role CHPs should have in improving health and provides advice and key actions as to how they could reduce health inequalities, some of which have been undertaken in CHP areas. Whilst some of the CHPs actions to tackle health inequalities reflect the information within the advice note, the interviewees did not refer to the note, so it is unclear as to whether the advice has been acted upon. Improving health 4.36 Most interviewees saw this priority as progressing but recognised that there is a lot to do and it was too early to say if they were making an impact on specific health outcomes However, there were many examples of specific work on smoking cessation, obesity, breast feeding and tackling alcohol and drug misuse and one interviewee said their CHP had directed work to those areas that will give the biggest bang. However some acknowledged that despite their efforts they were not seeing improved outcomes (which could reflect the fact that improved outcomes could be generational and not deliverable in a few short years) There were examples of CHPs working with other agencies to take account of the social determinants of health and so they were working on employability, housing and homelessness to improve specific health outcomes with particular groups of the population, one interviewee acknowledged that their CHP was working well with other agencies and we are seeing some improvements Several CHPs worked closely in partnership with the local authority to improve health. Some had accessed the Fairer Scotland Fund to resource new initiatives aimed at sections of the population, like a sexual health service for young people. Others had worked jointly to make decisions about NHS health improvement funding. Tackling inequalities 4.40 This priority was the one that many interviewees felt was one of the hardest to tackle. Interviewees described it as a big challenge particularly for the hard to reach groups and said that work is addressing inequalities but they are long term Despite the perceived difficulties there were examples of a range of actions to reduce health inequalities providing employment opportunities within the CHP to people with mental health issues, using health visitors to work with the 13 June

38 most vulnerable families to tackle inequalities, using social prescribing, e.g. exercise or self-help books to tackle depression One CHP in an urban area said that addressing inequalities was one of the big attractions to the council of a CHP. A CHP in a rural area talked about deprivation having a lot to do with lack of access to services In CHP areas that are Equally Well test sites there were good examples of innovative and multi-agency work to tackle inequalities for specific sections of the community, which included integrating mental health improvement in a community, addressing inequalities in early years, working with young people to address anti-social behaviour and underage drinking and supporting people into work CHPs cited the Keep Well programme as the main example of ongoing work to provide anticipatory/preventive care within local communities. This is normally focused on practices within particular deprived areas but in other areas the focus is on particular sections of the population like BME communities, LGBT communities and Gypsies/Travellers. In some areas it delivers anticipatory care for those experiencing health inequalities in remote and rural areas. For some CHPs, this mainly NHS led initiative, was the main thrust of their work to reduce inequalities. Interviewees felt that in time positive outcomes would be realised whereas others commented that the statistics have shown some improvements but the health gap between deprived and affluent areas continues to widen As already discussed, in several areas the Board leads on addressing health improvement and health inequalities with the Director or Deputy Director of Public Health leading on these matters in partnership with Community Planning Partners. This can have advantages in being able to dedicate more time to access a wide range of partners and link into the SOA but as mentioned earlier it can be perceived as reducing the role of the CHP. CHPs key Achievements 4.46 All interviewees were asked to identify what they believed were the key achievements of the CHP and the tangible benefits for local people. Their responses are discussed in the remainder of the chapter. Partnership working 4.47 The most commonly reported key achievement amongst all CHPs was working with other bodies and building good working relationships internally across the Health Board or externally with local authority and other partners such as GPs, CPPs and the voluntary sector. In the words of one Health Board Chair: the CHPs have been most effective at making joint working work and in particular making preventive health work, work In many cases the CHPs provided a platform to allow partners to work together through the CHP committee, working groups, CPP structures and through collaborative working on local initiatives with many new partnerships 28

39 being formed as a result. Examples included a CHP tackling health and employment issues with the local college and regeneration agency by setting up a course for single mothers to gain new skills in order to fill Health Board vacancies. Linking health and social care 4.49 Linking the health service with social care was difficult at first for both CHPs and local authorities due to the differences in cultures and staff. However both viewed overcoming these difficulties as a key achievement and created a more cohesive approach to delivering services For many interviewees there was a realisation that we should tackle issues together. Joint planning, management and co-location for services such as mental health, learning disabilities, drugs and alcohol, older people were created in many CHP areas as well as local service hubs or one-stop shops. One interviewee summarised how service users would benefit from a unified face as one door that s it. Listening and responding to local needs 4.51 Within many local communities the CHP had made the health service more understandable and accessible for local people. One interviewee said that the CHP has a high profile and a presence as a local service, whereas the Health Board is viewed as bureaucratic. Another CHP said that there was local engagement at a level you wouldn t have gotten before For some interviewees, the CHP has a clear remit to have a different relationship with local communities and considered themselves as the shop window of the health service. As a result there were examples of ways in which the public were engaged and involved through user friendly websites and meaningful consultations on service developments and changes. In one CHP the positive consultation about the development of a forensic unit as part of a new regional learning disability unit involved significant communications and public consultation so that issues and concerns from security of the institution to safety of the public were addressed. Direct contact with local households, public meetings and regular newsletters on progress of the unit resulted in no objections to the planning permission and no public outcry as has occurred in other parts of the country when similar units were proposed For most CHPs the Public Partnership Forum (PPF) has been central to achieving local engagement, finding out about the needs of the local community and hearing views from service users on how services could be improved. One interviewee commented on how responding to the needs of the local population based on the evidence was seen as a key achievement and so there was greater local ownership. Redesign and development of services 4.54 The development and redesign of services was an achievement for most CHPs. One interviewee described how the CHP had been significant in 29

40 making a difference compared with the LHCCs as there is a range of people from different disciplines around the CHP Committee allowing plans and knowledge to be shared to improve service provision CHPs talked about the difference they could make to people rather than budgets and were much more focused on what it means locally rather than merely implementing policy. One interviewee said they had redesigned services after mapping how people accessed them whilst other CHPs had focused on particular areas of service delivery including long term care provision, care at home and community nursing. Improved access and availability for service users 4.56 The new or redesigned services along with the improved partnership working had produced noticeable changes for some service users which included: better local access to diagnostic and treatment services, for example diabetes clinics and ultrasound scanning; increased availability of services, for example dentistry, physiotherapy and home care; and a more seamless service through the development of integrated or improved care pathways This chapter has provided examples of progress and achievements against CHP priority areas. However, it is important to remember that these developments and services are often locality or condition-specific and they are not consistent across CHP areas, Board areas or Scotland as a whole. This is because there are many hurdles that CHPs have to overcome in progressing their work and these, along with the facilitators of progress, are discussed in the next chapter. 30

41 5 FACILITATORS, CHALLENGES AND BARRIERS 5.1 All interviewees in Stage 1 of the study were asked for their perceptions of the main facilitators of CHP progress and on the challenges and barriers that had hindered progress. These issues were further explored in Stage 2 and this chapter brings together the detailed views of all interviewees. Facilitators 5.2 Interviewees easily identified a range of issues that had helped the CHPs make progress in delivering against their key areas of responsibility (Diagram 5.1). The most consistent response was the qualities of the CHP management team which were described as enthusiastic, committed, motivated, talented and engaged in delivering better health outcomes for their populations. 5.3 The next most popular facilitator was the tradition of close partnership working with the local authority. This provided many CHPs with established structures and well developed relationships that aided joint working and effective engagement. 5.4 Leadership was another key element that assisted the CHPs and this came from: the style, competence and commitment of the General Manager who constantly has to make adjustments to complement partners and does so effectively ; fierce support from the [Chair of the] Health Board and the General Managers have director status that helps to give the CHPs the necessary profile ; and the [CHP Committee] Chair has a clear vision shared with the GM of what they want from the CHP and a common approach [to achieve it]. 5.5 The leadership role played by these key individuals provided support to CHP staff, encouraged buy-in from wider partners and health colleagues and endorsed the significance of the CHP. 5.6 The remaining facilitators centred on the positioning of the CHP and the engagement of key stakeholders, which are discussed in more detail below: Positioning of the CHP co-terminosity with the local authority and other agencies was seen as an advantage having a geographical focus and co-terminosity with other agencies has facilitated service delivery, it helps to have an area that everyone can identify with ; co-location of staff assisted joint working and enabled good communication and sometimes led to joint training initiatives; and being an integral part of the CPP underpinned the work of the CHP through the SOA and greater understanding of health issues across a 31

42 wider range of partners there has been a cultural change among CPP partners, they understand the social factors that influence health and consider the health aspect of their work. Diagram 5.1: Facilitators 32

43 Engagement of key stakeholders: political buy-in from local authorities acted as a boost for several CHPs, where the elected members played an active and supportive role in feeding back to their Council on the work of the CHP; positive engagement with GPs for several CHPs had led to progress around key priorities like better access to primary care and effectively addressing anticipatory care and long term conditions; public involvement with the CHPs work was seen as a real benefit to some localities; and voluntary and community sector engagement was encouraging for many CHPs the voluntary sector are very active and keen to be involved and some CHPs developed strong community links. Challenges and barriers 5.7 Whilst the facilitators of CHP progress were consistently reported, there was a more diverse range of challenges and barriers identified by interviewees (see diagram 5.2). 5.8 In many cases the main challenges continued to be barriers for CHPs and interviewees did not distinguish between the two. Whilst there were particular barriers faced by CHPs that related to specific contexts, for example, the rural setting in which it operated, there were recurring issues that were common to many. We have grouped the challenges and barriers facing CHPs under the following headings: relationships; resources; structures; the role of CHPs; organisational differences; shifting the balance of care; reducing health inequalities; and single issues. 33

44 Diagram 5.2: Challenges and barriers Relationships 5.9 The relationship challenges and barriers were identified with four key stakeholder organisations the NHS Health Board, the local authority, the wider health family and. These challenges will be explored in turn. Relationships with GPs 5.10 The most commonly acknowledged barrier or challenge facing CHPs was the difficulty in effectively engaging with GPs. Interviewees felt that they were hindered on many levels and this view came across from all types of interviewees. Many said that GPs still mourned the loss of LHCCs and their ability to influence and control health related activities, which had led to a real sense of disengagement amongst many GPs The move towards CHPs occurred during the same period that the new GMS contract 14 was agreed by GPs. Interviewees acknowledged that whilst there is baggage on both sides about the contract, it directs and drives what GPs do and if it links in with what the CHP needs then fine, if not, GPs are not interested. For many GPs, the current contract means they work to a different agenda that sometimes does not mirror the Board or even local priorities. One 14 The contract created a major change in the types of staff that worked in primary care and in the tasks that they performed by the introduction of new funding streams and payments for different services 34

45 example of the impact of the poor relationship with some GPs was from a CHP where the GPs were not prepared to negotiate on their underused GP beds in a local hospital and this was preventing significant service redesign Interviewees stressed that much of what they were trying to achieve required engagement of GP practices, however the lack of flexibility in the content of the national contract did not always align with CHP aims and this impacted on service provision. Interviewees recognised that local enhanced services did influence some GP activity but in general the enhanced services were agreed at Board level and so CHPs had little opportunity to influence even the peripheral content The interviews with GPs in Stage 2 of the study reinforced some of the issues raised by other interviewees with most acknowledging that they had limited involvement with the CHP and that the driving force behind their day-to-day work was their GMS contract. They recognised the investment that CHPs had made to bring people together, e.g. GP forums but there was still wariness and suspicion amongst some and a feeling that both sides were working to separate agendas Although these challenges were ever present for many CHPs, there were examples of work to try and overcome the restrictions of the GMS contract and improve GP engagement. In one CHP, around 20% of the practices are Section 17c 15 practices and so have locally negotiated agreements with their NHS Board which enables flexible provision of services in accordance with local circumstances, and allows practices and the Board to take advantage of the contractual flexibilities. They are about to renegotiate the 17c contracts and are looking to attract more practices which would enable the Board and the CHP to have greater influence, more positive engagement with GPs and better aligned GP services that mirror local need and CHP priorities. Relationships with the Health Board 5.15 The relationship between CHPs and their Health Board varied significantly. As seen earlier in this chapter the relationship with the Health Board was identified as a facilitator of progress for some CHPs, however some CHPs viewed the relationship with their Boards as a challenge For these CHPs, who were part of a multi-chp Health Board, the issues revolved around the profile given to CHP activity. They often perceived a lack of buy-in at Board level and that secondary health services were the main priority acute dominates the agenda and the budget. One CHP highlighted that the statutory guidance asks for CHPs to be strategic but the Board is only letting them be operational. This limited influence is reiterated by an interviewee in the central belt who said they ve ceded some powers to the CHPs but the Board wants to command and control. 15 Section 17C is in respect of The National Health Service (Scotland) Act 1978, as amended under The Primary Medical Services (Scotland) Act 2004 and enables a General Practice to have a locally negotiated agreement for provision of services rather than a nationally negotiated contract. 35

46 5.17 The response from some Chairs and Chief Executives of Health Boards reflected these views. A few Chairs were concerned with the perceived level of autonomy that the CHPs were developing. The Board struggles to get the CHP to recognise itself as part of the Single Operating Division and therefore to work in accordance with the normal decision-making flow There was also a strong theme in responses that related to balancing the local identity of the CHPs whilst maintaining overall Health Board control. It is a balancing act: to give them the freedom to develop and serve the needs of the population but keep them in line with Board requirements. Holding the contextualised strategy of the Board together, whilst allowing the CHPs to deliver locally. Relationships with other health colleagues 5.19 As discussed in Chapter 3, whilst there were often systems and mechanisms in place to improve integration between CHPs and secondary and specialist health service colleagues, interviewees identified that engaging with secondary care was often a challenge Some interviewees highlighted their frustration at trying to engage colleagues working in acute services. An interviewee from a CHP said a key challenge was, the attitudes of other clinical professionals and trying to get them to respect the CHP and get on board. This difficulty is echoed across several CHPs and the secondary care interviewees in Stage 2 recognised some of the tensions and challenges in the relationship between them in terms of trust, capacity and willingness to engage with their peers. Part of this challenge is that CHPs are seen as having responsibility for primary and community care rather than having responsibility for the whole patient pathway. Relationships with the local authority 5.21 The study has highlighted the diversity of relationships between CHPs and their local authorities. There were four types of challenges, all related to process rather than subject content, identified by both CHP staff and local authority staff that faced CHPs in their relationship with local authorities changes in the political administration, lack of co-terminosity between local authority locality areas and CHP boundaries in some areas and changes in personnel and internal problems in the local authority Another challenge is around establishing joint strategic thinking to change mainstream services provided by each partner: discrete projects can be agreed jointly but there is a failure to shift the pattern of mainstream services significantly. 36

47 5.23 All but seven CHPs had experienced changes in the local political administration following the 2007 elections. Most CHPs did not identify these changes amongst their challenges, but for those who did it either related to: working effectively with councillors voted in on single issues, like hospital closures, to look at the wider health agenda; allowing time for new councillors to get up to speed with their council role and within that their CHP work; and assisting councillors to take a strategic role rather than one focused on their own ward only The difficulties of establishing operational relationships with the local authority when the CHP local areas are not co-terminous with the local authority s local service areas, e.g. in one local authority the three CHPs covered seven local area committees A change in local authority personnel (as with changes in personnel in other organisations) sometimes impacted on the ongoing joint understanding and productive working arrangements between the partner organisations A small number of CHPs discussed the difficulties in trying to create an effective partnership with local authorities that had internal problems and expressed the challenge in making any progress where there is a fragile Council situation and in fact felt that they were being held back in most cases. Resources 5.27 Many interviewees identified the current economic climate and future budget constraints as one of the main concerns. They all recognised the financial situation facing the public sector, were aware of efficiency savings that would need to be delivered and some said that their public sector partners were cash-strapped. In this respect the problems/challenges facing CHPs are no different from other parts of the system Interviewees acknowledged the potential tensions between the local authorities and the Health Boards about the share of spending towards CHP activity and recognised that the financial constraints came at a time when there was an increasing demand for services and a few were concerned that as money gets tight, the potential for tension between the partners will become a challenge where short term solutions to problems may be taken by partners to solve their own financial problems without due notice of the impact of decision making in one part of the system on the other. There may also be a tendency to tackle the short term, immediate problems rather than using resources more strategically to provide early intervention and prevention In addition to financial resources, the capacity of CHP teams was a concern for some interviewees. This was particularly the case in small CHP teams, where an over-reliance on individuals to carry out many roles, meant knowledge and expertise were concentrated in a few individuals and any staff 37

48 changes would be very detrimental to the CHP and significantly affect progress. Structures and governance 5.30 Along with the challenges of the financial climate and the engagement of GPs, the structure of the CHP Committee was a key challenge or barrier for many respondents This view was generally echoed by interviewees amongst the majority of CHPs that still operated with the original committee structure, i.e. average of 20 representatives. The main issue was felt to be the size of some CHP Committees, in that they were too large to be effective in terms of governance and decision-making. Interviewees stated that some members of the committee struggled with their role, possibly because they did not see their attendance as relevant or effective, which led to a lower number of active members. One local authority interviewee that attended the CHP Committee said it s a challenge to go to meetings because you don t get anything out of them and don t contribute to decisions or activity. In another local authority area the Chief Executive stated that it was not possible to force the elected members to attend the meetings Other comments included: it is slow and cumbersome, members of committee are unsure of their role ; the CHP Committee operates as well as it can given its size and composition, but it is not set up to be a dynamic decision maker As discussed in Chapter 3, some CHPs played an integral role within their CPP, often delivering the health and wellbeing elements of the single outcome agreements. Those who were not involved with the CPP recognised this as a challenge and reported that a lack of involvement with the CPP or the development of the SOA without their input was a barrier to future progress and effective partnership working particularly if they were to tackle issues like health inequalities. Where CHPs were involved with CPPs this often led to increased partnership working with other agencies, for example in one CHP they worked closely with the police around prostitution and teenage drinking and accessed the more sophisticated data that the police collected which the CHP used to inform planning. Some interviewees from local authorities and national bodies felt strongly that there needed to be greater integration with the CPPs and the SOAs and the fit between CPPs and CHPs needs to be further examined. Within the local authorities the SOA is the framework that shapes and directs much of their work and service delivery and so interviewees from local authorities in particular (as well as some from CHPs) felt that stronger links needed to be made, and even suggested that in the future the SOA could be the vehicle that sets the direction for the delivery of health and social care in a locality. 38

49 The role of the CHP 5.34 Some interviewees highlighted that the concept of the CHP varied across Scotland which resulted in vagueness on what the CHP is going to do and this was a particular challenge when there was not a common understanding between the council and the Health Board around what CHPs are for and what they should do. (These comments were made despite the fact that the original guidance and regulations were quite explicit about what CHPs were to do) This lack of clarity was sometimes reinforced by the challenge of evidencing the difference the CHP was making in a locality and demonstrating the added value to local authority colleagues (although recognising that some local authorities found it easier to evidence the positive impact CHPs are having). Some interviewees recognised that the inability to specifically attribute progress and change to the CHP (because CHPs work as part of an integrated health system) reduced the CHPs credibility and added to the uncertainty as to the real difference being made to service delivery Some interviewees questioned the willingness of the Boards to empower CHPs and that any perceived lack of authority or decision-making ability could undermine CHPs and result in partners, like local authorities, liaising with Boards over local matters when they want a decision made For a few interviewees from areas where there is one Health Board and one local authority and there was already a history of joint working, the need for the CHP structure was queried. Organisational differences 5.38 Many of the interviewees acknowledged the different cultures and organisational approaches in the NHS and the local authority. Working across these different cultures together with the different management, planning cycles and organisational arrangements could in some cases hamper joint working and effective information sharing in some CHP areas Trying to bridge the different cultures and breakdown the them and us mentality was hindered further by organisational issues and tensions around personnel matters, in particular terms and conditions of employment for some particular groups of staff. Interviewees provided several examples of the inequalities across multi-disciplinary teams with cases where staff from one organisation line managed staff from another but were paid considerably less than the team members they managed. This has implications when looking at developing joint or integrated teams and was raised by several General Managers as a challenge that they had to overcome. 39

50 Shifting the balance of care 5.40 Whilst there are plenty of examples of activities and developments around shifting the balance of care, there were few cases where this resulted in a shift of financial resource out of acute and into primary or community care services or out of primary care into community care. Many interviewees commented on the difficulties in making significant progress in some areas without disinvesting from acute services. They sometimes saw this as a lack of real commitment and making changes around the edges. The political difficulties of reducing acute services to support more community-based services were raised by interviewees in several CHP areas However there was acknowledgment of the practical challenges of funding new models of working when infrastructure costs still existed and some secondary care interviewees questioned whether diluting services would necessarily lead to better health provision and patient care and that there was still a need for an evidence base to support changed pathways of care Some viewed shifting the balance as an ongoing creep or taking place by stealth suggesting that it was taking place surreptitiously rather than in an open and transparent way. Others were pragmatic about a staged approach that would eventually redirect the funding stream through the change in care pathways. These changes in how services are managed lead to changes in management arrangements with the money following the posts and the shift in resources comes about in this way Several interviewees identified the need to quantify locally what services should and could be shifted and then have a grown up dialogue about the resource. Reducing health inequalities 5.44 The disparate nature of health inequalities, the role of Public Health and the local authority in addressing this agenda, the recognition of the social determinants of health and the need for a wide-ranging approach across partners were some of the reasons reported as to why some CHPs found it difficult to make a significant difference to this priority. There was also the challenge of getting those who most need services to access them Interviewees, also raised the fact that much of the work around reducing health inequalities is project based, externally or short term funded and not an integral part of mainstream provision, this was recognised and summed up by one interviewee in a local authority health planning role: we have done things on a project by project basis but we haven t really addressed health inequalities across primary and social care.we need to inequality proof everything we do The challenge of addressing health inequalities is linked to the positioning of CHPs in relation to the CPP as this was seen to be the structure where the social determinants of health inequality can best be addressed. As seen 40

51 earlier in the report the CHPs have varying relationships with their CPP. Even where the relationship is close, for example the CHP is the health and wellbeing arm of the CPP, there may be issues to be addressed in terms of the influence the CHP/health arm has over the other CPP themes, as all will be important in tackling health inequalities. Additional challenges and barriers 5.47 There were a number of additional issues raised by several CHP interviewees that they perceived hindered progress: effect of HEAT targets in their current form, some felt they lacked meaning and were dominated by measuring acute activity, in addition targets are very much driven by the here and now which some felt made it difficult to focus on the anticipatory and preventive upstream work, there were also concerns about the fit between the SOAs and HEAT targets, in some areas the HEAT targets being seen by CHP staff as a barrier to closer working on the SOA because of the perceived need to address HEAT targets as the main priority; demographic pressures some interviewees identified that providing services to their ageing populations was expensive and was only going to become more problematic in the future; impact of Agenda for Change some interviewees felt strongly that the length of time taken to review bandings had slowed up service redesign and with some roles it was widening the gap between local authority and NHS salaries which was adding to difficulties across the two partner organisations; rurality and remoteness interviewees from CHPs in rural settings identified two specific challenges that impacted on their progress and success access to services in terms of the transport links and infrastructure and availability of services and staff with the expertise, some said they have to work hard at getting the best staff in ; workforce planning it was not only in remote areas that staffing issues were identified as current and potential future challenges. This was a particular challenge as services were shifted into communities and recruiting physiotherapy and home care staff was a struggle for some CHPs; proximity to urban CHPs - having big neighbours was identified as a difficulty for some CHPs because they felt that the needs of other areas often set the agenda and dominated the focus of the Health Board and its resources This chapter has analysed the facilitators and barriers to progress and the next chapter sets out respondents views on how to maximise the CHPs potential. 41

52 6 MAXIMISING THE CHPS POTENTIAL 6.1 The first two stages of this research identified a number of ideas for ways in which the effectiveness of the CHPs could be improved. The main ideas focused around: structures and governance; relationship with GPs; shifting the balance of care, including concerns about resources and improving the interface between primary and secondary care; improving efficiencies given the current financial climate further engagement with the public; and further alignment of local authority and health priorities linked to the central role of the SOA. 6.2 The findings and ideas for improvement from Stages 1 and 2 were broadly endorsed and further developed in the Findings and Reflection events held as Stage 3 of the study. The purpose of these events was to allow all those who had participated in the research an opportunity to hear initial findings from it and to help reflect on what the next steps should be. To help guide the events the study team, together with the Research Advisory Group, designed four questions. The questions touched on key issues that appeared to be emerging from the research. This chapter summarises the ideas from these events. Summary of suggestions made during Stage We have analysed the discussions from the four Findings and Reflection events and summarise the suggestions put forward under each of the four questions posed at these events. How can the role and effectiveness of CHPs be further enhanced through their relationships with the wider health family? 6.4 The discussions around this question at the events reinforced the findings of the first two stages. Participants stated that effective leadership is critical and that effectiveness is also closely linked to positive relationships. One group commented that it is the role of the CHP Chair to facilitate these relationships. 6.5 In terms of who is included in the wider health family one group interpreted this as including secondary and acute care, independent contractors, in particular GPs, allied health professionals and voluntary sector health-related services and the Health Board itself. 6.6 There was strong interest in progressing the agenda for CHPs and the areas on which the groups focused were as follows: Primary and secondary care It was proposed that the CHPs should be seen as representing the integration across acute/secondary and primary/community and that CHPs should be at the 42

53 heart of clinical care pathways across the primary-secondary spectrum (it was recognised that the Integrated Resource Framework (IRF) will assist in this). It was described as horizontal process management, focusing on the patient s pathway across the vertical service providers. Linked to the above participants suggested that CHPs should be empowered and accountable for Shifting the Balance of Care. There should be common targets across primary and secondary care. There should be more specific projects, where both sides can work together, to enhance closer working relationships and understanding. The shared work on clinical pathways in some areas is seen as a positive example of this. GPs: CHPs need to be better able to engage with GPs and at the centre of this is the GMS contract. There needs to be national and Health Board discussions about how to get better alignment between the outcomes for the Boards and the GPs. The issue of distribution of GPs needs to be addressed so that access is more equitable. CHPs need to devote time to building their relationships with GPs, as some CHPs have demonstrated, through proactive engagement and incentives. Health Boards: The positioning of CHPs in relation to Health Boards determines the status and authority of the CHP and in turn determines the CHP s ability to influence. Health Boards should be encouraged (where this has not already happened) to allow CHPs to influence strategic thinking and planning as set out in the original guidance for CHPs. There needs to be equity of status between acute and primary sectors at Health Board level. Having shared agendas and targets can assist in this. Voluntary sector health services: There is a need to have greater integration of the voluntary sector with the work of the CHPs and Health Boards. The voluntary sector provides a huge resource that the Health Boards need to utilise. It is recognised that the Single Outcome Agreements may help in this involvement of the voluntary sector as the role for the voluntary sector is becoming more clearly defined. One particular request has been put forward by the Coalition of Carers in Scotland (which represents 80 local carer organisations involving about 60,000 carers), that CHPs would benefit from having carer representation on the CHP committee. This request is made in the light of the importance of carers given the focus on shifting the balance of care. How can the role and effectiveness of CHPs be enhanced through their relationships with the local authority and the community planning partnership? 6.7 As with the previous question the discussion at the events reinforced the research findings with regard to the CHPs relationships with local authorities 43

54 and community planning partnerships. In particular the issue of positive leadership was stressed along with recognition of the variableness of relationships: there were several examples of positive relationships not just between health and social care but also with education, children s services and action on substance misuse. 6.8 The variety between areas was highlighted in comments concerning the current financial constraints: with some areas seeing this as leading to a withdrawal from partnership working, and other areas seeing this as supporting closer working. 6.9 In relation to community planning partnerships there was a strong sense that CHPs should have a clear and stated role across all aspects of the CPP s work, not just the health and wellbeing theme, to enable them to take more effective action on the underlying causes of inequalities in health in partnership with other local organisations The main points for strengthening the role and effectiveness of the CHPs were as follows: Elected members: The participants highlighted the role that elected members can play in supporting the CHPs work. This role needs to be enhanced in particular with those elected members who are the most influential decision takers. Shared accountability: There was support for bringing SOA and HEAT targets closer together in a simplified framework, decided at local level, with shared accountability for outcomes. Part of the perceived problem lies in the fact that HEAT targets are set nationally while the SOA is developed locally and some people feel that the emphasis on short term targets such as reduced waiting times can impede a longer-term planning approach to health improvement. Budgets: Participants suggested that local authorities and Health Boards should allocate their budgets at the same time to prevent confusion and promote cohesion. There was support for greater alignment of budgets between the local authority and health linked to shared outcomes and accountability highlighted above. Part of this will aim to reduce any duplication in resourcing. Redesign of services: There is scope to redesign services (across the various life stages and across the main public and voluntary sector providers of health, education, social services) looking at how best to use resources, how to improve effectiveness and better achieve long term outcomes. Part of this redesign process will require attention to workforce planning and workforce development across the public and voluntary sectors. 44

55 Involving the public: One group suggested that the Citizens Panel has been used effectively by local authorities to engage with the public and that it might be helpful for CHPs to engage with the public through this mechanism in addition to the Public Partnership Forums. What should the balance be between local flexibility and national direction? 6.11 There was strong support for the no one size fits all approach that was adopted in establishing the CHPs. Participants regarded local flexibility as critical to the success of CHPs but at the same time saw the need for some national direction in order to support local flexibility. Many of the issues they raised reflected those highlighted in the other three questions The participants reflected on key areas of work such as the integration of health and social care and the future of primary care services where there are other reviews taking place (such as the recent Arbuthnott report) and thought that a national input on strategic direction in these areas would be helpful Other areas participants raised as to where they thought national input would help included: support for the role of CHPs in building relationships across the whole system, between community, primary, secondary and acute as well as across health and social care and other areas of CPP work; help with the issue of the GMS contract to give greater flexibility to CHPs in relation to working with GPs; guidance on the role of elected members to increase their role in relationship building and supporting the work of the CHPs generally; to provide greater clarity and examples of care pathways that work; further support on Shifting the Balance of Care, ideas for implementation/how resources can be shifted/capacity created; and input on the roles and responsibilities of the special health boards in relation to CHPs e.g. the Scottish Ambulance Service There was recognition that the context in which CHPs operate has changed since they were first established and there is a need now for updated guidance to take account of these contextual changes. However, it should also be recognised that there have been lessons learnt since the original guidance was written. For example, one suggestion was that the membership of the CHP committee, as set out in the original guidance, should be revisited. The original guidance included a wide range of people which, it was felt, either leads to very large, less effective meetings if all members attend or leads to people being nominal members but not attending The new guidance might also consider broader issues such as the potential for working across health board and CHP boundaries. 45

56 6.16 One group commented that they would like to see the update of guidance reignite the excitement that existed when the CHPs began, around the potential for what they can achieve. We should focus on the possibilities of what the CHPs can achieve and trust them to get on with it There was a strong view that there should be a Scottish Government response to this report with identified actions. How can CHPs play a realistic role in how they contribute to addressing health inequalities? 6.18 Participants recognised that whilst there is a lot happening around tackling health inequalities there is a strong sense that they are still not making enough of a difference. They reflected findings from the earlier stages of the work that there are too many pilots and not enough mainstreaming in this area of work. They also echoed the findings from the earlier stages of the research that it is hard to measure progress in this area Defining what is meant by health inequalities is important: and it may be more appropriate to refer to tackling inequalities as this broader approach is more likely to impact on people s health. There is a difference in approach between responding to the consequences of inequalities on the one hand i.e. through making health and other public services accessible and suitable for people with greater but preventable health problems, and, on the other hand trying to prevent inequalities occurring in the first place, through prevention and addressing wider social determinants e.g. low income, lack of employment, poor physical environments There was general consensus that targeting the underlying problems that lead to health inequalities is crucial and that to do this there has to be involvement across the various dimensions of the CPPs. The CHPs should have a clear role within the CPPs and be involved with the various agencies and departments involved in the decision-making process about investment and respective contributions. As one group put it we need a critical mass of CHP people involved in all aspects of community planning Early intervention and prevention is seen as critical with some concern voiced that CHPs have been too focused on older people s services and less on children s services Overall participants thought that this challenging area requires significant service transformation if a real difference is to be made. This may include disinvestment from more well off areas to poorer areas as well as a shift from dealing with consequences and crisis upstream to preventing these occurring in the first place. Participants thought that a piecemeal approach to service redesign should be avoided. They also suggested that there should be stronger clarity about the approach to take (as discussed at Para above) and that CHPs should all be involved at CPP level Within this overall approach they suggested that the specific role for CHPs should include: 46

57 targeting health services to more vulnerable individuals; health improvement initiatives; working with communities to focus on community-led change The next chapter provides conclusions to the study. 47

58 7 CONCLUSIONS 7.1 This chapter provides our conclusions to the research and provides suggestions for consideration of forward action. 7.2 The picture that emerges is one of great variation across the 40 CHPs with a complexity of relationships and structures. The no one size fits all described in the statutory guidance has proved to be the case. The research team s sense is that the majority of those who have participated in this research like the fact that the CHPs have been allowed to develop according to local need and context and have no wish to see this change. The fact that there is so much variety across the 40 CHPs is testament to the local nature of each CHP and is seen as a strength. 7.3 The CHPs have successfully developed at a time of significant changes in terms of policies and new ways of working. In particular the advent of the SOAs has changed the relationship between local authorities and national government and has led to a greater emphasis on the role of community planning partnerships. Within this context the role for Health Boards, which still have to meet nationally-set targets, is sometimes perceived to be at odds with the local community planning approach. 7.4 There have been a variety of perceptions of the CHPs role and purpose (see Chapter 3). One perception of the CHP role that we think is helpful was made during the research by an interviewee who likened the role of CHPs to adaptors, meaning the role of providing the link between different bodies, to help them understand each other better and to broker joint working. These adaptors can be: between the public and the Health Board; between primary and secondary care; between the local authority and the Health Board; and between health and other community planning partners. 7.5 The term adaptor is similar to that of CHP facilitator now used in one Health Board area to describe the individual post-holders function. This seems to us to be a good way to describe the role and explains why CHP relationships have been shown during this study to be so crucial. 7.6 The extent to which this adaptor/facilitator/link role is required and the form it takes varies from Health Board to Health Board. It depends on a number of factors including pre-existing and current relationships between the local authority, the Health Board, and other community planning partners as well as relationships within the health family itself. In a few areas, because existing relationships between local authority and Health Board were already close, it was less evident to those involved how this adaptor role could add value. 7.7 The CHP role is therefore potentially extremely complex, demanding and important. 48

59 7.8 The role is central in our view to addressing key priorities including shifting the balance of care, tackling inequalities, and integrating services for children, older people and other vulnerable groups. It can be visualized as acting horizontally across different areas of vertical service provision to help broker joint working and, where appropriate, integration. 7.9 This horizontal facilitating process is central to CHPs work and one which in our view should be fostered. We have observed a shift in awareness of the potential of this horizontal role during the course of this study. Our sense is that representatives from both Health Boards and local authorities have become more aware that the role of adaptor, broker and manager of the horizontal process is critical and want to support it. The CHPs are well placed to fulfil this role and those who took part in the Findings and Reflection Events in Stage 3 recognised this. They wanted to see the CHPs take a greater role in managing the overall process of patient pathways between community care, primary and secondary care settings. Part of this process will involve CHPs having stronger relationships with GPs and this is an area that has been highlighted during the research Leadership by Health Board Chairs and Chief Executives, elected Councillors and local authority Chief Executives, and by CHP General Managers is a common theme throughout this report. It is recognised that where leadership has been effective the CHP has been able to achieve more because the leaders have supported the work of the CHP and importantly have made sure within their own organisations that the work of the CHPs is understood In terms of elected Councillors, there is huge commitment and energy shown by many, turning up to chair/attend meetings and engage with the issues. However, there is clearly also more to be done in terms of ensuring that newly elected members are brought up to speed and that key issues are fed back to appropriate parts of the local authority s structure Health Board Chairs and Chief Executives have a central role in taking forward what happens next to build on the findings of this report We provide suggestions for further consideration in Table 7.1. We are fully aware that due to the variability across CHPs some of these suggestions will not be relevant in some areas. However we hope they will serve to stimulate discussion The suggestions are grouped under the following headings: governance and structures; the role of CHPs; the horizontal pathway process. These three themes have been selected as providing scope to address many of the key suggestions made during the course of the research. It is recognised that there will be some ideas/suggestions contained in the report that are not included here, which may be of particular interest to specific 49

60 Health Boards and CHPs and we would encourage each Health Board and CPP to consider the findings of the report and relate these to their own local circumstances so that specific issues for action in each area can be identified. Table 7.1: Ideas for further consideration Agencies Health Board Themes Governance and Structures Review whether the CHP Committee is fit for purpose/working effectively (size, fit, frequency, attendance) Review Health Board s leadership role in relation to CHPs: can more be done to support them? Is the CHP able to influence Board strategy as well as deliver it? (as was stated in the original guidance) The role of CHPs Affirm the role of CHPs across the patient pathway from community care to secondary care How can the Health Board further support the CHPs role as adaptor Horizontal pathway management/process Give CHPs a clear role to be responsible for the horizontal pathway process Review how Health Boards (in discussion with Scottish Government) can support CHPs work in relation to GPs. Local Authority Ensure elected members have induction/development time to enable them to cover all aspects of the CHP agenda Ensure CHP issues are fed in at appropriate levels to Council structures Review structures between Health Board/CHP and Local Authority: is there duplication? Review joint working/co-location to build on progress made Review role of CHP in integration of services for vulnerable people (children, those with learning disabilities, those with mental health problems, older people) to see if there is scope for further development. Review the level of integration between health and social care is it right or is further change needed? CPP Ensure that CHP voice is heard at CPP level Ideally the CHP should be able to influence across the CPP themes, not just health, in order to tackle inequalities. Is there more that can be addressed at the community end of this pathway that the CPP can influence? CHP Aim to have direct relationship with CPP Review voluntary sector involvement with CHP does it need to Develop clear understanding within the CHP about its priorities in relation to the horizontal pathway and the Review what more can be done to develop the management/improvem ents to the horizontal pathway process. As part of this, review 50

61 Agencies Themes Governance and Structures be strengthened? The role of CHPs relationships it needs to further develop. Horizontal pathway management/process MCNs role and how to further develop this area National/COSLA/S cottish Government Review initial guidance and update this to take account of the changing context and what has been learnt over the first five years Input from COSLA on role of elected members in relation to CHPs (this suggestion was made by COSLA at a feedback meeting with the Health and well being Committee). Within the revised guidance comment on the horizontal role of CHPs across the community, primary, secondary patient pathway Discuss with Health Boards issues relating to GP contracts and CHPs 7.13 Despite the challenges raised during the study, many of those interviewed thought that the CHP in their area was working well and that they would continue to build on the progress that has been made so far. The overall sense is that the CHPs are ready to move onto the next chapter of their development. 51

62 Appendix 1 RESEARCH ADVISORY GROUP MEMBERS The Research Advisory Group consisted of: Fiona Palin, ADSW, Highland Council; Ron Culley, COSLA; Jim McGoldrick, Fife NHS; Kathleen Bessos, Shifting the Balance of Care, Scottish Government; Fiona Hodgkiss, Health Analytical Services Division; Christine Sheehy, Health Analytical Services Division; Gill McVicar, Association of CHPs; Kay Barton, Health Improvement, Scottish Government; Graeme Dickson, Scottish Government; Fiona MacKenzie, NHS Forth Valley; Brian Morton, Royal College of Nurses. 52

63 Appendix 2: STAKEHOLDERS INTERVIEWED DURING STAGE 1 CHPs Aberdeen General Manager Local Authority contact: Head of Adult Services Committee Chair Clinical Lead Aberdeenshire General Manager Local Authority contact: Director of Housing and Social work Committee Chair Clinical Lead Angus General Manager Local Authority contact: Director of Social Work and Health Liaison Committee Chair Clinical Lead Argyll and Bute General Manager Local Authority contact: Director of Community Services Committee Chair Clinical Lead Borders General Manager Local Authority contact Committee Chair Clinical Lead Clackmannanshire General Manager Local Authority contacts: Head of Social Services, Head of Strategic Policy Committee Chair Clinical Lead x 2 Dumfries and Galloway General Managers of LHPs x 2 Director of Health Services/Chair LHP Management Team Clinical Leads of LHPs x 4 53

64 Dundee General Manager Local Authority contact: Manager, Community Services Committee Chair Clinical Lead Strategy and Performance Manager Dunfermline and West Fife General Manager Local Authority contact: Senior Manager Children and Families and Criminal Justice Committee Chair Clinical Lead East Ayrshire General Manager Local Authority contact: Head of Service Community Care Committee Chair Clinical Lead CHP Facilitator East Dunbartonshire Director Local Authority contact: Head of Social Work Committee Chair Clinical Lead East Glasgow Director Local Authority contact: Director of Social Work Committee Chair Clinical Lead East Lothian General Manager Local Authority Contact: Executive Director of Community Services Committee Chair Clinical Lead East Renfrewshire Director Committee Chair Clinical Lead Edinburgh City General Manager Local Authority contact: Director of Health and Social Care Committee Chair 54

65 Falkirk General Manager Local Authority contact: Head of Policy and Performance Review Committee Chair Clinical Lead Glenrothes and North East Fife General Manager Local Authority contact: Director of Social Work Committee Chair Clinical Lead Inverclyde Director Local Authority contact: Corporate Director, Education and Social Care Committee Chair Clinical Lead Kirkcaldy and Levenmouth General Manager Local Authority contact: Senior Manager, Older People s Services Committee Chair Clinical Lead Mid Highland General Manager Local Authority contact: Area Community Care Manager Committee Chair Clinical Lead Midlothian General Manager Local Authority contact: Director of Social Work Committee Chair Clinical Lead Moray General Manager Local Authority contact: Lead System Manager for Social Work Committee Chair Clinical Lead North Ayrshire General Manager North Glasgow Director Local Authority contact: Director of Social Work Committee Chair Clinical Lead 55

66 North Highland General Manager Local Authority contact: Area Manager Social Work Committee Chair Clinical Lead North Lanarkshire Local Authority contact: Manager of Community Care Networks Committee Chair Clinical Lead Orkney Director General Manager Clinical Lead Perth and Kinross General Manager Local Authority contact: Director of Housing and Community Care Committee Chair Clinical Lead Renfrewshire Director Local Authority contact: Chief Executive Committee Chair Clinical Lead Head of Community Care Head of Planning and Health Improvement Shetland Local Authority contact: Director of Education Committee Chair Clinical Lead Director of Community Care Director of Clinical Services South Ayrshire General Manager Local Authority contact: Head of Community Care Committee Chair Clinical Lead South East Glasgow Director Local Authority contact: Director of Social Work Committee Chair Clinical Lead 56

67 South East Highland Director Local Authority contact: Area Manager, Social Work Committee Chair Clinical Lead South Lanarkshire Director Local Authority contact: Executive Director of Social Work Committee Chair Clinical Lead South West Glasgow Director Local Authority contact: Director of Social Work Committee Chair Clinical Lead Stirling General Manager Local Authority contact: Director of Community Services Committee Chair Clinical Lead West Dunbartonshire Director Local Authority contact: Head of Service, Older People's Team Committee Chair Clinical Lead West Glasgow Director Local Authority contact: Director of Social Work Committee Chair Clinical Lead West Lothian Director Head of Health Local Authority contact: Director of Social Policy Committee Chair Clinical Lead Western Isles General Manager Local Authority contact: Head of Service, Community Care Committee Chair Clinical Lead Service Manager, Community Care Services 57

68 NHS Boards NHS Ayrshire and Arran Health Care Director for Integrated Care and Partner Services Chair NHS Borders Chief Executive Chair NHS Dumfries and Galloway Chief Executive Chair Medical Director NHS Fife Chief Executive Chair NHS Forth Valley Chief Executive Chair NHS Grampian Chief Executive Chair NHS Greater Glasgow and Clyde Chief Executive Director of Corporate Policy and Planning Chair NHS Highland Chief Operating Officer Chair NHS Lanarkshire Chief Executive Chair NHS Lothian Chief Executive Director of Planning NHS Shetland Chief Executive Chair 58

69 NHS Tayside Chief Executive Chief Executive of the Delivery Unit Chair NHS Orkney Chief Executive Chair NHS Western Isles Chief Executive Chair 59

70 Appendix 3: STAKEHOLDERS INTERVIEWED DURING STAGE 2 South Lanarkshire Dr Lesley Armitage, Consultant in Public Health Medicine Peter McCrossan, Associate Director of Nursing and AHPs Cllr James Handibode, South Lanarkshire Council John Mitchell, Vice Chair, Public Partnership Forum Fiona Porter, Head of Finance, Primary Care Dr Chris Mackintosh, Associate Medical Director Ian Ross, Director of Strategic Implementation, Planning and Performance Rosemary Lyness, Director, Acute Division Roy Garscadden, Head of Planning, Acute Division David Hume, General Manager for Emergency & Medical Clinical Division Members of the Community Planning Partnership Maria Reid, Assistant Health Promotion Manager, NHSL Michele Dowling, Planning Manager (Health), South Lanarkshire Council Patrick Murphy, South Lanarkshire Leisure Dr Sharon Russell, GP Edinburgh CHP David Small, CHP General Manager Lynda Cowie, Chief Nurse Sue Brace, Head of Strategic Planning, Edinburgh Council PPF Representatives (Jim Brown and one other) David Jack, CPP Manager Mike Grieve, Acute Sector Manager Duncan Miller, General Manager, Primary Care Contracts Dr Ramon McDermott, GP Lyn McDonald, Director of Operations, UHD James McCaffery, CEO, ERI Dr Ian McKay, Clinical Director of CHP Seb Fischer, Vol Sector Rep Peter Gabbitas, Director of Edinburgh CHP Stuart McLauglin, Partnership Representative Dunfermline & West Fife CHP Tim Kendrick, CPP Manager Dr David Alexander, GP Jesse Roberts, Voluntary Sector Rep Susan Manion, CHP General Manager Marilyn Dennison, PPF Rep Lesley Eydmann, Localities Manager John Wilson, Chief Exec, Operating Division, NHS Fife Pauline Small, Lead Nurse Dr Robert Cargill, Consultant (Sec. Care) 60

71 Borders CHCP Ralph Roberts, CHP Director Sarah Glendinning, CPP Manager Andrew Leitch, PPF Rep Annette Scobie, Vol Sector Rep Dr Rolland, GP Hamish McRitchie, Chair of Clinical Board Rachel Bacon, Acute Sector Manager Isabel Swan, Lead Nurse Renfrewshire CHP Stuart Graham, CPP Dr John Ip, GP Susan McLean, Chair of PPF Fiona McNeill, Head of Mental Health at CHP David Leese, Director of CHP Chris Johnstone, Associate Medical Director and Clinical Governance Lead Jane Grant & Anne Harkness, CEO of Acute & Director of Rehab, NHS GGC Kate Sloan, Nurse Fiona Nicolson Vol Sector Rep Mid Highland CHP Alison Phimister, Localities Manager for Ross, West Ness, Cromarty, Lochalsh and Skye Pat Dobbie, PPF Representative Gill McVicar, CHP General Manager Melanie Meecham, Primary Care Advisor Findlay Hickey, Lead Pharmacist Susan Eddie, General Manager of Raigmore Hospital Alison Hudson, Lead Nurse Bob Cameron CPP Manager Cllr Margaret Davidson Harriet Dempster, Director of Social Work, Highland Council Dr Miles Mack, GP 61

72 Appendix 4: LINKS TO KEY POLICY DOCUMENTS Agenda for Change (Department for Health, 2004) asset/dh_ pdf National Strategy for the Development of the Social Service Workforce in Scotland: a plan for action (Scottish Executive, 2005) Changing Lives: Report of the 21st Century Social Work Review (Scottish Executive, 2006) Better Health, Better Care: Action Plan (Scottish Government, 2007) Mental Health in Scotland: closing the gaps making a difference (Scottish Government, 2007) Equally Well: Report of the Ministerial Task Force on Health Inequalities (Scottish Government, June 2008) Towards a Mentally Flourishing Scotland: the future of mental health improvement in Scotland (Scottish Government, 2008) A Force for Improvement: The Workforce Response to Better Health, Better Care (Scottish Government, 2009) Achieving our Potential: A Framework to tackle poverty and income inequality in Scotland (Scottish Government, 2008) The Equally Well Implementation Plan Early Years and Early Intervention: A Scottish Government and COSLA policy statement Overview of Evidence Relating to Shifting the Balance of Care: A Contribution to the Knowledge Base Improving the Health and Wellbeing of People with Long Term Conditions in Scotland: A National Action Plan. (Scottish Government, June 2009) 62

73 Community Care outcomes - National Outcomes For Community Care (Scottish Government, April 2007) 63

74 Appendix 5: INTERVIEWEES PERCEPTIONS OF THE DEVELOPMENT OF THE CHPS Development Perceptions of the development of the CHPs are divided into the development prior to the CHPs being established and since they were established. Development: prior to establishment We asked interviewees to comment on the main factors influencing the development of their CHP. In terms of the initial development of the CHPs, interviewees thought that what had been in place before in terms of local health structures influenced the CHP s development. This reflects the fact that the policy intention of CHPs was to build on the progress that had been made by LHCCs and to evolve that to include more substantive joint working arrangements with local authorities. For example, many of those we interviewed cited the former LHCCs and that these had been built on; others cited the former NHS Trust and saw this as the precursor for the CHPs. It is interesting to note that Orkney, where it has taken longer to come up with a final CHP structure, had no LHCC. In some areas respondents pointed out that the LHCC had already been working closely with the social work teams and provided a good basis for moving forward. Several interviewees cited the Joint Futures agenda and the work that had already been ongoing around this saying that their CHP had built on this work. The statutory guidance (outlined in Section 2 of this report) was mentioned as an important factor by CHPs. Co-terminosity with local authority boundaries was also mentioned as an important factor in determining the structure for CHPs. One area stated that it would have chosen to have only two CHPs in terms of the population size and need but that because there are three local authority areas it was decided by the partners that there should be three CHPs. Some of those we interviewed spoke of the already existing close working relationships with their local authority. For example: we already had a health and social care partnership and lots of partnership working and we evolved this to meet the Guidance given. Several interviewees stated that the needs of their local population had been a key influence on the development of their CHP and the issues on which it focuses. 64

75 Development: since establishment Changes within the external context have played a significant part in the development of CHPs during and since their establishment. These include the major change for four CHPs (Argyll and Bute, Renfrewshire, East and West Dunbartonshire) brought about by the demise of the Argyll and Clyde Health Board. In particular Argyll and Bute CHP is significantly different from any other CHP because of this change as part of the dissolution agreement allowed for the CHP to have devolved responsibility for its budget for secondary care as well as primary and community care. The political change brought about after the local elections in 2007 influenced development for some CHPs. One CHP said it felt that they had had a dummy run prior to 2007 and as a result were more able to assist the new Councillors after the election. Some CHPs cited negative audits of their local authority (from Audit Scotland/Social Work Inspection Agency) as having had a negative impact on their CHP s development. This was because of the attention these local authorities had to give to the issues raised and because it involved personnel changes in senior positions. General changes in local authority personnel were mentioned by a few other CHPs as causing difficulties for them: they had built up productive joint working arrangements with one Director of Social Work for example and then had to start that process again when change occurred. 65

76 Appendix 6: EXAMPLES OF PRACTICE FROM THE STUDY Managing the patient pathway In one CHP they used visioning events to bring together acute clinicians, specialist nurses, GPs, community nurses and patients to discuss models of care and patient pathways and discuss what could be done differently in the redesign of services for example in dermatology. The interviewees from this CHP described this form of interaction as very productive and unimaginable a few years ago. *** One CHP decided that tackling LTC was part of the everyday work of many health and care professionals and wanted to provide support at the grassroots level and weave activities into what was already being done. So they created four lead LTC clinical groups which have been developed in a way that gives the groups the authority to make changes and improve coordination- Coronary Heart Disease Group, Respiratory Conditions Group, Diabetes Group, Older People's Group. Each group involves relevant representatives with key responsibilities within managed services so that they can address issues and outcomes and have access to budgets to make the necessary changes. The groups focus on the development of clinical pathway models that deliver care closer to home and changes include: Respiratory medicine the development of agreed integrated pathway for COPD to be implemented across primary and acute services; Diabetes the management of diabetes in the community setting; and Older People s Services further development of the Intermediate Care Services which includes a review of inpatient, day care and community team focusing on both anticipatory care and discharge processes. Anticipatory care In one CHP there is a COPD pilot using enhanced service funding and involving 29 GP practices. This has led to an agreed approach to case management involving respiratory nurses, the LTC manager, and community nurses in case management of COPD patients. The process involves identifying COPD patients in the practice. ( A case-finder model is used to identify the top 1% of patients with a specific condition in this case COPD patients, - this uses a triangulated approach whereby the GP, social worker, and community nurse each identifies the top 1% most severe patients they know and then compare their findings. The patients are then screened to identify those most in need and these are actively recruited to take part in the pilot. The nurses then work with the patient to ensure they: participate in anticipatory care and know what to do when they begin to feel ill; have access to and understand how to use rescue medication; and self manage their condition so far as they can. 66

77 Shifting the balance of care One CHP s new homecare service is designed to work with service users to set goals with the aim of increasing independence. Following referral to the homecare service, service users are assessed and allocated a number of hours of care. Users then start a six week period of reablement. Outcomes are agreed with service users at the outset with the aim of regaining daily living skills. At the end of the re-ablement period, some service users no longer require support, whilst others have reduced care requirements which are then met by the home care team. The staff involved in the service underwent training to provide them with the skills, knowledge and a greater understanding of the new re-ablement service so that they were equipped to adapt to their changing role. The new service has been evaluated and this showed that over the six week re-ablement period, there was a considerable impact on reducing the number of hours of care required by service users. Whilst the costs of delivering the re-ablement service were higher than the more traditional service, over the longer term, those receiving the re-ablement service require less care. This has freed up capacity and allowed for the care of more clients using the same level of resources as well as leading to significant savings in the homecare service. *** The shift between who delivers services is illustrated in one CHP where there is a new approach to the triage of orthopaedic patients. Physiotherapists triage the patients and can also carry out some treatments. This has led to a 40% reduction in the number of referrals to consultants. The pilot is now being extended to GPs who will be taught to do the same triaging and treatment work currently being undertaken by physiotherapists. *** There is a new approach to the care of patients with dementia in one town in a CHP area. Inpatient beds have been removed and replaced with a 24/7 outreach initiative. This involves a co-located multi-disciplinary team from the voluntary sector, social work and health. It has also involved the re-skilling of staff. The CHP hopes to develop similar services in other towns. Alert form In one CHP, GPs have agreed to complete an alert form for the top 1% of LTC patients with COPD. This is uploaded electronically onto a software package designed to help GPs manage out of hours services it contains the out of hours patients records. Anyone seeing that patient out of hours, for example the locum doctor or a paramedic, has the patient s background records easily to hand and can manage their treatment without necessarily referring them to hospital. *** 67

78 In one CHP, the Palpitation Pathway Project in local GP surgeries, supported by the relevant hospital consultant, has led to a change in the threshold for referral to cardiology, with fewer people being referred to hospital as a result. *** In another CHP, their IMPACT service, co-ordinated by community nurses and delivered through general practice, aims to target patients at most risk of readmission to hospital for anticipatory care. The programme identifies individuals, discusses their needs and then offers a comprehensive and holistic assessment which improves care and reduces the patient s admission risk. The perception from health professionals is that patients are receiving a better service and the SPARRA data will be examined to identify if these perceived improvements translate into reduced readmissions. The new service has required new ways of working, including improved multidisciplinary teamwork, communication and sharing of information, data collection, with new roles and responsibility, and the need for shared training. Access to services One of the main improvements in two of the CHPs visited in Stage 2 was the provision of salaried NHS dentists. This has led to increased dentist provision in these localities in one of the CHPs the PPF representative viewed this as a key success and indicated that without the new provision, people would have gone without a dentistry service. In the other CHP, the improvement in access to services was evidenced by a significant reduction in calls to the dental helpline which provided patients with advice on dental practices taking new patients and emergency care. In one CHP area there is a diabetes initiative whereby the GP sees the insulin dependent patients in the primary care setting and nurses come from the general hospital into the community to support patients at home Various examples of scanning services brought to more local settings such as community hospitals. *** *** 68

79 Health improvement and tackling health inequalities In one CHP the health inequalities subgroup (HISG) of the CHP covers health improvement outcomes through a partnership approach with the local authority and the HISG is co-chaired by the CPP Manager and Deputy Director of Public Health. The work of the group has strong links to the SOA and other health indicators and although no longer a requirement, they still use a joint health improvement plan (JHIP), as a framework to direct joint working to improve health and target inequalities which is tracked through the SOA and community planning. The HISG focuses on four themes physical activity, food and health, building community capacity and the environment to address needs of deprived communities. This focus is intended so as not to duplicate the activity to address health inequalities being undertaken by other partnerships across the area. This focused approach has led to four action plans which are financed through the Fairer Scotland Fund and the CHP is now considering how their joint efforts to improve health and tackle inequalities can be more effectively co-ordinated. *** A CHCP has worked with a local college to develop an employability programme for single mothers to move them towards employment with the health Board (where there was a high level of vacancies). As a result, 15 women started jobs with the health Board. This is an example of tackling social conditions to improve health, recognising that women s health is likely to improve as a result of being employed. Joint working The CHCP worked with education partners to deliver a programme of sexual health and relationships education in local schools (with the aim of addressing a high level of teen pregnancies). It also worked with education to implement a children s oral hygiene campaign, which involved volunteers going into nurseries to encourage tooth brushing among the children. This has resulted in improvements in rates of dental cavities and tooth extractions for that age group. Co-location of voluntary sector body working on dementia alongside social work and health. *** The Director of Public health is a jointly appointed and funded post by the health Board and local authority and is based within the local authority. *** 69

80 An example of joint working within one CHP is described as follows: The local authority Chief Executive and Director of Social Work meet on a regular basis with the Director of the CHP and discuss the day-to-day management. There is co-location between the CHP Management and the Council with both based within the Council Headquarters although it is not an integrated health and social care partnership. The proximity of the management team of the CHP and the Council helps build the relationship and facilitate good communication. District Nursing services work together with area based Social Work. There are also community based teams for older adult mental health and learning disabilities. There are other areas of joint working with the CHP such as Children and Young People and the Vulnerable Elderly. PPF Involvement In one CHP some of the PPF representatives visited a diagnostic and treatment centre (DTC) in Basingstoke in order to increase their knowledge and understanding of the DTC that was due to be developed at their local hospital. It was intended that this would enable them to make informed contributions to the development of the DTC and better inform the public about the new centre. *** In another CHP the PPF representative holds a respected position on the CHP committee. This is not a tokenistic role as the PPF representative is expected to contribute and be involved in all aspects of the CHP s developments and activities. The representative talked of her surprise at the level of genuine and senior-level involvement with the PPF and the support provided to encourage full participation. 70

81 ISSN ISBN (Web only publication) ISBN: APS Group Scotland DPPASxxxxx (05/10)