Scottish NHS health boards structures are under review

Shona Robison - credit Scottish Govt

The last Scottish Government term, the only one in the parliament’s history to enjoy an overall majority, was largely defined by a certain referendum. 

Structural change in health and social care, however, was arguably the biggest legislative undertaking, merging budgets of health boards and local authorities to provide new integrated governing bodies.

But integration has been a long journey, and one which seems far from complete.

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Debates about who should sit on these bodies and what integration should look like on the ground raged through the parliament committee rooms and beyond. This culminated in April, when the new Integrated Joint Boards (IJBs) were launched. 

However, debates about what it all meant, and what integrated care should look like, continued.

In December, Audit Scotland had reported the IJBs have done inadequate workforce planning, with a lack of evidence as to how third sector or independent services would be involved. Budget disputes were still being fought out between local councillors and NHS officials, it was suggested, despite £250m being set aside in John Swinney’s budget.

“I don’t mind the health service getting more money, the health service needs more money, but don’t say they’re giving to us when they’re giving to the health service,” David O’Neill, president of local authorities’ umbrella body COSLA, told Holyrood in February.

In March, the country’s spending watchdog warned the shift to new models of care was not happening fast enough to meet the growing needs of an ageing population.

And as the IJBs launched in April, it was unclear any of the issues had been resolved. 

COSLA health and social work spokesperson, Councillor Peter Johnston, said: “What IJBs are being asked to do is incredibly difficult and we hope transformative, however, we, and Audit Scotland, need to let them get on with it now.”

Meanwhile Scotland’s new clinical strategy, launched in February, suggested structural change would continue. Care, it said, would move closer to communities using smaller and rural hospitals and primary care hubs, with more patients self-managing their own conditions.

Primary care would be more collaborative, it said, using “multidisciplinary teams” including expanded roles for advanced nurse practitioners, pharmacists and allied health professionals.
Like integration, however, while ambition remained bold, evidence of it happening on the ground was less clear, as health boards and councils faced difficult budget decisions.

As the election approached, the SNP manifesto hinted at further reform to come. 

Five new elective treatment centres in the model of the Jubilee Hospital in Clydebank would be established in Aberdeen, Inverness, Dundee, Livingston and Edinburgh, it said. 
This would potentially take responsibility for more planned operations away from health boards. 

Indeed, the spotlight was shone on the structure of the territorial health boards themselves, with the manifesto also promising to review their number.

Health Secretary Shona Robison was clearly frustrated with a lack of progress from the boards on digital solutions when she spoke to Holyrood’s eHealth conference in March. 
Robison told the conference the “not invented here” syndrome needed to become a thing of the past. “I have made it very clear to boards in the here and now, lines on maps should not dictate their decision-making,” she said.

And ahead of the SNP’s spring conference, Nicola Sturgeon told Holyrood: “We’ve got health boards and councils working together around social care, we’ve got a number of councils co-operating around city deals and in other arrangements and we’ve obviously had police reform, so all of these different things are happening and you do get to a point where you have to question whether the framework around that is any longer appropriate.”

Robison confirmed the review at a post-election parliamentary debate. 

“We have committed in this session of parliament to review the number, structure and regulation of health boards and their relationship with local councils, with a view to reducing unnecessary backroom duplication and removing impediments to better care,” she said.

Scottish Conservatives’ deputy leader, Jackson Carlaw, welcomed the idea.

“There is no agenda or determination to drive through structural change; nevertheless, there is recognition that the development of secondary care depends on an understanding of what the whole health board structure should be,” he said.

Some within the SNP have been more decisive about the need for structural change. Bruce Crawford MSP said: “We need to tackle the scale of that architecture and landscape if we are to make it fit for purpose and to meet the huge challenges of the future. Can we find a way to remove duplication from those services and to find administrative savings that we can put into the front line?”

However, Scottish Labour warned a review cannot be used to bury bad statistics. “Of course, Labour will engage in that process but a review cannot be a way of avoiding failures with missed targets. Another question that patients will ask is how long they will have to wait for the outcomes of any such review,” the party’s new health spokesman, Anas Sarwar, said.

Indeed, top-down targets on the NHS are also to be reviewed, according to Robison. “The time is now right to take stock of what we ask from the NHS, in conjunction with our partners in social care, to ensure that our approach is consistent with the outcomes-based focus of health and social care integration that is enshrined in statute and with the new integrated delivery landscape,” she said.

That landscape will depend on the work of those on the ground, regardless of what the governance structure above them looks like. The National Clinical Strategy highlighted an example from the Netherlands known as Buurtzorg, which means ‘neighbourhood care’.

This was started by community nurses, effectively empowering the role of the district nurse to do one long and detailed visit in the place of many visits by care workers. This increased the unit cost of interventions but this was compensated for by a 50 per cent reduction in total demand, according to the National Clinical Strategy. 

“The learning from this powerful example is that post-integration structures must not be afraid to experiment with quite devolved structures for professional teams, with a minimum of bureaucracy, but based upon clinically relevant shared objectives,” it said.

“Above all, their success relates to taking ownership of people’s problems and feeling empowered to address the problems using locally available resources with flexibility.”

Perhaps a hint that any progress on the integration journey will come from those who have to deliver it on the ground.