Supporting and Promoting Joint Working between Local Authority and NHS Bodies: Ladder of Support and Intervention

The UNISON Scotland Response April 2004

Executive Summary

UNISON Scotland believes that the starting point for scrutiny should be ‘bottom up' through open, transparent and democratically accountable public bodies. In regards to the Joint Future Agenda, we believe that the local partners should be required to produce a corporate strategy on participation and involvement which demonstrates how users, community organisations, staff and their trade unions can be involved in the planning, design, monitoring and review of services.

UNISON Scotland believes that equal access, representation and the capacity to participate are essential and for staff and their trade unions this has to be based on a genuine collective partnership model.

UNISON Scotland believes that service improvement has to be linked first and foremost to the availability of resources and the wider social and economic needs of the community. In addition, we believe that the crude adoption of ‘continuos improvement', ‘performance management' and similar initiatives is not appropriate to public services. These initiatives are incompatible with the need to encourage innovation and end the blame culture and they can often lead to increased stress and harassment in the work place.

UNISON Scotland acknowledges that interventions arising out of the framework will vary from supportive to corrective. Whilst we recognise that in extreme circumstances corrective intervention may be necessary, we are pleased that the emphasis in the document is on supportive interventions with inspection working in partnership with public bodies. In addition, UNISON Scotland believes that given the number of inspection bodies it is important that inspection is co-ordinated to avoid duplication, additional workload and inconsistency.

UNISON Scotland believes that there is a need for consistency and transparency within any framework and we are concerned that important elements of both appear to be missing from the proposed framework of support and intervention. It is the opinion of UNISON Scotland that the document would have benefited from a greater degree of clarity in regards to the threshold for an intervention decision and also the evidence upon which this decision would be made

Introduction

UNISON Scotland welcomes this opportunity to comment on the Scottish Executive's proposals for implementing a framework - the ladder of support and intervention - to support joint working between the NHS and local authorities.

UNISON is Scotland's largest trade union representing 150,000 members delivering public services. Over 85,000 of these members work for local authorities in Scotland and just under 50,000 work in the NHS in Scotland. We represent NHS nursing, ancillary and clerical staff in addition to a wide range of local authority staff who are involved in building communities, supporting families, protecting vulnerable people and caring for children.

UNISON Scotland members, as health and local government workers, as users of public services and as ordinary voters have a direct interest in commenting on these proposals, which cover issues of great concern not only in their professional lives but as citizens too.

This paper constitutes UNISON Scotland's response to the Scottish Executive consultation document ‘Promoting Joint Working between Local Authority and NHS Bodies: Ladder of Support and Intervention'.

Background

The proposals for a ladder of support and intervention, outlined in the consultation document, have been developed under Section 17 of the Community Care and Health (Scotland) Act 2002. These proposals will enable Ministers to intervene in local authorities or health boards, where performance of their health, social care or housing functions applicable to community care could be improved, by directing them to apply a range of joint working arrangements.

The ladder of support and intervention is seen as an administrative framework designed to emphasise the opportunity for self-improvement. The focus of the framework is on support rather than intervention and it concentrates on methods of delivering service improvement through support mechanisms and local action. This is intended to provide local partners with the opportunity to improve results at their own hand, with or without external facilitation.

The framework itself contains a set of steps that Scottish Ministers, local authorities and NHS bodies believe would be appropriate in most cases to achieve the desired improvements, once Scottish Ministers have taken the view that joint working would improve the performance of these bodies' community care and health functions.

However, where joint working appears to be failing or where joint working would be a solution to poor performance of a function, the power of intervention can be considered. Given that Ministerial intervention is a last resort, the document outlines that the evidence would have to demonstrate serious or sustained poor performance, which was unlikely to improve without intervention, even after support had been provided.

Responses

1. UNISON Scotland views on the process Scottish Ministers will apply in considering exercising these powers, including the balance between "support" and "intervention".

UNISON Scotland welcomes the Scottish Executives new initiative - ‘Re-invigorating the Joint Future Agenda' - to drive forward the Joint Futures programme. We also welcome the focus of this initiative and are supportive of the Executives aim to ensure individuals and carers receive tangible benefits as a result of better joint working.

UNISON Scotland is in broad agreement with the arrangements outlined in the proposed ladder of support and intervention and welcomes the emphasis in these arrangements on allowing Local Partners to resolve performance issues at their own hand, with Ministerial intervention as a last resort.

UNISON Scotland is broadly supportive of the framework actions, which emphasise identifying and meeting development needs and supporting continuous improvement, rather than imposing sanctions. However, UNISON Scotland also believes that there is a need for consistency and transparency within any framework and we are concerned that important elements of both appear to be missing from the proposed framework of support and intervention.

It is the opinion of UNISON Scotland that the Executive needs to give greater clarity in regards to the threshold for an intervention decision and also the evidence upon which this decision would be made. It is our opinion that the document fails to properly explain the criteria or indicators that will allow Ministers to assess or judge performance.

Also, UNISON Scotland believes the document fails to clearly outline what level and what type of intervention will be appropriate for those agencies considered to be failing in delivery of Joint Working services. Whilst acknowledging that ‘a one size fits all' approach is not appropriate in terms of deciding on intervention, UNISON Scotland believes the assertion that "the level of intervention would be appropriate to the need identified" to be ambiguous and lacking in clarity.

 We believe that further clarification is needed in regards to Ministerial decision-making on interventions. Failure to do so will leave a large measure of doubt about the ability of the framework to consider cases of inadequate performance in a manner that is transparent, consistent and able to inspire confidence amongst staff and users of joint working services.

 As those responsible for delivering the benefits of the Joint Future programme to Scotland's communities, we believe Scotland's local authorities and the various NHS bodies to have an important understanding of local issues and local conditions on the ground.

UNISON Scotland would be concerned that this valuable knowledge and local insight is not lost during the process of intervention. However, the document does not envisage any involvement for these agencies after the decision to directly intervene has been taken by Ministers.

UNISON Scotland believes this to be imprudent and remain unconvinced that the ‘heavy hand of central government' can deliver service improvements in Joint Working activity without the input of the local partners, at all rungs in the ladder of support and intervention.

2. UNISON Scotland views on the arrangements for measuring and assessing performance.

Whilst UNISON Scotland welcomes the fact that a decision to intervene will be made "against a more widely based assessment of the quality of a service in an area", we believe that the proposal would benefit from greater detail as to what exactly is to be included in any assessment.

UNISON Scotland believes that in scrutinising public services it should be recognised that there is a wide range of factors, which determine the performance of public services. These include factors like the funding available, access, the service environment and the relationship with users and the wider community.

UNISON Scotland believes that service improvement has to be linked not only to the availability of resources but also to the wider social and economic needs of a community. We would therefore urge the Executive to ensure that a more holistic approach is taken when assessing performance.

UNISON Scotland believes that performance should be assessed not measured. It is our belief that there are significant practical difficulties with performance measures particularly performance indicators and league tables together with a "one size fits all" approach to standards.

 UNISON Scotland believes that performance assessment should be based on 4 key elements. These are inputs i.e. on the resources used to produce a service, outputs i.e. it should measure the goods and services delivered, outcomes i.e. it should indicate the impact or benefit of services and processes i.e. measures the manner in which the outcomes are achieved.

The document states that JPIAF measures "will shortly move to setting targets to underpin key national outcomes". This is clearly a move in the direction of setting national targets and is a matter of some concern for UNISON Scotland.

UNISON Scotland believes there is a role for national inspection regimes in setting broad standards, issuing guidance and providing support. However, we also believe that these standards should not be a substitute for broader forms of democratic accountability. The inspection bodies also need to have clear policy objectives set by ministers who are democratically accountable to the Scottish Parliament. ‘Independent' does not mean ‘unaccountable'.

As stated above, UNISON Scotland is not intrinsically opposed to the establishment of national standards, we believe that they can be used to promote positive developments in relation to staff governance and health and safety standards. We are however concerned that this is done with the involvement of staff and their trade unions.

However, disappointingly, this involvement was not apparent during the 2003 establishment of performance indicators to measure waiting times for assessment and services; and trade union involvement remains unlikely in any future setting of standards.

As the largest trade union representing both health and local government staff in Scotland, we believe trade union non-participation in the setting of national standards to be unsound. We believe that the involvement of staff and their trade unions at both local and national level to be key in any successful development of national standards. It is the belief of UNISON Scotland that scrutiny works most effectively when operating in partnership with staff interests.

3. Unison Scotland's views on the ‘preventative' arrangements to support local partners improve performance at their own hand.

UNISON Scotland has a number of concerns regarding the systems outlined in the document for supporting local partners to improve their performance. Firstly, we would like to make known our disappointment that the Executive does not envisage any staff or trade union input to Joint Working Improvement Teams.

We believe that staff and their trade unions have a valuable contribution to make in improving the performance of joint working initiatives. Our exclusion, therefore, from this important element of the improvement process leads us to conclude that the arrangements to support local partners do not operate in full partnership with staff interests.

UNISON Scotland is also concerned at the large number of audit, inspection, assessment and monitoring bodies that will be used to provide indicators of the success or otherwise of joint working in local authorities and NHS Boards.

Whilst we are supportive of a co-ordinated approach to scrutiny, we believe that with this large number of inspection bodies, 14 as proposed in the document, there is a real danger of duplication of effort in the scrutiny of joint working arrangements.

4. UNISON Scotland's view on the arrangements for intervention and reporting.

UNISON Scotland is broadly supportive of the arrangements for intervention and reporting as outlined in the document.