The Scottish Government

« Previous | Contents | Next »

Listen

Part 1: The Consultation Paper

Introduction

1. The Scottish Government has announced its intention of:

• introducing independent, external scrutiny of proposals for major changes in NHS services before full public consultation takes place;
• consulting on what form the independent scrutiny should take.

The Government wants to know the views of the people who use NHS services on what form this independent, external scrutiny should take, and has said its final decision will be informed by the responses to this consultation exercise.

2. Because of the need to take early decisions and reduce uncertainty, specific arrangements for independent scrutiny have been announced separately about Accident and Emergency services at Ayr and Monklands Hospitals, and on NHS Greater Glasgow and Clyde's proposals for services across the Clyde area. The consultation proposals build on these arrangements but the Government is also open to consider other ideas and approaches.

Independent scrutiny

3. A key message of the Kerr Report ² - Building a Health Service Fit for the Future - was that the NHS needs to change. But decisions on the delivery of health services are frequently difficult, and change to local services can often be controversial, and at times hard to accept. A complex range of factors - clinical needs, patient safety, workforce issues, finance, and the views of patients and the public - have to be considered. We need consultation and decision processes which allow necessary change to take place, but ensure that it is based on robust evidence and that the views of the public are heard and taken into account.

4. This is why a key principle of Kerr is that the NHS needs to develop options for change with people, not for them. Independent scrutiny is a way of improving existing processes to ensure that there is comprehensive information and advice available to inform public debate.

5. The starting point for making decisions on the delivery of health services has to be that the NHS is a public service - a service that is used for and paid for by the public. This means that NHS Boards must take full account of local circumstances in reaching decisions, and must have regard to the views of local people and organisations.

6. The Scottish Health Council ³ was established in 2005 to ensure that the public engagement processes of Boards are conducted thoroughly and openly. This has led to some important lessons, and has had a positive effect on communication and engagement practice in the NHS.

7. It remains the case, however, that in some instances there has been controversy and disagreement. This has included questioning of the information and evidence base on which decisions are taken. It is important to find ways of addressing these concerns as far as possible: ensuring that decisions are based on the best available clinical and financial evidence, and robust assessment and appraisal of options.

8. The Government believes that the public and Ministers require stronger and more comprehensive reassurance and advice than is available at present. The purpose of independent scrutiny will be to provide more rigorous examination of the information and evidence, and an independent assessment for the public and Ministers, while retaining the responsibility and accountability of NHS Boards and Ministers for decisions.

9. The Scottish Government supports the general principles set out for the future of healthcare services in Scotland in the Kerr Report. This includes a clear policy presumption against centralisation:

"Future decisions about the concentration of services on fewer sites should be limited on the grounds of resource or workforce constraints to services which:

• are highly specialised and a clinical benefit can be demonstrated, or
• receive seriously ill patients 24 hours per day, or
• care for medically unstable patients through the night, and for which
• it can be demonstrated that service redesign will not achieve a sustainable outcome."

In order to meet these conditions it is essential that any proposals for service change should be robust; all alternatives for service redesign must have been considered; and the NHS board should be able to demonstrate that due weight has been given to public opinion.

10. Independent scrutiny will be required where there are proposals for significant service change which will have a major impact on the way services are delivered ⁴. In most cases it will be reasonably clear whether the issues involved for the public locally are such that independent scrutiny is needed, but there may sometimes be uncertainty. The final decision on this will be a matter for Ministers, taking into account the impact of the proposed changes on different groups and communities, and any concerns expressed by patient or carer groups, communities or stakeholders locally. Often a major service change will involve changes and developments in a number of services across the area of an NHS Board to meet the needs of patients, and independent scrutiny should consider the overall plan for change and alternative options.

11. It is proposed that independent scrutiny will take place before full public consultation. It will aim to ensure that plans for service change deliver safe, sustainable, evidence-based and value for money services, and that all options which meet these criteria have been fully taken into account.

12. Having independent scrutiny at the early stages of the decision-making process should ensure that there is an agreed and accepted information and evidence base for decisions, although there may still be debate on the assessment and interpretation of evidence and the right choices. There can be no illusions that independent scrutiny will avoid difficult choices having to be made. But it has the potential to improve the quality of evidence, debate and decision-making, and to make this process more transparent and understandable to the public.

Options for an independent scrutiny approach

13. There are a range of options for carrying out independent scrutiny and three possible options are set out below. It is suggested that the preferred option is an independent expert panel to examine and scrutinise proposals for major change to local NHS services.

Option 1: Decision conference

14. A decision conference would involve an independent moderator supporting a widely-based representative group of local people to hear the clinical, financial and patient evidence for, and implications of, the Board's proposed options. Local groups would also be invited to present alternative evidence-based perspectives to the conference. The moderator would advise and support the conference, and identify appropriate clinical, financial and public/patient criteria to enable it to determine which options should go forward to the wider public consultation stage.

15. This approach builds on existing local involvement processes to develop a publicly endorsed, evidence-based option, or options, for consultation. It has recently been used successfully in Scotland ⁵ as a way of publicly validating the evidence for a proposed service change.

16. However, the choice of moderator, and the selection of the 'representative' group of local people, are critical to the effectiveness of this approach. It is not clear that this process would be able to provide sufficient rigour or independence of scrutiny, or that it would have the ability to assess and evaluate evidence thoroughly and in-depth.

Option 2: A scrutiny body

17. An independent body, such as a local authority, could potentially be asked to scrutinise the evidence and the merits of proposals for a major change in local NHS services. Such a system operates in England ⁶.

18. Local authorities could be given a statutory right to be informed when an NHS Board was planning a major service change, and to be provided with the necessary information and support to enable them to decide if the proposed change was in the best interests of the local population. If the local authority was not satisfied, or felt that it had not been adequately consulted, it would refer the proposal to Ministers for decision. Ministers could then either invite the NHS body to reconsider its proposals, or refer the matter to an Independent Panel for further advice - see option 3.

19. This option could potentially introduce a strong locally-based element to the independent scrutiny of service change, and would allow health service change to be considered in the wider context of the delivery of public services at a local level. However, in Scotland there is already close partnership working between local authorities and the NHS, and involvement of councillors in the governance of NHS Boards. It is not clear that this approach would add significantly to current decision-making and scrutiny processes. There is also the risk, compared with other options, that it could add time and complexity to the process.

Option 3: An Expert Panel

20. The NHS has used the approach of an independent, expert panel a number of times in the past ⁷. It could involve a panel led by a non-clinical person with the skills and experience to chair a scrutiny process. In order to ensure their independence and expertise, the chair would be selected through the public appointments process, and would be accountable to Ministers.

21. The panel would have a majority of lay (non-clinical members) in order to ensure public confidence that it would take a fully independent view. The members of the panel would be nominated on the basis of their knowledge and expertise by appropriate organisations, and would have the necessary expertise to consider the clinical, financial and patient evidence for service change and the options developed by the NHS Board. The panel would also encourage the submission of alternative evidence-based perspectives from community and patient groups.

22. A suitable panel, composed of people with no direct interest or involvement in local NHS services, would be set up to examine each proposal for major service change brought forward by NHS Boards. The panel would operate from the early stages of the process of public engagement and development of options by the NHS Board, as evidence and options are being pulled together. It would assess the information and evidence available, and seek to ensure that the full range of safe and sustainable options was being identified and evaluated in a clear and transparent way. Each panel would focus primarily on the local circumstances of the area concerned, but would be expected also to reflect a consistent policy approach to the design and delivery of services across Scotland.

23. The panel would provide a commentary on the evidence presented in support of the proposed change and the options considered. This would be published before the formal consultation stage, and would be made available to Ministers as an input to the final decision-making and approval process. The NHS Board would be able to reflect their conclusions in the final proposal for public consultation. If there was significant change in circumstances, or in the options being considered during the consultation stage, then the Panel might be invited to review their assessment. It is unlikely, however, that the evidence or options available would change substantially at this stage.

24. Overall, this would add rigour and robust scrutiny to the process of option development and appraisal, and represents the preferred approach of the Scottish Government. It would fit well with existing processes and practices of public engagement and development of options, and ensure clear lines of accountability for scrutiny and decision-making. The aim would be to ensure that the panel was able to provide effective independent scrutiny, without adding unnecessary delay or complexity to the decision-making process.

Conclusions

25. Delivering a modern health service involves complex clinical, workforce, financial and other issues that can be difficult to communicate and understand, and sometimes involves making difficult choices. It will not always be possible to reach decisions that all sections of the public agree with. However, it is essential that the NHS is able to demonstrate that it has listened to the views of the public, and that decisions are made on the basis of comprehensive information and evidence. Independent scrutiny can ensure that there is rigorous assessment of the evidence and options, and that public views are reflected in this process.

26. In considering the options for independent scrutiny, the third option, to establish a national panel of experts, offers the best way of ensuring that there is rigorous and robust assessment of the evidence, and that all options are fully considered and taken into account.

Questions

27. We would welcome your comments on the following questions:

(please complete the form at page 20 and the template for answer at pages 21-24)

Question 1: Do you agree that an expert panel is the most effective way to provide independent scrutiny? If not, what would be your preferred choice?

Question 2: Do you agree that the role of the panel should be to assess the safety, sustainability, evidence-base and value for money of proposals for major changes to local NHS services?

Question 3: Do you agree that the chair should be a lay person appointed by Scottish Ministers?

Question 4: Do you agree that the panel should have a lay majority among its members?

Question 5: Do you agree that the panel should assess the evidence and options during the process of public engagement prior to consultation, and provide a commentary on these that would be available to the Board and to Ministers in reaching decisions?

Question 6: Do you have any other comments on how independent scrutiny should be carried out, or on the guidance on "Informing, engaging and consulting the public in developing health and community care services" at Annex 3?

Question 7: Do you have any other comments on either the consultation process or your preferred choice?

28. You can submit your response to these questions online using the form at www.scotland.gov.uk/consultations/health/IndependentScrutiny.asp

or you can use the form in part 2.

Will my comments be made public?

29. Copies of the written responses received to a consultation exercise, where permission is given by the respondent, are placed in the Library at:

30. If you do not wish your response to be made public, please ensure that you indicate clearly that all or part of your response is to be treated as confidential. Confidentiality will be strictly respected. Confidential responses will still count in any analysis and your views will of course be taken into account in the same way as non-confidential responses.

What happens next?

31. NHS Boards have been asked to pass this consultation paper to local community and patient groups in their area.

32. When this consultation is concluded, the responses will be analysed and the views expressed will be summarised. Direct quotes from individual respondents will only be used where respondents have given their permission for publication of their response.

33. A report will be published and the Cabinet Secretary will consider the views expressed and the issues raised before coming to an informed decision on the form of independent scrutiny to be introduced. The Cabinet Secretary will consider all other information available to her and all representations made to her before coming to a final view.

34. The Scottish Government will then issue guidance to the NHS on the implementation of the preferred approach.

How will I know what the Cabinet Secretary decides?

35. The Cabinet Secretary's decision and a report on the consultation will be published on www.scotland.gov.uk/Consultations/Closed. A copy will also be sent to the address provided by each respondent.

Comments

36. If you have any comments about how this consultation exercise has been conducted, please send these to:

« Previous | Contents | Next »