The Scottish Government

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1. Introduction

1. The Scottish Government wants to encourage greater public and patient involvement in the planning and delivery of local NHS services in Scotland. The Government believes that direct elections to NHS Boards in Scotland can help to secure this. Subject to consultation on the issue, we intend to introduce legislation in a Local Healthcare Bill to provide for direct elections. Direct elections would mean a significant change to the way the NHS is run, and the Government therefore wants to consult on the proposals before reaching decisions. The aim of this consultation paper is to gather views and comments on whether a Local Healthcare Bill should include provision for direct elections to NHS Boards, and if so what form these might take. The Government wants your comments on the options available.

2. How the NHS works

2.1 NHS services in Scotland are planned and delivered by 14 territorial NHS Boards, plus seven Special Health Boards (such as the Scottish Ambulance Service Board) that provide cross-Scotland services. NHS Boards are statutory bodes, set up to ensure provision of health care in their area. This includes accident and emergency services, hospitals, primary medical services, and dental, ophthalmic and pharmaceutical services. Each Board is responsible for planning and delivery of these services in their area, and also for planning regional services between Board areas.

2.2 Boards are corporate bodies and consist of a chairman and other members appointed by Scottish Ministers. Annex A explains more about the make-up of the members of NHS Boards including how they are selected and appointed.

2.3 The NHS in Scotland is funded almost entirely from taxation, and costs around £10 billion a year in Scotland - about £2000 for every person in the country. Most of this budget is given out to NHS Boards to enable them to provide health care and related services in their area. Boards' budgets enable them to employ staff, pay contractors such as GPs, buy drugs and equipment and run hospitals so that healthcare can be provided, free, to everyone that needs it. Boards are responsible for how they spend this money, and are free to set local priorities. But they must act within any legislation made by the Government and are expected to operate within national policies and priorities set by the Government. The Boards are accountable to the Government for their performance and how they use the money, and through the Government to the Scottish Parliament and the people of Scotland.

2.4 The Government's policy is that healthcare services should be delivered as locally as possible, so that they are convenient and responsive to patients' needs. NHS Boards are responsible for delivering this policy. Some recent decisions to change the way NHS services in Scotland are delivered have raised strong feeling in local communities and many people believe that some NHS Boards have not taken sufficient account of the views of local people. The Government understands that difficult decisions about NHS services have to be made. It also believes, however, that local people must always be at the heart of the process, and that the service change process should be rigorous, evidence-based, and open to scrutiny. The Government has recently begun a consultation on how best to arrange independent scrutiny of proposals to change NHS services. The Government believe that elections to NHS Boards can provide a further, complementary, approach to ensuring that the voice of local people and communities is heard when major decisions are being made.

2.5 Our commitment to encouraging greater public and community involvement lies within the broader context of promoting effective governance across the public services, including the NHS. Key features of good governance in the NHS should ensure:

• a focus on quality services for patients;
• effective service delivery supported by clearly defined roles and responsibilities;
• promotion of the recognised values of the NHS in Scotland as a public service;
• that Boards make decisions in an informed and transparent manner;
• development of Boards so they are efficient and effective bodies; and
• that Boards engage with stakeholders and are properly accountable to Ministers and the Scottish Parliament.

2.6 It is important that in encouraging public/community involvement and proposing some form of direct elections to Health Boards, the good governance features set out above are reinforced and not undermined.

2.7 Good governance also encompasses effective scrutiny of the NHS. At present NHS Quality Improvement Scotland (" NHSQIS") largely fulfils this role. For the future, Professor Lorne Crerar has recently published his Independent Review of Regulation, Audit, Inspection and Complaints Handing of Public Services in Scotland. The broad principles and vision of this Review have been welcomed by the Scottish Government and are under consideration. Clearly, there is a relationship between any arrangements for external scrutiny and the additional internal scrutiny that may be achieved by introducing direct elections to NHS Boards. It will be important to ensure that the approaches add value and do not overlap.

2.8 The intention is that the proposed Local Healthcare Bill should further address concerns about the role patients and the public play in decisions about how local health services are designed and delivered. The consultation asks for your views on how this might best be done. There are a number of options. These range from strengthening existing policies, to ensure that the needs of local communities are heard more effectively, through to introducing new legislation that will require elections to be held to NHS Boards, thus placing locally elected members on Boards and (depending on the arrangements made) potentially giving them control over Boards' policies and priorities.

3. Consultation on Options for Change

3.1 Scotland benefits from a universal and comprehensive system of healthcare, available to all and free at the point of need. This approach continues to be supported by the great majority of people in Scotland, who value the fact that it provides services based on clinical need and not ability to pay. The Government is committed to maintaining these principles that underpin the NHS. Nothing in this consultation will change that. The challenge is how to maintain these principles while helping the NHS in Scotland to be more responsive to local communities' needs and priorities - and indeed to individual patients' priorities and choices.

3.2 This consultation paper sets out possible options under 2 headings: Section 1 asks questions about strengthening existing policies to ensure that the needs of local communities are heard more effectively, within the current framework of appointed NHS Boards. Section 2 asks your views on introducing new legislation to require elections to be held to NHS Boards to place locally elected members on Boards. Both options preserve 100% funding of NHS services from general taxation and maintain accountability of NHS Boards to the Scottish Government.

3.3 Different countries in the World organise and oversee healthcare services in different ways. For example, in New Zealand, the Government is responsible for health policy and strategy, with the delivery of health services through local, directly-elected Health Boards. These Boards remain fully accountable to the Minister for Health. In Sweden, the Government provides the legislative framework and also supervises and evaluates health services, while elected county councils are responsible for hospitals, the planning and delivery of acute and primary care services (as well as other public services).

3.4 We are inviting responses by 1 April 2008 on the issues raised in this consultation. Details of how you can respond are in Annex B at the back of the consultation paper.

3.5 The following sections contain a series of questions that we would like you to think about when considering how best to encourage greater public and patient involvement in the planning and delivery of local NHS services in Scotland. You should not feel restricted simply to answering these questions, however. If there are other issues you wish to raise relating to this set of topics, please feel free to do so.

Section 1

Making things better- this section seeks your views on how the role of patients and communities in deciding how NHS services in Scotland are planned and provided could be strengthened through augmenting existing policies, within the current framework of appointed NHS Boards .

1.1 When planning changes to services, NHS Boards are legally required to encourage public involvement. Health services deliver better care if they listen to and engage with patients and the communities they serve.

1.2 The Scottish Health Council has an important role in helping to ensure that patient and public involvement is effective in the NHS. The Council is a committee of NHSQIS and is under a duty to support, ensure and monitor the discharge by NHS Boards of their responsibility to encourage public involvement. Among its tasks, the Council works with NHS Boards to promote and provide:

• national standards for a patient-focused NHS that involves the public in health services;
• an external approach to checking that NHS Boards are delivering a patient-focused NHS;
• consistent information about how well NHS Boards are involving people in decisions about health services and what difference this is making;
• a national source of information and advice on best practice in involving the public in health services and ensuring a patient-focused NHS;
• effective ways of providing and obtaining feedback on people's experiences of health services.

1.3 As well as introducing a statutory duty to encourage public involvement and establishing the Scottish Health Council, a number of other actions have been taken to improve public engagement with the NHS in Scotland:

• a requirement has been set that Boards should achieve year-on-year improvements in patient focus and public involvement as demonstrated by the annual reports of the Council;
• the principles and practice in Communities Scotland's National Standards for Community Engagement have been endorsed as a guide to the NHS in Scotland in supporting everyday involvement of patients, carers and the public;
• national guidance has been developed on informing, engaging and consulting" the public in the development of proposals for major service change;
• Public Partnership Forums have been developed as a vehicle for proactively involving the public in the work of the Community Health Partnerships and their parent NHS Boards;
• the role of local authority representatives appointed to Health Boards has been supported, to help ensure local accountability and improve joint working arrangements where services are jointly managed by NHS Boards and local authorities;
• the Annual Review process between Boards and Ministers meeting has been opened up to local people and organisations so they can discuss and question Boards' stewardship and performance;
• the Scottish Government's Patient Experience Programme is being implemented to help develop and enhance how the views of patients and the public can be used to deliver improvements to patient experience across Scotland.

1.4 This work has helped to engage and involve communities in the development of local services. But there are still concerns that NHS Boards are not giving enough weight to local views. This has been recognised in setting up independent scrutiny panels to review proposals for major service change in Greater Glasgow Health Board's area and also to scrutinise proposals from NHS Lanarkshire and NHS Ayrshire and Arran for maintaining Accident and Emergency services at Monklands and Ayr Hospitals.

1.5 The Government wants to take the concept of independent scrutiny further by embedding this approach when considering all major service changes. As noted earlier in this paper, a separate consultation is currently under way on options for independent scrutiny of major service change proposals in the NHS in Scotland services.

1.6 The questions which follow, in this section of our consultation, are intended to open up discussion on how best to encourage and enhance public engagement with the NHS. However you should not feel restricted to answering these questions alone. If there are other issues and options which you think would encourage public engagement in the work of NHS Boards, then please let us know.

Section 2

A new approach- this section asks for your views on changing the current framework so that NHS Boards have directly elected members with the aim of bringing about greater patient and community involvement in planning and delivering local health services.

2.1 The proposed Local Healthcare Bill could provide for direct elections to territorial NHS Boards (the present proposals do not extend to Special Health Boards, which cover the whole of Scotland - it is proposed that they would continue to have only appointed members). Direct elections raise a number of important issues, set out below, on which the Scottish Government wants to hear your views. In particular, we need to know what you think about:

a. electoral processes;

b. the idea of piloting elections to NHS Boards in some areas; and

c. accountability and control of NHS Boards that would need to be addressed to maintain consistency across Scotland.

2.2 Before reading through the questions that follow, it will help to look at Annex A at the end of this document. Annex A describes how NHS Board members are selected and appointed at present. It also sets out the 3 categories of Board member - lay people appointed after a competitive process; "stakeholder" members who are appointed following nominations from specific organisations like local authorities and staff representative bodies; and executive members who are appointed because of the job they hold in the Board (for example, the Board Medical Director).

2.3. Electoral Process, Procedures and Systems

2.3.1. Members elected directly to an NHS Board would be responsible for a significant budget and for overseeing a vital public service. So people standing for election should be required to follow a formal process. The box below asks for your views on the electoral process, covering eligibility of people standing for election, eligibility to vote, and frequency of elections:

2.3.2 The proposed Local Healthcare Bill could provide for any proportion of NHS Board members to be elected - all of them; a majority of them, or fewer than half (a minority). The Bill could also provide for some or all of the existing categories of appointed NHS Board members to remain (see Annex A). The box below seeks your views on what proportion of the members should be elected, and what existing categories of appointed members, if any, should be retained:

2.3.3. NHS Boards cover large geographic areas - for example, the area covered by NHS Highland stretches from Wick to Campbeltown. Clearly it may be necessary, in arranging elections to Boards, to divide the areas up into some form of "electoral wards". This would also help to avoid candidates from a single area (for example, a large town in a rural Board area) dominating the election.

2.3.4. As well as the potential for candidates from particular geographic areas to dominate elections, there is a possibility that particular special interest group or groups (for example, those with a particular health condition or a particular position on an issue), or political parties, might field a large number of candidates to try to secure a dominant position on a Board with a view to securing Board decisions that favoured their "single issue". The box below seeks your views on these issues.

2,3.5. There are options for voting systems - for example, a simple "first past the post system", or a proportional representation system. Local authority elections and elections to the Scottish Parliament are based on types of proportional representation systems. Elections to the Westminster Parliament use "first past the post". There are many options around the type of voting system and options for how votes are to be cast. The box below seeks your views on the various options:

2.3.6. Appointed Board members currently receive payment of around £7,500 a year (members of NHS Boards responsible for Western Isles, Orkney and Shetland receive just over £5,000). This reflects the expectation that members will contribute around 4 days a month on average to Board business. Elected members on local authorities are paid around £15,000 a year.

2.4 Piloting the idea of Elections to NHS Boards

2.4.1. Piloting elections to NHS Boards would make it possible to compare and assess approaches to see what worked best in practice. For example, pilots could assess the outcome of electing a majority of members in one area, compared with electing a minority in another area. Different voting systems could also be tried out in pilots. It would be important for any pilot Board areas to reflect as afar as possible the geographic and economic/social diversity of Scotland. An assessment of the pilots would be carried out and published in each pilot area before final decisions were made about introducing elections to Boards across Scotland.

2.4.2 The box below poses questions on the idea of pilots:

2.5. Accountability of NHS Boards

2.5.1 The aim of direct elections is to achieve greater patient and community involvement in planning and delivering local health services. However Boards with elected members will have governance responsibilities not only for major service changes but also for the full range of planning and delivering safe, effective, sustainable, efficient and good quality NHS services in their areas. The governance responsibilities of NHS Board members are substantial. At present, Board members discharge these responsibilities within a framework of guidance, which Health Boards must follow but is not legally binding, and legislation. All NHS Board members are appointed by Scottish Ministers and their terms of appointment can be varied or withdrawn.

2.5.2 It is also possible that elected members could (by acting together) seek to bring about changes in the priorities or performance standards pursued by a particular NHS Board. Because performance standards and priorities are set out in guidance and are not legally binding at present, this would mean that one Board might follow priorities that varied from another, or that varied from the priorities and policies set out by Scottish Ministers. At present, people expect the NHS to be a national service with similar priorities and approaches across Scotland.

2.5.3 NHS Boards are clearly accountable to the Scottish Ministers and to the Scottish Parliament. This consultation does not propose that the Bill will change that accountability. Current legislation gives the Scottish Ministers power to direct and regulate NHS Boards and such legislation is legally binding on Boards. However as explained above most of the framework of governance, priorities and performance standards within which NHS Boards operate at present is not legally binding. The box below seeks views on these issues, and whether safeguards should be provided to retain national priorities and standards:

2.6. Costs of Direct Elections

2.6.1 Direct elections to NHS Boards would cost money. Based on recent studies by the Electoral Commission, the cost of initial elections across the 14 NHS Boards would be around £5m (the cost would depend on the scope of the elections and the voting methods used). Thereafter, additional costs, if any, would depend on whether elected Board members were remunerated, at what rate, and whether all, some or no appointed members remained. The box below seeks comments:

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