DESIGNED TO CARE

Renewing the National Health Service in Scotland

57. The Shields Report, published in March 1996, set out the main roles and responsibilities of Health Boards in the context of the internal market. With the abolition of the internal market, some of the detail of the Shields Report requires reconsideration. But the Government retain the view that the principal role of Health Boards remains the protection and improvement of the health of their resident populations. In more detail, Boards should focus on:

• health protection
• health improvement and health promotion
• needs assessment
• service development
• resource allocation
• resource utilisation
• performance management of Trusts' implementation of Health Improvement Programmes

and to do so with the underlying aim of promoting equity.

58. The main vehicle through which Boards are expected to ensure the discharge of these responsibilities is the Health Improvement Programme. Boards must put in place arrangements to ensure that the development of the Health Improvement Programme is a genuinely co-operative process in which local Trusts, GPs and others participate actively. Because Health Improvement Programmes are so important to the future pattern of local services, they are to be the subject of consultation. Boards will succeed in fulfilling these responsibilities only if they are able to provide responsive leadership to other organisations with an interest in health. This extends beyond the NHS to colleagues working in local authorities, voluntary organisations and the wider community.

59. The changes which are set out in this White Paper are considerable, and as part of the incremental approach designed to minimise upheaval, the Government have concluded that the existing Health Boards and their membership structure should be retained but with stronger community representation. Boards will therefore be able to lead the implementation of the changes and preserve a local identity in the development of services.

60. In developing Health Improvement Programmes, the NHS in Scotland will need to take full account of its relations with local authorities. The Government will give further consideration to the benefits of minor changes to some Health Board boundaries to align them with those of local authorities. The effective delivery of health care often depends on the active co-operation of other agencies, particularly local authority social work departments. There has been much debate about where the boundary between NHS care and social work led care should rest. Whatever the structure, some boundary will inevitably exist. The important principle must be that the patient's care comes first. The patient should not perceive the boundary as interfering with the care he or she receives. To achieve this, the NHS in Scotland and local authorities need to develop close working relationships. The Government intend to consult on this.

61. To enable Boards to discharge these responsibilities, the Government have concluded that they must be given new powers to ensure effective implementation of strategies which have been developed through close working with others. Specifically, Boards will be given the responsibility of ensuring that Trusts implement the proposals set out in Health Improvement Programmes. This will be achieved through Trust Implementation Plans, which will be agreed between the Trust and its Health Board and will set out what the Trust is committed to do to help implement the Health Improvement Programme. In particular, they will set out:

• the changes in the pattern of service which are to be achieved;
• the resources which the Board intends to make available; and
• the expected level of service to be delivered.

62. Performance against these agreements will be the subject of regular monitoring by the Health Board. The Trust's performance in achieving its Trust Implementation Plan will be made available to the public each year.

63. Health Boards will not be responsible for operational matters. These will remain the responsibility of Trusts, but Boards will be given powers of approval in relation to capital planning, property and senior medical posts. The Government's intention is that Health Boards should be able to ensure that the strategic direction which has been agreed and set out in Health Improvement Programmes can be implemented, and not frustrated by Trusts' developing and pursuing alternative strategies through their estate management and employment responsibilities.

64. Since 1995, the Scottish Ambulance Service has been the only Scotland-wide NHS Trust, delivering all of our accident and emergency services and non-emergency Patient Transport Services (PTS). As a result it has had to negotiate annual service contracts with all 15 Health Boards and, in relation to PTS, with all 46 hospital Trusts. This has been a considerable bureaucratic burden. The Government have therefore decided to make the Scottish Ambulance Service a Special Health Board and will give further consideration to the funding and performance management arrangements for the Service. The three existing Special Health Boards - the State Hospitals Board for Scotland, the Health Education Board for Scotland and the Scottish Council for Postgraduate Medical and Dental Education - will continue, and the position of the Mental Welfare Commission for Scotland will remain unchanged.