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Findings
Consultation Section 1 - Making things better
1. This section sought 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.
2. The section contained 8 specific questions that were relevant to the purpose of the section. Each of those questions, with an outline of the views received in response to the issue posed, are set out below.
Q1. Do you think the current proposals for independent scrutiny of service change proposals help achieve the aim of better engaging and involving local communities?
At the launch of the consultation a separate exercise was already taking place to evaluate the role of Independent Scrutiny. This question was included to allow consultees to consider the links between Independent Scrutiny and improvements in the current set up of public involvement by Boards.
In the consultation, while there was some concern about Independent Scrutiny adding another layer of bureaucracy, there was recognition that having Board proposals for major service change considered by an independent panel would add extra rigour to the decision making process. It was hoped that as Boards improved in the way they involved the public and gathered evidence for change that the need for a separate Panel would be removed.
Q2. How could additional guidance to NHS Boards on making public consultation as effective as possible help achieve this aim?
Consultation guidance was not universally perceived as helpful. Given the diversity of communities in Scotland and the diversity of the issues that the NHS has to engage them with, the current centralised guidance was seen as too remote to be of any significant benefit. NHS Boards felt that there was no sharing of best practice across the country and that experience of engaging with communities on certain issues was not being usefully shared among Boards.
Q3. Would the appointment of more lay members to NHS Boards - perhaps to directly represent patients or other groups - help achieve the aim? How might this be achieved?
The general feeling from consultation responses and meetings was that increasing the number of lay members was a good idea in principle. This would bring a broader range of people from the community onto the NHS Board, introducing more expertise and wider views. However, there was a downside that in doing so, NHS Boards would become too big and unmanageable. This may mean that the voices of those brought onto a Board are lost. The other concern raised was around the possibility of those representing a specific group undertaking lobbying for their own group and not participating fully in the strategic decision making process of the Board.
Q4. In particular, would adding more local authority councillors (one councillor from each local authority whose area a Board serves is currently appointed to that Board) help achieve the aim? Could local authorities have a role in scrutinising public and community engagement?
The role played by councillors was widely recognised. They provided a strong link to their authority and the community services that need to link with NHS services. There was a spread of opinion over the points raised in the question ranging from those who considered councillors were a "ready made" elected representative from the community to those who thought increasing the number of councillors on a Board would lead to the politicisation of Health Boards.
Q5. Should we develop further the role of the Scottish Health Council to bring about more effective engagement and involvement? If so, what additional responsibilities could the Council take on and what would the benefits be?
In general the role of the Scottish Health Council was not well understood and this brought about frustration over their role in public engagement in Board areas. While the SHC undertake reviews of the engagement processes of Boards, some felt that they should have a stronger voice in challenging Board proposals and providing a voice for the local community. Their role within the NHS was seen as administrative and there was little value perceived in the way in which they engaged with Boards. Generally it was felt that the SHC needed to have a more clearly defined, better understood role both in relation to the local community and to the NHS.
Q6. How could the Public Partnership Forums associated with Community Health Partnerships encourage greater public engagement?
The Public Partnership Forums and Community Health Partnerships were viewed as a very effective means of engaging with communities as they had a direct route of engagement with the NHS Board. However, those not directly involved with the NHS or the organisations that link with PPFs and CHPs were unaware of their existence or the role that they played in the planning and delivery of health services.
While some PPFs went to great lengths to organise events and publicise their role, this was approach was not widespread over Scotland.
Q7. How could local Community Planning Partnerships best ensure improved public engagement with NHS planning?
Once again the role of this group was not universally understood. Again neither was their existence outside of those organisations who were working with them. It was felt that a CPP was another body that could offer significant value in engaging with communities given it was a more established system than the PPF/ CHP and had broader links with health and social care sectors.
Q8. What other measures could be introduced to increase effective engagement and involvement of the public with the NHS in Scotland?
This question received a wide variety of responses ranging from improvements to current systems and organisations in place to support engagement e.g. better use of Community Councils, through to the methods used in engagement e.g. Citizens Jury's.
Consultation Section 2 - A new approach
3. This section asked for views on changing the current framework so that NHS Boards have directly elected members with the aim of bringing a stronger local voice to Health Board considerations.
4. The section contained 25 specific questions that were relevant to the purpose of the section. Each of those questions, with an outline of the views received in response to the issue posed, are set out below.
Q9. What eligibility criteria should candidates meet ( e.g., should they be resident in the Board area? Should there be any other qualifications?)
There was strong feeling that the candidates for election to an NHS Board should be resident in that Board area. This, it was felt, would bring the necessary local experience and identity to the Board and allow communities to identify strongly with their elected representative on the NHS Board.
Q10. How could equality and diversity of candidates be promoted?
It was felt that the very idea of introducing elections to NHS Boards would promote equality and diversity. The current public appointments interview process is viewed by some as a barrier to becoming involved in the running of their Board as they feel their educational background or occupation may not meet standards sought in the appointments process. Conversely, some respondents thought that candidates who were willing to go through a competitive appointments process would not wish to stand for election.
Q11. Should candidates have to submit profile statements and declare any interests and/or relevant qualifications / skills / experience, for example membership of a political party or a pressure group?
There was strong support for the idea that candidates should set out their background for the electorate to make an informed decision. Some viewed this as an important aspect in ensuring that single issue interests did not seek to dominate the Board.
Q12. Is there a case for excluding candidates standing as a representative of a political party?
While there was strong support among many respondents for the exclusion of candidates standing as a representative of a political party, there was recognition that this would not be practical. For example it would exclude a large number of people who are simply members of a party and it would not address those who stood with strong party political beliefs but who decided not to be a party member. It was felt that a sensible course of action was simply to let the electorate decide based upon a candidate's profile statement.
Q13. In what circumstances might someone be disqualified from seeking election?
It was felt that the standard exclusions of those seeking election to the Scottish Parliament or local authority should be used. This would mean consistency in approach.
Q14. Who should be allowed to vote in the election? Should the same rules as apply to local authority elections be followed?
Again it was felt that following the standards set out by Scottish Parliament or local authority elections should be followed. Only those resident in a Board area should be allowed to vote.
Q15. How often should elections be held, and when? Local authority elections are held every 4 years. Should elections to NHS Boards follow the same pattern?
Once more there was a strong consensus that the existing practices used by local authorities should be followed. There was some concern over costs of elections if they are to be held on a different day to Parliamentary or Local Authority elections. Additionally, there was concern around voter confusion or voter apathy due to the number of elections taking place.
Q16. Should directly elected members form a majority of the members on a Board?
There was a range of opinion over whether a majority, minority or balance (50%) should be held by elected members. A majority was seen as delivering a clear mandate for the local community on the Board, but there were fears around short-termism or single interest candidates affecting the strategic direction of the NHS in a local area. A minority of elected members could provide valuable input from local communities into the decision making process but there were concerns that, as they were a minority, their voices would not be sufficient to change Board policy. A balance would mean appointed and elected members would have to engage effectively to drive forward health care delivery in a Board area but, as it would be a balance, there was concern that necessary decisions would be put off and the Board would find it difficult to find direction.
Q17. Should the existing categories of appointed Board members (lay members, stakeholder members and executive members) remain in place?
There was general acceptance that having a mix of members around a Board was very useful. These members were able to bring a broad range of skills and backgrounds to the table and were capable of giving a Board both purpose and direction in the local delivery of services. The issue was raised that while this mix was useful, there was a lack of community voices on a Board and that would need to be addressed if a Board was not to be perceived as a body remote from the community that it serves.
Q18. Among the appointed "stakeholder" members on NHS Boards are local authority Councillors. What should there role be if directly elected members sit on Boards?
There was a strong consensus that local authority councillors should continue to serve on Boards. Their role should be to ensure strong links between their local authority and the NHS Board and ensuring that community planning issues are properly addressed by both their authority and the NHS Board.
Q19 Should NHS Board areas be divided up into electoral wards?
There were a range of views expressed to this question. Introducing small ward areas into an NHS Board would mean that local communities would feel represented on a Board and that a small or remote community would not be disadvantaged against a more urban and populated area. However, there were concerns that introducing ward areas may mean that not enough candidates would come forward to trigger an election. Having the entire Board area as the electoral area would ensure a broader range of candidates and would mitigate against candidates who were interested in standing only on a very local issue. This may mean that in Board areas with a mix of urban and rural populations, more candidates are returned from the urban centres.
Q20. Would the emergence of groups or individuals with particular views be a difficulty or a potential threat to good governance and direction of the NHS in Scotland?
The emergence of single issue candidates was broadly seen as a major threat to the continuation of a National Health Service. However, it was recognised that such candidates would from time to time emerge but that it was a matter for the electorate who they chose to return as their elected member on a Board.
Q21. Should safeguards be introduced to prevent unrepresentative / disproportionate representation of a political party or special interest group on a Board, and if so what form might such safeguards take?
There were a number of views around this question but a majority thought that the democratic process was where the safeguards lay i.e. the electorate would make their decision on who they wished to serve on the Board.
Q22. Would you favour a simple "first past the post" voting system, a proportional representation approach or another type of system?
There were a range of views expressed in relation to this question. "First past the post" was viewed as simple to set up and administer with a clear link between the voter and the elected candidate. However, with the move toward proportional representation at both Scottish Parliament and local authority elections, there was a body of opinion that thought this should be used for Health Boards also. This would provide consistency as well as allowing voters to spread votes among a number of candidates that they find suitable.
Q23. How should voters be allowed to cast their votes? By postal ballot or at a polling station? Or either, depending on the voter's choice?
Again, there was a broad range of views on this question. Postal ballots were seen as simple to set up and operate with the likelihood of a better turnout. There was some concern around fraud. Using the traditional mix of polling station and postal was positively received as this was a recognised method of running an election. There was concern over the expense and disruption of doing it in this way e.g. closing schools to set up polling stations. A few respondents suggested that internet, telephone and other alternative methods of voting should also be considered.
Q24. Should directly elected Board members be remunerated? If so, at what rate - the same as appointed members currently receive?
There was a range of opinion expressed over remuneration. Some respondents felt that elected members should be paid at the same rate as appointed Board members. Some thought that there should be no payment, only the reimbursement of expenses. A few thought that payment should be the same as local authority elected members.
Q25. Are pilots a good idea?
Most respondents thought that if elections were to go ahead it would be sensible to pilot these first and then assess the impact made. Some respondents thought that piloting would delay the introduction of elections to the whole of Scotland and that any elections should be rolled out immediately.
Q26. How many pilots should there be?
There was a range of views on this but it was generally thought to be important that any pilots captured the diversity of Scotland's Health Boards by using a rural and an urban Board to pilot the proposals in.
Q27. How should pilot areas be selected?
Generally, consultees wanted to see a mix of areas (urban and rural) included in a pilot. There was some opinion that the Boards selected should be undergoing some form of service change in order to properly test the impact of elections and the role of elected members.
Q28. How long should pilots run for?
The general view was that pilots would have to be carried out over a longer period of time (at least 2 years) in order that the full range of decision making duties and service change issues experienced in a Board area could take place in the pilot area.
Q29. What criteria should be used to assess and evaluate the pilots?
There were a number of views relating to this question. Some respondents felt that there needed to be a clear indication of improved public engagement within the pilot area. There was also a feeling that clear evidence should exist of continued improvement in health indicators in the pilot area to ensure that elected members were having a positive impact on the planning and delivery of health services in the area.
Q30. Should NHS Boards continue to provide generally consistent levels of performance across Scotland and follow national policies and priorities? Or should elected NHS Boards have the freedom to exercise local discretion and flexibility?
There was very strong feeling that NHS Boards should continue to deliver consistent levels of service across the nation, following national policies and priorities. While some indicated that the introduction of elections may threaten this, others commented that some small local flexibility on the delivery of services should be allowed in response to local needs and circumstances.
Q31. Should current guidance e.g. on governance, priorities and performance standards be set out in future in legally-binding form, to ensure that elected Boards comply with them? What would be the advantages and disadvantages of this?
There was concern that introducing some legally binding standards etc. may constrain local flexibility in the delivery of services, it may also divert resources from areas where no legally binding target exists.
Q32. Ministers currently have powers to remove members. Should they be able to remove elected members? What sort of reasons might justify such a power being used?
A range of opinion was expressed in response to this question. Some felt that as the Board member was elected locally that it was a local matter regarding their removal. This could either be through a Board Code of Conduct or at the next election. Other respondents felt that given the national importance of the NHS that Scottish Government Ministers should retain the right to remove members if their actions warrant that approach.
Q33. Should NHS resources be used to support direct elections? What do you think would be a reasonable amount to spend on elections?
There was general unease that money for patient care could be used to pay for an election. Many respondents felt that this should come from other Government sources. Most consultees commented on the need to keep costs to a minimum to ensure minimal impact to funding for patient services.
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