Health and Sport Committee

Meeting date: Tuesday, January 24, 2017

Official Report 522KB pdf

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Scottish Health Council

Agenda item 2 is an evidence session with the Scottish health council. I welcome to the meeting Richard Norris, who is director of the Scottish health council; Pam Whittle, who is its chair; and Robbie Pearson, who is chief executive of Healthcare Improvement Scotland. I invite the panel to make an opening statement.

As members will know, the Scottish health council was established in 2005 to ensure, support and monitor the effectiveness of national health service boards’ involvement of patients and the public in their activities. Originally, it was set up within the confines of NHS Quality Improvement Scotland but, as a result of the Public Services Reform (Scotland) Act 2010, it is now part of Healthcare Improvement Scotland. It has 14 local offices across Scotland and around £2.3 million of Healthcare Improvement Scotland’s budget.

Our local offices support a range of activities with communities, and they provide advice and facilitate and support events. They do that in the context of supporting the NHS. They work with the third sector and many different networks, evaluate activities, and try to build skills and confidence.

The local offices gather patient and public views on a wide variety of topics, often through local discussion groups and street canvassing. For example, the Scottish health council supported the recent review of maternity and neonatal care by delivering a programme of engagement activities throughout Scotland. The local offices talked to a wide and diverse range of groups—65 in total—and there were one-to-one discussions and questionnaires to get a range of views.

More recently, the Scottish health council has been involved in the delivery of the our voice initiative, which is a more recent initiative on gaining public views. It has worked very closely with the Scottish Government, the Convention of Scottish Local Authorities, the Health and Social Care Alliance Scotland and others to introduce that new approach. Perhaps that is a more visible role for the Scottish health council in public engagement, as opposed to simply ensuring that health boards are engaged in public involvement.

A lot of issues have been raised in the time that I have been the chair of the Scottish health council. The introduction of the our voice initiative has added to changes in ways that services are delivered. We have recognised that, and I am one of the joint chairs of the separate review of the Scottish health council that is currently taking place. That review has not reported yet. I will be extremely interested to hear the views that will be expressed today and will ensure that they are considered as part of that review.

Thank you. Donald Cameron has the first question.

I thank the panel for coming and thank the Scottish health council for its written submission. I will ask about the independence of the Scottish health council. You are a committee of Healthcare Improvement Scotland, which is a non-territorial health board, as we all know, that sits under the Scottish Government. What response do you give to the widespread concerns about the Scottish health council’s independence from both Healthcare Improvement Scotland and the Government? On the subject of independent scrutiny, can you comment on what appears to be a very limited use of the independent scrutiny panels? I think that there were three between 2007 and 2009 but none since.

I ask Richard Norris to answer the question on the independent scrutiny panels.

The decision to establish an independent scrutiny panel would be made by the Scottish Government. When they were established, they were an innovation. There might be occasions when they still might be useful. However, what we have also seen happen is that NHS boards often commission independent reports on clinical issues that they face. That is perhaps a development that happened because of the independent scrutiny panels, so there can still be independent scrutiny.

We provided a view some years ago to the Scottish Government that there was benefit in independent scrutiny because it reassured members of the public who might not have as much confidence as might be desirable that there was sound clinical evidence for making changes. I think that independent scrutiny could potentially still be useful, particularly in light of the integration of health and social care services.

Although we are a governance committee of Healthcare Improvement Scotland, the actual work of the committee is undertaken more or less separately. For example, when we are considering views about whether something is of any significance, we do not refer that to Healthcare Improvement Scotland. The committee itself has a minority of members who come from Healthcare Improvement Scotland, because five of the eight committee members are not HIS board members but are appointed separately and not by ministers.

Do you want to add anything to that, Robbie?

It is important for the distinctive identity of the Scottish health council that, although it operates within Healthcare Improvement Scotland, it is quite assertive in terms of retaining its independence. That is particularly the case when we get into issues of major service change.

Just to be clear, the decision to set up a scrutiny panel would be the Government’s decision.

Richard Norris can answer that.

Yes, it would be the Government’s decision.

How independent is that?

The decision to call an independent scrutiny panel is the Government’s, but—

Can you call one?

Not at the moment. It is not within our ability to call one.

It is only the Government that can call one.

Yes, but the appointment of the people would be independent.

This applies to any Government: if the Government did not want scrutiny, it would be unlikely to form scrutiny panels. Does that logically follow?

I think that it is important to distinguish between the architecture around independent scrutiny panels and their independence. Obviously, at the moment, it is up to the Government to call an independent scrutiny panel—that is the current arrangement. However, the important point in the context of Healthcare Improvement Scotland and specifically the Scottish health council is that we would be clear in the instances when an independent scrutiny panel was established that it would be absolutely independent of the Scottish Government.

Can I ask about the health committee itself? I had a wee look and saw that it has a former civil servant, a former council chief executive, a former NHS chief executive, a solicitor, a former MSP and a consultant who gets the majority of her work from Scottish Government quangos. Do you think that that is a representative organisation?

We have a former civil servant.

A former senior civil servant.

Yes.

A former council chief executive.

Yes.

A former NHS chief executive.

That is it.

According to the list that I saw, there are more.

More members of the health care committee?

More members of the Scottish health council committee: a solicitor, a former MSP and a consultant.

That is not a medical consultant. That is a consultant who—

It is a consultant who gets the majority of their work from the Scottish Government.

More or less, yes.

Does that sound like a diverse and representative body? That is the organisation that is to promote the patient voice.

I am a bit concerned that you may have the wrong list. There are five.

If I have, I apologise. That is the list that I have.

There are five council members. One of them is a solicitor by profession, but does not work as a solicitor. One has a special interest in older people and works with older people. One of them works with disability groups, and the other one works with a housing group.

We will come back to that before the end of the meeting. There seems to be a bit of confusion.

Yes, I am a bit confused.

Obviously, the Scottish health council is intended to improve patient focus. As I prepared for this morning’s meeting, it appeared to me that just over a thousand people have been engaged via social media and events in recent times.

It is also fair to say that I have had several emails from constituents who became aware that you were giving evidence this morning. They are clearly unhappy that the Scottish health council is not helping them to influence decisions that have a major impact on the delivery of health services in their area. Do you have any comment on that?

That probably goes into the realms of how we engage with our local communities more specifically. Perhaps Richard Norris would like to follow that up.

Our role, as Pam Whittle has described, is to support boards to engage with local communities and to support communities to have their voice heard.

What is not our role is to campaign on behalf of local groups. That is an important distinction. If there are groups or communities that feel that we have not done enough to help facilitate their voice being heard, we are always interested in hearing from them and in reflecting on whether we can do more in that area. However, there is sometimes an issue as to how we execute that role. It is very important that people understand that we are not there to campaign on their behalf.

I will come back just briefly, because we are pressed for time this morning. That is absolutely not the issue; the constituents who are contacting me do not have that misunderstanding. They appreciate that you have a facilitative role.

What proactive work do you lead on a national basis with health boards, to make sure that participation is optimised and maximised?

That is fundamental to the role of the Scottish health council. The original premise for establishing it was to ensure among NHS boards a more consistent approach to engaging with local communities. I will ask Richard to say a bit more about that in a moment.

One of the key comments that comes out consistently from engagement with communities is, “I am always asked for my voice and my views at the end of a process, and not at the beginning.” If we are going to have more fundamental and radical service change, it is essential that we learn the importance of that voice being heard consistently at the start—not at the middle or, indeed, the end—of the journey. It is an important message, which is heard loud and clear, about the consistency and the quality of the engagement between NHS boards and communities.

Richard Norris might wish to say more about our overall approach to promoting a more consistent and higher quality engagement with individuals and communities.

We work at a number of levels. At the local level, we have offices in each territorial health board area. They give quite practical assistance and advice to boards and they meet with local communities.

A few years ago, we developed a participation standard and, at the national level, we conduct biannual processes in which boards look at the standard and we talk to local communities to verify the progress that the boards think that they have made.

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We have also published a thing that we call the participation toolkit, which has a range of engagement methods. Often, there is no one correct engagement method; it will depend on the context and the issues. We will engage locally with boards and communities to help them choose which engagement method would be the most appropriate.

We do a number of things. We help out with evaluating boards’ activities and we have produced guidance where we feel that boards need a bit more help with understanding how to engage on a particular issue. For example, it was clear to us that the options appraisal guidance that was produced by the Scottish Government and the Treasury was very technical, and when boards conducted options appraisals they were struggling to understand how they could involve people meaningfully. We worked with patients, patient representatives and boards to develop some guidance to support meaningful engagement with patients and community groups on that.

We carry out a range of activities nationally and locally to support boards on engagement.

Do NHS boards self-assess on the participation standard? Is there any sanction if boards are clearly not meeting an acceptable participation standard?

At the moment, there is a public petition open on a service change to a care home, with questions about the efficacy of the consultation process. What is your role in reducing the number of cases in which people feel compelled to take additional action?

I would like to know whether there is self-assessment of the participation standard and what your views are on how to ensure that people feel satisfied with the processes that we have in place.

The participation standard is designed to give comparative evidence across Scotland on how boards are engaging with communities. Boards will self-assess, but we will verify that by talking about the assessment with the people with whom the boards have worked in local communities. We will feed back to boards how we feel that they are making progress.

One element of that is how well they are using complaints and feedback to improve services. We conduct an assessment of that across Scotland every two years.

Can you say a bit more about the particular case of the care home?

There is a public petition on a service change to a care home and it is questioning the consultation process. If constituents were aware that the Scottish health council existed, would they not come to you to see what action you might take before it gets to that stage? How aware is the general public that you exist?

An issue that has arisen for us in terms of integration is our role in social care and care homes. We have been involved in some cases, when people have asked us for information. Your point is right: our profile probably needs to be higher, in the light of integration and the demand to understand the best ways to engage.

I would like to clarify my earlier point about the committee. I am getting a bit worried, Mrs Whittle, that you do not know your fellow board members. You, a former senior civil servant, are the chair; the members are George Black, the former chief executive of Glasgow City Council; John Glennie, the former chief executive of Borders Council; Kim Schmulian, a solicitor; Elizabeth Cuthbertson, a consultant; Irene Oldfather, a former member of the Scottish Parliament; Marianne Wong, a fitness consultant; and Alison Cox, a consultant who gets most of her work from the Scottish Government. That is the board.

Are they diverse, representative and independent? That is the question that I am asking.

They are certainly independent.

Do you recognise that that is the board?

Yes. It is the board.

Thank you.

It is just that, when you described them as consultants—

They describe themselves as consultants.

Elizabeth Cuthbertson actually works for a housing group, so I am not sure that you could count her as a consultant. You have said what their professional backgrounds are, but, as individuals, they are very outspoken in support of the wider public.

Okay.

Good morning, panel, and thank you for coming to see us today. I am going to pick up on some of Alison Johnstone’s questions about the Scottish health council’s role as the patient voice. We have had a good discussion about the level of engagement. I also want to speak to what Mr Pearson said about the health council being quite assertive in the area of major service change.

I have been an MSP for nine months, and in that time I have made quite assertive representations to the cabinet secretary about three major service changes that directly affect my constituents—potential changes at St John’s hospital in Livingston, which serves my constituents; the closure of cleft lip and palate services in Edinburgh; and the redesign of the centre for integrative care, which many of my constituents travel a great distance to use. I have made three major representations in nine months. The health council has made six in six years.

What bar do you set? If you are acting as the patient voice, how do you determine when you will make a view available to the Scottish Government and when you will not? You seem to have made awfully few representations in the past six years.

To clarify, the Scottish health council has three broad roles. The first is to promote consistency of engagement at the local level between NHS boards, communities, individuals and patients. The second is about support for that level of engagement, and the third, which has been quite a strong focus in the past year or so, is on quality assurance of major service change. At any one time, there are 35 to 40 service changes happening in Scotland in which the Scottish health council is engaged in providing support, and some of those reach the threshold of what we consider to be major service change.

It is important to distinguish the role of the Scottish health council. It is there not to make representations but to play a quality assurance role and to offer ministers a view on whether a change is a major service change. Ultimately, decisions on major service changes in the NHS are a matter for ministers.

Your other point was about how assertive the Scottish health council is in exerting its independence. Pam Whittle talked about the distinctive accountability of the Scottish health council, which sits within Healthcare Improvement Scotland. There is no chain of command that takes decisions or views in respect of major service change back into the board of Healthcare Improvement Scotland. The role is quite distinct from the board of HIS. It is important that that independence is protected in order that there is confidence in the Scottish health council’s decisions.

Can you give us an idea of the anatomy of the six views that you have offered to the Scottish Government on major service changes? What do such views contain?

If I may, I will hand over to Richard Norris to elaborate on that. When the guidance came out in 2010, the Scottish health council established guidance on the criteria for consideration of major service change. Perhaps Richard Norris will say a bit more about the criteria.

And what is contained in the specific views that the health council has offered.

Yes.

When a board is looking at making a service change, the Scottish Government expects it to go to the Government with a view on whether the proposal constitutes a major service change. As part of that process, the Scottish Government asks boards to ask us for our views. It is not always possible to say at the start of a process whether a service change will become major. We sometimes need to explore that a bit further before it becomes clear.

We would normally ask the board to use the guidance that we produce on identifying major service change, which Robbie Pearson mentioned. It identifies nine areas. For example, in our view, if a proposal concerns unscheduled or emergency care, that makes it more likely that it should be seen as a major service change. We ask the board to go through the nine issues and give us its views on what it thinks the issues are with the service change that it is proposing.

We will support the board in its engagement with the community. We will be present at some of the local meetings and we will talk to local community and patients groups. We will then look at all the information. Our staff and four members of our committee will meet to discuss the case and we will arrive at our own view on whether the proposal meets the threshold of being a major service change.

It is not a science; it is quite a subjective process. We are mindful of similar examples because we want to be consistent in our approach. We will look across Scotland to see whether there are similar examples that will give us an idea of where the proposal sits. We then provide our view to the board, which will go to the Government, and the Government will make its decision on whether it views the proposal as a major service change.

The distinction is not always helpful. If a proposal is not a major service change, it implies that it is not important, but service changes are always important to the people who are affected by them. Also, it sometimes creates two classes of service change and suggests that all service changes fall into one category or the other, but it is more graded than that; it is not a binary issue.

The reason why we give our view is that we are thoughtful about advising on what would be a proportionate degree of engagement for the board and, for example, whether the proposal requires a formal consultation. We are aware that for some of the campaign groups—this has certainly been the case recently—the real issue is the referral to the minister. That is why the decision on whether a proposal should be deemed a major service change is rightfully for the Scottish Government to make, because a formal consultation is entailed when it is deemed to be major.

The Parliament passed a motion before Christmas—albeit that it was an Opposition-led motion—stating that we expect the cabinet secretary to bring major service redesign proposals to Parliament so that there will at least be scrutiny and discussion. My anxiety about the bar being set very high for what we define as major service change is that, although the Government is not bound by that motion, the Parliament will take a dim view if we do not get a look in. We might not even get to the races on some proposals because ministers can hide behind your view—or your lack of a view—on whether a proposal is a major service change, and they may decide not to bring it to Parliament at all.

That is really a comment. You do not have to come back on it.

I have to pick up Mr Cole-Hamilton on what he said. As a clinician, I am extremely concerned about his suggestion that this Parliament would prevent major service change that is driven by a clinical need or the lack of a clinical—

I never said “prevent”; I was talking about scrutinising service changes.

Okay. I wanted to have that clarified, because that suggestion would have concerned me.

I have a health background. I was—and I still am—a nurse, and I have been involved in lots of major service changes in my career, particularly in my role as a Unison divisional convener. Some of those service redesigns were more welcome than others, shall we say? I fully appreciate that any such redesign causes anxiety to the service users and the staff who are involved in running or managing the service. What difference does media interest or public concern make to how you view services and your decisions on whether a proposal is a major or a minor change?

That is one of our nine categories. Political and public concern is one of the areas that we say need to be looked at, so we acknowledge that it has to be taken into account. I suppose it is about trying to get the right balance between the different factors.

We were aware of the parliamentary debate and that we were being asked to give an independent view, and we wanted to base our views on our normal process, whereby we look at service redesign in the context of other changes. If there is a high degree of public and political concern, that makes a service change more likely to be seen as major, but that would probably not be sufficient—there would need to be other factors as well.

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Will you elaborate on what those other factors might be?

As I mentioned earlier, one of the categories is whether the change is concerned with unscheduled or emergency care. From past experience, we know that a change is always more likely to be seen as major if it is concerned with unscheduled or emergency care. We also look at the number of patients who are affected, the experience of similar proposals in other parts of Scotland, any possible knock-on effects or ways in which the change could impact on other services and whether any particularly strong financial issues are involved.

When we produced our list of nine issues, which was seven years ago, we consulted health boards, patients, the public and professionals. Our experience is that some of the categories tend to be used more than others. For example, whether a change is concerned with unscheduled or emergency care tends to be a big factor.

Throughout the committee’s evidence sessions, we have had lots of discussion about the changes that need to be made to the NHS, including the shift in resources from acute services to community services, the integration joint boards’ budgets and so on, and the delivery of care at different venues. How do you see your role in that process? Do you foresee more complaints coming to you? Do you think that you will be more active in encouraging health boards or IJBs to consult more widely? I am interested in how you see the future of the Scottish health council against that background.

The answer is yes. To be honest, I do not think that there is any doubt that the role of the Scottish health council will need to change in the future because of the changing ways in which services are provided. At present we have no formal remit in relation to IJBs unless it is around the health elements of their care. The development of our voice will also change our role.

Looking at the criteria that you describe, I find it astonishing that, in six years, from 2011 to October 2016, only six out of 27 changes have been deemed to be major. For example, the closure of the CIC was deemed to be a minor change. Who ultimately makes the decision whether a change is major? On how many of the six changes that have been deemed to be major have you taken a different view from that of the health board, or have you simply gone along with the health boards’ conclusions that the changes are major?

Just to clarify, I note that the guidance makes it clear that, when boards wish to know whether a proposal constitutes a major service change, they should seek advice from the Scottish Government. We are asked to provide a view, but the decision whether something is seen as a major service change is not ours.

You asked how often we disagree with the health board. As you say, most service changes are not deemed to be major, and often, when a change is major, that is fairly clear to everybody. I will give a recent example. NHS Greater Glasgow and Clyde expressed in a board paper its view that the changes to maternity services at Lightburn hospital were not major, but we took a different view. That has not happened a lot, because there have not been a lot of major service changes, but we have noticed more major service change taking place recently and we think that that trend will probably continue.

Ultimately, the Government decides whether a controversial decision should be referred to it. Is that pretty much the case?

Yes.

Where a proposal has been deemed to be a minor change, will you describe your role in supporting the health board in the consultation? There seems to be a lot of criticism of your role in that regard. When there is a major change, you have a major role, but there are a lot of examples of poor consultation when it comes to minor changes.

I will quote the views of a number of people that appear in an article in today’s Times. Evonne McLatchie of Dunfermline, who opposed the change to cleft palate surgery being centralised in Glasgow, said:

“The SHC is a chocolate fireguard. One public engagement meeting was arranged the day before the decision. They couldn’t produce minutes or a record of answers from officials. I’ve complained to the health secretary that they are hopeless.”

The article states:

“Catherine Hughes, a disabled patient who campaigned against closing the CIC beds ward, said consultations were ‘utterly useless’ and added: ‘The SHC is toothless, just a tick box outfit which doesn’t explore key points thoroughly.’ ... In the CIC engagement process, a patient panel was chaired by ... the official proposing the cuts.”

It continues:

“Carolann Davidson, campaigning to save the children’s ward from closure at the Royal Alexandra Hospital ... says: ’Our engagement process is a seriously flawed shambles with managers dominating and little information.’”

There is a lot of anger out there from patients and communities about the consultation process for minor changes. What role do you have in influencing such consultations?

When the proposal is not a major change, our role is advisory. We will support the board and feed back to it our findings. For example, with the engagement exercise around the centre for integrative care, we publicly fed back to the board the views that were given to us by the participants. However, we are clear that the decision ultimately belongs to the board.

I accept that people have given their views and said that they feel that the engagement process was not as good as it should have been. That is what they said to us. However, there was certainly evidence that there was a very open and realistic discussion at the board, which was fully aware of the strength of feeling of the campaign groups. I compare that with the situation when we started. A common feature was that there would be a controversial proposal with lots of public controversy, and there could be marches and lots of media coverage, but when the proposal went to the board, there would be little discussion and it would be passed unanimously or nearly unanimously.

With the proposal on the centre for integrative care, we saw a very open and lively discussion at the board. The chair of the board did not support the proposal but supported the case that had been put by the campaigners. That demonstrates that the board was clearly aware of the issues and the strength of feeling.

However, our role is not—and has never been—to replace the board’s governance or ability to make decisions. We cannot say to a board that it has made the wrong decision or that it should not have taken the decision that it took. Quite properly, it is the board’s role to take the decision. Our role is to help the boards to go through an engagement process so that they are fully aware of all the issues when they make their decisions.

At no time did I ask whether your role was about influencing decisions. My question was about how you facilitate appropriate and proper engagement. The concerns in the quotes that I read out are about the engagement process. Ultimately, those people will also have concerns about the final decisions, but they were specifically expressing concerns about the engagement process. Are you saying that you are happy with the way that the health boards conduct engagement processes?

No.

No.

You are not. What influence do you have over engagement processes? If you are unhappy about them, how public do you go in explaining your unhappiness about consultation processes?

We wrote formally to NHS Greater Glasgow and Clyde and we put in that letter the feedback that we had received from people who had been involved in the engagement process. We drew that formally to the board’s attention and we also had meetings with the board. That is quite normal and it would happen in other circumstances with other boards.

In your opinion, health boards are carrying out consultation processes that are, to be frank, not up to scratch. However, by the sound of it, unlike in the case of major changes, you do not have a huge say on consultations on minor changes.

We hope that, in most cases, boards will take our views on board as learning for the future, if not for the decision that is concerned. However, you are absolutely right to say that we do not have a remit to intervene and prevent boards from engaging in change that is not deemed to be major or to give them orders, if you like, on how they should do that.

Are all the minutes of your meetings and discussions with the Government publicly available, or do people have to make a freedom of information request to get them?

In a spirit of openness, we would be happy to share with the committee—

That is not what I was asking. Are the minutes of your discussions with the Government, health boards and so on all publicly available?

If you are asking whether they are available on our website or readily available by clicking on something, not everything is there. From a transparency point of view, there are things that are missing, but we would be happy to share with the committee minutes of Scottish health council meetings or other documentation.

I am not talking about health council meetings. If you meet health board A, B or C to discuss issue A, B or C, are the minutes of that meeting published anywhere?

We do not normally publish those.

Thank you.

I must declare that I am a health professional, too. As a health professional who has come into politics, seeing how politically heated some of the discussions can be and how much of a political football the NHS can become has been difficult for me.

When it comes to difficult decisions in relation to which there are safety grounds for a change, how much weight should be given to what the public want and how much weight should be given to what the clinicians suggest as a way forward?

I can make some opening remarks about that. On the lessons that can be learned from our engagement with communities and patients, an important consideration is where that engagement sits with the range of experts and voices. As I said earlier, in the traditional approach, some of the process around service change can appear opaque. Patients are engaged with further and further down the track, so the level of their engagement can feel pretty minimal.

It is key that we have much earlier and more open engagement about the quality of care, of which safety is a fundamental part. Some of the work that has been shared by the chief medical officer on realistic medicine and the national clinical strategy has started a more open conversation about the quality of healthcare that we want in Scotland and how we deliver it. We need to have a different relationship between patients, experts and clinicians. It is key that we make sure that that conversation is held at the start of the process so that there is better understanding.

Language is an important issue, because people can get lost in technical and obscure language. It is important that we are not condescending or patronising in how we engage with patients and that we level with them about some of the challenges that we face in delivering increasingly complex healthcare, including the workforce challenges.

I will pass over to Pam Whittle and Richard Norris to talk about the balance when it comes to engagement on safety and patient care.

The Scottish Government’s guidance on how boards should engage with the public, which was produced in 2010, uses a phrase that has been used previously—in fact, it has probably been used for 10 years or so, if not longer. It says that it expects boards to give the views of patients and the public “the same priority” as they give to clinical standards and financial performance, except—this is an important proviso—when there are exceptional grounds to do with, for example, safety. When we have had discussions with patients and the public about how they feel that that balance should work and whether it is the right one, they have said that they feel that it is right. They agree that the point about overriding clinical safety issues is important.

As Robbie Pearson said, our view is that the issue is best tackled by boards being open and honest with their communities and not appearing to prejudge issues or using that as a reason not to engage. That is tricky, and we understand that it is sometimes difficult for boards to achieve that balance. We would never stand in the way of a board making temporary changes that it felt that it had to make to ensure that services were safe. We would never say that a board should not do that without engagement; we would want a board to make whatever urgent changes were required to ensure that services were safe.

It is probably worth pointing out that the Scottish health council’s role focuses on boards’ engagement with the public—it looks at whether a board has engaged or is engaging with the public. The fact that it does not have the remit to focus on other elements might be a stumbling block in the process.

10:45  

In a complete change of subject, although this has been touched on, I want to ask about your citizens panel—is that what you call it?

Yes.

I am interested in how people become a member of your citizens panel. People are not randomly selected, as for jury service, so I presume that they put themselves forward for the role.

We have only just done that—the current panel is the first one that we have had. It is semi-random, is it not, Richard?

It is random in the sense that people do not self-select for it. As Pam Whittle said, the panel is partly a test, as it is an innovative process. We used the electoral register to identify people initially, and we then mailed them and invited them to join the panel. We were quite ambitious and wanted to recruit 1,300 people across Scotland. That was important, because we wanted a minimum of 30 in each integration joint board area to ensure that the panel was reasonably demographically representative of the people of Scotland. We also recruited by standing on the street, going into shops and so on. We approached people and asked them.

The result is that the make-up of the panel is broadly representative. We ended up with more women than men, but in other respects it is broadly representative. We are now analysing the first set of results. It is random in the sense that, importantly, people did not self-select and say that they wanted to join; instead, they were approached. It is a panel of citizens as opposed to people who commonly get involved in participation networks. There is nothing wrong with people who get involved, but we were clear that we wanted the panel to be more representative of the people of Scotland.

I want to touch on two or three things.

On the role of the SHC, which, as you described at the start, is to monitor the health boards’ involvement of the public, the process is that a health board puts forward a proposal, the SHC is involved in part of the engagement process and then it moves on with a recommendation to Government. Specifically on Lightburn hospital, which I know something about as it is local to me, it is heartening that the SHC played a role in redefining the proposals as a major service change. The health board clearly did not want to do that and originally proposed it as a minor change.

My first question is to set the scene. Are you comfortable with the overall flow of that process? I suppose that my next question is a leading one, but take it as you like. Would you be happier with Government ministers intervening much earlier in the process, as has been called for by others?

I will make some broad remarks and then hand over to Pam Whittle and Richard Norris on the SHC role.

A point that was touched on earlier and that we will need to think about is that, of the £13 billion which is spent on health and social care, £8 billion is sitting in the integration authorities. A bit of redesign and rethinking is required by the SHC and HIS in the round on how we relate to the different world that is emerging.

The cabinet secretary intends that, as we get to the end of this session of Parliament, the majority of the spend on the health and social care budget will be within the integration authorities. That is a bit of the journey that we now need to think about in the context of service change and existing advice, support and guidance from the SHC.

On specifics, I will hand over to Pam Whittle and Richard Norris.

In the Lightburn case, there was an issue about exploring with communities and the board some of the aspects of that change so that we could give it proper consideration. The Government could have called the case in earlier in the process, but it chose not to—it was clear that it wanted to follow the local process.

I agree with Robbie Pearson that this is a good time to look again at how the process works. For example, we give our own view. To be blunt, when that started, the process was fairly informal, and there was not really a lot of interest in our view or how we arrived at it. Understandably, that has changed, as proposals get called in. Perhaps it would be helpful to think again about how that role should work, particularly in the light of integration.

I would like people to have more confidence in the local decision-making process so that it is not necessary to have a big discussion every time about whether a designated major service change should be seen as major. Frankly, I would like to get away from the overly simplistic division between major and non-major changes. As I have said, that sends an unfortunate message to people who are affected by a change that is very important for them. Just because a change is not major, that does not mean that it is not important.

When we started, we referred to “significant service change”. It was then called “major service change”. It was felt that it was bad to refer to “significant service change”, because that meant that other change was insignificant. We cannot really win with the terminology, but it would be helpful to look again at a better way of classifying change.

I want to move on to the relationship between the Scottish health council and the health board in fulfilling the remit that we talked about at the start. As I mentioned, I am aware of the Lightburn situation. Local groups have raised a lot of concerns with me about the engagement process—we are not yet on to the consultation process. For example, there was a meeting at which there were 13 members of the stakeholder reference group, seven of whom were health board employees, including the chair. We talk about politicising these things. The director of planning went to the media and took a full page in a local newspaper to argue the case that the health board was pushing forward. The health board’s public involvement manager told the stakeholder group that the board was not in a position to invest in the hospital. That prejudges the process.

Two of the meetings were held on the same day at a location that most of the community agreed was fairly inaccessible to the people who were affected by the change. I turned up at one of those meetings, and the health board tried to prevent me from speaking in it. That was an interesting process. As you can imagine, I made my views known at that meeting.

There are a number of examples of people calling into question that engagement process, and we have heard about issues in other areas. My question is about how you intervene—you have touched on that process—and the idea that changes are a fait accompli, if I am still allowed to use a French phrase in a post-Brexit world. Do you have any evidence or data on the number of proposals that are changed through consultation processes, or is the reality by and large that, once a health board has made a decision, it is just carried through? Are there any data on the percentage of proposals that are changed through engagement and consultation processes?

We regularly find that we have to really push some health boards to consider the options appraisal approach. There needs to be some sharing, and it should not be a matter of saying, “This is it.” We would like the public to be really engaged in developing options. Our view is that a process is much more likely to be successful if the public are engaged.

Sometimes there is resistance to the options appraisal approach and sometimes there is not. That might be why, in some areas, there is only a small number of major changes—because people might already have moved through that process and they have perhaps worked together in a better way. However, we know that, in some cases, there is resistance to developing a full options appraisal.

I will add two points.

Before a board goes to a formal consultation, we monitor the quality of its engagement processes. The option appraisal process and the option development process, which Pam Whittle mentioned, are important. If we do not think that the board has done sufficient work to go to a formal consultation, we will say so at that point. We do not think that there is any benefit in boards going to formal consultations if they have not done sufficient work to prepare for them.

Once the consultation has come to an end, we publish a formal report in which we describe what the board did and how it has complied—or not—with the guidance. In practice, if we do not feel that the board is doing as much as it should to demonstrate compliance with the guidance, we do not want to let it get to the end of the consultation. We want to step in and tell the board that it needs to be more thoughtful about how it is approaching the consultation, that we have some suggestions to make and that we would like to discuss the matter with it. We would hope to agree a way forward with it.

I have listened intently to some of the answers that you have given. Will you honestly tell me how relevant the SHC is? Your remit is to monitor what health boards do for patients and how they carry out their functions. Should your role be increased? With all the changes that Richard Norris said have come along in the past couple of years, should you be given more teeth? To be honest, I do not think that you have any teeth.

There is no doubt that the council’s role needs to change. At times, I have been quite frustrated that there is not wider awareness of what the health council is. Even its name is a little bit confusing. Many factors have stacked up, so there is a need for change. We will need to consider whether that change should be teeth or separation of different aspects of the role.

One of the problems in my area is that NHS Lanarkshire does not correctly get across to the public what it is doing. Basically, it does not publicise it enough. With the greatest respect to Ivan McKee, I say that I have also attended meetings at which I have been totally aghast at what the board was doing.

How do you sit down with a board such as NHS Lanarkshire and entice it to change its views and consider what it is doing? I have to point out that some of the things that it is doing are correct. We have to change. It is a new world and things have changed since the NHS nearly 70 years ago, so we have to revamp and redress things. Like my colleague Maree Todd, I hate the NHS getting used as a political football all the time. We should all work together. We have one of the best health services in the world and we continually kick it. What would you do to try to get NHS boards to put across their views better? They ain’t doing it.

We are extremely aware of that. NHS boards might see us as not really being part of the system and not necessarily knowing what is going on. That is a useful perspective because we tend to be more like the public in that respect. If the boards cannot convince us, they do not have a hope of convincing the public.

We constantly try to work with boards to make them more effective at engaging with the public. Recently, some boards have recognised the importance of doing that and made significant progress, but those are isolated approaches. I would like that approach to be taken much more broadly across the piece.

How can you get across to the public the fact that you exist?

That is absolutely the right question. It is one of the points that we hope we will be able to address.

I sense a lot of frustration from committee members. I certainly feel that. The Scottish health council has a budget of £2.3 million and is looking for extra funding from the Scottish Government. According to the accounts, it has engaged with 1,180 people over the past two years.

I am really struggling. You have 14 offices and have managed to contact and engage with just over 1,000 people in two years with a budget of £2.3 million. I fail to see what we get for our money. Richard Lyle is absolutely right: you are a toothless hamster. I do not see where you add value. A major overhaul of some kind is needed if we are to have transparency and processes in which patients and the public genuinely engage. In my experience as an elected representative since 2003, we absolutely do not have those at the moment.

There are a lot of frustrated people in the room. The committee will have a discussion afterwards on the evidence that it has received.

What is the timescale for the council’s review?

I anticipate that we will be able to publish it in February.

Is there still time to submit to it?

I am more than happy to take your comments.

Thank you.

I thank the witnesses for attending. We will suspend briefly to change the panel.

11:01 Meeting suspended.  

11:05 On resuming—