Scotland’s independent think tank
Scotland’s independent think tank

Delivering the Care & Health Services Which We Will All Need (Eventually) – David Belfall

In this blog I seek to compare the current arrangements for managing community health and social care services in Scotland – through “Integrated Joint Boards” with the National Care Service (as proposed until 23 January). With an ageing population these services are a crucial part of our public services. They are also expensive. The annual budget of the Glasgow IJB is £1.5 billion and that of the Edinburgh IJB £900 million. There are 31 IJBs across Scotland with a total annual budget which must be around £5 billion pa.

My blog takes account of my experience as a non-voting “service user representative” on the Edinburgh IJB from June 2024 until January 2025.

My view is that IJBs are dysfunctional and not fit for purpose. I reach that view not because of the personalities involved, but because, in my view, the basic structure is fundamentally flawed.

Integrated Joint Boards
IJBs were set up in 2015 under the Public Sector (Joint Working) (Scotland) Act 2014. That Act sought to bring together the community health services of the local NHS Board – basically all health services apart from hospitals – with the social care responsibilities of Councils. The voting members of IJBs are equal numbers of Councillors appointed by the Council and representatives appointed by the Health Board. The Chair is appointed for 2 years by the Council and is then replaced by an appointment from the Health Board.

In my time on the Edinburgh IJB there were 5 voting members from the Council – all Councillors from different political parties, reflecting the fragmented political make-up of Edinburgh City Council – and 5 Non-Executive Board members of NHS Lothian. It is important to understand that the 5 NED members of the NHS Lothian Board were originally appointed to that Board to bring their experiences and skills from their working and private lives to bear on the work of NHS Lothian which then appoints them, additionally, to serve on the EIJB as voting members. They receive an allowance (usually for one day’s work) from the NHS Board, but are not NHS employees.

The structure is inherently unstable and does not provide the continuous firm leadership which an organisation with a budget of £900M pa needs.

The problem is compounded – at least in Edinburgh – by the fact that the Chief Officer of the EIJB has changed so frequently. The Board is now about to greet its sixth Chief Officer since it first met on 17 July 2015 – plus 2 interims.

This unstable structure is especially difficult for the other senior officials – and there are some very able officials at the EIJB – because of the changes in leadership so often.

Also relevant is the fact that IJBs do not employ any staff of their own. All IJB staff are employed either by the Council or the Health Board. The IJB – with its operational arm the Health and Social Care Partnership – is a commissioning body. With its budget – which is provided by the Council and the Health Board – it commissions services, most but not all of which are provided by the Council and the Health Board from which it obtains its budget!

This curious arrangement – which, so far as I am aware, is not replicated in any public service anywhere in the UK – is compounded by the fact that demand is growing faster than the resources provided. In an excellent report in July 2024 Audit Scotland drew attention to this disparity. The report did not receive the attention it deserved.

The consequence of the disparity between resources and demand is that IJBs spend much of their time trying to work out where savings can be made. In Edinburgh the challenge is to find £105M of savings in 3 years between 2025 and 2028.

Since most of an IJB’s resources is tied up in services which it is legally obliged to provide, the focus has been on other services, particularly preventative services and services provided by the voluntary sector. However, any short term savings which can be obtained in respect of these services come at the expense of additional future demand – and therefore cost. As Audit Scotland has eloquently put it : “…collaborative, preventative and person-centred working is shrinking at a time when it is most needed”.

The IJB model for providing community health and social care services is therefore deeply flawed. A massive additional financial input might help, but it would not resolve the fundamental structural problem.

What then has been the alternative?
The Scottish Government’s answer has been to create a National Care Service, based on the model advocated in a report from a group led by Derek Feeley, former Chief Executive of NHS Scotland and published in 2021.Essentially Feeley proposed a National Care Service on the lines of the National Health Service, with a central body and local delivery mechanisms, similar to NHS Boards, which would be employing bodies, taking over health employees of the Health Board and social workers employed by the Council. The proposed removal of social workers from Council control immediately raised complaints about the lack of democratic control, to which I will return, but in truth the current IJB model has only a tenuous connection with local democracy.

However, as Feeley made clear, the introduction of a National Care Service would require substantial additional public expenditure and, since he reported, the public finances have deteriorated significantly. The consequence is that, although there is legislation creating a National Care Service on the statute book, its implementation has been repeatedly deferred, and has now been abandoned by the Scottish Government in the statement made to the Scottish Parliament on Thursday 23 January 2025 by Maree Todd MSP, the Minister for Social Care.

Where do we go from here?
In her statement Ms Todd said, among other things, that “…I will move quickly to establish a National Care Service Advisory Board, on a non-statutory basis. It is my intention that the Advisory Board will include people with lived experience of accessing care services, those who work in the sector, care providers, the third sector, trade unions the NHS and local government. I expect the Board to meet for the first time in March this year…” What could we expect that Board to consider?

The case for a National Care Service was based on the need for greater consistency and quality across the services provided across Scotland by the IJBs. Can these objectives be met without the massive restructuring which the creation of a National Care Service would have entailed?

In this connection it should be noted that, apart from the work of Audit Scotland and the scrutiny provided by the Care Inspectorate and the Mental Welfare Commission, IJBs are free to go their own way. There is no representative body for IJBs such as COSLA provides for local authorities. Nor is there any annual conference or other arrangement for sharing experiences and good practice. IJBs generally conduct their business in isolation from each other.

There is already scope for greater sharing of information between IJBs, and for providing some form of inspection or monitoring by a national body. There would be a cost to this, but not nearly so much as a National Care Service would entail.

The function of IJBs would also repay consideration. What does “integration” mean? Does it just mean a mechanism for managing parallel health and care services, and ensuring that there is no unnecessary friction between them? Or does it mean much more integrated patterns of working such as asking care workers to undertake basic health checks? Co-operation between health and care services is certainly vital in dealing with the central problem of delayed discharge from hospital, but is there scope for ensuring that health staff are better able to identify care needs in the community and ensure that they are met? A central monitoring body could certainly help in ensuring that synergies of this kind are identified and addressed.

There remains the issue of the structure of the IJB itself. The current arrangements are a compromise – in my view an unsatisfactory compromise – between a model based on local democracy and a model based on expertise and continuity of leadership – in other words a quango.

The argument for a quango would be based on the need to attract, and then appoint, really senior people from the business world or the professions as Chairs and Board members, with appropriate skills and background, to lead an organisation with a hefty budget and very significant responsibilities for a substantial period – say 5 years. They would need to be paid sufficiently to attract people of high quality.

The argument for a democratic model would be based on the need for the leader(s) of such an organisation to be publicly accountable, and to be able to serve as the public voice for such important public services. Is it beyond possibility that IJB Chairs could be directly elected at the time of Council elections? Or would such a system run into opposition in the Scottish Parliament, given its reluctance to create powerful democratically elected posts at local level such as elected mayors?

In this blog I do not wish to express any preference between the quango model and the democratically elected model – but I do suggest that either would be preferable to the current arrangement.

The future
But I should not just stop there, because it is clear that, whatever model of management is adopted for community health and social care, additional resources will undoubtedly be needed as a result of an ageing population. The statistic which will remain with me as a result of my membership of the Edinburgh IJB is the estimate that Edinburgh will need a new 60-70 bed old people’s care home – capital cost say £3m, running cost say £4m pa – every year for the next 20 years.

Failure to provide the resources needed across the spectrum of community health and care services will inevitably result in decline in the services provided – of which the increasing difficulty in obtaining a GP appointment is already evident. In that event families who can afford it will turn to private services and those who cannot will be increasingly dependent on the voluntary services who already provide substantial support to those in need

Are our politicians up for up for the challenges which the future holds in this area – and indeed in relation to public services generally? Public opinion surveys suggest that the general public recognise the need for greater expenditure on the NHS and care services. Of course, whether they are prepared to vote for the extra taxes or alternative funding models (yet to be devised) which that would mean is a different question entirely. And certainly our mainstream political parties, locked in their perpetual mutual blame game, are unlikely to test the public willingness to vote for more taxes. But their failure to do so – and the decline in public services which will result – may well lead to the public turning to more extreme parties of the left and right under the illusion – and of course it is an illusion – that their simple remedies will serve to solve very complex social and financial problems.

David Belfall was a senior civil servant at the Scottish Office/Executive between 1988 and 2002. David was Group Head responsible successively for Police and Fire Services, Health Policy and Public Health and Housing and Area Regeneration. Following retirement, among other things, he was a Non-Executive Member of NHS Lothian Board for 5 years. During his time with NHS Lothian, David was Chair of the North Edinburgh Community Health Partnership and then of the combined Edinburgh Community Health Partnership. He was a non-voting member of the Edinburgh Integration Joint Board for 7 months in 2024-25. He is writing in a personal capacity.

5 comments

  • Eric Mackay

    Yes indeed David . We have shared the complex task of effective implementation . I would highlight your suggestion that such key operating structures , responsible for significant budgets , need incisive strategic leadership and membership . All too often , the established stakeholder formula produces excellent specialists but those not necessarily familiar with the different arenas of cross cutting and the joining up of structures / policy / needs / staff to maximise and produce effective and economic optimums out of sometimes very tangled inter related skeins .

  • Jean Henretty

    Totally agree. As an ex ward manager in geriatric service I predicted the IJB would not improve care in community. Basic flaw is that health and social care professionals do not agree, social v medical model of care. In some cases nurse professionals will share an office with care manager but not communicate. The system should have been reformed from the ground not top. Joint training, understanding the need for medical and social model. Carers could be given basic “nursing” training to assess clients/patients and call on community nursing team to advise on care.
    Moving frail elderly from long term geriatric wards has placed them alone in front of a screen with under qualified staff given 15 minutes to provide care. Either return them to modern care facilities where they won’t be lonely, or provide nursing care similar to Buurtzorg model in their community.
    As for IJB, scrap them immediately as they are only finance officers cutting funding. Place all community care back into the NHS where it worked very well for years.

    • David Belfall

      Jean, Might you also agree that IJBs do not have sufficient access to the front line perspective, and that they do not pay sufficient regard to the contribution which voluntary sector organisations do and could play in community health and social care?

  • Mike Foulis

    David, very interesting. Was there not another possible IJB model when all this was being set up, based on what Highland did, i.e. actually transferring employment of the relevant staff (those dealing with children to the Council and those dealing with older people to the HB)? As far as I know, no other LA/HB combo adopted it, possibly because it looked like too much effort. Though Highland, or the Council at least, were convinced that it was essential to have any hope of making an impact. Might be interesting to know if they are still operating on those lines and, if so, whether it made any difference.

    • David Belfall

      Good to hear from you after so long, Mike. The distribution of responsibilities in the IJB world can be very odd. Thus the Greater Glasgow IJB is responsible for children’s services, homelessness and criminal justice services whereas the Edinburgh one and several others are not. And the appointment of (non-voting) care and user “representatives” amounts to nothing more than the tokenistic involvement of people who have no power to influence events, still less make things happen – as I found out for myself. I cannot answer your question about Highland directly but, while I can see that geriatric health and social care services could be centralised in the HB, I am less sure about children’s services being handled to the Council, since while there are specialists in paediatric care in the health service there are also many other health workers – GPs for instance – who will have important contacts with children as part of, but not all of, their work. I am yet to find anyone prepared to argue that IJBs were a good idea. Apart from anything else, the Feeley report and the now failed attempt to establish a National Care Service represented a clear acceptance that IJBs could not do the job needed.

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