Scottish Government

Health Protection in Scotland - A Consultation Paper

Chapter 6: Options for Organisational Arrangements for Health Protection in Scotland

2. This chapter sets out options for re-organising health protection services in Scotland. Consultees are invited to review each option, outline what they see are the strengths and weaknesses of each, and indicate which they prefer.

3. Background

4. Many of the issues confronting health protection services in Scotland were considered in the Review of the Public Health Function in 1999. Among its key recommendations, which were accepted by the Scottish Executive, were:

• NHS Boards should have sufficient staff to develop and discharge the communicable disease and environmental health control function. (A staffing norm for each mainland Board was provided). The further development of supra-regional and national CD&EH networks should seek to ensure that out-of-hours cover arrangements across Scotland are adequate.
• the development of joint training opportunities for public health specialists and EHOs should be enhanced and local level public health liaison committees between CD&EH specialists, EHOs and other professionals strengthened,;
• Closer technological and organisational ties should mean greater integration of communicable and non-communicable disease surveillance and control. Incremental development in areas of common interest should allow progressive integration of these important functions.
• Multidisciplinary team working between CPHMs, public health nurses, good networks with professional colleagues in public health, clinical and microbiological disciplines, and adequate cross-cover arrangements between and among Boards are crucial and should be strengthened;

These recommendations remain extant and form part of the policy framework within which decisions on new organisational arrangements should be made.

Other Relevant Initiatives

2. A number of other initiatives need also to be borne in mind, in considering the arrangements for health protection in Scotland. These include:

• The current review of public health legislation. The basis of public health law in Scotland still lies in 19 ^th century legislation and, in particular, the Public Health (Scotland) Act 1897. That visionary statute has served us well but the climate is now right for change, given developments in the public health field, and a review of the legislation is in train. New legislation will, of course, be dependent, among other things, on Parliamentary time being available. The extent to which any forthcoming legislation in the public health field could be used as a vehicle for any changes arising from the consultation would depend on issues such as timing, scope and nature of the proposals.
• The Review of Management and Decision-Making in NHSScotland. This project is examining the style of management and decision-making processes appropriate for a post-devolution and post-internal market NHSScotland, including the relationship between the Scottish Executive and NHSScotland, the optimum number and configuration of NHS organisations appropriate to the size and geography of Scotland, and consequential legislative changes.
• Arrangements for more systematic regional and national planning for services and responses that needed to be planned and implemented for populations larger than those of NHS Board areas (HDL (2002) 10). These arrangements bring NHS Boards together in three regional planning groupings - West, South East and North of Scotland-to plan and implement health care services, to harmonise regionally NHS Boards' service plans and to plan for and respond to a variety of emergency situations. These arrangements also required NHS Boards and the regional planning groups to engage the appropriate senior clinical and other staff to plan for particular services, and also to involve Local Authority partners in the regional planning arrangements.
• The Review of the Common Services Agency (CSA). A review is currently in train of the existing and potential responsibilities of the Common Services Agency, and other aspects, including the Agency's relationships with NHSScotland, its governance and accountability, and the legislative implications of any proposed changes. Consultation with NHS bodies on the review will close on 2 December 2002. The review's recommendations are mostly aimed at the governance of the CSA, and it has concluded that current responsibilities remain appropriate, while recognising that this may be impacted upon by the Review of Management and Decision Making in NHS Scotland, the review of health protection arrangements or by the introduction of the new GMS contract.

Options for new organisational arrangements

2. As earlier proposed, the following table sets out the various bodies around whose functions options have been developed.

3. 1. National Radiological Protection Board (NRPB) 2. National Focus for Chemical Incidents ("Chemical Focus") 3. Scottish Poisons Information Bureau (SPIB) 4. Scottish Centre for Infection and Environmental Health (SCIEH) 5. Information and Statistics Division (the health surveillance elements - ISD) 6. Scottish National Reference Laboratories 7. NHS Boards (health protection functions especially those delivered by communicable disease and environmental health teams.)

4. Six options involving permutations of the seven services have been developed based on their potential viability as organisational entities. Figure 1 outlines the differing options. They are:

Option 1: Full integration of all Scottish health protection services into the proposed new HPA

All seven of the current local and Scotland-wide health protection services detailed above become part of a new Health Protection Agency (HPA), covering Scotland and England and providing certain services to Wales and Northern Ireland.

The inclusion of the health protection functions of NHS Boards in Scotland goes beyond what is currently being developed in other parts of the UK. This may not be a substantive issue in terms of considering the relative merits of this option, in principle, but could be expected to complicate any potential implementation process and timescale.

Figure 1

OPTIONS FOR NEW ORGANISATIONAL ARRANGEMENTS FOR HEALTH PROTECTION IN SCOTLAND

Option 2: Integration of all Scotland-wide services into the proposed new HPA but no change to local arrangements

All Scotland-wide health protection services (i.e. services 1-6 detailed above) would become part of the proposed new HPA. NHS Boards would retain responsibility for local health protection services (i.e. service 7 detailed above)

Option 3 Integration of certain Scotland-wide services into the proposed new HPA but no change to other Scottish arrangements

Certain Scotland-wide services, NRPB, Chemical Focus, SPIB would be incorporated into a new HPA (i.e.. services 1-3 detailed above) and arrangements made for these services to continue to be provided in Scotland. Other Scotland-wide services SCIEH, ISD, and the Scottish National Reference Laboratories (i.e. services 4-6) would remain as related but independent functioning organisations. NHS Boards' health protection arrangements would be unchanged.

Option 4 Integration of certain Scotland-wide services into the proposed new HPA and the establishment of a Scottish Health Protection Organisation for the remaining Scotland-wide services

Certain Scotland-wide services, NRPB, Chemical Focus, SPIB would be incorporated into the proposed new HPA (i.e. services 1-3 detailed above) and arrangements made for these services to continue to be provided in Scotland. Other Scotland-wide services SCIEH, ISD, and the Scottish National Reference Laboratories (i.e. services 4-6) would come together within a new Scottish organisation. NHS Boards' health protection arrangements would be unchanged.

Option 5 No integration into proposed new HPA but the establishment of a Scottish Health Protection Organisation for all Scotland-wide services with no change to local services

All Scotland-wide agencies (i.e. services 1-6) become integrated into a Scottish Health Protection Organisation with no change to NHS Boards' health protection arrangements. .

Option 6 No integration into new HPA, establishment of a Scottish Health Protection Organisation for all Scotland-wide and local services

All Scotland-wide and local agencies become integrated to create a distinct separate Scottish Health Protection Organisation. It would incorporate all the seven listed (see box) organisations, including the health protection functions of NHS Boards. An organisation would be created in Scotland along the lines proposed for England with NHS Boards' services becoming field services for the new organisation.

Legislative and Practical Considerations

1. In considering the relative merits of these options, it is important to recognise and take account of the varying impact and interaction of a range of factors. These include:

• considerations relating to value for money, efficiency and effectiveness. For example, establishing a new body to provide radiological protection services or advice on chemical incidents in Scotland, either on its own or as part of an organisation with other responsibilities, along the lines set out in Option 6, may not be viable on economic grounds or having regard to the availability of expertise in a specialised field. In particular, the present cross-border delivery of the radiological protection function has operated effectively, an advantage which may be eroded, if services were organised on a geographical basis;
• the extent to which the current UK-wide discharge of some services could be maintained by service level or contractual agreements between the Scottish Executive and the HPA, on terms and conditions geared to Scottish needs and circumstances;
• the degree to which legislation will be required to give effect to any of the options. Options 1-4, in particular, would be likely to have implications for both the UK and Scottish Parliaments;

The Strengths and weaknesses of options on organisational arrangements

1. Each option will have advantages and disadvantages. In judging them and framing a view on which is the best for Scotland, it would be helpful if consultees could address the following questions:

1. will the option improve the co-ordination and implementation of the range of health protection measures needed to deal with the challenges outlined in Chapter 3?

2. will it improve the effectiveness and efficiency of the key health protection functions of surveillance, investigation, risk assessment, management and communication and managing emergencies as outlined in Chapter 4?

3. will it enhance the accountability of health protection services in Scotland by more closely aligning policy, resource allocation and performance management functions?

4. will it facilitate collaboration with UK, European and international counterparts in protecting health, especially in securing the best possible specialist advice and in recognising and responding promptly to emerging infections and the deliberate release of biological and chemical agents;

5. will it provide incentives for people working in health protection to improve their individual and collective performance through a continuing process of personal, professional and organisational development?

If it were considered that an option could be strengthened or varied to secure the more effective discharge of the health protection function in Scotland, it would be helpful to have details.

Conclusion

1. Whatever arrangements come into place, it will be important to secure an enhanced Scotland-wide overview expert panel. Currently, the Scottish Executive has commissioned the Advisory Group on Infection (AGI) to advise on general and specific issues. This Group meets as and when issues arise. With each option, we would propose to establish this Group on a firmer footing, with regular meetings and an agenda of Scotland-specific matters.
2. Of equal importance will be negotiation of formal agreements which secure and strengthen networks, services and advisory capacity currently provided to Scotland by bodies whose functions are proposed for transfer to the proposed HPA.
3. It will be crucial, as well, to maintain and enhance collaboration and networking among the key stakeholders in the health protection function in Scotland, including local authorities, the environmental health profession, the Food Standards Agency, the Scottish Environment Protection Agency and the Drinking Water Quality Unit.

Questions

Taking into account the considerations and criteria set out earlier in this Chapter, it would be helpful to have views on:

• which option is preferred and for what reasons?
• do you see any downsides to the option you prefer?
• can you suggest any other option which would meet the criteria listed?
• do you agree that the role of the Advisory Group on Infection should be enhanced to provide an overview of health protection arrangements in Scotland? Are there any other functions the Group might discharge?