Supporting and Promoting Joint Working between Local Authority
and NHS Bodies: Ladder of Support and Intervention
The UNISON Scotland Response April 2004
UNISON Scotland believes that the starting point
for scrutiny should be ‘bottom up' through open, transparent and
democratically accountable public bodies. In regards to the Joint
Future Agenda, we believe that the local partners should be required
to produce a corporate strategy on participation and involvement
which demonstrates how users, community organisations, staff and
their trade unions can be involved in the planning, design, monitoring
and review of services.
UNISON Scotland believes that equal access, representation
and the capacity to participate are essential and for staff and
their trade unions this has to be based on a genuine collective
UNISON Scotland believes that service improvement
has to be linked first and foremost to the availability of resources
and the wider social and economic needs of the community. In addition,
we believe that the crude adoption of ‘continuos improvement',
‘performance management' and similar initiatives is not appropriate
to public services. These initiatives are incompatible with the
need to encourage innovation and end the blame culture and they
can often lead to increased stress and harassment in the work
UNISON Scotland acknowledges that interventions
arising out of the framework will vary from supportive to corrective.
Whilst we recognise that in extreme circumstances corrective intervention
may be necessary, we are pleased that the emphasis in the document
is on supportive interventions with inspection working in partnership
with public bodies. In addition, UNISON Scotland believes that
given the number of inspection bodies it is important that inspection
is co-ordinated to avoid duplication, additional workload and
UNISON Scotland believes that there is a need for consistency
and transparency within any framework and we are concerned that
important elements of both appear to be missing from the proposed
framework of support and intervention. It is the opinion of UNISON
Scotland that the document would have benefited from a greater
degree of clarity in regards to the threshold for an intervention
decision and also the evidence upon which this decision would
UNISON Scotland welcomes this opportunity to
comment on the Scottish Executive's proposals for implementing
a framework - the ladder of support and intervention -
to support joint working between the NHS and local authorities.
UNISON is Scotland's largest trade union representing
150,000 members delivering public services. Over 85,000 of these
members work for local authorities in Scotland and just under
50,000 work in the NHS in Scotland. We represent NHS nursing,
ancillary and clerical staff in addition to a wide range of local
authority staff who are involved in building communities, supporting
families, protecting vulnerable people and caring for children.
UNISON Scotland members, as health and local government workers,
as users of public services and as ordinary voters have a direct
interest in commenting on these proposals, which cover issues
of great concern not only in their professional lives but as citizens
This paper constitutes UNISON Scotland's response
to the Scottish Executive consultation document ‘Promoting
Joint Working between Local Authority and NHS Bodies: Ladder of
Support and Intervention'.
The proposals for a ladder of support and intervention, outlined
in the consultation document, have been developed under Section
17 of the Community Care and Health (Scotland) Act 2002. These
proposals will enable Ministers to intervene in local authorities
or health boards, where performance of their health, social care
or housing functions applicable to community care could be improved,
by directing them to apply a range of joint working arrangements.
The ladder of support and intervention is seen as an administrative
framework designed to emphasise the opportunity for self-improvement.
The focus of the framework is on support rather than intervention
and it concentrates on methods of delivering service improvement
through support mechanisms and local action. This is intended
to provide local partners with the opportunity to improve results
at their own hand, with or without external facilitation.
The framework itself contains a set of steps that Scottish Ministers,
local authorities and NHS bodies believe would be appropriate
in most cases to achieve the desired improvements, once Scottish
Ministers have taken the view that joint working would improve
the performance of these bodies' community care and health functions.
However, where joint working appears to be failing or where joint
working would be a solution to poor performance of a function,
the power of intervention can be considered. Given that Ministerial
intervention is a last resort, the document outlines that the
evidence would have to demonstrate serious or sustained poor performance,
which was unlikely to improve without intervention, even after
support had been provided.
1. UNISON Scotland views on the process Scottish
Ministers will apply in considering exercising these powers, including
the balance between "support" and "intervention".
UNISON Scotland welcomes the Scottish Executives new initiative
- ‘Re-invigorating the Joint Future Agenda' - to drive
forward the Joint Futures programme. We also welcome the focus
of this initiative and are supportive of the Executives aim to
ensure individuals and carers receive tangible benefits as a result
of better joint working.
UNISON Scotland is in broad agreement with the arrangements outlined
in the proposed ladder of support and intervention and welcomes
the emphasis in these arrangements on allowing Local Partners
to resolve performance issues at their own hand, with Ministerial
intervention as a last resort.
UNISON Scotland is broadly supportive of the framework actions,
which emphasise identifying and meeting development needs and
supporting continuous improvement, rather than imposing sanctions.
However, UNISON Scotland also believes that there is a need for
consistency and transparency within any framework and we are concerned
that important elements of both appear to be missing from the
proposed framework of support and intervention.
It is the opinion of UNISON Scotland that the Executive needs
to give greater clarity in regards to the threshold for an intervention
decision and also the evidence upon which this decision would
be made. It is our opinion that the document fails to properly
explain the criteria or indicators that will allow Ministers to
assess or judge performance.
Also, UNISON Scotland believes the document fails to clearly
outline what level and what type of intervention will be appropriate
for those agencies considered to be failing in delivery of Joint
Working services. Whilst acknowledging that ‘a one size fits all'
approach is not appropriate in terms of deciding on intervention,
UNISON Scotland believes the assertion that "the level of intervention
would be appropriate to the need identified" to be ambiguous
and lacking in clarity.
We believe that further clarification is needed in regards
to Ministerial decision-making on interventions. Failure to do
so will leave a large measure of doubt about the ability of the
framework to consider cases of inadequate performance in a manner
that is transparent, consistent and able to inspire confidence
amongst staff and users of joint working services.
As those responsible for delivering the benefits of the
Joint Future programme to Scotland's communities, we believe Scotland's
local authorities and the various NHS bodies to have an important
understanding of local issues and local conditions on the ground.
UNISON Scotland would be concerned that this valuable knowledge
and local insight is not lost during the process of intervention.
However, the document does not envisage any involvement for these
agencies after the decision to directly intervene has been taken
UNISON Scotland believes this to be imprudent and remain unconvinced
that the ‘heavy hand of central government' can deliver service
improvements in Joint Working activity without the input of the
local partners, at all rungs in the ladder of support and intervention.
2. UNISON Scotland views on the arrangements for measuring
and assessing performance.
Whilst UNISON Scotland welcomes the fact that a decision to intervene
will be made "against a more widely based assessment of the
quality of a service in an area", we believe that the proposal
would benefit from greater detail as to what exactly is to be
included in any assessment.
UNISON Scotland believes that in scrutinising public services
it should be recognised that there is a wide range of factors,
which determine the performance of public services. These include
factors like the funding available, access, the service environment
and the relationship with users and the wider community.
UNISON Scotland believes that service improvement has to be linked
not only to the availability of resources but also to the wider
social and economic needs of a community. We would therefore urge
the Executive to ensure that a more holistic approach is taken
when assessing performance.
UNISON Scotland believes that performance should
be assessed not measured. It is our belief that there are significant
practical difficulties with performance measures particularly
performance indicators and league tables together with a "one
size fits all" approach to standards.
UNISON Scotland believes that performance
assessment should be based on 4 key elements. These are inputs
i.e. on the resources used to produce a service, outputs
i.e. it should measure the goods and services delivered, outcomes
i.e. it should indicate the impact or benefit of services and
processes i.e. measures the manner in which the
outcomes are achieved.
The document states that JPIAF measures "will shortly move
to setting targets to underpin key national outcomes". This
is clearly a move in the direction of setting national targets
and is a matter of some concern for UNISON Scotland.
UNISON Scotland believes there is a role for national inspection
regimes in setting broad standards, issuing guidance and providing
support. However, we also believe that these standards should
not be a substitute for broader forms of democratic accountability.
The inspection bodies also need to have clear policy objectives
set by ministers who are democratically accountable to the Scottish
Parliament. ‘Independent' does not mean ‘unaccountable'.
As stated above, UNISON Scotland is not intrinsically opposed
to the establishment of national standards, we believe that they
can be used to promote positive developments in relation to staff
governance and health and safety standards. We are however concerned
that this is done with the involvement of staff and their trade
However, disappointingly, this involvement was not apparent during
the 2003 establishment of performance indicators to measure waiting
times for assessment and services; and trade union involvement
remains unlikely in any future setting of standards.
As the largest trade union representing both health and local
government staff in Scotland, we believe trade union non-participation
in the setting of national standards to be unsound. We believe
that the involvement of staff and their trade unions at both local
and national level to be key in any successful development of
national standards. It is the belief of UNISON Scotland that scrutiny
works most effectively when operating in partnership with staff
3. Unison Scotland's views on the ‘preventative' arrangements
to support local partners improve performance at their own hand.
UNISON Scotland has a number of concerns regarding the systems
outlined in the document for supporting local partners to improve
their performance. Firstly, we would like to make known our disappointment
that the Executive does not envisage any staff or trade union
input to Joint Working Improvement Teams.
We believe that staff and their trade unions have a valuable
contribution to make in improving the performance of joint working
initiatives. Our exclusion, therefore, from this important element
of the improvement process leads us to conclude that the arrangements
to support local partners do not operate in full partnership with
UNISON Scotland is also concerned at the large number of audit,
inspection, assessment and monitoring bodies that will be used
to provide indicators of the success or otherwise of joint working
in local authorities and NHS Boards.
Whilst we are supportive of a co-ordinated approach to scrutiny,
we believe that with this large number of inspection bodies, 14
as proposed in the document, there is a real danger of duplication
of effort in the scrutiny of joint working arrangements.
4. UNISON Scotland's view on the arrangements for intervention
UNISON Scotland is broadly supportive of the
arrangements for intervention and reporting as outlined in the