 I welcome everyone to the 30th meeting of the Public Audit Committee in 2023. I'm also very pleased to welcome in the public gallery this morning members of the Public Audit and Public Administration Committee of the Welsh Senate, so you're very welcome. Thank you for being here. The first item on our agenda is for members of the committee to consider whether or not to take agenda items 3 and 4 in private. Are we all agreed? We are agreed. In that case, we can turn to the principal item on our agenda this morning, which is further consideration of the Joint Auditory General for Scotland and Account Commission report on adult mental health. Can I welcome everyone to the meeting this morning? The committee is taking evidence on a round table format, which is intended to promote discussion between witnesses and participants, so feel free to interact. If anyone wishes to come in on the discussion, if you're in the room, if you just indicate in one of the clerks in the room, we'll pick that up and we'll do our level best to bring you in. For those who are joining us online, you're very welcome. If you want to come in in addition to any times that we direct questions to you, if you use the chatroom function and just indicate in there a request to speak, RTS, or any other way to communicate the fact that you want to come in on any particular question. But I say to all of the witnesses, we do have some time constraints, so don't feel obliged that you have to come in on every single question, and I'll do my level best to bring as many of you in as possible, but experience tells us that there may be occasions where we can't bring everybody in on every question that wants to come in. I also say to those who are joining us remotely that the broadcast unit has set up your audio and camera, so you don't need to do anything with that. If you can keep them on at all times and when it's your turn to speak, we'll make sure that your audio is on so that we can all hear you. As is customary with a round table format, I'm going to ask everybody who's taken part this morning to introduce themselves and just tell us which organisation that you're from, and I'm going to start by turning to the people who join us in the committee room and ask Hannah to introduce herself, first of all. Policy manager with Remick for Mental Health at Cozlo. Richmond. Hello, Richmond Davies. I work in Public Health Scotland as the head of Public Health Analytics and Intelligence. Thank you. And now turning to the people that join us on remote, Simon, can I start with you? Hello, it's Simon Burt. I'm the general manager in Scottish Borders, and I manage Integrated Mental Health Services and also Integrated Learning Disability Services. Thanks, Simon and Pamela. Good morning, I'm Pamela Creman. I'm the chief officer for Highland Health and Social Care Partnership. Thanks, Pamela Fiona. Good morning, I'm Fiona Davies. I'm the chief officer in Argyll and Bute Health and Social Care Partnership, which has fully delegated mental health services, and I'm here to represent Health and Social Care Scotland. I'm also a registered mental health nurse. Thanks, Fiona. Gillian. I'm Gillian Galloway, interim chief officer for Argyll and Social Care Partnership with responsibility for Integrated Community Mental Health. Thank you, and Joe. I'm sure Health and Social Care Partnership. I'm head of service for mental health, learning disabilities and drugs and alcohol services. And that's in East Ayrshire, Joe, isn't it? Yeah. And finally, but last but not least, Tracy, could you introduce yourself, please? Morning, everybody. I'm Jason Hegan. I'm working for Mental Health in NHS Lodea. Thanks very much indeed. I'm going to kick us off this morning with some questions before I turn to other members of the committee. You will have read, I'm sure, the report, which is the kind of genesis of our round table discussions, which have taken place over the last few weeks, which contains a recommendation that people should be provided with a choice about whether they access mental health services remotely through telephone, video link, or face to face. And I just wonder how you, as different agencies responsible for providing these services and having oversight of these services, have responded to that recommendation. I'm going to begin by maybe asking Simon to comment on that. Thank you, chair. I suppose it's the majority of our services, in fact, all of our services in secondary care. We do provide both face to face and the opportunity for online interaction with healthcare professionals and social care professionals. So, in the main, we've returned since COVID to face to face. In primary care, we have a new-ish service, which is called Renew, which is our primary care mental health service, which is primarily, well, it is, a talking therapies service, and that's commissioned by our GPs, and we provide it, and that is predominantly an online service. But we do, where people struggle to access online, provide face to face where that's required, but the vast majority is online. The feedback and the outcomes we get is very good, very high, both from the commissioners, the GPs, and from people who access the service, we're a rural service without really any, well, we have no major cities, so it's a real challenge geographically, both the people to travel and access services and also, as a small board, we tend to get the small amount of funding for various initiatives. So, I suppose it's about the practicality of being able to provide a service that allows access to the majority, and so there has to be some compromises in regards to face to face for that service. Generally, we see between 300 and 350 patients a month, and most of those are online. Okay, thank you. I wonder whether, Tracey McKiggan, whether you've got a perspective, but maybe from a more urban landscape in the Lothians, whether you've got a perspective on this recommendation on face to face versus remote consultations? Yes, so, within psychological therapies and plans, we are the highest users of near-me consultations in NHS Lothian, so we have not shifted back post-COVID, and we give everybody that's able to the opportunity to have a new consultation. In the psychological therapies, we also have a number of online platforms that people can use for CBT, et cetera, so we are embracing the online where possible. The feedback, especially in children, is that they like it because they're used to using devices. We obviously have to take into consideration things like privacy and making sure that young people are not being coerced when we are not in the room with them, and that they have the ability to speak properly, but all of that is risk assessed before we start the consultations. I don't know whether you saw the evidence session that we had last week, but Kirsten Urquhart from YoungScot took part, and she said regarding young people, going on TikTok is not the same as knowing where to find and how to use a mental health support tool. In other words, she was saying that amongst younger adults, there were issues there about whether they could access online appointments or whether they would maybe prefer face-to-face appointments as well. We ran a survey probably about a year ago now, and the online was very well received by the young people that we surveyed, so we do risk assess it, we do give them choice, but for the majority of young people, they are accessing it well, and the feedback was very positive. I'm going to reflect on one of the exhibits in the report, Exhibit 3, which is a chart that shows the variations from health board area to health board area about psychological therapies appointment types. This is for the year 2022. I don't know whether anybody wants to comment on why you think there is such a huge variation. The example that I cited last week, which comes out of this evidence to me, is the big difference between face-to-face appointments in NHS Ayrshire and Arran, for example, where it's as high as 86 per cent. When I look in an area where I represent Graham Simpson and represent NHS Lanarkshire, the figure is just 32 per cent, less than a third of our face-to-face appointments, and 68 per cent are through remote video and telephone links. Does anybody have a view on why two areas with more or less a similar demographic, slightly different population size, but a similar demographic, why there is such a big variation? I don't know, Richmond, whether you have any perspectives on that. No, we don't, because Public Health Scotland receives these figures in a kind of established method for the data coming into Public Health Scotland, and this is what it is. This is what happens in Ayrshire and Arran. It appears as if they have a lot of face-to-face compared to some other areas. The reasons may vary because of choice, because of the demographics in terms of deprivation, and there may be so many other reasons why, which the local boards will be able to provide. But in our reports we do have, in the reports we do provide, we do have a metadata, data quality section at the end, which highlights some of the challenges some of the boards do have on various aspects with regards to their data. But the nuances with the tendencies and the populations, I think the local boards will know why. But from a Public Health Scotland point of view, do you dig into the reasons why there are such stark variances in areas that cover similar population types? Yes, well, we do have staff who interact quite a lot with the boards, and they tend to understand the reasons why there are these variations. But I don't think there's anything in particular you can latch on to, because it's a combination of resources, the combination of the deprivation for people, availability of public transport, availability of parking, so there are so many reasons why, and it's very difficult to latch on to one of those reasons why. Okay, I've got an indication that I think Gillian wants to come in on this question, so I'll bring you in next, Gillian. It is around the levels of remote consultation that have taken place. It doesn't take into account the levels that have been offered, so it may be that a high number has been offered, and it's purely around the uptake rather than the availability of that as an option, and that's maybe something that we could consider looking into the information behind that as well. Okay, thanks for that. Graham, I think you wanted to come in on this question, is that right? Yeah, it was probably a previous question. I just want to go back to Tracy. Particularly when you're dealing with young people and you're having online consultations, how do you ensure that there's nobody else in the room, you know, prodding them to say certain things? As I said earlier, we do have a risk assessment process, so if there was any intelligence that was a risk to the young person, then we wouldn't go ahead. We also, if the child is 12 or over, request consent from the child, so they need to tell us that it's okay to go ahead and that they're okay with either sharing or not sharing information, so we try to put as many safeguards in as we possibly can, and if during the consultation we felt there was a risk, we would suggest that we end and we can be in person. But how do you ensure there's nobody else in the room? I mean, we can see you, the background's blurred. I've no idea whether there's anyone else with you, perhaps passing you notes on what to say. I mean, we just don't know, do we? So how do you ensure that with a young person there is nobody else there? There may be other people there, but the young person will have given consent for them to be there or not, so it's not about saying they have to be completely on their own, it's about what they're comfortable with, and if they say they want a parent or guardian or a friend with them and they give consent for that, then that would go ahead. We just, we try to risk assess it as best we can. You're never going to completely eliminate the risk, except that, but for young people that were surveyed, they felt that this was a good way to get their healthcare, and it also allows us to see more people than bringing everybody into an inpatient or a clinic set. Okay, so you can't eliminate, you don't eliminate the risk, but the risk would be virtually eliminated if it was face to face. Would you accept that? There's probably a less risk, you will still have people in the room and you might still have people who feel under pressure to have that person in the room, so I don't think you can say you eliminate it completely, but it may be less, but it's a system that has worked well for us since the start of Covid. Can I take us back to the variability question, which I think Simon Burt wanted to come in on? Hi, thank you. It is really interesting to see the variability because you obviously see some areas where there's real geographical challenges and transport and they almost the exact opposite. Board has been one of those where most of ours is online and we're rural whereas there's neighbouring boards where it's the other way around. I think it must be around resources committed to that particular area of activity, must be one of the big reasons because it is more resource intensive to be able to offer predominantly face to face appointments. We were more or less starting from a standstill in terms of our primary care psychological therapy service, so I think that's my assumption without seeing the investment figures in those areas. Just on the risk issue, I think there will be a risk assessment around where some young people may be at risk at home and I'm sure that will be taken into account in the risk assessment around whether online or face to face, so is required. I'm sure that mitigates against some of the risk that's there and obvious but clearly not all the risk. Thank you. Thank you. A couple of you have mentioned funding and that leads me to ask you about the impact of the emergency budget review last year, which led to a cut in mental health funding of £38 million for 22 to 23 year and there were also cuts in funding for improving primary care services by £65 million and we know of course primary care GPs are principally and almost always the root of entry into adult mental health services for people, so I wonder whether anybody wants to reflect on how you have coped with that, what the impact of that cut has been and has it had an effect on your ability to provide sustainable and effective adult mental health services, including at a primary care level? Who wants to have a go at that? Simon, you want to come in, could you start us off on this and I hope that other people might be able to make a contribution on this question that we've got from the committee? Simon? Absolutely, thank you. Particularly around primary care, so we anticipating additional funding in primary care was originally indicated. We did quite a lot of stakeholder engagement around what the gaps were in primary care, so we were pretty much unified on the gap in the borders was around young people, particularly with anxiety disorders and depression, so we know there's a gap there, so the impact of not having the funding was that that gap and our plans to bridge that gap have had to be held in abeyance for the moment. We also know that there's other gaps, particularly around people with neurodevelopmental disorders where they need an assessment and they don't have necessarily complex needs requiring secondary care, so there's a big and very quickly growing gap there. People with emotional and stable personality disorders as well is another area of where we know there's an area of need, particularly in primary care, out with secondary care services, so the impact on GP practices are obvious with those gaps, notwithstanding the impact on the individuals themselves. Thank you. Pamela Creman, from a highland health and social care partnership perspective, could you maybe give us your reflections on the impact of that emergency budget review and any effects it had on services in your area? I'll then ask Fiona Davis a similar question. Yes, of course. Being remote and rural based, most of our services are delivered in the community with a centralized inpatient adult mental health unit in Inverness, so we've been doing quite a lot of work just reflecting on the near-week or digital therapist discussion that we just had public and people who are using services, the engagement with them has really been important in order to shape and change your service and it's been important to have that discussion with them about our financial position as well in terms of our opportunities for redesigning to co-produce service ideas going forward. You'll see in the previous report that you referenced that Exhibit 3 that NHS Highland has 56% use of online therapies for psychological therapies, and that's been a really positive experience. We've measured people's experience in that, but we've also engaged them in terms of the services that we're able to deliver within our financial envelope and how to make them sustainable, and that's about engaging them in choice as well in terms of what we can all do to improve the situation. One of the ways to engage them was to talk about waiting times and engage with them about how we could modify and redesign our service to get them to be seen quicker. So we've just actually finished a period of two strategic plans. One is our joint strategic plan, which is wider than just mental health, but we also have in parallel to that developed mental health and learnings ability strategy, which has been co-produced with people with lived experience and with other sector organisations. So a really good and a really live document, and we've got our mental health and primary care services. We do have structures within the organisation to engage with our GPs around our primary mental health workers, and one of the outputs that we've had is to try and create that tiered model and try and create equitable services across Highland. They're not all going to be equitable in terms of face-to-face contact or visiting clinicians, but we do have robust and we've been able to staff much better recently, our community mental health teams, and look at the way in which we use our workforce in a different way and we develop them in a different way so that it's not all about having higher level clinicians. For example, we've been able to diversify the primary mental health workers. That would be a good example of that. Thanks very much indeed. One of the pieces of evidence that we have taken has been about whether or not the whole system is over-medicalised or not, and we might get on to that during the course of our discussions this morning. I asked Fiona to come in and I also now have indications from Jo and Hannah, so if I come to you first of all for Fiona, then Jo, I'll bring you in next. Thank you chair. Similar to Palmer in Highland, you'd imagine in our Gile and Bute we have a similar rural and island geography. Over the last few years, our mental health service journey has been moving away from that traditional medical model and investing in urgent care services, being able to be responsive to people who were in mental health crisis and in offering earlier intervention in primary care and other settings, and working in developing community hubs where people get support from people, peers, people that have had mental health issues themselves. The change in the budget last year and the change in the funding coming through from primary care really has just limited our ability to take forward all of our plans at the timescale that we were looking to do so. The implementation of the primary care changes for mental health have been particularly challenging in our island settings and in our most rural communities in our Gile, and so we haven't been able to get coverage for every GP practice, which was the ambition within the primary care improvement plan, and our intention had been to build on the existing services with the new funding, so the absence of that has meant that we've had to curtail really some of our planning around ensuring that we have appropriate access to early intervention services across every GP practice in our Gile and Buten. We're still committed to that, but we'll need to work through how we do that with the delay in funding. Fiona, thank you very much. That's a very clear answer. That's very illuminating. Joe, I'm going to turn to you, then I'll bring Hannah in after you. Joe. Thank you. Thank you, Chair. Just to agree with the points that have previously been made, we in Ayrshire have been building a pathway for mental health support from that front door, as you describe it, in the GP practice right through to significant acute mental health response. Our work in primary care has gone really well. We've established mental health practitioners in all practices in Ayrshire, particularly in East Ayrshire that I'm representing today. What we had hoped to do was consolidate the mental health practitioner, so each GP practice has some time from a mental health practitioner, but there's no buffer in the system if you like. If a mental health practitioner is sick or needs to attend training or we have a maternity leave, there's no cover, which means a person in the community can build up a relationship with a mental health practitioner, but then suddenly that service is no longer available in their primary care surgery. We had hoped to consolidate and expand that. We now no longer can do that. What we are doing is working closely with our third sector. We have a really vibrant third sector in East Ayrshire. We have community link workers that are developed through the third sector and available across our communities, so the pathway between community groups, the community link workers, the mental health practitioners, and then into secondary care services becomes really important, but it's also really challenged. I think that the capacity we build in primary care has taken some pressure off the primary care mental health teams who are a specialist team and some pressure off the community mental health teams, but those teams are still extremely busy. Demand has certainly gone up and so to make sure those teams can focus on the people who are more significantly on well still remains a challenge. I would also mention and I think Simon brought it up, but demand and demand is an awful word. This is need from people, families that are struggling, but a lot more people need help to understand the neurodiversity in themselves and in their families and this is new work. This was not what mental health teams were originally built for, funded for, trained for, so we're doing a lot of work to understand the size of that need and it is significant. We need to really think where's the best way to address that that doesn't further overwhelm those existing specialised teams. Before you sign off on that, can I just come back to you and ask you, so you've described all these increased needs which there are. Presumably in an area like East Asia, not least the cost of living crisis, the impact of the pandemic and so on, these have all presumably heightened need in the community that you serve. Would that be a fair assessment? Absolutely, absolutely and across all levels of mental health I would suggest. We can see significant increases in demand for acute admission, for referral to community mental health team, increased use of detention, but also there's a group in the middle who are distressed, not coping with life, but we wouldn't describe them as having a mental illness, but yet all parts of our system are aware of a challenge there in terms of meeting the needs of those people and some of that is definitely linked to cost of living challenges with heating, housing, eating, all the things that have been discussed before. Thanks very much for your comment on that. Hannah Axon from COSLA, I'm going to bring you in now Hannah. I just wanted to add a couple of points on wider funding arrangements around mental health, so there are long-standing issues with annual funding, with directed pots of money with specific purposes and we know that we have challenges in the workforce in mental health, so when we're looking at annual funding that's amplifying the issue that we have in terms of the retention of staff and the directed pots of funding can restrict partnership working, so when we're looking to make use of the way we use money within the system, so yes we have a reduction in funding and that's problematic, but we also need to look at the models that we're using in terms of funding services more generally to make sure that we can make the best use of the money that we have when there are a number of issues around that at the moment. Thanks and certainly workforce planning and some of the other points that you raised Hannah are ones that we are going to return to, but we are pressed for time, so I'm going to move on and invite the Deputy Convener Sharon Dowey to put some questions to you. Sharon. Good morning, thank you. I'm going to ask about partnership working to address poor mental health and I was going to start off by asking this question to Mabifuna Davis and then to Hannah Axon, so to find out more about how integrated joint boards and councils are addressing the recommendation to urgently improve how mental health, primary care, housing, employability and welfare support services work together to address and prevent the causes of poor mental health by developing shared goals and targets, sharing data and jointly funding services, so if I could maybe ask Fiona Davis to come in on that one first. Yes, of course. Good morning. I probably can't speak on behalf of every partnership. Every partnership is required to do a joint strategic plan, which does all those things that you've just listed. I won't repeat them all back to you, but I can't speak for the quality of all of those or the extent of it. That's not really how the network of health and social care Scotland works, but I can certainly speak to my own experience in our Garland Bute, where as we have a fully delegated model, so what that means is we have all health and social care services for adults and children within our integrated joint board, it really maximises the opportunity for us to hear from all of our partners and from our communities and to bring all of that knowledge and intelligence together from our public health data, from our social care data to really understand the experience of people within our geographical areas and to hear people's qualitative description of their own lives and what's happening for them and their families and to bring that all together into a planning process. We've always followed the legislation from the implementation of the joint working act, so we're now on our third iteration of our joint strategic plan and over the years it's matured and deepened in its understanding and connection with communities, looking right across the social determinants of health into poverty and into a much wider understanding of the causes of mental distress and a mental ill health and bringing that together and that's how then I described earlier how we've tried to move away from traditional models into much more community facing and community engaged and community led initiatives to really build resilience in our communities and to maximise chance of people being well, whether that's physically well or mentally well and to do that in the context of where they live and reside, so that's certainly how it operates in in my part of the world and that is what all integrated joint boards and for highland integration authority because obviously they don't have an integrated joint board, that's at the very heart of integrated working, so to some degree and obviously the model varies from area to area that planning would be evident within the joint strategic plan of the integrated joint board. Okay, thank you. Can I ask Hannah to comment? Yeah, I mean, obviously local planning arrangements, I've learned as outlined how we approach it locally in her area and I think there's a looking at how we continue to build on that, looking at the role of our community planning partnerships and how we draw that through within the new mental health and wellbeing strategy, there are a number of commitments looking at planning, how we look at our current planning structures to see where there are improvements that can be made in relation to mental health to look at how we improve the understanding of the social economic determinants and find the levers to support people working together. I don't think it's a rapid immediate fix, I think it's that building on what we have to make what we have better and that action is certainly outlined in the plan. Are there any barriers to different groups working together? You mentioned earlier on about making the best use of money, you spoke about direct ports of funding and restricts partnership working, so is there any kind of barriers that you are facing? It jumps to mind in the first instance, making sure that people have the time and space to do that work and when people are dealing with mental health as the core of their business, they're trying to get through supporting people and making sure that's not building in the time to do that work together can be challenging, so that's the one that jumps straight to mind. Sorry, I think that Richmond wants to come in on this question. Yes, so in Public Health Scotland we've just set up our wider determinants of mental health programme of work where we plan to bring together quite a lot of our partners because we are jointly sponsored by COSLA and the Scottish Government, bring together quite a lot of people, including people with lived and living experience as well, to get a better handle on these wider determinants of health, the housing situation, the unemployment situation, poverty and people living in areas of high crime and less green space and all that kind of thing, which these are the upstream determinants of health, which have an impact on their mental health. So, while we are cited on delivering services and making sure waiting lists, we work with partners in NHS PCs and NHS boards to be cited on waiting times and waiting lists to make sure people are seen quickly, but we are equally cited on the upstream issues because they take some time to get there, but they are absolutely necessary because 50% of people exhibit mental health problems before the age of 14, so it's so vital to act very early to be able to intervene in a very early stage before they present themselves and before things get worse and overwhelm the service, which has resource problems, which is also in line with those Christi commission principles that we talk about at the Public Audit Committee so much about that early intervention being absolutely critical. So, thanks very much for that, Sharon. I think Simon and Joe want to come in on this question as well, so Simon will turn to you first. Thank you, chair. I think we have some good examples locally of how we've worked better as an integrated network of stakeholders, particularly in secondary care, so we have an integrated mental health service, an integrated learning disability service. We unfortunately have two budgets, but the head of service, which happens to be me, has the overall responsibility for both budgets, so we can plan together, we plan what we're providing from the social care budget and the healthcare budget, and we've got some good examples where we've had projects with the third sector very recently with community rehab services, which were redesigned and improved with additional investment from both partners and working with the RSL's third sector council and health board to provide a new and improved service to which is working really well. I think that the budgets is a problem. I think where you have more than one budget, you're going to have a problem because for obvious reasons. So, I think if we can move more to dealing with budgets, particularly between health and social care, as one budget, it's the taxpayer's pound. Let's use it as best we can with best value. That's how I always talk, but then the reality is council sets efficiency targets, the health board does, and we end up in all of these discussions, which doesn't really help move things forward for the service user and doesn't always get your best value either. But I think we've got a long way to go in terms of planning in primary care, that primary care area with the third sector, with people lived experience. We really need to move more towards integrated planning. So, we have an integrated partnership board for the mental health service where we have all our partners sitting there and we work together strategically and operationally. I think we need something similar in the outwith secondary care, which importantly includes people lived experience as well. It's really helpful having people lived experience on our partnership boards. They hold us to account. They ask questions. How have you engaged with us with this proposal that you're discussing? It happened yesterday a couple of times. We're kept a task and we improve our engagement that way. So, I think there's a way to go, but I do think there's that type of model. The integrated model that we have in secondary care is something that we should be looking to develop more in primary care. Thank you. Can I just ask a further question that you just said about two budgets? I'm afraid that there's different models round the country, but you said there was two budgets, but you're in charge of both of them. So, take it in other areas. That isn't the case? I think that in other areas there's less integrated services, so they probably have a health, mental health service and social work mental health service, and budgets will be managed by two different managers. That doesn't happen within our mental health service and our learning disability service in the Borders. That's the difference. That makes sense. Yes, thank you. I think the next one who wanted to come in person was Joe. I think Julian also wanted to come in on this question, and then we'll maybe move on to the next question after that. Joe, do you want to come in next, please? Yes, thank you, chair. A couple of points. Fiona's described the strategic planning landscape in terms of how we work in an integrated way, and that is really strong and really evident. So, we can see that in our community planning strategic plan, in the ITV strategic plan, and then on particular themes such as we would have a trauma informed plan, a suicide prevention plan. All of those will demonstrate how we work with mental health, housing, employability, police, et cetera. But I would mention two things. One, I think Simon was mentioning it. There's two levels of how we work to support individuals across that spectrum of factors that will affect their wellbeing. There's that strategic landscape that we've described and is evident, but there's also the very person-specific work, and we're seeing more evidence of that in East Ayrshire. We're piloting an approach at the minute. We call it the Tuesday morning, and what happens is police, mental health, addictions, housing, and the third sector get together on a Tuesday morning, and we talk about our 15 most vulnerable people who, across those agencies, we're all worried about and we're all watching very intently, and we decide whose best place to try and engage with each of those 15 people this week, given the scenario they're in this week. Because we're doing that together, then we have greater flexibility from those various departments, and we're seeing some really good results on a person-by-person basis on that. We're just beginning to write that up to try and evaluate it effectively, but it's that shared information and a shared goal that you described, where all of those agencies are sitting on a Tuesday morning thinking, okay, what are we doing about Jimmy today, across all of us, and to get Jimmy more stable, and that will affect the demand that's coming in to each of those services. So I think there's two levels in terms of how we do that, integrated working, and they're both vitally important. And Gillian next, and then we'll go to the next question. Gillian. Yeah, just following on from what Simon was speaking about in relation to the integrated teams, and within Angus, obviously we have a geographical challenge in some of our localities as well, but what we're focused on is developing mental health enhanced community services across. So we have primary care, we have community mental health, we have substance use teams as well supporting that. Just reflecting back on the conversation around the cost of living crisis and the pandemic, that has also resulted in an increase in individuals using substances as well. In addition to that, though, we have wellbeing services, psychology, care support workers, and everybody can self-refer, you can be referred from your GP, you can be referred to from other partners as well. So we've taken a no wrong door approach and no rejected referral to this, so we will find the right person and that allows us to better coordinate the support required and that joint working between all partners, including our third sector colleagues. In addition to that, we've also not put any ages around this, so we have extended our peer support and GP practices as well to support a living to 16-year-olds specifically, and that's been very well received along with our social prescribers and listening service, and the evaluation from our enhanced community support hubs is very, very positive, and it is in the process of being rolled out across Angus and indeed to Tayside are taking some of that learning as well. Okay, thanks for that. Next question. The role of primary care mental health and wellbeing services in supporting people with mental health problems and or directing people to the most appropriate source of support or service. I put down for Joe Gibson, maybe, to come in first on that question. Yes, thank you. I think we've covered some of it already. That front door is vital and the pathway is smooth from that front door is vital, and I do think we probably have improvements we could make around referrals being, we sometimes call it, bounced about between different teams, so what I think Gillian described as a no wrong door is the key. That's where we need to get to, that a person can come in, contract their GP practice, hopefully have a conversation with a mental health practitioner or a peer worker, and from there get directed to the service that's best going to meet their needs, and that that happens once and smoothly so that the person gets the help sooner, but also we haven't created an administration burden that is tying people up that's not needed. The report does talk about information systems and data collection in mental health, and everyone is aware how challenging that is, so we do need investment in information systems that mean we can move these referrals around in a very straightforward way, and people are clear where someone's getting support and where they are in the system. I think that could be improved. The other thing I think we could think about is talking about referrals at all in some of this, because has that put another step in the journey for the staff, but also for the person seeking help, where if we, I think what we can do when we work deeper into communities and in locality models, we talk about speaking to my colleague or pop along and see, and it becomes much less clinical and feels much more achievable if you're feeling that life is very difficult. So I think that whole language, it would help that we declinicalise that language and talk about people seeing someone else or joining that group or popping in and making things a bit less formal. But that's tricky to achieve, both of those, to declinicalise the referral pathway at the same time as improving information and recording, but that's probably where we need to go. You mentioned earlier on about community-linked workers, you also said that you'd a vibrant third sector. I was just wondering, there's lots and lots of money getting invested into mental health. Do you think there's a clear enough pathway that when groups or organisations in localities get funding from the Scottish Government, is the availability of that extra pathway made clear enough to the local authorities or to GP practices so that they're aware that there's another group that's been created that can help? Can I come in on that? So, yeah, there's a lot more available for people. There is a challenge of making sure people are aware of that, about keeping service directories up to date and promoting those services. We do find that our community-linked workers, our mental health practitioners are key to that. If they're informed and know what's available there, the link person that moves that information on the people towards those new services. The problem with that is what I think Hannah mentioned earlier, much of that money that's gone into the third sector for those well-being services is short-term in nature, so we just get the services established, people begin to realise this is good for me or my family, and then there's a challenge about whether it's continuing next year. So, we do need to be more thoughtful about how we do that. The investment we're putting in to build the service and its reputation, and then we go back to the start again. I have a number of comments that Jo made at the end there. I think that GPs are absolutely crucial in terms of supporting people's mental health. They are a first port of call for the majority, but they need to have the knowledge of what's out there and the confidence of what is out there in order to refer into it. Unstable funds for third sector organisations for local authority services, so it won't just be mental health provisions that link workers need to refer into. We're talking sort of about that as wide determinants again around employability, around sort of support, around poverty, and the funding there is being cut back and cut back and cut back. So, they're very important. They need to be able to refer confidently into services that exist. We're aware of some of the children's funding, which goes up to 26. There's a bit of a crossover with adults that there have been some challenges in terms of GP referrals into those services. It's getting better, but ensuring that people have that information and are confident in pressing the button to send people somewhere other than CAMHS is an ongoing challenge, given the capacity of GPs as well, even more so, because they've got more and more information to take on, but services around the GP practices, they might be referring into needs stability as well. Thank you. Okay. Apologies for those who also wanted to come in on that question. You'll get an opportunity shortly, I'm sure, but Graham Simpson's got a number of points that he wants to raise to keep the conversation going. Graham? Yeah, I'll try to keep the conversation going, as always, convener. So, looking at integrated working, we've been exploring, well, I've certainly been exploring in my questions the past couple of weeks, gaps in the system as it relates to the police. The police tell us, I'm sure it's the same for our colleagues in Wales, that they spend the majority of their time up to 80% dealing with people with mental health problems, rather than dealing with crime. So, they're getting called out to people with mental health problems up to 80% of the time, that's what they're doing, and out of hours, and by the way, I think that there should be no such thing as out of hours when we're talking about mental health, but there is. Some of the people on this call, your service is shut down at certain times, maybe that's part of the problem. So, you've got whole squads of police sat in hospital A&Es with people waiting for them to be seen, and in Lanarkshire, which the convener and I both represent, I've heard that we have had entire shifts of police officers sat in hospitals with people, and they've had to introduce, I think it's an informal system now, with NHS Lanarkshire, where if that is the case, the police have to pick up the phone and say, look, can you help us out, can you stop moving people through the system? So, I guess what I'm asking is that if there's anyone on this call or on this meeting, has a better system in terms of working with the police? Yeah, sorry, I think, great. Tracy from Lothian wants to come in on that question, so. Well, that's good, because it's hospitals in Lothian that will be dealing with this on the ground, so Tracy. So, in Lothian, we have a mental health assessment service, which is 24-7, and it runs from the Royal Edinburgh hospital and it tries to take away from the emergency departments, and we have a professional-to-professional line that the police can call and ask before they have to bring anybody up. And if the person is well known to us and we have a safety plan for the person, then we'll have a discussion with the police, we'll have a discussion with the person and we'll make a decision as to what needs to happen for the next 12 hours until the day shift, you know, if the person is known to be made to mental health or to the GP, there'll be a safety plan put in place that allows the police to leave the person safely wherever that decision is made, and either to find them, say, and have some real look after them, or to leave them in the home, or to take them to the next door neighbour because we know that's what normally happens. And then the services and the next day we'll pick them up. We've always also recently introduced what's called a navigator role, so these are third sector organisation people, and they will help to navigate with a person what they need for that person for that period of time, so the police can make contact with us and we can contact the navigators to go and help the person to get to emergency housing or to emergency social work or whatever it is they need at the time. And we have also recently introduced an unscheduled care service for young people, and that's only been in place for the last year. But again, that's one in 2047, and that's to allow the emergency departments at the Royal Infirmary and at St John's to repair straight to the unscheduled care service for children. Tracy, that's really interesting. So what you're describing there is a system where police presumably are not having to sit in A&E for hours at a time. On occasion, if the person's got a physical injury and has to go to the emergency department, but we try and avoid it wherever possible if it's their mental health, that is the primary problem. Okay, and is anyone aware of anything similar elsewhere in Scotland? Okay, thank you, Gillian. We have a particular care service within T-Side, and that supports individuals who do need mental health assessment if they are being looked after by the police in the first instance, and that is run from our Carshview centre in Dundee. There's very close links with ED, so they have a very good pathway if people do present at A&E with no physical injury that requires them to be A&E. They can be supported and transferred to Carshview safely for that assessment. We also have, in working with Scottish Ambulance Service in place, we have a mental health nurse who goes out with a paramedic and a mental health car, and the police also have access to that service as well, if they so wish. It's very similar to Tracy, and it is something that we are keen to further develop with our Police Scotland partners. Was there anyone else? Next question, I think, Graeme. Next question. No, I mean, I think that's absolutely fascinating, but it's obviously we've got a bit of a patchwork of systems in Scotland, so some places are apparently doing very well, and others less well. I think the committee would love to hear more details of the schemes that have been described to us, so I wonder if the witnesses could send us more information, that would be really good. I wonder if any of the people here today have had a look at the model that was referred to in the report that operates in Trieste in Italy. Essentially, it's a 24-hour day, seven days a week service where people can go, there's no waiting list, you can just turn up. One of the side benefits is that it actually has saved money, but it has led to a better service for the people who need it. Have any of you had a look at that model and what do you think of it? Perhaps I'll pick on Hannah. I thought it was very interesting. I think that my first question was how would that work if you tried to sort of scale it up, so it might work very well in a city centre where there might be a lot of drop-ins and it was sustainable. It might be more difficult to manage in a rural setting where there might be less people coming in, so I think there's probably learning that can be drawn from it, but like many things I was considering, I don't know that it could be picked up and rolled out in other places in the format that it exists, so that was my first thought, though I think there's probably a lot of principles that we can pick up and give some consideration to. Simon. We looked at it a few years ago and it is really interesting, but for the previous witnesses' reasons, with a rural area, you wouldn't be able to replicate that across five localities, but most people live in the central belt of two big communities where 60% of the population lives, so that would be the sort of limiting factor, but I think the principle around being able, like a walk-in, is really, without stigma, if you can avoid that, because that's the other issue that people will have, is something that's, I think, that principle of having a walk-in and easy access, so another witness was talking about referrals and that creates a bureaucracy in itself having a referral, because then you have a waiting list and then you've got to manage it, and it doesn't help anyone, but walk-in is totally different, it's there and it's accessible and you can have a conversation. We have obvious places where that could happen, which is health centres, and everyone goes generally to their GP, so really do we need to be developing some of those into well-being centres rather than health centres? Is it more about health and social care and that they become more of a community hub? I think that's something that would be certainly a route to go down, particularly in rural areas, but I wouldn't see why that wouldn't be something that could be looked at in all areas, really. Thank you. Well, good, so I look forward to you really looking at it in the borders. Of course, one of the problems that we've already looked at in previous sessions is if you go to a GP, you have to make an appointment and you have to explain to someone what your problem is, and that someone might not be medically qualified, so that in itself can be a barrier. So having somewhere you can just walk in and immediately get some help would, I think, be a very positive development. So good luck to you, Simon, as you look at that system again. If I can move on to data, convener, and this was a big, I suppose criticism is a fair word in the report and it's a theme that comes up in a lot of reports from the auditor general is the lack of data and the lack of quality data. In fact, just reading from the report, data is not available to determine how many people have severe and enduring mental health conditions in Scotland. Information is not available to accurately assess demand for mental health support in primary care in Scotland, but it's likely that demand is high. Well, yes. In 2018, a survey of more than 1,000 GPs across England and Wales estimated that 41 per cent of appointments relate to mental health. So the question would be, do you agree that data collection and indeed the quality of data should be improved? If you do agree with that, are any of you tackling that? Richmond might be the best person to start on that. So the data schemes are from various sources. So, for example, inpatient mental health care, we have robust data on that. It's been collected since 1963 and it went digital in 1997. So if you're admitted to hospital with a mental health problem, we will know about you and we will produce statistics that describe what happened and what happened next. Where there's a problem at the moment is psychological therapies and also child and adolescent mental health services. We receive aggregate figures from the service. So these are numbers, numbers of this, numbers waiting, numbers being referred and numbers discharge and that kind of thing. And with numbers, there's only so much you can do when you don't have the whole information about each individual who attended. So to address that, we decided to develop what we call a child adolescent and psychological therapies national data set, which is in the experimental phase. And so this is more individual level data, which we're collecting from the data suppliers. But it's not perfect. We have a long way to go. We've been working very hard with the suppliers to improve the quality of the data. The challenge is that data doesn't already exist in existing systems, established systems that have been around for many years, through which we receive all our other data from the service. So that is an issue. The other issue is the community. What happens in the community? What happens in primary care? What happens when, I don't know, say a school nurse interacts with children with mental health problems? A district nurse interacts with somebody elderly with mental health problems. A health visitor goes to say a new mother with mental health problems. All those interactions, we don't know about nationally, but it is known locally. But the challenge is how do you, if that information is to be collected nationally, it needs to have the infrastructure which hospital services have at the moment because they have an established infrastructure for collecting information nationally. So that's a challenge at the moment, and we've been working with partners to see how the data could be improved. We produce things like definitions to make sure things are collected in a consistent manner, and they're measuring the same thing. So we're doing all of these things with a view to improving the quality of the data we receive in month on month. So that's the journey we are on at the moment. So we haven't got there as yet. No, well, that's very honest of you, Richmond. It sounds to me that you recognise everything that the oldest general is saying. There is some data. There's data in one part of the system. There's data in another part of the system, but nobody's collecting it. That's probably your job, isn't it, to collect it? Yes, indeed. So our job is to collect it nationally, yes. But to collect it nationally, the local, where the data is sitting locally, needs to have the infrastructure to make sure what they have collected in Ayrsharn Arran, for example, is identical in definition terms to what they've collected in Orkney. And then have the means, the electronic mechanism for bringing the information in. And these are challenges we are overcoming slowly, and we will get there. We are also in primary care, for example, because GP information is so rich, because for many, many people who attend their GPs and never interact with the hospital, they interact with the GPs, they go back home, and they are managed in that kind of way. And most GP practices would have, some would have link walkers, some would have mental health nurses who manage those individuals at home. So that information we don't know about, because we haven't been able to establish a mechanism to have a flow of data. However, the good news is that the Scottish Government has worked with NHS National Services Scotland because they have the means, because it occurred during COVID-19, to collect critical information from primary care. So we are developing a primary care intelligence system in Public Health Scotland in anticipation of this new stream of information coming in. Yep. Are you getting any resistance from anyone? Well, it's just that the, not resistance, it's just to make sure there's a governance framework which involves GPs because GPs need to be involved because in data protection terms, they are a data controller of their data, and they need to be involved in being satisfied that there is a good use being made of the data that is being collected. So NHS National Services Scotland will be setting up the structures for all of that, and Public Health Scotland will be able to have the intelligence required to better understand what's happening in primary care. Okay, no, that's very interesting. It's all the rest of you need to work with Richmond and do what he asks. And to that point, I think both Fiona and Simon indicated they want to come in on this data question, Graham. So Fiona, do you want to come in first? Then I'll bring in Simon. And I didn't know whether this was something that Pamela might have a view on as well before we move on. Thank you, convener. Yes, just to continue from where Richmond left off, one of the local issues in trying to take forward this data issue is in the way that Simon referenced earlier is that the council budgets and the NHS budgets that come into integrated boards aren't pulled, that our data systems often reflect that same difference of an NHS system and a local authority system. And there's very few places I'm not really aware of any that have really cracked at federating or sharing data easily between council employed staff and NHS employed staff within integrated arrangements. We're currently trying to implement an integrated system, but we're really having to design it as we go. There isn't enough the shelf product ready for us to buy. And that's a huge amount of work for my staff, the leadership across all the professions who have to be assured that what's going into that data is appropriate. And when Richmond's ready for us, that we can provide what he's looking for to feed his national framework and that that's appropriately governed. So it really is quite a challenge within our integrated arrangements to have data systems because it's one thing a health visitor visiting a child, but if I've got a children social worker visiting a child who identifies a mental health issue, then I'm looking for that data if you like to cross from a council employed member of staff into the health part of my data system. And at the moment that is very clunky and requires really manual people skills to get that data to go across. Well, thanks for that. I mean, we set up these integrated joint boards and sometimes they don't sound very integrated at all. So Simon, you want to come in? Thank you. I mean, just on that last comment, it's frustrating, but my experience is it's better than it was. So I think we're going in the right direction, but I think we probably all agree if we were going to devise a health and social care system from today, we wouldn't devise what we've got now. So it's really hard to go backwards and undo things. That's the problem. But just in answer to your original question to us, absolutely data is really, really important, particularly around outcomes and service user, people that experiences views of the input that they've had. So the challenge is what's already been described, but it's that consistency. So we collect the same data, keep it simple, otherwise we end up with a huge bureaucracy, which takes resources away from actually helping people. But if we don't measure what we do, we don't know whether we've made an impact and we don't know whether we need to continue, therefore, resourcing that service. So it's absolutely fundamental. We're good at, and ironically, the tiny element on number of people we support are the people in hospital. So in general, psychiatry in the borders, I have 19 beds of which 14 or 15 we use generally, but the vast majority of people are in the community, which we do very little measuring on. So it's completely the wrong way round. And so, and I don't have an answer, but we do, we're working at it obviously, Public Health Scotland, et cetera. So we need to get there when we have good data, but not overly bureaucratic. Otherwise, particularly smaller organisations will sink with the demands of having to provide that information. Thank you. Good. Well, you need to go and see Richmond, I think, and they can all get your axe together. So I think Hannah wanted in, and I think you will want to move on. That's correct. That's great. Hannah, do you want to come on? So I just wanted to flag some of the work that was going on around the health and social care data strategy. So the data issue in terms of data sharing is a known one, and something that there is ongoing work to look at. So there's work going on around information governments and approaches to information governments across health and social care. There's some work related to Microsoft 365 Federation, which probably goes beyond my technical capacity to explain, but allows the sort of sharing of information such as calendar information across different parts of the system. There's work looking at and integrated health and social care record, as well as interoperability of data, so being able to move the data from one system to the other. So it isn't something where we don't know that there's a problem there and no one's looking at it. There are a number of streams of work trying to take that forward and look at solutions to something that's very tricky. Right. Thanks very much indeed. I have to report that Pamela in the Highlands was having some technical difficulties, but I think that they've now been solved, so I'll endeavour Pamela to bring you in on the next set of questions for which I turn to Willie Coffey to put Willie. Thank you very much, convener, and good morning, everyone. It takes us neatly into talking about outcomes, I think, in general. The Auditor General's report was pretty critical, I think, and that was probably aimed at Dr Davis, saying that the Scottish Government doesn't have sufficient oversight of mental health services and no information on quality of care outcomes for people. Now we've discussed this kind of systematic approach to collecting data just a moment ago, but what about outcomes, Dr Davis? The outcomes framework has been published. Could you describe to us how, whether you accept that criticism in the Auditor General's report and what the Government is doing to address that? So the outcomes framework was developed through collaboration, and Public Health Scotland was involved in aspects of developing the outcomes framework. It's a staged process, so having developed and published an outcomes framework, the next stage is what we call an evaluability assessment, which has commenced, and Public Health Scotland has a couple of people who are involved in that process working with others as well. The evaluability assessment uses evidence to see how you demonstrate that what exists in the outcomes framework, how you demonstrate and how you measure that you're moving in that particular direction using proper evidence, and it is part of the discipline of public health science for which we have that discipline in PHS. So it is a process, it was only published on the 3rd of November, and already people are working on it, and we will, there is a plan, they have a plan for deliverables up till March 2024. So we are on that journey to make it clearer to those who have been exposed to these outcomes framework to see how it's operationalised and be able to report. I think, too, convener, that in all the years that people have been working in this area, why haven't we reached out to people and asked them how they feel and what they think about the service and the quality of it or whatever that they've experienced and captured that? Is that a fundamental thing that we just haven't got round to doing, or is that going to be at the heart of any new way of measuring real value and real outcomes for people in Scotland? So when the mental health and wellbeing, so the outcomes framework document is linked to the mental health and wellbeing strategy, and the mental health and wellbeing delivery plan, action plan. So during that entire process, people with and organisations representing people with lived and living experience were heavily involved in all of those processes. So the intelligence from all of that exists, and that is the basis on which that influence the approach to the outcomes framework as well. So all of that work has been done, lots of consultation with lots of people and third sector organisations and individuals as well. All of that has been done, and that's why you have these outputs based on those evidence, which are this soft evidence as well as the hard evidence as well. In the lowliness it wants to come in, and I think Hannah's also indicated that she wants to come in in the room. Tracy, we'll come to you next. It's not at the national level that you're talking about, but at a very local level we are doing what we just suggested in an inpatient basis. So we use the patient's counsel who are a collective advocacy service, and they, on an annual basis, provide a report to us that tells us what the patients think of the care they're receiving, and we use that to fund improvements in our service. We are currently working with the patient experience team in NHS Llorian to develop a survey that we'll then use for inpatients as they're leaving the hospital for them, their families to complete, again so that we can use the feedback from that to try and improve the quality of the service, depending on the feedback. It's not scaled up to cover all services at the moment, but it's a start towards doing it like what we just suggested. I just wanted to emphasise what Richmond was saying about the sort of lived experience engagement around the mental health and wellbeing strategy and the actions that sit within it. There is engagement on the strategy itself, but there continues to be engagement within the individual actions with people for whom the services are relevant. I've given an example, a very live one of self-harm, which is a piece of work that's on going, where there's a great deal of lived experience engagement, so very live to that, and also a commitment to keep that conversation open where it's needed across the different things that we're doing. Looking ahead, though, if we or this committee or the public wanted to know what the positive outcomes were for people in mental health services in Scotland, would we look to the individual IJBs and health boards, or would we look to the Government for the answer to that? An awful lot of money increased spending has been spent in this whole area, and I'm going to come to that in a wee while. The public can rightly ask what's happening with the money that we're spending, and is it having a positive outcome for people? Where would we get the answer? Would we turn to Dr Davies' team for a national picture, or should we ask all our individual health boards for a response to that, what do you think? I would say it's both. Rather than always viewing something nationally, because there's a lot of local intelligence happening, a lot of surveys happening locally. In Public Health Scotland, we do have the local intelligence support team, so they're supporting IJBs and GP clusters, and what I've been told about the stuff that they do, lots of local surveys, the advice a GP practice wants to better understand people's experiences or people's views within their local air, and our analytical staff would provide them with advice on how to do things like structural in the questions for the questioner, and that kind of thing. So it's all happening locally. Nationally, there is the things like the health survey, the patient experience of it, the inpatient experience of it, which asks a lot of questions about what people feel, what are their views, what they think, what they would like to change. So I think it's all rather than just one air to look at. The last query for me and then for the time, convener, Dr Davies, you also mentioned the new psychological therapy specification earlier. It's just probably the same question applying to that. How will that roll out and how will you also monitor progress within that? So the new child and adolescent and psychological therapies national dataset will include things like outcome measures, and there are some standardized outcome measures as well. So it will involve the details of the patients, the referral details, the appointment details, diagnosis and treatment and intervention details, and the clinical outcomes for that individual and what measures were used to determine what the outcomes were for those individuals. And then the discharge details, what happened next to the individual, where did they go? Or did they die? So that's what we want to collect, and that's a very rich dataset which provides an opportunity to be able to have a much fuller understanding of what's happening within those domains of psychological therapy and child and adolescent mental health. We feel that's the way to go because we have the equivalent of that for inpatient experiences, people who are admitted to hospital, not just for mental health problems, but for surgical procedures. We understand a lot about them, and this is an opportunity to transfer that experience, which has been in existence for many, many decades, into this new area and focusing on children, focusing on adolescents as well. Thank you very much for that, and then just our team can be done. Thank you for that forbearance, Willie, much appreciated. Can I just come back on that very last point, Richmond, because you're talking about CAMHS, which is extremely important to all of us and is something that the Parliament has concerned itself a great deal with, but obviously this report is about adult mental health, so could you tell us a little bit more about what data collection there is in adult mental health regarding people's experience and what those outcomes are? So for adult mental health in, as I said earlier, in hospitals, we have a lot of information about them and we publish that on our website. For adult mental health in the community, that is a gap because adult mental health services in the community are provided by a whole suite of different organisations, professionals, social care, community linked workers, thought sector organisations. It is so huge and vast and it is provided in different ways as well, and how they assess what good looks like for them is different from place to place, so there needs to be some standardisation on what this good looks like and how it is reported as well. The evidence that you've given on this area this morning has been very valuable to us, so thank you for that. I'm going to now introduce Colin Beattie to put some questions to you and elicit some more useful information for the committee's consideration. Colin. I'd like to look at accountability and performance reporting and, of course, inevitably I'm drawn to IJBs when I look at that. I recall some years ago the Auditor General actually produced a report on IJBs which was fairly substandard. Now I look at adult mental health services and, again, we see deficiencies within the IJBs. There's a lack of accountability, no public accountability for IJBs. The Scottish Government holds the NHS boards accountable, but the IJBs are responsible for planning, funding and overseeing the provision of these services. Operationally, they're managed by HSCPs. Now, this seems really quite an odd way for these services to be run without the level of accountability nationally which should be there and the IJBs seem to be hidden in some place there in the background and yet they are key to delivering services. So clearly they're not getting it right. The report says IJBs have to improve accountability arrangements. Now that will require everybody working together in order to make that happen. So the question I've put is how do we make that happen? How do we make it make IJBs more accountable and how do we bring better transparency in regard to their operations? Hannah, you're here so I'll maybe ask you first. Actually Colin, we've got, in the interest of time, Fiona online who wants to come in and she's an IJB chief officer. Gillian is also an IJB chief officer and I don't know whether Simon's got a view too, but Fiona has indicated she wants to come in so I'm going to bring Fiona in first. Okay, thank you. Yes, thank you, convener, and thank you for the question. I am here to represent the chief officer network so I did feel obliged really to take this question. And I suppose I would suggest that rather than IJBs being deficient that the structure that set up IJBs maybe is what we should be challenging IJBs work to the parliamentary act that was passed where the arrangements such as you've described them were legislated. So I think it's maybe slightly unfair to say that IJBs are deficient in operating to the legislation as it was written. We do what we can within the current framework that is provided for us. Obviously the proposals for the national care service are well documented and discussed and I don't want to go down that line today, but part of that reform is recognising some of the limitations within the governance structures that existed in the joint bodies public act of 2014. But I think IJBs do a really good job of working with non-executives from the health board for their area with locally elected members from their local authorities and a huge range of stakeholders and work to the high standards of transparency and accountability in publishing the health and wellbeing outcome data and lots of other information points about what they're doing that is available in the public domain on the website of each and every integrated joint board. So I certainly wouldn't suggest that there isn't limitations in the framework, but I think that integration joint boards that are currently operating are doing the very best within the structure that's provided for them on the whole to improve it. I think probably takes us into that national care service discussion and I think that's probably a broader one than we can spend the time in this question today. I take on board what you say, but I'm looking at the Auditor General's report and he has highlighted areas where there is a lack of accountability within IJBs. We're not saying they're not doing a good job, we're just saying we can't see it. You may see it locally, but on a national basis we don't see it. So what can be done about that? Well, I do think that that is the structure as it was designed, so I think we have to agree that maybe the design needs to be changed. I think the way that IJBs share that information, the way they work with local authorities and boards, does need to be done maybe in a different way. I think the information is there, so if it's not seen, I think we just need to think about how we can make it much more visible to a wider range of people, including those that are interested at a national level. I think Gillian, we're lost connection with Gillian, but it's been restored. So I'm going to invite you Gillian to give any reflections you've got on that point about the governance arrangements with IJBs that Colin had put. I actually didn't hear it because I actually left the meeting. Apologies. It was just due to the technical issues. Gillian, what I was raising was the fact that IJBs, the way they're constructed, don't have any national accountability, they don't have any direct accountability, and there's a lack of transparency in the way they operate. Now that's not to say that they're not operating well locally. What I'm saying is it's not evident and the Auditor General's report reflects that. How do we fix that? Do we have contact? I think again, I think we're having... I'm going to go over to Simon who can hear as loud and clear, and if we can fix Gillian's connection again, we'll do that. But Simon, you've got some views on this IJB structure thing. Yeah, thank you. I mean, I agree with the previous witness around how it's made up is the challenge. But I do think progress has been made, as I've said in the previous comments, because when it first came into being, basically its accountability was for everything locally, everything that was going wrong. So the health board would say, oh, it's the IJB, council says the IJB, or they'd say it's each other. So as an integrated manager, I'd be sat in rooms where I would hear this sort of thing going on. We've moved a long way from that now, and there's far more structure locally to work collectively across the two main organisations, the health board and the council, and we are collectively taking more responsibility for the problems and the solutions irrespective of whether it's predominantly a social care or predominantly a healthcare problem. It's not ideal, but we're certainly moving there. But I think the IJB does as well as it can within the legal framework that it's got. So that may be where we need to look. Simon, what would have to change to make this better, to get in proper accountability and performance review? Well, I just think it's the whole designs. We're up against it where we have the health board and the council and the IJB. As I said before, all the taxpayers interested in and the government is that the taxpayer's pound is used as well as it should be to provide the best outcomes. We've already heard we're not good enough at measuring outcomes to know whether the money that's been invested is invested well enough. So wherever you have more than one budget, you're going to have a problem. So I do think it comes down to that fundamental structural problem that we've got around budgets and the two organisations. That's a personal view. But as an integrated manager, that's the sort of problems I have and have had over the years all the time is that I have to go to the council to explain something, the health board and the IJB. So it's almost as if a third party has come in that I have to negotiate with. As I say, that's moved on quite a bit locally, but it's a challenge that's inherently there all the time. So that's not particularly an answer, but I think that's the problem area that needs looking at. Certainly it seems as if the structure, the governance structure needs to look at. The problem is that service delivery varies in different areas of Scotland. How do we get a more consistent approach? Because there doesn't seem to be a consistent approach among IJBs, and I'm focusing on IJBs for a particular purpose. Sorry, Simon. Hannah, can you come in on that question too, as well as your earlier point? Just very quickly, I think I would agree with some of the points that I know I was making around this conversation. It's very live, isn't it, around national care service and how and where accountability sits. We obviously have the agreed shared legal accountability for health and integrated health and social care services, but we'll also be considering standards accountability and how that works through that structure. That thinking needs to feed it into the design of that process. Obviously there will be a lot of things that have been, there continues to be a lot of engagement and discussion around that. In terms of consistency, consistency of what is probably my question, because I think what we want is consistency of outcomes for people, consistency in the way services are designed and delivered is something that may or may not work. There's that sort of point that we were making earlier, that lifting that model and putting it in different places isn't going to result in success everywhere, so the services are going to look different and they are going to need to do things in different ways to deal with the respective challenges they have in particular areas. So I think the consistency of outcomes for people is what we need to be looking at and working towards. I think Simon was nodding at that question, that answer from Hannah as well. Again, in the interest of time, I think that Willie has got another area that he wants to explore with you, so I'm going to hand over to Willie. Again, convener, in this time, because we're the audit committee, I want to ask you about money. If you look at Exhibit 7 in the Auditor General's report, you can see quite clearly the funding allocation for adult mental health services has really significantly increased over the years. In 2020 it was £130 million, 2021 it's £296 million, 2022 to £58 million and this year £290 million. My question is, is this money being spent wisely, appropriately and is it having a positive impact on adult mental health services in the areas that you collectively represent? Can you see the benefit of this money in the spend? The public are bound to want to know that. Any of our colleagues from the health boards, I would welcome a view if it's quite clear as we can, convener. Right on that point, Willie, Tracy wants to come in on that question. What we have in Lodian is the Dallodian strategic development framework, and there are a number of pillars on the number of parameters. One of the pillars is on mental health, illness and wellbeing, and that's a joint plan for integration joint boards and the health boards, and then the money flows from the priorities that are agreed to the Lodian strategic development framework. So there is a complete oversight across the inpatient and community services around how we best spend the money for the priority areas that have been identified. So I think there's always room for improvement, but I think we do see a better rigor around how we spend and allocate resources. The other thing to mention is going back to the data and the digital systems, and we're looking at how we can consolidate those because they do work on different systems, as other people have mentioned, and I think if we could get that mailed, that would help us to use resources better as well. Because you do waste money when you're having to do multiple different systems. So hopefully that gives some reassurance that we have got our governance around things that we need to do on an annual basis. Can I ask you just what is the money actually doing because we keep hearing about high vacancy and turnover rates within the service? So what actually is the money being spent on this additional, substantial additional funding across the board? What is it actually being spent on? Well, we did two examples. So it reduced the psychological therapies waiting time for people quite dramatically. It reduced the terms waiting times quite dramatically. There has been an increase in inpatient requirements post Covid. So we have additional beds open at the moment. We've got a ward of 15 beds that's in addition to normal because of the acuity of people. So it's been used in different ways, but to meet the needs that are coming through. Is there a time for another perspective, maybe one other perspective, Richard? I think Willie Fiona Davis wants to come in on that as well. So Fiona. Thank you, convener. So for somebody that's worked in mental health services for 30 years, the increased investment is very welcome timely and I would suggest overdue. And partly I think we have to reflect that for the whole of my career we've been working in anti stigma to encourage people to come forward to be able to say I'm struggling with my mental health. I'm not feeling well. Things aren't going well for me, or I'm thinking of considering taking my life. And so some of the demand that we're seeing are people coming forward who 20 or 30 years ago would have tried to manage at home or tried to hide how they were feeling. And it's a wonderful sign of changes in our society and culture that more people are coming forward and telling us that they're having difficulties, but we have to be able to match that with appropriate support. So in my area, what this money has given us is a 12 hour unscheduled care service. So we run from 8 o'clock in the morning to late o'clock at night. Now I have to remind you I have 23 inhabited islands as well as my beautiful peninsulas and other areas in our gar where I'm sure you've all holidayed if you don't know it very well. And so being able to provide that type of a response within an hour for people in mental health crisis has been a huge boom for those people, but also for all of the practitioners in our A&Es and other services who would have struggled with these people overnight previously with nothing to do and nothing to offer them. And in addition, it's brought a huge variety of new practitioners working in primary care. Now, as I said, we haven't got someone in every practice. Some of our practices are very small and very rural, but the vast majority of our larger term practices and our smaller medium sized practices now have mental health practitioner access at various points through the week that they wouldn't have had before. So yes, it's making a difference. When Richmond finalises his outcome, I'll be able to prove that to you in more rigor and more detail than I can now. But these are real posts that are making a real difference to real people. That's really good to hear that view, and I thank you. Is there anyone else? I think Willie Simon wants to come in on this point briefly as well. Yeah, to echo everything that Fiona's been saying, but just for some concrete examples locally here, the Distress Brief Interventions DBI, which was funded centrally through pilot funding, but we've committed to funding that through Action 15 funding. That is evaluated and proves and provides really good outcome data. So that's a really welcome service that we've got in the borders. Renew, I mentioned earlier, our primary care mental health service delivered through psychological therapies is a huge success developed very closely with GPs. They love the service. The main outcome for them is that people don't keep coming back because they gave them drugs before and it doesn't work, obviously. So that's all they could do. Now we've got talking therapies and those people aren't generally coming back into their practices and they're thrilled with that. Obviously, that must be good outcomes for the individual as well measured. So that's a huge change for us locally and we work really well within addictions as well with our borders addiction service where there's been a lot of additional investment there and they provide really good outcomes meeting their three-week treatment target consistently at 100%. So that's again a huge change and something that we have, which is really a sort of added extra to a community link worker, is something called a local area coordination service worker LAX, which does more or less what a link worker does, but crucially more, which is that community capacity building element. So they will work with communities to try to help them develop opportunities for people to get engaged with, which weren't there before. That's been evaluated and researched for every pound you invest, you get £4 of return on that investment. And that's the crucial area is that community capacity building element. So some funding's gone into that as well, which has enhanced that. And also through advanced nurse practitioners, as we've heard before, there's a huge recruitment challenge with consultants particularly, but also CPNs, community psychiatric nurses, but with advanced nurse practitioners, they work in partnership with our consultants. So where we've got those pressures, that's a different skills mix and is proving successful, although early days at the moment. So just some examples there of how the money's been spent and the value that it's created. Great to hear that, convener. So it'd be great if the other colleagues around the online table could send in some examples to the committee about how the spend is making a positive difference in their areas. That would be greatly welcomed, I'm sure, by the committee. Absolutely. Hannah, you've got a very quick last word on this before we've come to the last question that we've got. Very quick. I suppose recognising some of the investment around early intervention and prevention. So there are two funds off my head, I can think of, that are focused on really early intervention within the community. Some of them leisure focus, some of them sports focus, but some of them bringing in counselling and working with minority groups. So I think, given the discussion about the risk of over-medicalisation, over-clinicalisation earlier, that's really welcome. I would caveat that with my concerns around the sort of ring-fence funding and directed funding and the annual funds, but the shift there, the King Act, that's something that isn't meant to come or does really welcome. Thank you. The last question that we've got, and I'm going to, Joe, I think I'm going to bring you in first on this one because I've not heard from you for a while. And that's on plans and strategic direction. So the government published in 2017, The Mental Health Strategy 2017-2027, October 2020, Mental Health Scotland's transition and recovery, a mental health and wellbeing strategy a couple of years later. And we've heard this morning about the launch in the beginning of this month about a delivery plan, a workforce action plan, and the outcomes framework which we spoke of. I mean, Joe, beginning with you, I mean, do you think there's been a surfeit of plans and strategies? And have they, do they demonstrate an evolution of thinking or is it just a matter of the wheel keeping on being reinvented and not enough is changing on the ground? Okay, tricky question. So there are a copious amount of strategies. In a way, it's a positive sign because it shows mental health has gone up the agenda in terms of profile nationally. And that's what many of us have been lobbying for for some years. And it links to the increased funding that we've seen in the previous exhibit. There is a wee risk that not all the strategies are aligned. You've mentioned three or four there, convener. There's also a reasonably new suicide prevention strategy, an up-and-coming self-harm strategy. So on the ground, we're trying to work in our integrated teams and across partners to understand what the ask is of all of these strategies and how we can implement that locally. That in itself is a really big piece of work. It's a useful piece of work because it's helping us refine our priorities and investment plans. Future investment is a bit unknown, so we're developing plans and not sure whether we'll have investment to do that or not. The other point is we need the underlying architecture to deliver some of this. What we don't want to do is come back here in three or five years and again say we don't have a great account of the outcomes we've achieved. None of us want that, so we do need information systems particularly and data analysis and evaluation to demonstrate the impact we're having. So that's really important for all of us. I think the wealth of strategies does create, there is a challenge still about supporting people with serious mental illness and improving the general mental health of our population. They are two different things, obviously connected, absolutely, but we have got to a point I think in Scotland where anything to do with mental wellbeing is considered the job of mental health services and that is not actually possible. The report also demonstrates the challenges in our workforce in terms of vacancy rates, sickness, we have a stressed workforce, we do need to safeguard their wellbeing as well, so some of these strategies we need to get more specific. We need to be clear what we're asking our teams to do and what's not in their job and some of that is for communities and other parts of the system to think about in terms of the wellbeing of individuals, but we need to be clear what's separate around specialist mental health care. Joe Gibson, thank you very much for that perspective. I think that that's a really good note upon which to conclude our evidence session this morning. I want to thank everyone who's taken part. I'm sorry that we've had some technical difficulties which have meant that not everyone has been able to hear everything and we've not been able to hear you as much as we would have liked, so apologies for that. But can I thank everyone who's joined us online and can I thank Hannah and Richmond who've joined us in the committee room? It's been a very valuable session for us. We've gathered a lot of important evidence and we'll certainly be having discussions about how best we can marshal that evidence to improve both the resourcing and support that you get in the work that you do, the very important work that you do and that you've got oversight over, so thank you very much indeed. I'm going to draw the public part of this morning's committee session to a close and we'll retire into private session. Thank you very much.