 Welcome, everyone, to the Equal Opportunities Committee. It's the eighth meeting of 2015. I can ask you to set any electronic devices to flight mode or switch off, please. I'd like to start with introductions. We're supported at the table by the clerkin and research staff, official reporters and broadcasting services, and around the room by the security office. Welcome to Observers in the Public Gallery. My name is Margaret McCulloch, and I'm the committee's convener. Members will now introduce themselves starting here on my right. Good morning, everyone. I'm Sandra White, MSP for Glasgow. I'm Kelvin, and I'm the deputy convener of the committee. Good morning, John Finnie, MSP Highlands and Islands. I'm John Mason, MSP for Glasgow Shetleston. I'm Christian Arad, MSP for the North East of Scotland. Good morning, Annabelle Gold, MSP for the West of Scotland. Apologies for Jane Baxter, who's unable to attend this morning. The first item is a decision on taking business in private. Members are asked to agree to take item 3 in private, which is consideration of petition PE 1372 by Friends of the East Scotland on access to justice on environmental matters. The reason for this is that we will be discussing legal advice. Are we agreed? John Finnie? I know that the committee wants to be open and transparent, and I understand the protocol that has you asking for this matter to be considered in private. I am content that that is the position given the long-standing protocol. However, this matter has been on the agenda from almost day 1 of this committee in the session. It is a manifesto commitment of the party of government, so I'm hoping that we're going to see some action today rather than just more words. Can we agree that we will hold this session in private then? Agree, thank you very much. Agenda item 2 is an evidence session on our inquiry into age and social isolation. I welcome the panel and can ask witnesses to introduce themselves. I can also invite witnesses to outline briefly their current work. I can start with you, Joe Plays. I'm Joe McElham, manager for older adult services in North Lanarkshire Council. In that capacity, I have responsibility for the strategic and operational management of older adult services across the council, including areas that are relevant to the subject today. I'm Jane Kellock, interim head of social policy with West Lothian Council. Social policy, in partnership with other council service areas, delivers a wide range of social work and social care services. We cover children, young people in their families, adults and older people in carers and criminal justice service areas also. The services that we provide are mainly targeted to people who are made more vulnerable by their age, health and life circumstances. I'm David Rowland, head of health and community care with the newly formed North Ayrshire health and social care partnership. Within that role, I have responsibility for all community health services in North Ayrshire and for adult and older people's social work services and for the planning and delivery of those services very closely linking with the third sector and the independent sector as well. Hello, I'm Yvette Burgess, unit director of the housing support enabling unit, and I'm here today representing the housing co-ordinating group. This is a group that was formed a couple of years ago, bringing together various housing organisations, including the Scottish Federation of Housing Associations, the Chartered Institute of Housing, Cairn Repair Scotland, various housing organisations, including the Association of Local Chief Housing Officers. What we're trying to do is bring a co-ordinated voice to the housing world cross-sector. I'm Graham Wharton, professor of general practice at Glasgow University. I've spent a lot of time working with the deep end practices, which are the 100 most deprived practices in Scotland. We've heard that a range of factors can contribute to social isolation and loneliness among older and younger people, for example poverty, bereavement and mental illness. We've also heard that feeling being socially isolated and lonely can have a significant impact on the individuals. Can you explain to me or tell me its impact of social isolation understood clearly among social providers in health, social work and housing? Are they aware of it and if so, what action does it take when it's identified? Who would like to start answering first? David, you're smiling up, picking you. In all honesty, I think we're beginning to scratch the surface. I think there's an understanding that social isolation is a major issue. It affects the health and wellbeing of the individuals who experience it. I don't think we are as good as we should be at identifying individuals who are suffering from or struggling with social isolation. Therefore, I don't think we make the connections particularly well for those individuals in terms of how we might address the issues that they face. I think there's a variety of things that we can do to get better at that. I think that if we understand how and why individuals use our services in a particular way, then we might have a better understanding of those who are actually facing social isolation and then be able to make the connections that we need. If I give you an example, I was looking at our recent data for people who have used our community alarm systems in North Ayrshire. There's a very small number of individuals who use the community alarms three, four or five times a day over the course of a month. Sitting behind that, there are sometimes a small number of issues that are genuine and need to be addressed, but sometimes it's more about just making contact and just looking for a bit of reassurance that they're okay. I'm very keen that we use that data in a very different way going forward so that we begin to understand the true needs of the individuals who are using the alarm system in that way. We are undertaking a review of our care at home service and I'm very keen that it's part of that. We look towards how we can provide something that's more than just a befriending service, something that is a bit of reassurance to local people who are perhaps living alone and feeling vulnerable and isolated. For me, it's all a bit digging beneath the traditional data sets that we have and understanding what's actually happening behind all of that and using that in a very positive way. Thank you. Anyone else like to come in on that? I think we need to steer clear of defining socialisation or loneliness as a problem that people either have or haven't got as something that professionals identify and somehow process and solve. I think that's not a good way of approaching it. Individuals are very unique in terms of their circumstances. I think that the statutory services are limited in what they can do to address societal problems in terms of the loss of institutional activity, whether it's through work, trade unions, church or even family. All those things have to be replaced by a different type of social institution that gives a people a role and a purpose in their lives. The one institution that still works in terms of connectedness is the health service, because by virtue of the health problems that people have either at a young age or an old age, they will have contact with the health service and that's a really important resource. The strengths of the health system that we've got are within general practice. There's contact, not just contact but continuity of contact and coverage, so everybody's included. With the exception of the post office, nobody else has got that in quite the same degree. It's not exclusive to general practice, it's not consistent within general practice but it's a huge important resource, the contact, the continuity and the coverage. What comes from that is cumulative knowledge of individuals and communities that can't be known elsewhere. One of the challenges is to share resources differently so that power, resource and responsibility are more based in communities. Only people who work in communities, particularly the street-wise people who work within primary healthcare teams, are able to imagine how things could be improved. Everybody needs, especially when they get older, a small number of professionals whom they know and trust, who will see them as individuals not as problems and are then in a position to do something about it. I've got the opportunity to talk later about the problems within the system, but essentially the system that I described with continuity, contact and coverage needs to be better connected with a whole lot of other resources within the community, especially in the third sector. Building all those relationships is a task. Just as you build up a relationship with patients over time, the relationships between agencies within communities have to have their own trust and knowledge and experience. My view would be that, in many ways, the health service needs to be reimagined as a social institution that addresses the problems of the future rather than what it's currently doing, which is continuing to operate on a rescue in dire straits mode. The centre of gravity needs to shift away from out-of-hours emergency hospital beds to upstream in the community, helping people to live well and long with whatever problems they have. Healthcare obviously isn't the solution to that, but it's strategically very importantly placed. It's a huge resource that we don't have anywhere else, and I think that the danger is that we have taken it for granted somewhat, and it's in rather a weak position in order to address the challenges that are clearly lying ahead. I endorse both the previous contributions, and I connect that we don't currently identify people who could, in fact, be connected and be better supported. In fact, GP practices quite often will, in fact, be in touch with people. The other place, in terms of NHS, is that there are pressures in the emergency department, and some of those pressures are related to people who turn up at the emergency department in the hospital on a very frequent basis. They are there because they are feeling isolated. There is an issue of loneliness, and they have established a pattern of going there, but, in fact, what we don't then do is find alternative approaches. The third sector is vitally important in that. An example from North Lanarkshire, the Lanarkshire partnership area, is that in the acute hospitals we have used reshaving care money and have continued that to create a post where the third sector actually has a presence in the hospital. It's just one post, but that one person has demonstrated already the effectiveness of connecting many, many people who have been coming through the hospital social isolation identified as an issue for them, but now we're able to pick that up because statutory services currently are not, and probably can't, even in the longer term, take over that responsibility. The third sector is an important part of what we need to do here. Annabelle? It would be quite interesting to know if the people who were coming along where they would be referred to, and I don't know if you would have a pattern of how often they actually turned up. Once they were referred, did they actually stop coming to the hospital? I don't know if that's too much detail, but that would be quite interesting to see how effective that is. We can obtain a report for the committee on that. Just briefly, I wanted to mention the role of housing, because although we're talking about health and social care, I'm very conscious that people who are homeless, young people who are homeless, older people who are looking to move, they're coming into contact with housing organisations. The online housing staff are often well placed to be identifying isolation, certainly in loneliness, and in some cases, in many cases, housing associations, but also local housing departments are delivering activities and other types of services that help to combat that and also help to prevent it, as we've been hearing, moving upstream before it gets to the stage where people are lonely and not getting out, not getting to the services that they need before that gets to a problem. Those other housing organisations are well placed to connect with voluntary services or to provide them themselves. Does the housing organisations give staff training to the staff to raise that as part of an awareness for them when they go in and speak to people and meet people? Is it on their radar to identify it? As we've been hearing, issues about isolation and loneliness don't tend to occur in themselves. There will be issues about homelessness, social connection and social networks as an increasing recognition about the importance of social networks in helping people to be resilient during times of transition and change. To answer your question about training, it's very much part of the way that front-line services are increasingly thinking, but probably the issue is that there's not always an awareness about how to deal with it and where the services are locally that people should be referred to, and I'm sure there is an issue there about making sure up-to-date information is available. Thank you very much. Jane, do you want to come in? Yes, I certainly agree with the whole systems approach that we need to take to tackling social isolation, but I see it more as a societal issue. The issue for me is that everyone requires to be socially connected. That's part of our human condition. So, when systems break down in such a way that we disconnect from others or when life circumstances come along where we lose people that we are close to, then we need to be able to respond to that in a very human way and not stigmatise people or further isolate them by treating them as if there was something wrong with them as an individual. I think that all the agencies in the partnerships that we have around the country need to be responsive to that and to look to the structures of how we deliver services, the way that we make contact with people, the way that we speak to them on an individual basis. All of that is very important in terms of being able to keep our communities connected. Thank you. I'll move on to Sandra now. Thank you very much, convener. Very interesting issues that came out of that particular question. We know that there are services out there, but the problem is that people are being able to find them in the hard-to-reach, trying to bring them forward. Graham had mentioned the fact about—I think that Joe also—the fact about strategy services and perhaps having to be replaced by something else. I'm very familiar with the links programme, which others had mentioned, and how we try to get the aims of the links programme out to the hard-to-reach people. There's a deep-end practice, which, when I was on audit committee, went out and looked at the deep-end practice, which obviously got people in disadvantaged areas. How do the services that are provided by yourself and, obviously, the link programme in deep-end practice reach out to the folk who are not aware that the services are there? Is it difficult to do? I'm never comfortable with the phrase hard-to-reach. Sometimes it's recognised as being a synonym for easy-to-ignore. Often we do have contact. It's what happens or doesn't happen with the contact that's the issue. That's certainly the case in deep-end practices, which have plenty of contact with patients but often lack the resources, time within consultations and links to other services in order to address needs. There's a big mountain of unmet need there. God Sandra, you asked so many questions that could spend their whole morning. Links is an important and very topical development. There's a story behind it. We started off in the deep-end, asking practices to what extent they were involved in social prescribing, which was using local community resources. Practices varied in what they knew, because in the last 10 years general practice has become very introspective for all sorts of reasons and hasn't been looking out. Then we moved on with the Government support to do a links project, which was trying to build on that. Then there was a project called the bridge project in three practices, which sought to link a practice's knowledge of elderly patients with community resources for social and physical activity. Two interesting things were learnt from that. One was that every locality is different, so it has to be imagined and developed locally. It can't be done from a centre. An anecdote. A GP in Racheisi identified six elderly patients whom she thought would be ideal for this. None of whom thought it was a good idea. That makes the point that there isn't simply a question of shifting people along. There's a relationship and a person. The important thing is that, because she's working in general practice, it wasn't a once-and-for-all opportunity that the relationship exists and it can be returned to. Although the link to community resources didn't happen then, it's a bit like smoking. Sometimes everybody wants to give up smoking, but they're not ready for it. You come back to it in six months' time. It's important to have the continuity and to have a service that has the flexibility to work in that way. If you have an outreach programme where everything is determined by somebody whose job it is to go out, you may lose that flexibility. That's gone on to the link worker programme, which Government is sponsoring and evaluating in seven practices, which implants a community links practitioner within general practices, all in the deep end. Their job is to do what their practices can't do, which is to spend time making links with the community resources and the practices are finding their own ways of using those links. There's an important issue there that's not just about information. Some people just need information to be signposted. There are people with agency and education who just need to know where something is and they'll go and find it. Particularly in deprived areas, people often lack the knowledge, the articulacy, the agency to do that, especially if it's compounded by mental health problems, which are twice as common in deprived areas. Many people have attachment issues. Their whole life, because of emotional damage early on, is characterised by difficulties of attachment. Never mind with services but with friends and family. They need a long-term relationship to make a bit of progress. It's not just links and signposts and information, it's relationships over a period of time. Interestingly, my understanding is that a lot of what the link workers do is not signposting. It's helping patients who are floundering, dealing with rather impersonal, dysfunctional, fragmented services. The way that services are configured often makes it very difficult for patients to find a way around them, especially if they have more than one problem. That's called a treatment burden. I always have a slight worry with the links worker initiative that it's not addressing the fundamental problem, which is that services are so fragmented, dysfunctional and impersonal and difficult for some patients to find their way around. If you have a link worker, you may solve it for the individual patient without solving the system problem. I think that it's early days that the link worker initiative. In a sense, every practice should have one, but it is an expensive solution, so every practice couldn't have one. The challenge is to translate what's being learnt through that project into something that is sustainable at every level. Essentially, that's building social relationships within local communities, not necessarily with expensive professional salaries. That's unaffordable. Because of what I said about the contact and the continuity and the coverage, general practice is a very good place to start, but it's not a good place at the moment because it's under such pressure. I can talk about that more if you wish. I presume that what you're saying is great, but it shouldn't just all be down to general practitioners and other ways of doing it. I don't know if anyone else wanted to come in, but David had mentioned earlier in regard to joined up. You mentioned the word links, but you mentioned the fact about working together in an alliance type thing. Housing in every other aspect is very important, and it should be more joined up. It's how we get to the joined up part of it. For my perspective, there are two bits of work that we are looking to take forward this year. Part of it mirrors some of what Graham has just described in terms of recognising the importance of general practice and the universality of general practice, but they need to support general practice. We are putting connector posts into six GP practices in North Ayrshire this year to trial precisely that links type model, but Graham is absolutely right as well. In itself, I don't think it's sustainable, so part of that role has to be about beginning to build community capacity and community resilience so that over time we begin to develop that community network that people know and understand and understand how to engage with so that it becomes sustainable over time. The other bit of work that we are doing just now relates very much to the housing side of things. We are just starting a major refurb programme in terms of our sheltered housing. Within each of the sheltered housing, refurbers will be a community hub developed. We are looking to develop alliances with the third sector to begin to work with local communities to design the services that will actually go into those hubs. We are working firstly with the residents so that we understand what services they want so that we get that connectedness within the complex itself. We are then reaching out to the community as well to say how do we make those facilities community-based centres, community-based hubs, for connecting the individuals who live on their own within those facilities with individuals who live on their own or with others out in the wider community. I think that it is about making those connections at a number of levels. GP practice, Graham's right, is absolutely key, but it is about finding other ways to sustain that in the wider community as well. George, do you want to come in? I think that it is interesting, Graham's right, that link workers are involved in helping people to navigate the complexity of a service system. That would suggest that link workers are dealing with people who are involved with services. I think that a large area of concern for the committee for the report that you are producing is around people who are not involved in services and how do we actually work in that more preventive way. We redesigned day services for older people in North Lanarkshire. It was quite a complex redesign of all the details of that, but one of the things that we did was that we recognised that we had many, many people who were being referred to a traditional day centre model. When you asked why they were being referred, it was because they were lonely. Our systems drew them into referral to a day centre. As part of the redesign programme, we interviewed quite a big cross-section of the people on that waiting list and asked them what they wanted in their lives. Not one person said that they wanted to go to a day centre. They said all sorts of different things, resuming the capacity to go for a pub lunch, bowling club or getting back to church. Part of the redesign that we did was that we took some of the posts and changed them into what perhaps I do not know enough about the links programme and the GP practice, but these are roles of locality link officer. When people are referred and the only reason that they are coming into the formal system is because of loneliness, what we are offering is that the locality link officer speaks to them about what is in their area that could actually meet some of the things that they want to aspire to in their lives. The turnover in that, the number of people they see is really quite significant. As we then developed that, we also became aware that having identified the opportunity for the person, many people said that they cannot access that opportunity for reasons to do with, for example, transport. I need a carer, perhaps for a very small intervention, simply to get from my house into a taxi, I need a carer and from the taxi into the centre or into the lunch or whatever. I do not need somebody there all the time but these are the things that are stopping us. We then created a post-ciprocality support officer whose job it is to provide those very small interventions and what that has done creates the opportunity for that person to be connected into the life of their community and clearly also what it does. It removes the need for them to be involved in formal services and it means that the formal service is able to concentrate on people who have very high levels of need. Can I just come in very briefly on that? You are really talking about person-centred care, everybody is talking about that, really talking about the individual and sort of structuring the help and support and the care around individual. When you questioned the group of people or the individual, did anybody ask them were they lonely or were they isolated? We have heard as well that people do not like to use the word lonely and isolated, it might be a feeling of failure, other typecasts, they do not want to use the word. Were they asked that question, are you lonely, have you been lonely and would this help? Certainly we were talking to people about the specific format of those interviews, it is a little while ago now so I am not sure that I can recall that Margaret. On reason for referral, this was what was identified and quite often it was people who did have some care need or difficulty about getting out of the house and their carer was feeling unsupported and was not getting a break. Connection, people talk about wanting to actually have the activity that they had in their life before, the thing that they missed in their life before following a bereavement, things that they did with the partner who has deceased, that got lost in the grieving process and were never resumed afterwards, so people will articulate it in that way. I think that basically bringing the voluntary third sector into sheltered, housing, bailed, etc. I think that someone is going to ask a question on that later on anyway, so I think that that is an interesting prospect. I was interested in Joe, but you said that I take it that this new service that the council has is complementary to the day centre still exists, I presume. Do you charge the people there to go to the day centres or because sometimes there are people who are going to the day centres? Sometimes, obviously, the cost is something that they can't afford. Is there a charging mechanism in language? Just briefly, what we did with that day service was that we then integrated it so that it had a wider range of interventions for people who did have a higher level of need, so it's integrated between health and social work. I was talking about waiting lists. It actually doesn't have a waiting list because we are able now to help so many other people to be involved in their local community, but we don't have a charge, so that's a wider issue. I won't get to any further, but thank you. I think that Jane Briflaw wants to come in and then we need to move on. Again, going back to the point of being everybody's business, I think that all of the staff that we have working within the council and our partnerships really should be in a position to be understanding social isolation and being able to make those connections for people, not necessarily having to have separate workers who do that. It should be something really that's part of everybody's role, so maybe there's a question there about raising awareness of what social isolation is about, so that it isn't ignored and it's part of the assessment process and the conversations that we have when we meet with people. Okay, you're okay, so... Can we move on to John Mason now, thank you. I mean, I've really touched on quite a range of issues and transport just got mentioned by somebody there very briefly, but that's kind of what I wanted to move on to. I mean, how much is isolation and loneliness linked to, for example, lack of transport, some of these kind of practical issues? I mean, all my mother has that experience of, you know, the challenges of getting to the taxi and then out of the taxi and things more than anything else. Or, I mean, I realise there's a lot of factors in all of this, but I mean, another suggestion has been that some especially older people are perhaps fearful of engaging with health and social work services in case they get kind of transported very quickly to a care home, which they don't actually want. So, is that kind of balance between, you know, the kind of easy, well, easy, obvious practical issues and the kind of more the way people feel about it? I do think there's something there about services having to be acceptable to the individuals and I do think, I think you're right, there probably is a bit of a fear there of being taken into hospital or into care. And we certainly know that when people are looked after in their own homes, the outcomes are better for them. They aren't as disconnected from the world that they're in. So, going back to my original point about restructuring services, looking at pathways for individuals in and out of care, we need to make sure that those support individuals to come back to their homes. We need to make sure that they don't even remain in their home situation having care and treatment at the home. How do you decide that homes can be very isolated although they're in their community? Somebody in hospital can also be, or a care home can also be quite isolated. How do you handle that? I think that people can be isolated in any circumstance. It is about having a range of services and responses within those services to meeting people's needs. I think that it's as simple as that, of understanding what people need. We have a range of mechanisms. The third sector in our area is very alive to social isolation. We have had an ageing well programme for many years. The primary purpose of that is health and wellbeing, but it's also about socialisation and social connectedness. Programmes such as that look to particular groups of individuals who may be more vulnerable. There's a directory that's come out for men who are retired or just about to retire to try to normalise the idea that you need to be socially connected when you're older. Similarly, in care home settings, there are activities in there that help to connect people. In any, it's a human need, so we need to be able to, in any of our services, address people's need to be connected to others in a way that suits them. I don't know, Professor Watt, dealing with GPs. Are some of your 100 deep-end practices in rural areas where transport and things become an issue? It transports an issue in the city. Resources is a part of isolation for some people. The Government targets the 15 per cent most deprived data zones. That's a large part of the Scottish population, two thirds of which is registered with about 700 practices across the country. Most general practices are dealing with a bit of deprivation, including remote and rural. The thing about the deep-end practices is that they're dealing with deprivation in high volume. Between 50 and 90 per cent of their patients are living in that area. There are about a couple of hundred practices in Scotland that don't have any patients. They probably have an older profile. It's multifaceted and you can't produce a formula. It's based on the individual. Sometimes it's to do with physical isolation or lack of it. It's just how their life has ended up. It can be the resources in a community where it's difficult to get to places that may be a community that doesn't have many resources to go to. There's the very fiercely independent type of person who just refuses all kinds of help, with whom you nevertheless still have to have a relationship with. The key to it is that everybody's different. They need to be taken on their own terms. That requires a pragmatic, flexible decision making at street level based on a good knowledge of what's available. Is that what somebody asked about asking people whether they were lonely? There was a study of interviews with GPs asking that. One of the replies was that it was easier to ask about impotence than loneliness because you could do something about impotence. Loneliness is much more difficult. That's a separate issue. I think that's too negative an issue because there are lots of things that you can do. The question is, are those things being done? When I took a Hollywood magazine's reporter through to government to interview three GPs, I told her afterwards that she realised that there were 60 years of experience in the room. That's an enormous amount of cumulative knowledge of people. There's a danger that we'll lose that, the stuff in the paper yesterday about the GP numbers. I think that there's a general point that needs to be made, which is that if primary care, including general practice and all the other community-based services isn't strong, then patients will fast-track to out-of-hours A&E and to dire emergency situations. That's always happened to some extent in deprived areas because of resources. It's beginning to happen more widely because, as the Royal College of GPs keep saying, there's been a disinvestment in general practice from 11 to 9 per cent of the total health budget. That has an effect over a period of time in that the system is less strong. What I mean by strong is that a whole lot of horizontal links are not fast-tracking vertically into secondary care, but are you able to contain a problem in the community, either within a consultation or by a local referral? There's various bits of information that we just lack. Is a local health system weak or strong in that respect in terms of its links, the knowledge and confidence that is shared between services and professions? We just don't know. At the level of the street-wise teams, they know what the strengths are, but the system is not necessarily investing in it. We talked about patient-centred care, and everybody is doing that, but somehow the patient isn't at the centre. You've argued that the health service is linked in with most people, and it's better than anything else that we've got. Is that true of older people but not true of younger people? How well are younger people connected to the health service? The younger people are generally healthier, but there are plenty of young people with health problems. Single mothers are isolated and lonely often. There are plenty of mental health problems in younger people, but essentially contact rates are much higher at adult age. The health service probably has a bigger role to play. On the question of patient-centred care, the key thing is what is the individual patient or person story experience like. What's it like to be old in Knightswood or Leith or Aberfeldy? Is it a good experience? We just don't know that. Until you have an information system that mirrors activity, you're not well informed and not able to improve things. As we move towards more community-based integrated care, we're going to have to develop information systems that tell us how strong local systems are, where the problems are and how things are going to be improved. There's just so much going on here. I'd like to broaden out to the others as well. Are young people a bit of an issue in here because we've been looking at young and old, but we tend to focus on the older people. It's more obvious. What about other subgroups within all of that? Is there a particular issue for ethnic minority groups with loneliness and isolation? What about LGBT? Are there other groups like that that are extra isolated? Just thinking about young people generally, particularly where they're facing homelessness, there's been various bits of work, research done to highlight issues around loneliness, the importance of social connection and also there are issues there about health and this whole issue about access to health. There's been projects, thinking of some in England, where they've used other homeless people who've come through that, if you like, and are prepared to volunteer as bodies or work as bodies with young people to encourage them to use the health services that they so desperately need sometimes in the case of people who've been homeless and young people like that. I'm looking at the principles of early action, early intervention. Where can we get in early in a problem or an issue, any problem or issue, to make a difference closer to the individual and their families and their communities? In terms of children and young people, Graeme said earlier about attachment and that's a real focus of our early years work, is encouraging parents, particularly young, more vulnerable parents, to be well attached with their children. Quite a lot of our services are put in around that time to try to support. There's something as well about a whole population approach to this, trying to make sure that none of the vulnerable fall through the net, not just offering a service out there but proactively going and seeking and reaching out to people rather than expecting them to come to us. We have a particular example in Westlothian where we're working very closely in partnership with the family nurse partnership, the NHS targeted service for teenage mothers. The council has invested in its own young mother service for the other vulnerable young mothers who don't fit with that particular service model. What we're trying to do is to make sure that no mother who is young and vulnerable goes by without one or other of the services making a concerted effort to engage with that young person and to continue to engage with them even if it's not the right time for them at that time. Also, to flex around them what services we've got that they might be interested in. Some people like group work programmes, other people like one-to-one, others don't contact all that often. We need to be able to flex those systems to meet the needs of individuals in a non-stigmatising way. Interesting. You've got these two groups or two ways of reaching vulnerable young mothers if we take that group. Do you feel that you're reaching 100 per cent or almost? We're not far off. I can't remember offhand just how many ultimately turned down a service but we keep statistics of tracking young mothers through those systems. We're fairly assured that we are reaching out in that way to young mothers. I think that when you have a particular population that you know is made more vulnerable of all sorts of social ills, then trying to reach all of them in a systematic and robust and persistent way is pretty important. In the bridge project that I mentioned, that was the one where practice knowledge of elderly patients was supposed to be linked to community resources for social and physical activity. Anecdotally, so I don't know whether that is widely true, in Bridgeston it was felt that immigrants and ethnic groups were much better organised in terms of social activity that could support people. The vulnerable population was the elderly white population. Can we now move on to Annabelle? Yes, convener, you may. I'm trying to sit at the top of a tree and get a bird's eye view of all this because the detail can be bewildering. There are two aspects that I'm interested in. Professor Watt has already referred to this and we've also had evidence about this as a concept of social prescribing. I have a very simple question for you all. Is social prescribing an understood phrase? Is it in the lexicon of professionals? I began to look at this. We felt that it wasn't in common parlance. We initially did an email survey of practices to see who would respond to it and we got about a 10 per cent response. It's much more understood now but the issue is not understanding the term. It's whether people see it as part of their job to be social prescribing. I'm answering the question from a general practice point of view, not because general practice is the most important thing but it is disproportionately influential within the system that we're talking about. Social prescribing implies that practices will be outward looking. They'll be thinking about themselves as a hub of a local health system and using their opportunities to develop that. If you're totally preoccupied in a reactive way to dealing with everyday concerns, you're just not going to be looking outside. The issue is not understanding of the term and it's not understanding of what would be required because there are models being developed all over the place. The real issue is a resource issue of whether we're investing in it as a substantial activity. The health service is 90 per cent of its workers in primary care, 10 per cent in hospital but 90 per cent of the money goes to hospital and 10 per cent to primary care. The average spend on a patient in general practice in Scotland is about £123 a year, which is almost the cost of an outpatient appointment. We spend peanuts on it and we can't begin to imagine developing a strong primary care system with that level of funding. One of the consequences of that is that the community hasn't been treated as a sink for years and years. It is now full. It's a bit like a flash flood. The current issue with A&E is simply because primary care has lost the capacity to absorb that it always has. GPs are looking to retirement because it's not a job that energises them, it drains them. On that point, Professor Watt, if I might just ask your colleagues on the panel here, is social prescribing a term in your lexicon? I really just want to yes or no. It's to try to engage the extent in which people are aware of this. Joe? Yes, it is associated with healthcare and with GP practice. It's not a term that goes more widely. In the local context, it would be very much associated with the capacity that GPs have to allocate a series of free sessions in the local gym as part of dealing with a diagnosis of a particular health condition, but we do have that facility there and it is used. We also have an exercise referral scheme in Westlothian that comes under the social prescribing banner. That's quite well used. We've had a number of initiatives over the years, so it has grown in terms of its familiarity, particularly in general practice. I think that Graeme and Joe are absolutely right. The sea change that's coming for me now is not just a phrase that's used, it's that GPs are starting to want to shape what social prescribing might look like and take ownership of what the models that they prescribe into might look like. For all the adversity that Graeme mentioned this morning, they recognise that the current model cannot continue, so they need to find a way to promote early intervention for folks who use their services and therefore are looking to come up with models of what alternatives might be to a lifetime of illness. I was saying the housing world, the term is probably not very well understood, but there is a clear focus on providing activities that could easily be linked in with social prescribing, so things like walking groups that are being organised, craft cafes, activities like that, which are particularly well suited to helping on the Londoners and health front. Professor Watt, coming back to you and I've listened with care to your very justifiable concerns about the problems of structure and resource and capacity to deal with either delivering or trying to implement a policy of social prescription. Can I ask this question? It seems to me, going back to what you were saying about the coverage of the NHS, and I think what we now know to be from the projects of which we're aware, like Depend and Links, that patients do have a confidence in their GP, possibly born out of a reassurance that the GP is to be trusted and can assist. Does that mean that we should maybe be considering for GPs a patient protocol of social prescribing? I often quote Mr Spock from Star Trek talking to Captain Kirk who says that it's not logical. There's so much human behaviour, it's not logical. That means that you can't produce a logic plan or a formula or a protocol that predicts what's going to happen. The thing about general practice is that it's unconditional. It responds to whatever the patient brings or their circumstances. That's almost the only part of the public service that is unconditional and that requires knowledge, continuity, pragmatism and good conscience. A protocol implies that this is a thing that can be managed. I think that it's as much a cultural development as a managerial development and that's to do with hearts and minds and values. Given that it seems that there's possibly not an even pattern of awareness amongst the GP profession, and that's not a criticism, that's just a statement of reality. Given that, is there more that perhaps could be done at the GP level because of the core asset that the GP is to the local community? Is there something more that could be done to assist GPs in having on the radar screen social prescribing? Yes. It's not just information, it's not just flags on the screen. You need to know who you're referring to. Do you have trust in them? The whole question of trust is based on positive experiences and confidence that they will be continued. There needs to be continuity, a huge resource. When people retire they take all that with them. That's a real hazard that we face. One of the things that I think the deep end project has been important for is that it has engaged with practices and on the projects that we've been able to get involved with, it's put them on the front foot. They're not reacting to things that other people have imagined and say, please do this, do that. That's a very important development. Is that a model that could be commended to the medical profession in Scotland? I appreciate the projects that you refer have only been able to cover certain geographies. I would be very careful at the present time not to be prescribing more things that general practice should do, unless there were resources to help them to do it. That was my first caveat. What is a good principle before you contemplate, implement or application of the principle? Of course you must have resource and structure and process in place, but we are interested as a committee to know what's a good principle. The principle is that general practices, because of the features that are described, are the natural hubs of local health systems, but hubs don't go anywhere unless they're connected by spokes to the rest of the wheel, the rest of the table here. There's building that needs to be done there. There's a leadership role for practices that needs to be valued and supported. One of the issues in primary care is that it's a highly disaggregated system, as a thousand general practices in Scotland. They often don't know what's happening down the road in the next practice, never mind the other side of the country. The whole issue of sharing good experience and learning from it is something that is under-supported. The system operates as a thousand small boats as opposed to an armada sailing in the right directions. I've just come back from a meeting in Vermont. Professor Watt, other professions, albeit that they may range hugely in size of practice unit, manage to observe some kind of collect of fraternity or sorority, as with the Equal Opportunities Committee, in terms of sharing professional experience advice. That might be done through their professional journal, through the professional website. Why are doctors different? Well, your question is a very deep question. What you say about sharing evidence and experience is most true in the hospital side, in established specialties such as diabetes, or in other areas of the world. There are international conferences and gravy trains for all of that. Many of our institutions and our research and our teaching are based on that vertical model, based on problems, not people. A GP is an expert in a community. He's an Easter houseologist or a particologist. He knows a little about a lot, and his expertise is to make pragmatic decisions around... I mean, our ambition is that people should stop saying, oh, you just want to be a GP. Being a GP is a hugely important job at the front line of the health service, but the nature of the work, its unconditionality, its continuity are difficult to research and to produce evidence. That's why the deep end project, in the absence of much evidence from deprived areas, has capitalised on the experience and views of practitioners. The gap that we've filled is the infrastructure that allows people to share experience and views. It's enormously empowering for the individuals to find out that they're in the same boat. It's a very effective intervention because a professional group within itself can challenge itself and move forward, I think, more easily than being criticised from outside. Professor Watt, I think that the whole committee is fully supportive of GPs and that mark greatly the job that they do throughout Scotland. It's trying to work out a way in which we take that asset, which is undisputed, and help it to enhance its contribution. Absolutely. To the community. Well, I was saying, I was in Vermont last week and they had 10 years ago invented, because they didn't have it, infrastructure, really a learning organisation for their family practices. It's very different, obviously, of the states from here. What was interesting was that they now have infrastructure that is dedicated to what you've just described, whereas the health service that we've got has a general management philosophy in infrastructure. At the community level, it's mainly based around managing area-based services, whereas general practice has always been independent of that. The system has always had difficulty in engaging with general practice, which generally takes a back foot and doesn't get involved. The challenge is that general practice has to be on the front foot, and that will mean things like protected time for sharing activity, for leadership. All of our projects are based on the primary care collaborative model, which was the most successful initiative in engaging practices where they tended to work in clusters of five or six on the work of their own choosing with protected time for sharing experience, with a role for GP leadership, which would allow their experience to be communicated to others. In a sense, what you're doing is you're building a learning organisation, infrastructure that historically has not existed. I think that we can't just have a thousand flowers blooming. They have to be connected in some organised way. I'm sorry, but we're running out of time, and I've also got two other witnesses who want to contribute to the conversation. Can we move on to Joe and then David to give their input to your question as well, Annabelle? I think that GP's, as important as they are, are not in and of themselves the solution to the challenge and the problem. They are part of the solution if they work well in a whole system approach within each locality. Establishing the connectivity between the GP and other services, and their knowledge and awareness of what's available in their locality in terms of the third sector. Information and the flow of information, the use of new technologies to deliver the information in a readily accessible format is important for all parts of the system. It's also important to have information available so that people can be self-managing and find the information that they need without ever going to a GP or any other service, because many people won't go to service. For me, the beauty of general practice is the relationship between the GP and their patient. That's the relationship that can often last 20, 30 or 40 years. If we were to move to protocolise general practice, we'd run the real risk of breaking that relationship. The open approach that general practice has to provide in care and assessing needs leads us to a situation where they can truly inform the future direction of health and social care. That's where the new health and social care partnerships come to the fore. Through the locality planning structures that we're going to have to establish over the coming year to two years, through engaging local communities, local practitioners at all levels, including general practitioners, in conversations about what are the needs of the local communities, and how can those needs best be met, and how can resources best be allocated to meet those needs. That's how we'll bring the standardisation across GP practices within those localities and hopefully embed things like social prescribing within the localities as well, so that they're targeted at and tailored to local need. I'm neatly to my final question, convener, which is this whole issue of social isolation in relation to the integration plans required under the 2014 act. Are you satisfied that social isolation is again on the radar screen when these plans are being drawn up? I'm satisfied that the opportunity is there, and what will be important is how that opportunity is translated into reality and into change. The opportunity is there because the national integration outcomes are a clarity around the importance of wellbeing and supporting wellbeing, not simply providing care to the best of your ability, but promoting wellbeing, which is important. It isn't necessarily about being involved in care. The national integration outcomes emphasise prevention and supporting people not to be involved in services, and that's where they give the opportunity. There is also a statutory obligation to report on what is happening by locality. The opportunity is there to demonstrate that third sector are fully involved and that they are being resourced to provide the contribution that they know that they can make in each locality. I think that it's really important that housing is involved in this, as well as local voluntary services and voluntary organisations. Of course, that's something that we're still watching around the country to see how that's going to pan out. Housing organisations are very clear about the contribution that they can make to the process and should be around the table. Obviously, their links with the voluntary sector are very important in all of that. Joe, you said that it's an opportunity. Is that an opportunity that we're confident is being recognised by all health boards and local authorities? As I would have to say, it might be difficult for me to express an opinion across all health boards and local authorities. Certainly, in the area that I'm working in, I'm completely confident that this is very high on the agenda and is recognised. I agree very much with that. I think that there's a range of opportunities around for us in the service areas to be providing more joined up, more flexible and services that intervene earlier. Ortheoshaar is the same. What I was going to say was that I absolutely recognise the opportunities, as Joe described them, and what I want to provide some reassurance to the committee today is that we've actually translated that into a clear commitment within our strategic plan. One of our five strategic priorities is to improve mental health and wellbeing, and whilst we're out to consultation on that plan, that was the priority that got the warmest welcome from the local population and was given the highest priority by them in terms of the feedback that we received. It's there, it's explicit our commitment to the local population and social isolation and loneliness that fits right up with the middle of that, so it's very, very high on our agenda. Thank you very much. We're moving on now to the topic of sheltered housing for older people on 13 March. One of the witnesses described the lack of sheltered housing for older people as a demographic time bomb. The appeal of sheltered housing is that it can provide community support without taking away the person's independence. Do you think that that is a way to combat social isolation? Is that possible? Or, as we also heard as well, that you could be in a nursing home surrounded by people every day, 24 hours a day, but you could still be lonely? In terms of sheltered housing, I think that we need to recognise that the sheltered housing model is going through change and has been for a few years. What we tend to traditionally think of as housing for older people with resident warden, that's really moved on to flexible services coming in and out, a recognition about the role of those services as hubs, as we've heard already, from North Ayrshire and from South Lanarkshire's councils experience as well, moving on to thinking about serving communities more broadly. In terms of whether there should be more of it, it's perhaps a bigger issue about analysing what it is that people desire, what sort of aspirations they have as they come up to older age, what choices are they likely to make if that option is available. Generally speaking, the traditional sheltered housing has been going through a period of reconfiguration, so what I would suggest is rather than just reproducing the traditional model, then looking more broadly about people's aspirations and needs, but recognising some of the very valuable aspects of the traditional model, that feeling of security, people moving in, choosing to go into that sort of service because they felt there was some security there, that there would always be somebody on call, that there would be a support worker that they would know, whether they called that a warden or a support worker or a housing manager. So some of those elements, as well as the option of socialising near their home, I don't think we should underestimate the importance of the communal areas that are typically part of sheltered housing. We've been hearing how much of a problem community transport is and how limiting physical and sensory issues are as people get older is harder for them to go far. Having that option of a communal area where they can organise events, organise activities, share common interests is so important. So definitely we should be looking at that as continuing to be an option for people. Kate, David, would you like to comment? I would very much like to echo what Yvette has said. I think it is about the individual and I think it's about respecting what the individual wants to see and the choices they want to make in their life. For some people to put them into a sheltered housing complex would be completely isolating because it takes them away from their community network and we mustn't do that, we must find a way to support individuals at home for as long as possible so that they can continue to access that network that they've established over years and years and years. For others, a move into a sheltered housing complex is going to be the right decision, it's going to be a new lease of life, it's going to open up new social doors to them and I think it's about recognising that as well. My point is that it's not a panacea, I think we need a multi-pronged approach to how we address this issue going forward and this is one real viable option for us and it's important that we get the capacity right because your previous contributors are absolutely correct. If we don't get the capacity right then it will be a time bomb for us but it's about recognising that it's not right for everyone. We're actually running short of time so can I ask you to condense your answers from now on? I've got two other members that would like to come in to ask questions and we'll move on now to John Finnie. It's a question for Ms Burgess and it's about the unwitting loneliness social isolation that can happen when housing providers perhaps put young homeless people in inappropriate accommodation or accommodation that transpires to be inappropriate and likewise when they're given tenancy of a house without the necessary skills to maintain that tenancy of the door keeping themselves on all the rest. Is there a growing awareness of that or how has that been tackled please? I think in terms of what we're talking about really is support that people might need, young people particularly who've never experienced a tenancy before and haven't had a chance to develop the life skills needed to get on with neighbours etc. The legislation that we have now around homelessness does include obviously the requirement that local authorities assess somebody's housing support needs when they're homeless and that includes young people. There is a growing awareness I think at that stage about the support needs that a young person might have and then a duty to make provision for that support. I think that the support is essential. Housing support service will typically look at issues around social skills, will look at things like life skills development, an important part of that will be looking at their social network. Does that need to be encouraged and boosted up or perhaps there's an issue there about somebody deciding that really they have to move away from their existing social circle. It might be because of drugs, alcohol issues and that can lead to a lot of isolation for a young person or for anybody else going through that. That's where some formal support can really help to see that person through to making other social contacts to prevent the isolation that can often lead to further problems. I hope that's answered your question to some extent. It is, thank you. That's reassuring. A question of a May for the panel generally. We've heard a lot about the use of social media and technology now, whilst accepting that there are a range of skills within our community. In fact, there are a range of opportunities because of the technical limitation in some areas. What part can that play in reducing loneliness and social isolation? I think that there are two strands. One is enabling people who may be digitally excluded who don't have the knowledge and experience of the grandchildren to show them how to do it. That is a piece of work that is important to address. In each area, there should be access for people who currently don't use, who are not out of choice but because they don't know how to use an iPad to stay in touch with relatives and contacts who are a long distance away. Where we've actually set out to do that, there has been an uptick for that, so it isn't a case that people are saying, I'm not interested in that. When we actually speak to people, they say that they understand the concept of being excluded, they feel left behind because everybody now knows someone, knows other people who actually are using these media as part of their day-to-day lives, so not being able to do it is an issue for many people. There has to be that offer there, and that doesn't just involve social work. It's actually just an important part of a library function in any kind of public service, offering that so that people can actually have the capacity. The second area is developing the web-based information portals, giving people access to the information. Again, it's too easy to say that there are lots of people in the group that we're talking about, older people who don't access the internet. That may be the case, but increasingly they are accessing the internet, but their children and their families have connections in order to help them to do that. The development of the website approach, which, in terms of example, we have a website called Making Life Easier, which gives people a range of options to access low-level supports. People who don't see themselves as service users of any service, people see themselves as consumers, and actually wouldn't. The point that I think earlier, some people don't want to be referred to as social work service because they think the next thing that will happen is that they're in a care home, and they will say to their family, I don't have any account to you to make a contact with social work service, but actually they'll be perfectly happy for their family to look up a website where they can get access to a range of low-level supports without, in fact, requiring to ever become a service user of a service. There are two things, given people the capacity to use these where they don't have the social media capacity at the moment, but also having the right information available at the local level that people are actually able to get, not just accessing a national level generic database, but actually here's what's available in Coatbridge and we've actually got that up to date for you to use. I don't know if any other panel members wish to comment. Is there a danger that in cash-strap times this would become an alternative to seeing the whites of the eyes of an actual human coming to assist you? I would say on the contrary what it does is it allows those people who do need to face to face contact. It allows them to get access to that more readily because you're actually getting the kind of self-screening, if you like. That website actually allows self-assessment and allows the website itself to actually say at a certain point in terms of the person answering self-assessment questions, actually what we would suggest to you is that you should come in and see us because actually the information you've given us now is telling us that the solution isn't one that's available without you actually getting that kind of support. The use of technology is, I think, increasingly important, particularly from the point of view of the person using the service and having some support to use the various bits of technology around them increasingly, whether that's a community care alarm, whether it's access to the internet and using Skype or just using information systems. For some people, their support worker will be a good person to help to introduce them into all of that. I think that it's important increasingly that support workers and care workers feel confident about the range of technology available and increasingly can help people in this situation. The ultimate aim is that individuals are knowledgeable and confident in the problems that they've got and in accessing resources available to them. Self-help and self-management are desirable, but for many people they're not a starting point. If they are a starting point and they just need the information through IT and whatever, then that's great because it hopefully will take them out of the need for services. There's a very important and substantial part of the population for whom self-help and self-management are a distant destination and for them a long-term productive relationship by journey, if you like, is what's required. I just wanted to come in in a supplementary. I had a very interesting presentation at the cross-party group load of people yesterday. I don't know if you've heard about this one. The University of Southampton and Kent and RBS here in Scotland are sponsoring it and it's a virtual reality. It's an avatar. Have you heard about that one? It's an avatar of people who care homes with all their information. The information goes into the tablet and I think that they're going to protocol it by 2020. It seems to be that you can call up anything from a warden to your doctor, etc. I wonder if anyone had heard of that. Certainly, it's been a new one to me. I'm sorry to spring it on you, but in June there's going to be a presentation about it. It seems very futuristic to me. It's a film avatar. If you've seen it, the technology and the graphics are fantastic and the story is very, very weak. I think that we need to concentrate on the story rather than the technology. Can we move on now to Christian? Given his answers, can you also try to bring in young people in social isolation? We've spoke quite a bit about elderly people and young people are really important as well. I was going to ask about how we can find further opportunities for joint working in the third sector to combat social isolation and loneliness, but I would like to come back on something regarding joint working. From the first of this month, services have services and social services have been integrated. I'm a bit surprised with some of the contribution this morning. We are not at the time of designing opportunities for this integration. We are at the time of implementation. Have we seen some of the implementation already? Have we seen some of the results already? And if you are not, it may be time that we do. I would be very clear that the process of integration, the delivery of integrated care and support, has been an evolving process that doesn't start with the legislation. A lot of the things that I've been talking about today have been happening over many, many years. The legislation takes us into a new stage of that evolution. I agree with you that it has to be about implementation. The locality dimension of the legislation is the insistence, quite rightly so, within the legislation that we have to have evidence not just within a partnership area but within that partnership for each locality. How are you responding to the needs of that geographical population within your localities? That's where there will be scope and opportunity for new design work that perhaps hasn't been as much to the fore as it has been up until now. I agree that we have to move into implementation stage. I very much agree with what Jo is saying there, that integration moving towards joint working, working within community planning partnerships, is not new to any of us and a lot of the work that we've been doing. In fact, I can't think of any work that our services do in complete isolation from anyone else. We are moving out of the silos that we were in maybe 10 or 15 years ago, very much with a view to what's the opportunity to engage, to work in partnership. I think that this is an evolutionary journey for us that new policy and legislation is promoting also. Mentioning children and families, the getting it right for every child agenda has been around for quite some time now. Our local authority areas have been very much looking to the principles of getting it right for every child for a number of years, particularly the notion of coming around the individual. How do you flex your services and structure your response in such a way that you're coming around the child? We've had some opportunities for that recently in the area of mental health and wellbeing for young people, again thinking about not just young people who have mental health problems but those who are made more vulnerable emotionally and mentally by their experiences. That whole spectrum of early vulnerability is all the way up to young people with really quite profound difficulties. How do you then bring the services around the table to around that child to say how best can we support this young person? It's not always about putting a service in. Sometimes it's about the services coming together and saying, while the young person has a relationship with this particular person, how do we support that person with this particular level of need that that young person has so it might be about consultancy or training for that individual member of staff? So it's really about that building on the relationships that people have with children and young people, how best can we support that, rather than pinging them off into another service and another service. So it's even not as patient-centered but as person-centered and getting it right for every child is exactly the kind of thing that should have been implemented and now we've, from the 1st of April, as you say, there is a lot of co-operation and joint working, so we have everything in place. But it's not working as much as it should be for young people yet, is what you are saying? We are still a bit lacking behind. Maybe some parts, the GPs for example, are not as much as involved as they should be? Well, I think it's about, you know, if we could have gotten this right easily, we would have done it a long time ago. It's a really complex area that we're in here around social care and healthcare and, you know, the evidence is around these days that really does point out just how complex our make-up is, as human beings, because we're very complex creatures and social ills don't come alone either, there's not an easy solution to any of these things. So I think it's, and also, you know, when we do have some answers and some solutions often there, very much part of what's going on at the time and in conjunction with a whole range of other things. So it's about having a really complex understanding that we require to have. What I'm liking these days is the opportunity to, I think, there's more of a shared understanding across social care, across education, NHS, about the issues and the problems. We're not siloed in our professionalisms anymore, and the challenge is how, and the opportunity is, how do we make that happen on the ground in a way that really works for people in our communities? I think we have a lot of good practice, a lot of good practice. Some of it's still in pockets, so the challenge for us is how do we then grow that and offer that out? How do we work in collaboration, not just within our local authority areas, but across Scotland in order to show that? I think that it's a very exciting time to be doing this. Just to add to that, really, that thinking about young people and thinking about housing services and just recognising that it won't necessarily be the case that integration encompasses all the services that young people will need to come into contact. It's a plea to remember that housing and housing support services, hospital services, those working with particularly young people going through transition, whether they're coming out of care or whether they're homeless or both, that the links need to continue regardless of whether a partnership decides to include homelessness and the services that particularly affect young people in the partnership or not, that we really need to build on the existing links and improve them rather than just expect that integration in itself will magically deal with the issues. Can you be involved and invest in two pieces of legislation, the right of every child and the integration of social services and health services? Yes. Can you make it very brief and then join Mason as well briefly, John? Getting a right for every child doesn't actually mention general practice, even though practices have a lot of knowledge about families, which is important. The health and social care integration is obviously important, but it is preoccupied with the integration of two rather different bureaucracies, so it will take a lot of time for that to iron itself out. At the end of the day, so often we pass the written and fail the practical, so the strategies and the policies are fine. It's delivering it, that's the issue. I got back to what I said earlier on about dysfunctional fragmented services. Spike Milligan described a man who invented a machine that did the work of two men but took three men to work it. That's health and social care. We need to imagine ways of doing the same thing with smaller numbers of people. At the end of the day, the gold standard is going to be what's it like for the individual patient. Has that experience been good? Does the family feel that their relative has been dealt with well? That will be the test of whether the bureaucracies are working well together. It's really especially on social care isolation and loneliness. It's about the person first and foremost. In fact, the person becomes a patient when he's failure of the services. I agree very much on this, Burgess, about the importance of housing. I was slightly surprised in one of the comments in your paper where it said about housing organisations might include helping a person relocate near our friends, family or support. That would be great, but my experience doesn't happen. It's incredibly difficult to get somebody to move to a particular location. It's the issue about allocation policies. There's huge pressure, as we all know, on social rented housing, but many housing organisations give additional points. We're still working generally with point systems for allocating properties, but we'll give points for social isolation. An example is trust housing, for instance. It gives additional points depending on how many times a week or a month somebody has a visit from a friend or a family member. However, as you say, that doesn't necessarily mean that everybody who needs to move closer to family and friends is given that opportunity when they want it. Another point that we talked about when we took evidence. I can see a distribution from the West Laws and Committee Health and Care Partnership talking about high-profile campaigns and particularly the one from organisations like Age Scotland, which really give a lot of media coverage and are very accessible to the population at large. Do you think that we should have that kind of national campaign? If it is, this national campaign should be targeted at the people who could be affected or more generally at the whole of the committees and maybe trying to build a committee of residents or something else. What would be your ideas on a national campaign? My opinion about national campaigns is quite often that they are based around the negative. I would suggest that any national campaign would be around social connectedness rather than disconnection. I agree entirely with that. If there could be a very positive message around social connectedness, it would lead the foundations for locality-based planning to understand the needs of particular communities and how we might respond effectively to that in light of that wider campaign about social connectedness. I think that that would be really helpful. Graham, do you want to come in as well? I think that politicians have great difficulty in closing hospitals because of the public emotional commitment to hospitals, but the service that we need in the future cannot be based on hospitals. The national campaign that I would like to see is one that convinces and engages the public, saying that what the NHS is about in the future is not just hospitals, it's about living well and long in the community. If resources are being transferred from secondary care to primary care, it's a good thing, not something that's being lost, it's something that's being gained. Unless the public sign up to that, we're going to be tied in forever into the wrong model. I think that the national campaign, the challenge there is how do you get a message that is relevant in every part of the target audience? The local level is where some of the answers are to be found for the questions that we're talking about here today. I would just be a note of caution about the national campaign approach. You asked a question but I wanted answers if it was possible of how can we do it a national one and staying positive. It's about public image and perceptions and challenging stereotypes, so thinking particularly about older people and anything to promote the idea of older people being active, doing things, contributing. All of those positive examples really encourage older people themselves to get on and do these things, and it encourages others who are in contact with older people whether they're neighbours or grandchildren or whoever to think of them as having that potential. Should it be gender targeted, age targeted? That's a very good question. I think that trying to do something that is quite broad-ranging, but it is a fact that, for instance, older men can feel particularly isolated. A given example, the Queen's Cross Housing Association realised that there were a group of men over 60 who weren't engaging in any of their services, and they realised that it was because they perceived the existing group activities around sheltered housing as being predominantly for women. That encouraged Queen's Cross Housing Association and recognised that they set up a group called the SAG group for men to particularly get involved. I think that you've got a point about thinking about which groups in that wider group of older people need particular encouragement to think about being continued to be active and sociable. Do you want to come in? I wouldn't want to see a stratified national campaign, if I'm being really honest, and I think that, to the point that I made and the point that Joe made as well, I think that a high-level national campaign focusing on key positive messages like social connectedness is absolutely a great thing for us to do, and we'd really, really welcome that. I think that the true understanding of how to stratify that message at a local level should come from a sense of where the priorities lie locally, and we'd therefore be looking for you to leave that to us within the evolving health and social care partnerships to take that national message and turn it into something really positive locally. It's easy for the general population to understand that older people can be isolated. It's maybe not so easy to understand that young people can be isolated. Is there a way we could do that nationally? I guess that that maybe gives a lead into a theme for a national campaign, which would be highlighting that this, in fact, is an issue across the entire life cycle so that it's not. That would be a very high-level message, but I think there have been other campaigns around mental health issues, for example, in the past, which have really pressed home this message. That mental health is an issue for everybody. You are standing in the supermarket beside people who have mental health difficulties, and I think that some of those have been quite powerful emotional content messages, so perhaps there could be a role to raise the profile in terms of social isolation as being everybody's issue. You're not simply doing a national campaign to highlight or to develop awareness that this happens and that it exists, but it's also awareness among the wider community about what it is that they can contribute or what they can do in terms of making a contribution as part of their community. I thank you all for coming along this morning and sharing your information, your experience, your knowledge with us. It's been really, really useful. That concludes the public part of today's meeting. Our next meeting will take place in Islay on 11 May, where the committee will take further evidence on its inquiry into age and social isolation. I formally close the general open part of the meeting. Thank you very much.