 Good morning and welcome to the sixth meeting of the Public Audit and Post Legislative Scrutiny Committee. Can I ask all those present to either switch off their electronic devices or switch them to silent mode so that they do not affect the work of the committee this morning? Item 1, the committee is invited to agree to take items 3 and 4 in private. Item 3 is consideration of evidence received under item 2 on the changing models of health and social care report. Item 4 is for the committee to consider its work programme. Do members agree to take items in private? Item 2 is an evidence session on the Auditor General for Scotland's report, Changing Models of Health and Social Care. We have already taken oral evidence on this report from the Auditor General, the Scottish Government and from two social care partnerships. We have agreed to take further evidence on the report today, including the extent in which funding decisions are allowing new models of health and social care to develop fully. I would like to welcome to the meeting this morning Jan Baird, director of adult care NHS Highlands and Bill Alexander, director of care and learning at Highlands Council, the Highlands partnership. I would also like to welcome Robert Calderwood, chief executive and Mark White, director of finance of NHS Greater Glasgow and Clyde. I invite Jan Baird to make a brief opening statement. I understand that NHS Greater Glasgow and Clyde do not wish to make an opening statement, is that correct? Thank you for inviting us and affording us the opportunity to say a few opening words. The Highlands partnership was the first to take the radical step of integration needed in our view to change models of health and social care. The benefits of the lead agency can be summed up as single management, single budgets and single governance. Single management of community health, children and family social work and education in one organisation, the Highlands Council. Single management of primary, secondary and community care for adults in one organisation, NHS Highlands. Single budgets with the quantum to deliver all of the functions transferred from the commissioning agency to the lead agency. Given the amounts involved, a very brave step for Highlands Council in 2012. Single governance with clear accountability across the lead agency and assurance route to the commissioner and committees and district partnerships where elected members can be involved, can inform and scrutinise. Changing models of health and social care needs to be transformational and engaged at every level, individual, team, community, organisation and national. Integration is not a quick fix nor a magic bullet, but alongside strategic commissioning and evidenced outcome focused approach, genuine and equal partnerships with the third and independent sector, self-management and the rest, it is delivering that change in Highland. It is a journey for which we have a clear plan and a methodology for driving the change that will reduce waste and harm, manage variation and drive up quality. There are still a number of challenges. How to embed and sustain some of the changes at community level, whilst ensuring the aspirations of the community empowerment act enable that community-driven change? How to work with the Highland pounds, not health or social care pounds, whilst evidencing efficiency and effectiveness to commissioners? How to improve and sustain the flow across and between services and care so that patients and carers do not get caught up in systems or have unnecessary delays? How to plan for increasing demand against a backdrop of reducing funds when the announcements about budget settlements are made at different stages of the planning cycle and changes to budgets and allocations can be made across the year? Highland believes that it is essential that we all remain committed to changing models of health and social care, not forgetting that this is about improving lives and work together to evidence the true benefits. I invite questions from members, Colin Beattie. What is clear from the Oratory General's report is that this is not proceeding as quickly as one would have hoped or as efficiently as one would have hoped. What are the main challenges that integration authorities are finding in implementing that? Clearly, there has got to be some sort of an acceleration, a step change that is going to permit us to go through, because it is a key policy, and it is absolutely essential that this happens. To hear if possible, I will kick off and offer some observations on that. I think that the first issue is to understand that the need for change means that we need to be all in agreement that the status quo is not the most designable outcome in the short to medium term, so we have to be able to embrace change. Do you believe that the status quo is sustainable? I believe that if we were to pursue a model based on the status quo, then there will be no ability in the short to medium term, particularly the duration of this parliamentary term, to move the significant resources that we aspire into primary and community and prevention services. We have to be very brave and take forward the service redesign that allows us to make the headroom within the overall health economy and health and social care economy to make those changes. Within Greater Glasgow and Clyde, as colleagues in the Parliament are aware, we are currently proposing a series of changes to how we deliver acute services that we believe will provide a safe and sustainable range of services while releasing a significant resource to enhance community-based services. That has proved and continues to prove as we go through the pre-engagement and consultation process challenging, because the public and many elected officials believe that hospital services and the status quo are indeed desirable. There needs to be a coming together and an understanding that we are all progressing change with a view to enhancing the population of Scotland in the medium to long term. I can understand the frustrations that people have about the speed of change. We visited Torbay when we were looking at the model of early day agency. Seven years in, they were just beginning to see some changes. We were four and a half years down the route and we are seeing changes in outcomes, and the focus was always on outcomes and efficiencies. We flow from that, but it is a major cultural change for staff and not just some staff across our organisations but all staff. We have to take our staff with us and also our communities with us, so it is really important that we have a step change. We do not see it as a quick fix, and whatever we change, we get the chocks in behind and do not allow us to slip back and make sure that we sustain that change. Otherwise, we will be having the same conversation 10 years down the line. I am actually quite concerned for what I hear from Glasgow and Clyde, because it does not sound as if there is much impetus or buy-in. Maybe I am wrong, but it does not sound that there is much impetus or buy-in on this integration process. I would have to disagree with colleagues. I mean, Greater Glasgow and Clyde had the first joint community health and care partnerships back in 2006. It was the health board that led the whole idea of health and social care integration within the framework that we had in 2006. We are one of the health boards who have successfully, with five of our six integration joint boards, agreed the totality of health and social care and criminal justice systems should be integrated into a successful organisation, because that is where we believe we can make the biggest impact. We have had a series of investments over the past 10 years, which has worked with colleagues in the Government, seen significant investment in health and social care premises. We have opened six of the largest health and social care premises in Scotland in the past three or four years, and we are actively under construction for two, and we have business cases well advanced for the other three. One of our big investments has been in creating health and social care infrastructure and integration. Indeed, as a health board, we have been successfully taking forward, firstly, with our previous acute services strategy from 2002 to 2015, where we closed five major acute hospitals on the back of building new and improved and more efficient healthcare facilities. As I made the opening comment, we are currently out to consultation, which will see more resources transfer, should those changes be agreed through due process, which will see more resources transfer from acute to health and social care partnerships. Can you quantify what resources have already been made available to the IGBs? The IGBs, which were constructed in Glasgow, are now strategically responsible for the commissioning of something like 70 per cent of the board's available allocations. Would you say that the integrated budgets are being used efficiently to achieve the change that is required? In any organisation that spends in excess of £3.1 billion of taxpayers' money, there are always opportunities to improve and to learn. The various IGBs are at different stages in their journey. When my colleague Julie Murray appeared before you before, she intimated that our experience in each furniture has been of a single integrated organisation going back 10 years, with many examples of successful integration. If I look at our experience with Glasgow City, we have had two episodes of engagement with the city, firstly back in 2006-2011, when we had a community health and care partnership, and then since 2015 we have had the shadow and now the formal IGB. Within the city, the impact on that integration has seen a significant improvement in delayed discharges. The city, in its intermediate care and step-down facilities, has been very innovative in seeking to address what was historically one of the poorest delayed discharges performance in the Scottish health service. Do you have a detailed plan to achieve your objectives? We would have to quantify what our various objectives are at the present moment in time. The health board is having to deal with multiple aspects of services, but at the present moment in time, if you look at acute services, and if you look at greater Glasgow and Clyde's activity, in the period 2012-13 through to 2015-16, the last full set of figures, we have seen a reduction in emergency department attendances of just under 2 per cent, which is the positive direction of providing the population with access to more appropriate and alternative facilities. However, despite that, over the same period, we have seen a rise in emergency admissions of some 9.6 per cent, recognising, as the Auditor General's report published this morning, the demographics of the population of Scotland, the ageing population and the fact that, regrettably, with age, we make greater use of NHS services. Against that backdrop, we have continued to move resources, move the emphasis into primary and community services while dealing with the pressure on the acute services. As I keep saying, we have proposals to further redesign acute services, the principal aim being to meet the healthcare needs in an acute environment for those patients that need to be there and create a more comprehensive range of community and primary care facilities for those patients who should not be in the acute setting. That, as the Auditor General's report points out both in part 1 and in paragraph 3 of our report and later on in the report, requires us to take quite bold decisions to move out of institutional care, release that money and put it into community and primary care alternatives. Just turning to Highland, there is just a brief question on that. Obviously, Highland is a wee bit further ahead perhaps than a lot of other areas. How are the lessons that you have learned on the way being shared with other organisations? In many ways, I do not think that they are. Obviously, we adopted the lead agency model for various reasons. Other boards have adopted the integrated board model, which has an entirely different governance process, decision-making process and financial model. Perhaps the integrated joint boards do not think that there is a lot to learn from the lead agency. We do think that there would be opportunities for sharing because, albeit that the structures are important, this is about systems getting along together. Just picking up your first question, Mr Beattie, I think that all that we managed to do when we achieved integration in 2012 was to bring two structures together. We did not deliver integrated services, we did not cut out duplication, we did not put in preventative responses. It is the change that has been possible given that structural change that we have then had to work through. Whether you are an integrated joint board or whether you are a lead agency, you still have to put those process changes in place and you still have to bring people together. I would suggest that there is lots of room for learning there, but I do not know if across Scotland there has been much sharing to date. Is there any mechanism in place for this? Is anybody managing this? There are lots of different groupings. Social work directors come together, education directors come together, chief executives of NHS boards come together. We do not have a single forum where we discuss integration strategically as a collective. There are chief officers of the IJBs, but I do not think that we are having that strategic discussion. There is no formal process for sharing the experiences that different areas have. That sounds unfortunate. I think that the biggest advantage is bringing the IJB chief officers together. We are part of that, although we do not have a chief officer in that same way, but we do input to that. I think that that is probably a forum that would be very useful for people and is welcomed by everyone to share. I want to quickly interject and ask the same question of Glasgow and Clyde. Is there a forum for IJBs to share their experience if they are not in Highland? Is there in your area? There are. The six chief officers meet regularly as a collective to look at the balance of locality needs and planning for localities versus interacting with the board with a population of 1.15 million to make sure that we do not have postcode prescribing and that there is a broad consistency of direct travel and that interaction with the acute service is a single entity within Greater Glasgow and Clyde. The six chief officers act as a collective and we also have where services are small and are provided across the board. Those are embedded within the lead agency approach within one of the IJBs so that a single chief officer would be, for example, Keith Redpath as the chief officer for Western Battonshire, is responsible for board-wide muscular skeletal services physiotherapy in the community across all six partnerships. The chief officers, as Jan has alluded to, meet regularly with colleagues in the Scottish Government health department under the auspices of Geoff Huggins and Paul Gray to talk about opportunities in learning but also to learn of challenges and difficulties. So there is a number of fora within which IJBs can interact and learn and, obviously, Audit Scotland and their role along with other external agencies bring forward examples of good practice, which is commended to the system. Liam Kerr Thank you. Good morning. I am interested in the people issues and particularly the role of the GPs and staff. The report talks about how GPs are central to developing new types of care, pressures building in general practice that we know about and it suggests that new models of care are needed. What are the new models of care, precisely, and how do you see the development of GP recruitment and training being adapted to those new care models? We acknowledge the role of GPs and all of our staff and the developments around community care. Developing a community service has been central to GPs at the heart of that. We have a number of different models, community huddles and virtual wards that involve GPs and the extended community care team to ensure that we are proactively managing patients within the community, particularly vulnerable patients. Recruitment of GPs and consultants is a challenge for all of us across Scotland. We are looking at different models of delivering what would be traditionally GP care. We have to realise that we cannot be person dependent on one profession. That is a multi-professional approach. We are looking at where practitioners and enhanced practitioners in the community might be able to supplement GP practices. It is a huge issue for communities in Highland. People feel very attached to the GP and want a GP in their community. We have to work closely with the communities on how we take those models forward to ensure that they realise that a safety element is still there. That might involve some kind of double running, but it means that we can demonstrate that the model is safe for them and that they will receive a good-quality service without the dependence on the GPs that perhaps have had in the past. It is widely accepted that GPs need to be fundamentally at the centre of developing a preventive culture and a community primary care-based service to the population. There are numerous pilot examples across Scotland to look at how GPs would fulfil that role. Professor Sir Lewis Ritchie once described in relation to his report for the review of Out of Ours. He talks about the general practitioner of the future becoming the conductor of the orchestra and not the soloist. It is all about multidisciplinary working. The Government has supported an initiative to recruit a significant number of additional pharmacists, the aim being to try and embed pharmacy in the general practice where those clusters of GPs come together to work in practices. There is a whole issue of the working—some colleagues refer to it as working at the top of your licence so that nurses, allied health professions all do more to take on a workload as part of the primary community service alongside the general practitioner. There are a number of initiatives taking that forward. The impact that that will have in GP recruitment should be positive. However, GP recruitment is a multifactorial issue at the moment as to why we are encountering the position that we find ourselves in at the moment. We need to work effectively from the university going forward over the next regrettably five to ten years to put primary care front and centre from day one in the medical schools and then much more right through the whole services that we go into the way forward. I saw from reading previous evidence that there is a whole issue of the GP principal as a private business model into the 17C contracts where they are salaried part of a team. All of those things will have part of a debate as we go forward. They will all impact on primary care differently in various health boards whether that is to do with the remote and rural aspect, which the Government has been seeking to address with regard to increased recruitment and the premier that has attached to general practitioners who undertake training for a remote and rural practice. Right through the way through to recognising that we have a changing workforce, we have a significantly greater proportion of medical graduates or female who have different expectations of how they want to plan out their career. We need to be aware of that and we need to work with them to make sure that we create career opportunities within Scotland that fits with that changing demographic of our workforce. I will come back to that if you do not mind in a second. John Baird, you particularly point out that this is a challenge for all across Scotland. Are you aware, is there or is there going to be a nationally co-ordinated approach to recruitment and training at any point? I am not aware of that. I am sure that there needs to be and I am sure that there will be. The models that Mr Caldwell was referring to, particularly around salary GPs, are something that we have started and we are exploring, as well as our integrated teams in the GP having that single point of access. I think that it is a very important point about training of GPs and expectations of GPs and other professions in the future. We still seem to be training people in silos. We do not work in silos anymore and people are coming out and having to re-learn how to work. That is extremely challenging for a health board when we have to continually keep the system moving because they come out with expectations of working in primary care or secondary care, working in a particular way. I would really welcome the opportunity to have some time with our universities and training colleges to encourage them to think about this legislation and the joint working that we expect in the future. I think that that is an important point. The committee knows that I have a thing about scenario planning, modelling and things. My penultimate question to you is what workforce planning is being carried out? Mr Caldwell talks about the time horizon of five to ten years. Why is that the time horizon? What scenario planning is being done? What modelling is being done to look at the needs of the future? I think that there are two aspects to that. First of all, NHS Education Scotland is responsible for working with the Government and colleagues in higher education across the universities to look at the educational component and the intakes to the medical schools, nursing colleges, etc. There is a central co-ordinated body within the NHS Scotland that creates that conduit to have the dialogue with the higher education sector and set out the needs. Also, in the Scottish Government health director, Shirley Rogers, who is director of HR and organisational development, has a significant role in co-ordinating the individual health boards, workforce planning scenarios and making sure that they are in inverted commerce future proofs with regard to how we deal with succession planning and future recruitment. The point that I made to set that in context, we have a shortage of GP principles. We have an inability today to fully recruit to the training opportunities that exist in Scotland. Those two issues will only be addressed in the medium to long term by making general practice much more attractive within the medical schools and therefore in the career development of medical graduates. The short-term issue of making Scotland more attractive to existing general practitioners is an issue that we need to look at in discussion. That again is being addressed to Governments looking at the long term with regard to increasing number of GP trainees and to create incentives to be the kind of general practitioners that Scotland needs to take into account with its geographical constraints. In the short term, the Government has been taking forward pilots in various health economies across the system, whether it is a deep end practice initiative that has been working in some of the areas of deprivation within Greater Glasgow or other initiatives that other colleagues and other health boards are taking forward. That is again looking at working with the general practice population today to make it more safe, sustainable and desirable. I mentioned Professor Sibley, which means that he was commissioned by the Government to look out of hours. Out of hours has been, since 2004, when it was no longer contractually an obligation of general practitioners to look after their registered population list. We have seen out of hours as a fundamental part of general practice decline. If I use Greater Glasgow and Clyde in 2004, we had some 650 plus general practitioners register to take shifts on in the out-of-hours service. That is down now to just over 300. Despite the fact that the number of general practitioners within Glasgow is probably—I do not have the exact numbers with me, but it is higher—we have more general practitioners working within Glasgow tonight, but fewer of them will now register for the out-of-hours. That puts significant pressure on the out-of-hours service, and that is the point that I was alluding to about having to understand the work-life balance and aspirations of our current and future workforce. We have a workforce plan that takes us to this short and medium and longer term, looking up to 2035. We are focused at the moment on testing new models. We think that it is really important to test out new models and to give support to existing GPs, recognising the retirement rate that is coming towards us. Building the flexibility of the roles, giving them more support to those GPs, and we have a specific out-of-hours, specific redesign, looking at how we deliver out-of-hours differently. All of that work is driven in the communities, but also with colleagues and partners in Scottish Ambulance Service, for example. The report makes a number of recommendations around the 2020 vision and suggests that, by the end of 2016, there should be a clear framework, including around predictions of supply and demand with recruitment and training plans. At the end of October, have the Scottish Government provided that clear framework of how it expects the NHS boards, councils, integration authorities to achieve the 2020 vision? I do not have specific information on that, I am afraid. I know that we are working to the 2020 vision and our own local plans reflect that. I would have to speak to colleagues to get their information from our HR colleagues, if that is helpful. I think that from that particular question, I would make reference to two points. I already alluded to the fact that Shelley Rogers, as co-ordinator, is bringing together all of the health board's workforce plans into a coherent whole that will look at the needs for Scotland over agreed time horizons going forward. I think that, when Paul Gray gave evidence to the committee, he alluded to the fact that the Government has a commitment to publish that by the end of the year. To the best of my knowledge, that is where all the organisations are working towards that position. In the Audit Scotland report, changing models of health and social care, we see that councils and NHS boards, in general, are finding it difficult to agree budgets for the new integration authorities. I wonder if you can say if that reflects your experience in Greater Glasgow and Clyde and Highlands? From a Greater Glasgow and Clyde perspective, I think that all six IGBs recognise the difficulty that we had in the first year because there is a significant gap in the timing between the approval of the draft finance bill and the ultimate allocations to health boards, which have traditionally been from a draft finance bill towards the end of September and early October through to Parliament approving that in early to mid February. Health boards do not get definitive allocations until after that process, so normally my allocation letter from Paul Gray as director general would be early March. This year, in 1617, that process was extended because of other issues, so it was mid to late May before the health board was in final receipt of its total allocations and, therefore, gross income for 1617. Throughout that process, the chief financial officers, along with the chief officers of the IGBs worked collectively with the boards, executives to deal with the scenario planning that underpins utilising those resources to meet the needs of the population. If you expressed the question of whether people have welcomed more funding to deal with the challenges that they were being confronted with, the answer would be undoubtedly yes. All of my colleagues would welcome more resources to deal with the challenges, but the process this year was full transparency throughout the process. Although there was a greater certainty in the period of October and in councils taking definitive decisions at their meetings in early February, there was the same transparency of risk in the health board position. We made clear and chief financial officers were involved with Mark and his colleagues in looking at the 15-16 expenditure that the board had for all services that were now embedded. They saw the roll-over of those allocations, the uplift that the health board had received and the Government priorities. We debated how we would use the resources to deal with inflationary pressures and the Government priorities for 1617, which resulted in a service profile that is underpinned by that financial resource. Explain to me how long it took to set the budget and when it was set. The final budget to the IJBs was in writing set at the end of June after the board's LDP and discussions with the Government were concluded. The board's annual accounts for 15-16 and the roll-over consequences of that were agreed with our external auditors, which in our cases is Audit Scotland. Highland partnership, is it difficult? Absolutely. It is probably the thing that is the most difficult. Have we managed to do it? Yes, we have managed to do it. It is difficult for the reasons that Mr Coderwood has said. We have got two separate channels of funding that have to be brought together. Mr Coderwood has talked about the timescales. It has not helped by the fact that we have a single-year budget setting. Highland Council gave NHS Highland a three-year financial commitment and this year we were not able to honour that because of the significantly different grant settlement that there was for this year that we only understood very late on. It is clearly difficult when there are either flat or reducing budgets at a time of increasing and significant demand. It is also difficult when the channels of funding have to be spread more widely, so for the council, the channel that the council gets has to fund adult social care, but it also has to fund filling potholes. It also has to fund the running of schools, and therefore politicians have very difficult decisions to make. All of that is very challenging. We have managed to do it in part because we have structures, but in large part because we have relationships and you work through it, and ultimately because the greater imperative is to achieve that and to keep going because you can only deliver an integrated service if you do resolve that challenge. Probably it is that final overriding issue that hangs in there. When you walk away at seven o'clock at night, still not having quite sorted it out, you do not say, well, we are just going to stop, we are going to chuck it. You say, no, we have to get through this, and you just keep working at it. Highland Council included in its February budget meeting what the allocation would be to NHS Highland, and NHS Highland knew in advance of February what that was likely to be, but it was not easy to get there, and it is not going to be easy to get there this year, either. I appreciate that you have been very open about the difficult challenges. I am right that, in both cases, you have been able to set your budget for this year, but do you have a budget for next year or an indicative budget? In Highland, we are working on a scenario, we are a scenario planning, but that is based on assumptions about what the council's grant settlement might be, and it is based on assumptions about what the NHS might get. We will not know till December whether that is true. Those assumptions will be discussed, and at various levels in the two organisations, senior officer level and elected member level, will talk those through, but we will not know till December how much money we will have in both organisations. It will not be until December that we will be able to conclude those discussions in advance of, again, a February budget for the council. We have a budget for 2016-17. We are coming to the mid-year point that we are performing some detailed review of that, and that is proving quite challenging. We are not out the budget for 2016-17, but we have a budget that has a number of risks in it. In terms of 2017-18, as all my colleagues have alluded to, we did attempt to try to bring that planning process forward to align much more with local authorities, but we still have some way to go with that. We will, at NHS Glasgow, plan to issue to our IJBs some indicative numbers within the next 10 days to two weeks. They will obviously be heavily caveated, depending on a number of different factors. The out turn from 2016-17, the budget will come in the middle of December, so we are striving to try to get to a much more aligned process, but it does have its difficulties. Add to that that we all strive to have a longer plan, a three-year plan, so that we can get on with the business. That takes up a huge amount of energy and time of officers across the council and in the NHS debating and deciding. It is a very important decision, but it is taking a lot of time to do it every year. If we could get to a stage where we could agree a three-year plan and be clear about what our budgets are going to be and let us get on with it, I would be welcomed. Bill, you pointed out about the late nights. I am sure that you are all working very hard against the clock, but when you are working those long hours and you are just trying to get that all signed off for the year, when you look at the scale of transformational change that you are trying to achieve, do you feel at all optimistic that those outcomes can be delivered when you are talking about the scale of challenges that you are facing? Absolutly. Although there is still that challenge, we often refer to Jan and I meeting with councillors at the end of last week. We tell the story that Jan and I used to meet at breakfast, we used to meet at lunch and we used to shout at each other at tea time every single day to try and run joined-up services. Joined-up services are better than silo working, but they are very bureaucratic and they are very laborious. In terms of bureaucracy and hassle, it is a hell of a lot of work. Having an integrated arrangement where you just let one system get on and do it is much easier, but there is still hassle and there is still bureaucracy. The budget setting is one of the greatest challenges. We have got to meet at work because there is no alternative. We cannot continue to do what we have done in the past. We have to make it work. When we launched integration in 2012, the plan was a joint board and joint council, a complete sign-up to it. Everyone agreed that it was about making things better for the people of Highland and that is what we have to hold on to. I have to say that health and social care integration is a very needy way to address the challenges of the Scottish population going forward. Therefore, as a structural change bringing together health and social care and looking to plan them from a bottom-up locality basis is absolutely the right building going forward. What we have to do is be bold in that ambition and understand that we are going to have to take quite sizable changes in the way that we meet the population's needs. If I could reference this to the past, the last time we embarked on anything probably ambitious was in the early 90s when in mental health and learning disabilities we all agreed that large hospital institutions where people spend in ordinate lengths of time years and in case of learning disabilities lifetimes in institutional care was undoubtedly wrong. We were more able in those days to create what was referred to as bridging finance where we were able to roll a programme out across Scotland using a rolling programme of bridging finance to create the alternative community facilities and then, with the new facilities in place, run down and ultimately close mental health institutions and learning disabilities. To put that in context, in a period of less than 20 years, just within Greater Glasgow and Clyde, we have gone from almost 3000 learning disability beds now to less than a few hundred. We have gone from something that would have been in the region of 5,000 to 6,000 mental health beds down to literally 11,000 to 1,200. The service is significantly better with it all being community-based, all about intervention, all about prevention. That is an indication of what you can do. We have to achieve the same effects in a more constrained financial environment, but it is about making those bold changes into community and prevention and taking out the costs from the institutions. That, I have to say, across the piece, is going to be what will dictate the pace of that. It is when you can bring clinicians across the piece together to say that they genuinely believe that the alternative is better and that we have to be able to make that resource switch. Therefore, we have to be bold in switching off what has been the custom in practice. Thank you. Robert Ehrleron, you said that it was about emergency admissions that was always a 10 per cent rise. I think that that was from the period from 12.13 to 15.16. I wonder if you can say in that context how pressures on acute budgets are affecting the shift in resource that is needed? That is the rate-limiting factor—a present moment in time in this financial year, in 2016-17. Our acute services are overspending against the budgets allocated, and that is brought about by two principal reasons. One is that the demand is changing. In some cases, that might not be the numerical demand. It is the acuity of the patients coming into the system. It is the ability that we have to treat the patients differently and more aggressively with changes that have been made within the Scottish Health Service, changes that have been made with regard to access to end-of-life drugs. Those are all very important changes to individual clinical groups, but cumulatively, they have been behind, as Audit Scotland has alluded to in its report this morning, a 10 per cent year-on-year rise in prescribing costs. Although an element of that is the volume going up, a large element of that is that we are now prescribing very, very expensive, and what we would refer to as third and fourth-line treatments to patient populations. The acute sector is one of those conundrums. If I was to set it down in Glasgow, we use less occupied bed days. If we have patients in hospitals for less, if I take the same period, 12, 13 to 15, 16, we have reduced the bed days that we use for that right. Although the population of admissions is rising, they are in hospital cumulatively 6 per cent less days compared to the period. That is clinical teams interacting with the patients, making use of faster access to diagnosis, making greater use of interaction with social care colleagues for onward movement into community and ultimately back to their own home. That is at one level a success story, but the cost of that is significantly higher than it was in 12, 13. Despite the successes, we still have cost pressures. In acute, we need to continue to redesign acute services to strive to get the greatest efficiency. There are many success stories over the years. The problem is that we now have to take stock of where we are now in 2016. The previous success stories have only got us to where we are today, which is close to but not necessarily in balance. Increase in emergency admissions is not success, is it? I am saying that we can handle that 10 per cent increase in admissions in the expectation that it will go down, but we can handle it at the moment in a more efficient way. The clinical community in Scotland would sign up to handling the current demand in a different way within acute services, which would have the impact of improving efficiency and improving care for patients, but it would not be on the basis of how we do it today. It would be using our premises, our staff differently. How much does that overspend? For Glasgow this year, as an accountable officer, I am not allowed to overspend. The official answer is that I will not overspend the third first of all. The pressure at the moment is that we are currently, as we have said to 2018-16, at the acute division that is about £9 million overspend. Can I give you some examples in terms of Highland? I think that we all feel similar pressures with the demographic. We have focused and been able to do so because of our lead agency model on improving the community services and enabling better choice for GPs or integrated teams when it comes to decision about to admit or not to admit. That involves anticipated care planning, virtual wards, where consultants from the hospital and GPs and community teams plan together around the vulnerable clients and patients that they have in the community to try and make sure that measures are in place to prevent admission. Having those choices for GPs has made a big difference. We now have no patients waiting coming out of hospital for care at home because we have been able to work with our independent sector, improve the way that we deliver care at home and have patients moving more quickly through the hospital for care at home. It is not at all a good news story, but for care at home that is a good news story. That also helps a reactive service that helps to put in that emergency or crisis care rather than somebody ending up in hospital, which is part of the problem really. I just ask what are your long-term plans for transferring resources from the acute sector into the community? As I said, we are developing our teams in the community to work differently and to work with our colleagues in acute care quite differently. We have seen quite a significant shift over the years since we integrated, we have put a considerable amount of money into community care. The difficulty, I guess, for colleagues sometimes is to say, where is the money coming out of the acute sector, but of course it is not a level playing field, so we still have an increasing demand. As Mr Calderwood said, we have expectations around new medications and new interventions, so there is still a huge demand on the acute sector. We have shifted, so in 1112 we had a £70 million gap between our expenditure in community and institutional care, and in 2014-15 that was reduced to £26 million. We are seeing that we are investing in our communities, keeping people in the community and preventing those hospital admissions unless they are absolutely essential, and that makes sure that the hospitals—again, Mr Calderwood referred to people working to the top of their licence—hospitals are actually treating people who need to be there and have that level of care. Just one final point, convener. I think that someone made the point, I think that it made it in Robert earlier, about some resistance to change from perhaps local politicians, people in the community. Can I ask both of you what steps you are taking to engage with patients in communities to bring people on this journey with you? We are engaged on a whole range of initiatives. The IGBs, through their public engagement responsibilities and their patient panels, are actively engaged on an on-going weekly basis through that process, and that is to be a locality cluster that is built up. There is a significant engagement with the staff, through primary care community staff about alternative models and within the acute sector about opportunities. We provide regular interaction with our elected colleagues through the IGBs in relation to councillors and directly with MSPs on a newsletter basis or in an individual request for information where we meet. All changes that the board is proposing are signalled in our annual planning round of future changes and, depending on the changes, there is a comprehensive range of engagement and informal consultation that has to take place with the service users, with the communities and again through that process with the elected officials, all of which then results in final papers and recommendations coming back to the board, and in some instances the board makes recommendations to the cabinet secretary. On a personal basis, the vast majority of us, for ourselves and our families, would prefer community-based solutions. We often say that people would much rather stay at home than go into a care home. They would much rather be supported within the community than be admitted into hospital. Having said that, there is no doubt a challenge when it comes to reducing the number of beds or even closing a ward or closing a hospital in your particular community. That creates a response. That is something that we need to work through. We do that in a range of ways. We do endeavour to engage community groups, locally-based organisations, patient service user representatives in some of those change processes. We have a range of improvement groups and we have broad stakeholder involvement in those. Also, one of our success stories has been that when we initiated integration, we developed a range of what at the time we called district partnerships. They were locality planning groups and we endeavored to get community organisations based in those to talk the change through in those processes. That has not been an easy journey. The notion of locality planning groups was included in the public bodies bill. We now have the Community Empowerment Act and we are transforming our district partnerships into local community partnerships. We really do think that if you start to engage with people around the table over a cup of coffee talking about those things, you can change the way of thinking about it and we have some evidence of that. That does not mean that we still have major challenges with communities who see significant changes in the local infrastructure as being very worrying and very troubling. We always have a number of examples of those. When you have that feeling, it is difficult to recover the ground. It is difficult to get back to basics. It does need a lot of dialogue. Wherever possible, it is best to start with that dialogue in the first place, not to come to people with a plan but to talk about developing the plan around the table with people, but it is a long road. Bill Alexander, you said in an earlier response to Monica Lennon that integration makes things easier but two separate budgets and budget agreement does not. Are you suggesting that integration needs to go further? The integration journey has been an interesting one. Through the noughties of the 2000s, we all talked about getting to an integrated destination and when would that happen and what might it look like. I do not think that any of us believe that we are at the end point just yet. We are now well down the road. Unfortunately, no-one ever gave us a map so we do not know where the next turning might be. We have a compass and I think that we are all working in a particular direction. Clearly, there is a number of continuing developments. There is discussion around NHS governance, discussion around education governance, there is discussion about funding arrangements, there is discussion about the role of local government. All of this is going to play into this. There is discussion about local versus central. All of that will play into this. We believe that we are now in a place where we can consolidate, where we can sustain and we can continue to move forward. I have to say that discussions about regionalisation, discussions about changes to local governance are troubling and unsettling. I do not think that any of us think that we are at the final destination point. We do a lot of work in the north with our island colleagues and they certainly have aspirations towards a single public agency. They think that a single funding stream will be more helpful to them than two funding streams, so that is more difficult to achieve elsewhere. I do not think that any of us think that we are at an end point. Does there need to be better governance around IJBs? It is not for us to comment on IJB governance. We would suggest that the governance model that we have has clearer roles and clearer accountability. I would suggest that it has clearer roles for elected members, because the elected members act as elected members. When they are scrutinising the delivery of adult social care by NHS Highland, they are doing that as the council. There are fewer of them and that has been a challenge and probably a challenge that we underestimated when we moved towards integration, that when you move towards an integrated model, yes, you are enlarging the governance because you have governance over a larger remit, but also you are reducing it because you are sharing it out more broadly. Therefore, instead of, for example, I would work with 22 members at a committee, we have 11 members who now scrutinise the delivery of NHS Highland's delivery of adult social care, but they do act as elected members scrutinising the delivery. I think that they are confident to act as elected members. I am not quite sure what the elected members on an IJB think the role is and whether that is worked through, but we have gone through different iterations of governance. We started off with a model in 2012 and we have just changed that this year and we will continue to review that to try and get that quite right. You said that no one ever gave you a map for this. Do you think that there is a need across the country, across Scotland, for clearer targets, benchmarks, best practice, sharing for integration at national level? We welcome any strategic discussion like that and, as I said earlier, there are lots of different groups meeting in different places. I was with the Association of Directors of Education two weeks ago talking about integration. I will be with chief social officers next week talking about integration. There will be another meeting with chief officers of IJBs talking about integration. I just think that it would be good if we had an overall structure talking about integration. We would also make the point that when we integrated in 2012, we did it for Highland. I remember Mr Neil on many platforms in 2011 talking about developing and thinking about integration on the back of what was starting to happen in Scotland. However, we did it for Highland. We did not do it as part of a national initiative and we worked at our model for Highland. It would have been great to have had a map that we could have then highlandised in order to get to where we wanted to get to. In terms of support, the significant shift that is difficult for staff, difficult for evidencing and difficult for Government is how you evidence outcomes. We are still asked information about how many social workers we have or how many nurses we have, which means nothing if they are all not good at their job. It is how we make sure that the indicators and the targets that we have reflect the outcomes that we are trying to achieve. That is very difficult to do. Government has been working with that and helping us. We have just redesigned our performance management process and our balance score card to try and reflect a link right back to the health and wellbeing outcomes, because that is what we all aspire to deliver. However, it is actually very difficult to decide whether integration is wholly attributable here or is it a contribution where we do all the other things that we do. Undoubtedly, all the other things together may cut the jigs so that they achieve the outcomes. However, taking them apart and trying to have indicators or targets against each of them is problematic and difficult to evidence. Bob Culdor, do you agree that there needs to be a map or an overall structure? I think that there needs to be a clear understanding of direction of travel and potentially some vision of some stations that we will pass through on that journey. There has to be the opportunity for local innovation. Is that any of the stations? There will be a combination of that. I think that the Government has a significant role in setting the direction of travel for the health and social care services in Scotland as part of the public sector landscape. I think that the bottom-up innovation that is a core principle of the design of the IJB should not be lost. Although we have to watch that we do not have 57 varieties of everything because there is an issue of equity for the Scottish people, we should not have a single model that fits. If I look at Glasgow, Greater Glasgow and Clyde, I look at Highland, we have two different models. Where we are with our six IJBs is that we have, amicably with council colleagues created the Government structure, created the service delivery organisation and, albeit in their first year, I have had no instances reported back to me or my fellow local authority to be given that I have had no instances reported back where the IJB, as a governance body, has not collectively come to. In fact, I think that I have only had one debate reported to me on one IJB where it went to vote in all other instances. The policies and the way forward have been jointly agreed. Going back to your first question, are we at an end point? No, I think that the current legislation, the current organisational construct will mature and I think that some of the duplication between the parent bodies and the IJB will mature and potentially develop over time, which may require a tweaking to the regulation, but we need to learn. The end point was not my question, it was, do we need more guidance on how to get to that end point? Well, as I said, I think that we need to be quite clear collectively where we are going so that each of the IJBs and their respective parent bodies can demonstrate that they are on a progression to that point. Alex Neil Can I just go back to budgets? Obviously, money is absolutely vital to the whole thing. Are we now at the stage where, given what you have said, and I appreciate what you are saying about the time and the effort and the managerial time and the uncertainty going into the negotiations in 31 different partnerships across the country, has the time now come for the Scottish Government itself to change the way in which it allocates money and for it to take the IJBs and allocate each IJB a budget so that the social work element, the social care element, which currently is in the local government settlement and the health element, which is currently part of the health budget, come together and we have a national level if you like, an IJB support budget that is then allocated to the 31 IJBs so that that means that you do not have all this negotiation and all the difficulties. It is allocated at a national level and presumably also given that we are now moving back into a comprehensive spending review over a three-year period, based in particularly what Jan said clearly, the certainty of knowing in the next three years that the minimum of money that you are going to get would be extremely helpful as well, but it seems to me that we are almost at the stage where we should be allocating directly the IJB budget, which would take all of this nonsense out of the system. That would be a debate for Parliament. I think that looking at Paul Gray's evidence to the committee at the moment, the Cabinet Secretary for Finance brings forward the finance bill to Parliament to debate the utilisation of that gross resource and then it is allocated to the various public sector priorities. Within health, under the Cabinet Secretary for Health and Social Care, there is a debate about how that has worked and then once that allocation to territorial boards is agreed, it is distributed under the NRAC formula and again a lot is made of that formula. Those of us that are losing obviously always have views about whether the formula is really reflective of our circumstances. It is always thus, but it is a recognised formula and then it comes to the health board. I can only speak for Greg Glasgow-Clyde, but the health board then has cognisance of the NRAC formula so that if we get a gross allocation for a 1.15 million population based on those characteristics, we can then subdivide that down to the six IJBs using the same formula, so there is an element to try and be transparent all of the way through from the Parliament to the IJBs. To thank you for your second question, it is a personal comment, I have to make this. I do not think at the moment the current construct of the IJBs with their strategic commissioning role for acute services can work in the model where all of the resources are not in. I was going to say the fudge, but the grey area in strategic commissioning of unscheduled care in an acute setting with the health board in its current construct being responsible for acute care and the balance of acute care, which is the semi-elective care and the regional tertiary model. That would be very challenging for Parliament to work all of that out and then come to a decision between that element for primary community unscheduled care and therefore what is left is for the rest. You would have to work through that governance bit, but if you were to look at true health and social care in primary community settings and taking into account locality needs, you would have to work through that as a formula. Is that not because you are a joint board or six joint boards, Robert Whale, as Highland is one now? If we take the Highland model, would that work with the Highland model? I will just offer you one comment, which is that Highland is the least single. It is not actually single from a health and social care perspective, because the Caroline Bute IGB gets about 80 per cent of acute care from Gary Glasgow and Clyde, simply because of the geography and the flow. If you look at the six or seven, I think it is six, health boards that are co-terminates with their local authority and therefore have a single IGB, then absolutely, if you put the totality of the funding in, you could work from a parliamentary level down and look at the totality. What that suggests—again, I stress this in personal—is that you do not need three legal entities to do that, if that is the model that you choose. If you look at Gary Glasgow and Clyde's extreme example, where we provide acute care for, in essence, ten IGBs, six or ten with our boundaries, but because of flows, we deal with Argyll and Bute, we deal with South Lanarkshire, we deal with North Ayrshire because of the geographical flows into our basic acute services. That model would be highly challenging to collect almost on a purchase provider old-speak way of collecting money from these bodies to then arrive at a budget to then design the acute service that the board, if it existed, would be responsible for commissioning. The debate has merit in it, but it would have to be part of a journey. The current construct could not switch to that, in my opinion, overnight. We would really welcome discussion and Scottish Government reconsidering that given the issues that we have raised today about timing and the desire and aspiration that we still have to lose the identity of the pound, which of course was in the legislation guidance, and the aspiration to move to that health and social care pound all in one. The other challenge, of course, is the local authorities having in terms of the other aspects of their budgets and where the cuts fall. Some areas of local authority budgets seem to be protected. Are we going to be looking at adult social care in the future being protected, given the demographic, given the change that we need to make? Currently, if there are a number of services within councils that are protected, then the cut falls higher across other services, and adult social care sits within that. Elected members have very difficult decisions to make, so we would welcome Parliament thinking differently about allocations of funding. On the back of what Jan is saying there, that elected members in Highland would certainly want me to say that we need to think about local democracy and the role of the elected member in their community to decide on local priorities, and they certainly would not want that to be lost. Let me rephrase the question then without saying that that is necessarily the answer in terms of a straightforward budget allocation from the Scottish Government to each IGB. First of all, from what Robert said, it is quite a complex relationship as things stand, particularly in Glasgow, when you are dealing with the boards dealing with six IGBs, not to mention what you do with Ayrshire and all the other bits and pieces. Let me rephrase the question. Is it time, given what you have said about the frustrations of the current way in which the moneys are allocated? Is it time for the Government now to be looking at doing that in a better way without defining here what that better way is? The army of finance people with all due respect, the army of finance people with all the different finance departments in the health service and in the local authority sector, is a use of resources that is not probably the best use of resource in terms of employing a lot of accountants when we need the money to go into the actual services for patients. Is there agreement between both of you and its very different systems operating in the Highland and in Glasgow, but is there agreement that we need now is the time to start looking at this to see if it can be simplified and made more straightforward, while at the same time ensuring that resources are allocated on the basis of need? I think that there is merit in continuing the dialogue to see how firstly we can move to that longer time horizon of setting a certainty of budget over the three-year period that we aspire to so that the respective organisations planning can be presented to the communities, to the public, with that certainty of direction of travel and consequence and movement of resource. I think that there is an element of duplication in the current system and it would be worthy of review after a period of time to see whether that duplication can and will be eradicated just by relationships, as Bill has alluded to, or whether there is the opportunity to streamline the thing. However, I come back to the point that I think that we have all made. Health and social care integration, leaving to one side the governance model, is undoubtedly the only way that we can address the demographics and the needs of the population of Scotland going forward because they have absolute, almost linear, consequences between each other. They have to work in partnership. We all are aware of stories of families interacting with multiple professionals who are capable, individually, of doing more. We need to enable that. We refer to things such as the one-stop phone call, the GP, phones at a certain point, to get the range of services that family needs, not 14 phone calls. The whole idea of a district nurse coming into a family should be able to commission the social care, the elements of the family. There should not need to be a referral to another professional to come in. I think that we are all agreed that we are all agreed that we are going the right way. Can I ask you, Bob, particularly because you are the chief executive for the long experience in the NHS. Clearly, there is a debate going on about the number of territorial health boards that we have. We have got 14 territorial health boards, and there is certainly a view in some of the other parties that have expressed this officially that we should go back to the days when there were three strategic health boards allocating resources to the various bits of the health service. Would it make life easier? The very good example that you gave of the complexity that Greater Glasgow and Clyde has, because even though you are Greater Glasgow and Clyde, I am right in saying that something like 40 per cent of all health care funded through the health service in Scotland is funded in one way or another through Greater Glasgow and Clyde health boards. Would it make sense now to, in looking at the conversation about the allocation of resources and making life easier for everybody, per the evidence that we have heard this morning, to be simultaneously talking about the rationalisation of the number of health boards? Would it make life easier? I am not sure whether a nurse in the UK is throwing me those questions. I know you are about to... I know you are about to... I hope that the last appearance for the committee will be my infamous appearance for the committee. I am just about to say, I am just about to retire. You do not need to stick to the party line. Well, that is also that as well, of course. What I can see too is that when I joined the national health service, there were four regional health boards for Scotland, and their specific responsibilities were to plan for acute services. The interaction with the local authorities around public health and community aspects was clearer so that there is precedence in that. We are not reinventing something, we are not inventing something that we have been trying to do. Where we are at the moment is if you look at the IGBs as being strategic entities that can develop and need to develop using that resource, there is an overlap in that role with the current health boards, which needs to be reviewed over time. I think that if you look at Angus Cameron's national clinical strategy, which is the Government of adopted, it talks much more about planning for populations, removing artificial boundaries, and if you look at the challenges that we have in acute services, there is no doubt that for acute services and the elements of special services in mental health, etc., you need bigger populations than the 31 IGBs have to make those strategic planning decisions. When you look at capital investment in a country like Scotland, you cannot look at capital investment times 31, and you need to look at a much more strategic map of Scotland. In my opinion, there are issues that take certain aspects of responsibilities for bigger populations. Whether you achieve that in a kind of codifying of health board responsibilities to act collegiately through a regional overarching network, or whether you take the view that you want to look at the public sector landscape in Scotland and come up with a more streamlined version, I think that there is much to commend that discussion. It is a significant debate and there is Mr Caldwood alluded that it would be difficult to get into some of the more sensitive areas, but I suggest that there are some things that are best done at a very local community level. There are some things that are best done at an authority-like level, that is not to say in the current authority boundaries that we have are perfect, but there are good things done at that level. There are some things that should be done at a regional level, but our experience would suggest that transformational change needs to be done at a local-ish level. The co-terminosity of the Highland Council area with NHS Highland allowing the chair of the board to meet regularly with the council leader, allowing the two chief executives to meet regularly, allowing senior officers to meet regularly, that has provided a platform for transformational change. I find it difficult to conceive how that transformational change would be achieved in Portree or in Vanessa or Dingwall if the decision-making was in Aberdein or Dundee. There is an underlying theme in your earlier evidence, and it referred to Colin previously. It seems to be a bit of a vacuum in terms of the need for a more business plan nationally, not just for integration but for acute services and so on. If you look at NHS England, for example, it does not just have a vision and a strategy. It has, at national level, a business plan that says that this is where we are going to shift resources from, where we are going to shift them into and it is a much more detailed approach, bringing together into one document workforce planning financial allocations, the strategy for shifting resources from the acute sector to primary and to the community and so on and so forth. I tried to initiate that when I was the health secretary. I would not go into any other detail on that, if it would be right to do so, but it seems to me that we are operating without that national plan that many other parts of the United Kingdom have. Secondly, as you have already referred to, financial allocations are on a year-to-year basis. Operating a budget in Glasgow is a case of around £3 billion a year. You do not get the allocation letter to about 28 days before the start of the new financial year. You do not have yourselves a detailed business plan for the next three or five years, because you do not know how much money you have for a start. It seems to me that there is quite a lot of improvements that the Scottish Government can make to the framework in which you are operating to help you guys to do your job. We are back on to, and we have not been for a while, on a three-year comprehensive spending review so that we know, as a Scottish Government, what our allocation is going to be. That might change in the autumn statement, but at the moment we know what the allocation is going to be for next year, the year after, and the year after that. If we could pass on that degree of planning, would that not help you guys so that, at least, you could plan three years in advance instead of getting 28 days notice of what the next year's budgets are going to be? The more we are able to plan long-term, the better, and the more the certainty we have around funding and everything else, we do lots of needs assessment and assessment of demographics locally so that we know what the challenges are going to be going forward. We know about the changes that we have to make. I shy away from a plethora of plans. I think that we have been there in the past. It is certainly helpful. Is that not the problem, John? There is a plethora, and the whole point of one national plan is that there would be one document covering all those things. One of the things that I felt when I was health secretary was that I got a workforce plan. You get different types of workforce plans. You get local workforce plans. You get workforce plans for different sectors within the national health service. I know under Shirley Rogers that that is changing, and it is a national workforce plan. However, the workforce plan is meaningless unless it is put in the wider context of the wider business plan. That was my frustration. There are so many plans when one would do. I understand that. We can see that there is a heading in that direction. How we look at it locally is that, particularly around the community planning, community empowerment again requests for locality plans. We have two sets of legislation, community empowerment and public bodies, both requiring plans. We are quite clear that those plans are worked up from a community basis. It is one plan that just feeds into the two sets of legislation, and we do not intend to produce different plans. From a Government point of view, we certainly welcome the vision. We certainly welcome the expectation in terms of outcomes. Delivery and improvement has to be at a local level. We have to be responsible for saying how we will deliver that, because that will be completely different in Highland as it is in Glasgow, and so it should be. However, if we are all focused on the same outcomes and you are clear about what outcomes are expected, I go back to the point of how we do that effectively. That gives us all the route map that we need to say that this is the way that we are going. Whether it is 2020 or 2035, how are we going to get there? Here is the funding that will allow you to make those longer term. This is not a quick fix, as I said in my opening statement. It does take time, but we are spending an awful lot of time refreshing plans every year and waiting to see what allocations are. I think that there is much to commend in the debate. I would give two practical examples. In 2002, after a two-year period of engagement with the population, the then Greater Glasgow Health Board published an acute services strategy, which attracted much common debate. Ultimately, after agreement with the Parliament on the way forward, that gave us a route map that resulted in 2015 as us reaching the end of that particular exercise in opening the Queen Elizabeth University hospital campus. It allowed us to align capital and resources to that journey. It tweaked, as it inevitably would over such a length of period, with debates carrying on through 2004-2006 as changes came. We debated them, but we had a direction of travel that we were able to align all our resources. Similarly, within Greater Glasgow and now Greater Glasgow and Clyde, we have had the same debate with the public about mental health and learning disabilities, which talks about the end point, the balance between institutional care, local care, crisis intervention and the skills needed. On the basis of publishing that, we have had a five-year certainty that we need this amount of capital or resources and the sense of skills. We have been able to move forward in that direction because we have been very clear what the status quo was and what the end point was. Greater Glasgow and Clyde will, in my opinion, along with every other health board, need to be very clear early in the new year what their next roadmap is. Where do they expect to be in 2021 and in 2025? The challenge will be how we engage collectively within our individual responsibilities and with the communities about describing what people find as challenging, which is not welcoming the status quo but promising something different, which people have concerns about, because they know what they have got. They are never always certain about what we are saying the future should look like. I think that that is where we are. We in Greater Glasgow and Clyde, and I am talking to my colleagues and other health boards, I think that they are in the same place. We need to engage with the community about this very clear vision of where we are going there and then, after the debate and agreement, we can then say where we are going, so when we put forward resource utilisation proposals, they are consistent with the direction of travel. They are not opportunistic. They are not just what today looks like. Let me just say that we are running short of time. If members could keep their—I still have a couple of members to bring in—a little bit shorter answers would be much appreciated. We could go on and debate that. My final question is clearly that we have Highland with one model. We will get the rest of the country basically with the other model. I know that it is early days, not so much in terms of Highland, because you have been going longer, but in terms of the statutory way in which this has been set up, it is early days for the joint boards. Even anecdotally, is there any evidence that one model is performing better than the other? That is a possible comparison, given the time. As I said, when we were exploring this, and we looked at Torbey, they were seven years down the line. We gave ourselves a five-year plan, which finishes next year, and we have achieved a number of the outcomes that we expected to. The IGBs are not in the same position, to be fair. Although, in places such as Keishrain for sure, they have been running for 10 years, places such as West Lothian have been running for 10 years or more. To allow us to look at that, it would be nice to have some overall evaluation that was able to externally take a view about that. I think that this is playing into the earlier theme as well, that the Scottish Government needs to be doing more in terms of benchmarking performance across the system. Including between the two different models. Can I add one very quick point to that? Mr Neil is talking about a single plan. I do not know if you can have a single plan, but there needs to be clarity around some of that. We have talked about a long-term financial plan, clarity on outcomes, consistency in organisational arrangements. Can I suggest that we also need to look at a new framework for delivery in adult social care and in adult services? Frankly, many of you in this room have heard me say this before. We need a go-fec for adults. Mr Calderwood talked about what a nurse might do in commissioning social care. We have not worked that out. We have not thought that through. In children's services, we know what a nurse does and we know what a social worker does. We have not worked that out yet in adult services. I would add to that that we need a national acute services plan. Which is integrated—absolute—is not looking at acute separately. That is right. Alison Harris. Good morning. I have been listening with interest to everything that has been said. A few things that have come through what has been said, if I could ask you to take you back to it. I think that, Jan, earlier on, I heard you say that you have to make this work, that it must be made better for the people. I just wanted to ask you when, actually, do you think that the people or the users or patients or whatever we are going to tell them, when do you think that they are actually going to see that this is an improvement? Well, I think that we are already capturing evidence of improvements being seen from work with our Highland Senior Citizens Network and our user groups across Highland. Interestingly, when we had the consultations with them, when we were developing the methodology and we were developing the model, they could not see why we had not done this years ago. To them, they do not care who employs the staff as long as they get the services. We are very consciously involving users and carers. Again, it goes back to communities and working with communities. We are ensuring that we actually get that feedback. It is always quite difficult to make sure that we get it accurately. Do we get it at the point of someone having a service on the way out when you get an evaluation form? We are looking at a whole range of ways of gathering that, and that informs our planning process going forward. I am conscious of time, so I did hear, Robert, that you said that you are having less hospital time, less bed times and so on, but I did hear you say that, on your acute side, that you are £9 million overspent currently? Is that correct? Do I pick that up? Correct, yes. With the fact that there are problems with GPs obtaining consultants and so on, are your locum costs high in Glasgow and are they contributing? I pause only to determine in a Glasgow context what is high. Well, £9 million over budget at this stage is quite high by my books. My finance strategy would tell me that that is less than something of a percent, but no, I accept all half of these. Are you through your year end yet? Well, therefore £9 million is a running over budget from my books. The quick answer to your comment is that we are finding that we are requiring to use more particularly medical locums in the past two years than has been a feature of the past. If you look only, I can only comment in Greater Glasgow and Clyde, but in Greater Glasgow and Clyde for senior medical staff for consultants, we had a financial position where we were in balance. In other words, our senior medical staff pay ran at about breakeven or marginally and underspend each year. In the past two years, we have seen the introduction of significant payments to locums, so much so that our expenditure this year is likely to be about £12 million in senior medical locum. That is driven by the fact that, over recent years, the intensity of activity and the volume of activity has increased so much so that when an individual post is not occupied, that can be either through maternity leave, vacancy or sickness. There is a requirement to backfill. That was not a phenomenon in the senior medical staff. It has always been an issue in junior doctors where there are rotas under a 48-hour working week, so if a junior or a number of juniors in a rota were not at work for whatever reasons, there was always a culture of medical locums for junior doctors, which tended to be some of themselves doing locums. Senior consultants used to always cover each other. We are now at a stage where, in many specialties, you almost need 99 per cent of your workforce at work to meet the status quo, so when they are not there, there is an immediate pressure either through legal compliance, i.e., a consultant needs to be on duty or on call, or through making the performance targets, be it unscheduled care performance or be it scheduled care performance, drive the needs for the senior medics to be about. That is a big cost pressure that is relatively new. The other thing is relatively new for us. Gail Ross Thank you, convener. I would like to draw the committee's attention to my register of interests, which states that I am a Highland councillor. I would like to extend a personal welcome to Jan Baird and Bill Alexander, who makes me feel a bit more at home seeing you here today. I sincerely thank the officers and staff at both NHS and Highland Council for all the work that has been undertaken. We know that it has not been easy, but we should not underestimate what has actually been done and we are really proud of what you have all achieved. I sincerely thank you. As we have heard, the lead agency model is not without its challenges. I want to speak a little bit about the staff, because there were huge amounts of staff involved. We know that some of them had to shift from one service to the other, especially at a time when we were also in the middle of reforms within the education service. There were a lot of things going on and still are to be fair. How did you make it work? How did you take the staff along with you, get them on board, information sharing and reassurance, and are they happy now? To answer your first and second question, yes, they are happy. We understand that none of them would like to go back to the way things were. Through the programme of change that we developed up to the point of integration, we had very great involvement with our staff and with unions. We had a separate partnership forum just for the programme of work so that we discussed all the developments and the way that we were progressing the programme. We had staff side representatives on the programme board. We went out to staff groups across Highland and spoke to staff groups in their silos, as we might say, or in their facilities. We had a risk log and an issues log for all staff to contribute any issues that they felt. Our chief executives throughout the programme were quite clear. If at any time there was anything that was deemed unsafe, we would stop the whole process and everyone knew that. We had, for example, some concerns raised through child protection and how that would all pan out. Our chief executives and Bill and I and others immediately met with pediatricians and child protection staff to listen to their fears and allay their fears and deal with issues right away. We dealt with things as soon as they came up. Staff felt well supported. We did have more issues from staff transferring into the council, nursing staff transferring into the council, and we discovered in discussions with them that that was about grieving for the NHS. Actually, leaving the NHS was really difficult for them. Now that they have made that change, they see the improvements and they are comfortable with it, but we had to support them through that particularly. Thank you. Across Scotland, there was a lot of concern about the fact that we were chuping 1,500 staff one way and 200 staff the other way. Actually, in the main, the chupy issue hasn't been a big issue. It was cultural issues. It was the branding. It was about different perceptions. There are still some oddities. My health colleagues in the council have got different public holidays, which is a bit weird. There is the odd grading issue, but in the main, the chupy issue hasn't been the big issue. It has been the cultural issues that Jan referred to and working that through. Actually, working through those things has been good, because people have more in common than they have a part. I agree that one of the key requirements for success of the new model is that the IGBs receive adequate resources, both financial and other. Looking at the six IGBs under the Glasgow model, it would appear that every single IGBs had its budget cut. I was wondering if you had any comment on that. All six IGBs have increased resources in 1617 versus 1516 in absolute terms, in the same way that the health board has an increased allocation in 1617 in cash terms compared to 1516. That appears to be at odds with the evidence that we took on 15 September when we queried East Renfrewshire's allocation, which had been cut. There was a confirmation from Julie Murray that both of them and the other boards had received savings targets that had been handed down to them. In fact, the resources were cut. Savings targets are absolutely the Government's set minimum 3 per cent efficiency target every year in the health service. The IGB and its health budget are part of the health service, so it is subject to 3 per cent. Yes, absolutely, every part of the business has to look at how it delivers its services on a year-on-year basis in a more effective and efficient way. All the IGBs seem to be struggling to get more resources in order to deliver the new model. It seems anomalous that the budgets are being cut at the same time as there is an imperative to increase the resources or to move the resources. I accept the point that you are making. I would make two points. First, if the health board receives an uplift in cash and it passes that uplift in cash on but the cost of doing business, as usual, with real inflation, is greater, that drives a need to look at and deliver your services in a more effective and efficient way. However, in cash terms, you have had an uplift. Audit Scotland's report published this morning, if you look at section 11, it highlights specific decisions taken by Parliament to make cuts in budgets that are ring fenced and passed straight through to IGBs. If you take the fact that the board gets an uplift and you pay your staff more than the uplift, then you have inflationary pressures. It is an interesting debate in semantics about cuts. It seems odd to me that when we are trying to push resources or move resources from one area to another, that the area in which those resources are supposed to be transferred in order to deliver the new model is receiving budget cuts rather than more resources. In real terms, we had over 69 million savings targets this year for 16, 17 and in Glasgow. 72 per cent of that is sitting within the corporate and acute functions. 28 per cent of it is sitting within the partnerships. Relatively, our savings targets have not been proportionally split across the whole organisation. The brunt of them sits within the acute and the corporate divisions. In relative terms, partnerships have to achieve savings of just over 2 per cent, where other parts of the business are looking at 7 per cent and 8 per cent. The shift in resources might not be at the top level, but we are striving to try to make sure that we are achieving that end result. I will leave it at that just now. Can I come back to something that was said right at the start of our evidence session? Mr Calderwood, in response to Colin Beattie, you said that the status quo prevents change. Can you tell me exactly what you mean by the status quo? Yes, I can give you a practical example. At the present moment in time, we are out to a series of service changes, one of which is redesigning older people services in the east end of Glasgow. The proposal is to cut back institutional services and invest in community services. As a consequence of that, it will take away a stand alone older people's hospital and close 56 beds. That has been the subject of debate in the Parliament as being something that is not welcome and not appropriate. That is what I call the debate that we have to get into between the status quo and the new world. You cannot, in the current financial climate, have both. You are saying that it is necessary to close hospitals if we are going to move towards true integration. It is a requirement within the current budget that, in order to do more locally in the patient's home or near the patient's home, you have to take the resources that were previously in institutional care and reinvest. The trek is in the timing of trying to get that ability to invest in the new services while running the old service down so that there is an element of the people seeing the new before they see the loss of the status quo. That is challenging in the current climates, but that is a practical example of where we have worked with the IGB to redesign a model for older people where we do not believe that they need to be in an institution because of the changes. We have put forward a proposal to release that resource and to reinvest it. The outcome of that will be the outcome of that going through the appropriate channels. However, it has already attracted significant comment as being the wrong thing to do. Your definition of that status quo is the difficult politics of that. Could you define the status quo as budgetary pressures? Is it just the politics that you think are preventing the change? The changes that we aspire to do for the population of Scotland are multifactorial. We have debated at different aspects this morning about how we can change the workforce and get the workforce that we want. We have debated about the investment in the alternative services, which will include not only money and the new workforce, but it will include capital. What we are saying at the moment is that, if everything that we do tonight is in the sense that every building, every member of staff and every way that they work is protected, then we are going to talk about only investing the uplift, then regrettably we are not currently in a financial position to give the public sector across the entirety of the public services real uplift. We have to redesign. We have to look at efficiency. We have to look at best practice. My final point on this would be Catherine Calder of the Chief Medical Officer's report on realistic medicine. That talks about us not overmedicating the Scottish population, recognising that some things that we do do not add value, and we need to work with the population to persuade them that going to the GP and getting antibiotics every other week is not in their long-term best interests. That is what I mean about the status quo. Everything within the status quo has to be challenged. Not necessarily always you are going to get a change, but it has to be challenged. It cannot start from the assumption that it is good and everything that you do next is a risk. Integration only recently became statutory, but it is a process that has been on-going for many, many years now. We know that, over the four-year period from 2010-11 to 2013, the balance of expenditure on the institutional services did not shift at all. Are you really saying that it is that complexity of reasons that is the reason for that? When do you think that it will shift? I think that it is going to be a slow process. We have not yet won the House in minds of the public that some of the changes that we are planning are better than what they have. We have an issue within the acute sector that there has been a number of Government initiatives over the years to improve the acute sector, to expand the acute sector in the context of the range of treatments that we provide for the Scottish population. We have had a quite different pay policy in Scotland compared to the rest of the United Kingdom, particularly aligned to low pay, and that has given that the head count in the acute sector is higher than in the community primary care. Will, at an absolute top level, always drive an apparent protection of costs in there? That is not because we are sitting out to do that, it is just a factor of all of these things. I am trying to say at the moment that there are examples of the fact that individual boards are bringing forward whereby they want to redesign services and have less reliance on the older, traditional model of institutional care in a hospital to care in the community, and we need to work through that. That will affect everything. If I join Greater Glasgow and Clyde tonight as an ITU nurse in a big critical care unit, I am not immediately attracted when I hear the chief executive talk about care in the community. That is not what I do tonight. You have to work with your own staff as well, who you want to change their skill sets and deliver their services in a different environment. You talked earlier about and asked us earlier about what support government can give. The changes that we have to make are very emotional for a lot of communities, and we need support both in national government and local government when it comes to making those really difficult decisions. No matter what evidence we have about safety and sustainability, communities are absolutely committed to looking after buildings. That is what they want in their community. It is a really difficult task for us, and we need support where the evidence is there. To make that shift, we cannot do on our own. We need the public to be behind us, but the public to turn to their politicians, whether locally or in this Parliament. We need that support to make those changes consistently. I thank you all very much indeed for your evidence this morning. It has been a long session and I am very much appreciated. I am now going to suspend the committee for about two to three minutes and we will move into private session.