 Good morning, and welcome to the third meeting of the Public Audit 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 is declaration of interests. I welcome Gail Ross to her first meeting of the Public Audit Committee and invite her to declare any interests relevant to the work of the committee. I am a councillor with the Highland Council. I am a board member of North Highland College. I am a board member of Cathness and North Sutherland Regeneration Partnership. I am a board member of Cathness Partnership and the Patent of Home Start Cathness and the Community Champion for Cathness Clicks. I am an ambassador for New Start Highland. Thank you very much, Gail. We now move on to agenda item 2. Item 2 is a decision to take items in private. Do members agree that we can take item 4 in private? That will allow us to consider the evidence that we hear on the changing models of health and social care report. Item 3 is Auditor General for Scotland's report on changing models of health and social care. It is an evidence session on the changing models of health and social care, and we will hear from two panels today. I welcome the members to our first panel. Paul Gray, director general of health and social care and chief executive in NHS Scotland. Dr Jason Leitch, clinical director and Geoff Huggins, director of health and social care integration from the Scottish Government. I now invite Paul Gray to make a brief opening statement before I open up to questions from members. Thank you very much, convener. I am pleased to be at this first meeting of the newly convened committee. I just want to say three things. First of all, I am delighted to be able to bring colleagues with me and they will support me in delivering the evidence to the committee. Secondly, if we do not have information that the committee requests to hand, we will simply say so and we will provide it as soon as we can after the committee has concluded. Thirdly, Professor Leitch was asked here in view of saying something about the NUCA project and I would want to be guided by you, convener, on when you would like that brought into the evidence and how long you would like us to take on that. Thank you very much indeed. Do you mean the evidence today, Mr Gray? I think that that would be useful to hear that today, if possible. Do members have any questions on the evidence that they have in front of them? Can you make a suggestion that it might be useful to have the NUCA presentation first because it will inform the questions? Is that possible, Professor Leitch? Are you ready to do it now? It's easy. I can do five minutes or three hours until I have to do the five-minute version. We'll make it five to seven minutes. Would that be okay? Thank you. Mr Neil understands the model somewhat because we've talked about it extensively, including in a visit to America. The first thing to tell you is that it is not perfect nor is it instantly transferable, but in summary, the South Central Foundation provide healthcare to 69,000 native Alaskans across a geography that is bigger than the rest of North America. The vast majority of them live in Anchorage, but they are spread throughout the whole geography, and if you lay Alaska on the map of America, it goes from Boston to Texas. It's an enormous state, but the people are very distributed, and they have a long history of inequality, a long history of alcoholism and drug abuse, particularly amongst that native Alaskan population. A number of years ago, the federal government, who was providing that healthcare through their Medicare and Medicaid services, negotiated with the native Alaskan leadership to say, we will give you all the money. We will give you the money for the healthcare for the 69,000, and you can decide what to do. A set of native Alaskan leaders, along with some friends of mine, frankly, a medical director, a chief executive, others who were in the states, formed what is now called South Central Foundation, and it provides the healthcare to these 69,000. That's the logistics of it. It provides it at about the same value as the rest of government-provided American healthcare, so slightly more expensive than ours, but not a private healthcare system. Get that model of American healthcare out of your head if that's where you are. It's not insurance, it's free at the point of delivery, much like the Veterans Association and our system. Their model, they then called Nuka. It doesn't really stand for anything, it's a native Alaskan word, N-U-K-A, and it has a number of features that are attractive, and people have started to visit it. I was the keynote speaker at their big event last June, and I spent a week with them exploring their model, and it is frankly the best primary care system I've ever seen, and I've seen a number of them around the world. You have to bear in mind the first thing I told you, though, it's only 69,000 people. It is not five and a half million people, so it is not just movable. The fundamental element of the model is that it is owned by the people. They don't call them patients, they call them customer owners, and they give you into trouble if you call them patients, both the staff and the customer owners. They have a model of primary care provision that is very, very team-based. Some of you would recognise it from your knowledge of the best parts of the national health service. You sign up with a team of four, you don't sign up with a GP, you sign up with a clinical team, you have a relationship with, it may be a doctor, but actually they have recruitment challenges, so it may be an advanced nurse practitioner in charge. They'll then be a nurse. There's always a mental health practitioner, which I think is crucial, and we'll perhaps come to that in questioning around some of the new models of care in Scotland and an administrator. So that team of four manage a panel of patients and they manage them in a supply-demand type way, so it seems hard to believe, but I checked surreptitiously to see if it was true. If you phoned before three in the afternoon, they guaranteed to see you that day, and there are appointments. I looked at the computers and checked to see if it was true. So they have absolutely nailed supply-demand. Even if your doctor is off sick or your nurse is on holiday or they then substitute other people in so they can do it, so they can see you the next day. They have no GP out of our service. Let me just repeat that. They have no GP out of our service. They don't need it. They say that if you have a proper accident or emergency, you will go to accident and emergency, which is there and open and available and helps people. But they have never felt a need for a GP after six o'clock service because they guarantee they'll see you up to six o'clock if you phoned before three. They see families. They see young kids with fevers. They see all of that during the day. The logistics are only one element though. My final remarks are about the culture of it. The logistics are very impressive. The culture of it is the most person-centred system I've ever watched. I sat in on some consultations. I went to see the mental health practitioners in action and it was all very much focused on the family. It was hugely integrated and delivered around the care of that individual. I only saw it in Anchorage. I didn't travel far out into the sticks but they repeat it. It's slightly less frequent, if you would forgive me, in a village of 36 people or a village of 400 people. They can't do that same-day thing out in those places. We brought it back and we've probably had about half a dozen people visit some doctors and nurses. We're testing it in a couple of areas. The most exciting area is in Skye. Again, very rural. It doesn't have all of the provision that you would have of rural areas. One of my pals from Alaska has just been to visit them and opened their new community hospital centre. They are doing exactly the same process. They're having team-based care. They're having that customer-owner-type conversation with the people. It seems to be going very well but it's small scale and we have to test our way into it for a Scottish context. It's not something you can just lift and lay it that's not going to work. You probably wouldn't want to start Scottish healthcare with Alaskan singing. That wouldn't be appropriate for Scottish healthcare. There are pieces of it that you wouldn't just instantly move into our environment. It's impressive and we are appropriately testing it in Scotland as one of the models for those new models. Jason, to add a comment because obviously we're discussing integration. The whole thrust of that is to redress the balance between primary and acute care. If we could tell us about the impact since it started of redressing the balance between primary and acute care. There's very, very impressive both data and narrative. There's a slide which I can share with you that Doug Ebey, who's their medical director, who I know very well, I present with him around the world a little bit, sharing our story of quality and safety and delivery that we've done and their version of that integration world, particularly primary and secondary care. They have the huge percentage reductions in ED attendances, massive reductions in unnecessary bed days. I can't remember the overall numbers but it's in the region of 50% ED reduction and consequent savings, consequent moving of money into that community base care. I keep having to say though, and I'm not just being careful because it's audit committee, I have to keep saying it's quite small in our terms, but that doesn't mean you can't scale it up to a bigger size. And other countries are looking at it. Singapore are looking at it very closely. They have a challenge with an elderly population struggling with integration just as you would expect. Japan is looking at it quite closely. So there's definitely something there. Whether we can translate it into Scotland is a different question. Can we have piloted in Fife as well? We have and the Fife pilot was really interesting. We sent the director of public health from Fife to Alaska and she became a real advocate, almost an evangelist for it. And she persuaded a couple of GPs in Fife to take it really seriously and they did really well in a bit of the practice. Part of her challenge was that it's such a cultural change. It's a big change. And other elements of the practice, but not quite a little bit more conventional, a little bit more scared of that big change, didn't embrace it quite like Margaret Hannah would have liked them to embrace it. It still goes on, there are still pieces of it happening, but it just illustrates the nature of change. That top-down suddenly Paul is sending a letter, please do Nuka, that's not going to really work. It would be nice if it did. But it's about that cultural change inside the people that we have to generate. It's certainly a model that I'm familiar with through the pilot in Forfer. I was very impressed when I heard Dr Andrew Thomson talk through how it was going to work. It's certainly something that the committee would be interested in. I think that the committee members have some questions on the main part of the Auditor General's report on the section 23 report. In the whole of this, I guess one of the central roles is that of the GP. It's in developing new types of care and so on. However, there does appear to be a number of challenges facing the GP workforce, not least being retention and recruitment and also their complaints about increasing workload. How are we addressing that? As the committee doubtless knows, we've announced 100 extra GP training places. Now that doesn't help today, Mr Vite. The committee will be perfectly alert to that point. However, we're seeking to add to the overall GP cohort. The negotiations that are proceeding about the new contractor intended to lay the ground for a flexible workforce that can respond to the changing needs of the population. We're also anxious to ensure that the good practice, in general practice, is spoken about. One of the things that is most likely to damage the likelihood of recruitment and retention is if we are constantly in a narrative of what is wrong. We had that problem, for example not in general practice, but in acute medicine in Aberdeen where their emergency department was constantly described as being in crisis. We had to redress some of the issues there. There was a staffling shortage, but once we got out of that conversation about crisis, they attracted some very good people into the emergency department that's now functioning very well. We're working with leaders in general practice, both in the BMA and in the Royal College of General Practitioners, to ensure that what we produce is a set of propositions that will make general practice attractive. We have a primary care transformation fund of £20.5 million. We are investing a further £10 million in primary care mental health services, which Jason Leitch has already referred to this year and next. There is investment and preparation for additional workforce in future years. I think a very strong and worthwhile conversation with the leadership of the general practice community all intended to build on the excellence that's there while recognising, and I don't want to pretend that I don't see it, that in some places in Scotland there is serious pressure on general practice. The obvious question is what sort of timescale are we looking at? If we're taking students in now, for example, and turning them up and hoping that they're going to go into general practice, that's quite a few years before they're going to pop out the other end. That's why I said that wouldn't be a fix for today, but it's an indication of support for general practice to announce these new places. Seven years would be a reasonable time frame, but what we're also doing is looking to enhance the technology available to general practice so that some of the workload can be taken off general practitioners. The work that we're doing to enhance other professions, for example physiotherapists, advanced nurse practitioners, that allows us a much wider sharing of expertise and different opportunities for patients to be seen by the appropriate clinical professional. I was recently at the new dice practice in Aberdeen. I do have some examples from places other than Aberdeen, I hasten to add, but the new dice general practice there, where they really have a very innovative model where patients are now very satisfied to be seen by the appropriate lead clinician rather than feeling that if they don't see a GP, they haven't seen the right person. There is evidence of developing general practice in ways that work. GP is also working increasingly with integration partnerships to ensure a whole population view of what's achievable. I realise that south of the border the situation is the same if not worse in some areas. What are the prospects of recruiting from there to get a quick fix? I know that there's issues around golden hallows and all this sort of thing. Scotland's an attractive place to work, and the success, for example, of our junior doctors campaign, where we did seek to recruit from elsewhere, not just in the UK but more generally, is evidence of the fact that we can put together an attractive proposition for people to come and work here. I'm keen that, however, we don't get into too much competition with colleagues south of the border. I would always pride myself on having good relations with other health services both in the UK and beyond, but I have absolutely no doubt that both in terms of its geography and in terms of the opportunities that Scotland presents and the variety of different practices that you could work in, Scotland is a very attractive place to be. So, continuing the theme of GPs, how is the Government addressing gaps in GP and community activity data? I'll bring Jeff Huggins in in this in a moment, but there is considerable work being done by Information Services division to ensure that we make the best use of local data. I wouldn't claim that there is perfection, but we are working to ensure through the integration partnerships that we have a much more transparent set of information available which enables us to make decisions, or make the local partnerships rather, to make decisions about the most appropriate models of care delivery. I saw that in action last week in Perth and Kinross where they were able to show me the data that they were using in order to decide how services should be structured, and through that were able to show why in Perth itself services were structured differently from the more rural areas. There was data to underpin these decisions. It wasn't simply the case that they said, well, Perth's a city and then there's the country, and we'll do it differently. They had hard information that enabled them to make these decisions, but Jeff Huggins would be able to say a bit more. I think one of the key underpinning elements of how we've been taking integration forward has been by providing better information that we can now, with the linked data that we have in Scotland, through the source resource, understand how people move through the system. We can look at the different care pathways that are followed by people with different diagnostic conditions, and we can also see how those vary from area to area. We've been effective in bringing together the social care data, with activity data around general practice, and I'll come back to that. But then also with hospital data and increasingly with other data sources, such as housing data. We're funding ISD to provide link workers who are supporting each of the partnerships then to understand and use the data, because simply having the numbers isn't always enough. Quite often you need somebody to help you navigate and understand what you can do with the data locally. That's changing how people see and understand what's going on within their locality. Paul has mentioned Perth and Kinross, and what we see with that is a very different footprint in terms of activity across the city area. As you move further west, you see less use of hospital services. You see a different pattern of social care between residential and non-residential, and that gives us questions both about why that might be happening within that area, but also how that area compares perhaps to other rural areas. We're having quite different conversations. This is going to be part of the meat and drink of GP clusters, in that the expectation and our objective with that is that different primary care practices sit down collectively and understand how things are working within their area and how that relates to the nearby clusters. There's a real opportunity within that. We saw the impact that can have through the dementia diagnosis work, through some of the work that we also did on antidepressant, in that once you begin to show people what's happening, because as a general practitioner or any clinician, you usually see the person who's in front of you. You don't see all of the people who have ever been in front of you, and so it's difficult to see the shape of what's going on. There's a lot of data support. The particular question around general practice data is one of the areas where, at the moment, in terms of the data that we have, there is less than we would want, and the work that's going on through SPIR is intended to address that, but rather than tell you exactly where that is today, I would suggest that we should probably write to you on that, because I'll probably get it wrong if I do it here. I suppose that, arising from what you've said there, does that mean that you say there's not enough data coming at the moment from GPs? GPs complain about the bureaucracy and the admin that they have to do already. Does that mean that there's potentially an extra burden coming to them? That's not the intention. The intention is, through the new information systems that are available to them, that we should be able to extract the data to understand the system dynamics rather than to ask them to fill in forms. That's not the intention here. At the moment, we're still working through some of the issues with that data linkage. It's not a thought that we want to invest further in data collection. I have a follow-up question on data, and then I'm going to bring in Liam, because we still want to talk about GP contracts. On the question of data, it's very clear to me, in my own community, that it's the most deprived GP surgeries that are really struggling. There's one in my own community that's been on teetering on the brink of closure and has now managed to get another GP in. In terms of the data, it is the data worse, Geoff, in the more deprived communities, because how have we got to the point where we are seeing GP surgeries in communities under threat of closure? Is the Government data that bad that has led us to that point where workforce planning hasn't been able to keep up with that? The data that we have across the piece is effectively the same data in most areas. There have been historically some quality issues in some areas, but it's not linked to deprivation. It's more linked to different IT systems within the different boards and the different councils. We are able to extract the data by deprivation and by age, and in some cases also by condition. That's been really quite interesting for us in that it shows that for the over 65s and over 75s, deprivation is perhaps less of an issue than we would have thought. Certainly below 65, deprivation is a key issue in terms of shaping use of services and access to services. It's taken us into a slightly different conversation as to what's actually going on and the linkages between resource utilization, activity and deprivation. In terms of the broader question about the shape of services and how those sit across the landscape, that's exactly the sort of issue that's being identified within the strategic commissioning plans of integration authorities. A number of those which you would expect have a strong focus on health inequalities and deprivation, and it's one of the things that we're beginning to see as a transition in the system at the moment, is in many areas at the point of delegation, primary care has been kept as a hosted service by one integration authority on behalf of a number of other integration authorities, and that reflected the board oversight of primary care before. What we're now beginning to see is that change quite quickly as individual integration authorities and indeed localities are looking at the pattern of general practice and primary care within their area against the outcomes and so it's been pulled down to the locality area rather than held up at the board area and that's been driven by this exactly the point that you make around health inequalities and provision. Thank you. It's important to separate data about the quality of the care families and individuals are receiving and the quality of their data around the nature of the delivery system. So primary care is one of our most electronic systems we have. The electronic data inside primary care is in many ways better than that inside hospitals. We know about the quality of the care delivery, we have electronic prescribing data, we know the drugs, we know the drug bill and we know the drug distribution and we can compare that across localities and we can make changes and introduce quality. The challenge in general practice and this is a challenge from the 1940s is the model we have is independent contracting. So the levers are entirely different. We don't employ the vast majority of these contractors. They are independent, they can make their own decisions about many, many things about the way they work, their times of working, the way they design their practices. We can influence that but we can't control it the way we can control the authority. The two priorities I don't think that we can underestimate the challenge of the new GB contract and the optimism that that might bring and the GP cluster model. If the GP clusters can gather around localities and design primary care in its broadest sense doctors, dentists, optometrists community nurses around that locality for whatever that context needs, finally those decisions can be made in place and the GP contract which could take away what many of the GP practices say is a tick box exercise to remove the co-off, to actually focus on quality for quality sake, rather than quality for pay, which seems something we've moved on from frankly. Good. It seems to me that those two things together might get us to where that data, the workforce data and the quality data become useful. OK. Liam, did you have a question on GP contracts? I think that leads on nicely. Yes, thank you, convener. So yes, just leading on from what Colin Beattie was asking and your point professor leech on GP contracts. So my understanding is this will be a new, I appreciate your point about consultants, but effectively an employment contract, a contract under which the GPs will operate. Now, presumably there is an issue with... You are not in a position to just go and say there's your new contract, sign that and crack on. There will need to be some negotiation and how confident are you that that will be a smooth process? One can never be absolutely confident about a negotiation. What I am confident about is that we have built and are maintaining sustainable relations with the Scottish General Practitioners Committee of the BMA and with the Royal College of General Practitioners. So in other words we're not in battle with them in a head-to-head way. They are generally supportive of the direction of travel that the Government has set out and have challenged us in a number of issues of which they've had concerns. But I'm confident that we have the relationships in place to continue to have robust and I think, ultimately successful negotiations. There is, of course, the point to add that while many GPs are independent contractors there is also the option of boards employing salaried GPs and that is another area that we're thinking very carefully about in terms of the negotiation with that. I completely respect the fact that general practice is generally built on the self-employed approach and I've no wish to undermine that but there are circumstances in which sometimes a salaried GP is the right answer and there is also perhaps a trend towards some GPs preferring to be salaried GPs so they don't have the uncertainties and pressures associated with self-employment. There are different ways in which the service can be delivered and to the point that the convener was making earlier it may be that in some cases a salaried GP response might be the right one. I'm not speaking about any specific case convener but that's an option that boards have under their hand. Following on from that you talked earlier about training up taking say seven years now obviously that leaves quite a long gap during which there will be retirements, there will be people leaving the service anyway so do we have to wait seven years before the situation starts to improve? We don't, that's a hundred additional places so that's in addition to everything else we were doing already there is also the point that we're working hard to ensure that what we call GP returners in other words people who were GPs before and want to come back to general practice to make that as simple as possible because that's another good source of people coming into general practice individuals who've taken a career break or worked in another country and now want to come back and are qualified to do so we're committed to making that as slick as possible. So the other, if I'm happy to give more detail convener but I'm conscious of time will that be helpful to go on a bit further? A little bit I think yes. So for example the things we're doing on recruitment and retention of the Scottish Rural Medicine collaborative one of the things we need to do of course is attracting GPs into rural as well as urban areas we've got a low there and we've got a retired GP locom pool to fill vacancies that simplifies the process so that retired GPs who want to remain in the workforce's locoms can do so recruiting GP early career development posts in Ayrshire and Arran and Lothian we've spoken about the NHS Education Scotland GP returner programme we've had 15 returning to practice over the last year through this programme and also the deep end practice pioneer scheme that improves services to deprived areas if I was only ever going to make one recommendation to the committee and it's usually for the committee to make recommendations to me it's go and see a GP deep end practice it's really worthwhile Could I maybe add something to the answer as well because the other thing that we're saying is changed models of service so we're seeing an increasing number of community and intermediate services which include GPs but also which include physiotherapists and podiatrists and in a number of areas also we're beginning to bring social care into that space so we're seeing a different form of service being offered which is also intended to lift the load from GPs so that the GP isn't the only conduit so on Monday of next week the Glasgow City Partnership will open the new Maryhill health and care centre and that will bring together allied health professions as well as support services including also within that space a physiotherapy gym so that people can come and have part of their rehab within the community rather than other settings so the models of care that GPs sit within are changing quite dramatically and quite quickly and again that's been one of the areas where integration authorities are seeing the future in terms of how they can design things learning also from the past the community hospitals of the past Mr Gray one of the biggest problems and deprived in deep end practices is the difficulty in getting doctors to actually work in those practices apart from the salaried option what else is the Scottish Government pursuing to solve that so for example again in terms of lifting load 250 community link workers and that builds on pilots that are already taking place in Glasgow and Dundee giving GP practices access to enhanced pharmacists so GPs can focus more on patients that require assessment we've put £3 million in to train an additional 500 advanced nurse practitioners so again that's taking load off general practice and a thousand paramedics being trained over five years to work in community settings and that should also as an added benefit reduce the need for some people particularly elderly people to go to A and E so there are a number of things in place that are here and starting now as opposed to ambitions or aspirations Is there not a systemic problem if we're struggling to attract medical students and young doctors to actually go into deprived communities and work there is there not a systemic problem in their training I think it's always a combination of factors as colleagues have said to go into different areas of practice I'm not promoting as the sole example of excellence deep end practices my point there though is to say that if we can show both to general practitioners who might be aspiring to go into practice in Scotland and to others with an interest how fulfilling it is to work in an area of multiple deprivation and not just you know it's a great job but there is support for it then I think we can attract more people into that if you are starting off on your career and making choices sometimes the choices you make initially in your career will define the whole of your career path if we can encourage more people to see the value and satisfaction that comes from working in some of the most deprived areas I believe will attract more people into that but some of the things we're doing are intended to support that these are not easy these are hard jobs so being a general practitioner is probably the much as some specialties will now write in and tell you I'm wrong but I think probably general practice the undifferentiated illness so when you open the door you don't know what's coming it could be anything it's likely to be a health challenge or a family challenge as well as the acute illness in the family that comes to they're enormously difficult and the most successful practices feel linked to the rest of the system so they feel linked to the acute medicine doctors who are in the hospital they feel linked to the social care system who are doing all the social supports and trying to bring those into away from single-handed three people in a practice in a town into that more cluster model but not just the GPs being integrated integrated with the diabetic secondary care doctor who will help them with their very difficult diabetic cases and the social care who help them with the frail elderly to keep them at home that's the key to making GP employment more attractive because otherwise it's a very very isolated place to work and you have that enormous responsibility for the undifferentiated illness that walks through the door Thank you, Professor Leitch I think we could discuss this all morning I think there's so many issues in it but I know we want to move on from this topic, Monica Lennon was keen to ask about workforce issues Before I do I want to just ask Professor Leitch a question at the very beginning you talked about the Alaskan example of a customer owner model as opposed to a patient model Could you maybe explain what that means please? So in their culture what it means is that the Alaskan community owns the health service so literally owns the health service so they gave them money to the Alaskan leadership Now the Alaskan leadership work a little bit like a local authority regional political thing they are elected from within the Alaskan community you can only be the chief executive of south central foundation if you are an Alaskan native the board has to have half a 51% in Alaskan natives and other non Alaskan natives on it so they feel possession of the system and they have effectively elected community leaders who make the choices about the way the system is distributed they've got a long legacy of doing that in other areas so that's not new for them the health bit was new for them I met the head of the Anchorage native Alaskan community and he was almost like a mayor he was elected from within his peer group and he was running a big part of the services for native Alaskans including their native Alaskan schools their native Alaskan community churches their native Alaskan healthcare but there's something cultural about ownership for them and I think it partly comes from the legacy of them being isolated not looked after racism a whole host of other things where things were done to them rather than done with them and I think there's something in that that we could learn about how we provide health and social care to communities about doing it with them rather than to them Okay that helps but there's no recommendation to shift from speaking about patients to owners here in Scotland I wouldn't be convinced of the nature of customer ownership in Scotland I do though in my role in the Government I have the person-centred care responsibility so I'm a big fan of empowering the community the individual, the family some of you will I hope get patient opinion updates in your inboxes every month or when somebody writes a story about your constituency so I'm all for hearing the voice of lived experience but I'm not sure that switch from people to customer owners is a particularly helpful one for us there are other elements of their care that I think are You've talked a lot about cultural change and attitudes and behaviours and how that can go a long way to transform how we deliver services but the reality is that we need resources and we need cash and assistance to do that the Audit Scotland report we're getting a picture here that resources have remained static from the period 2010-11 to 2013-14 would that hard reality how optimistic are you and that question to all of you that this transformational change can actually be achieved so I think one of the things that we've got to move into is describing the workforce not just in terms of the number of particular specialisms that exist today because we are looking for a more flexible workforce the recommendation that Audit Scotland made I'll not read it all out but the relevant bits that we should provide a framework by the end of 2016 that framework should include the longer term changes required to skills, job roles and responsibilities within the health and social care workforce and aligned predictions of supply and demand now we do intend by the end of this year to set out what's asked for here in terms of the workforce however it does require a degree of caution because in central Glasgow will be rather different from the workforce in the western Isles which will be rather different again from the workforce in the borders so I think the Auditor General helped fully acknowledged in her evidence on the 6th of June this year that they were not adopting what she called a cookie cutter approach that said you could find something in one place and it would be exactly the same everywhere else so I am accepting the recommendation that we say by the end of this year what the skills, job roles and responsibilities of the workforce should be and also how we plan to get there so it's not mere aspiration but with the caveat that that will not be a one size fits all prescription for the whole of Scotland there are of course increases in the workforce in qualified nurses and midwives and they are extremely important in the community increases in the number of doctors particularly consultants paramedics are an important contribution they are substantially over 13% over the last 10 years or so so we are seeing increases in the workforce that contributes outside the hospital but I'm very happy to provide as Audit Scotland have suggested something in more detail by the end of this year The basic answer to your question is incredibly optimistic I know no other way so I'm very optimistic that the healthcare system is resilient enough and of a high enough quality to find a way to transform to a new reality that transformation will be constant it's not going to be a moment in time where we suddenly say oh the health service is fixed thank goodness for that it's going to be a constant journey with the demographic shift with the resources there are some decisions I don't get to make like the resourcing so there's no point in me dwelling on it particularly what our role is is in supporting that delivery system particularly the workers and the families meet the system to do their absolute best and improve the quality in there I think we have some of the policy position now in place for the modern delivery we had visitors last week with 30 Swedish politicians and a pile of senior Danish clinicians last week on two big visits and they are facing exactly the same challenges of demographic the exact same challenges of resourcing and yet they came to visit us to see the way we design particularly the quality elements of our healthcare system they were very interested in health and social care integration they saw some of it in reality inside the microsystem and they were very interested in the way we had designed that high level policy position and yet empowered and released workers to make changes on the ground it's not an easy balance between those two things but there is something attractive about the way Scotland is trying to do that even Scandinavia are beginning to take seriously I think the other element is to think also and to see also how the workforce is changing how it does its business so as of today we have around 200,000 people working in the social care workforce which is around 1 in 12 people who work in Scotland and that's a significant number of people you know that's 8.7% of the working age of the working population in Scotland what we're seeing is the use of their time and the flexibility that they have to provide service changing so in terms of the additional hours that we've seen going into care at home more of that is now devoted to rehab to step down rather than simply on-going packages of care we're seeing frontline staff having additional flexibility around decisions that they can make themselves in respect of care and how they can organise their time we're also seeing increasing local procurement so less of the time is devoted to travel and more of the time is devoted to care so we're seeing across the system how we're actually using that resource in a way which is more empowering for staff offers better quality and with the work on living wage will be better paid for that staff and that we believe is a good investment in getting better outcomes so what we're seeing and Jason describes it at the micro system is different ways of doing the work to produce better outcomes for people within the likely resource that we have because 200,000 people is a lot of people to work in one sector within Scotland in terms of the broader objectives around economic growth and gain we also need to be putting people to work to do other things Thank you Professor Leitch, I admire your optimism I like to think of myself as an optimist even at this time of the morning but we've touched on the critical aspect of the home care, social care sector and that workforce is very significant but the reality on the ground for a lot of people who do those jobs is that it's very very hard work often on zero air contracts often on low pay often there's a lot of pressure to be flexibility so in many many areas it's not an attractive career path for younger people we still see occupational segregation there so we don't have a lot of men coming in to that workforce there's a lot of pressure there does that give concern well I think the commitment to seek to pay the living wage is an indication that we want to have a better remunerated that better qualified and better renovated workforce and if I can be allowed I don't usually express personal opinions on parliamentary committees but on this if I'm allowed I will I think the fact that some of our lowest paid people working the care of frail elderly and care of small children is not a good sign of how much we actually value those professions and speaking as the chief executive of the national health service in Scotland I think it's enormously important and many of these people that Jeff has mentioned are not employees of the national health service I think it's enormously important that we pursue the trajectory of ensuring firstly that the living wage is paid and that there is funding as the committee will know has been provided to support that that we pursue also the importance of people in these occupations having proper access to training and opportunities to learn and to grow and to have career paths now I don't want to be ignorant of the fact that some of the care providers are under significant commercial pressure there are recruitment difficulties there are increasing costs so I don't say that in a vacuum but I do believe that ensuring that people who work in occupations that care for the most vulnerable people in our society understand that these are valued professions that deliver enormous social good is very important indeed and I think that's inherent in some of the policies that we're seeking to pursue in a difficult and imperfect world I think your career progression point is very important I think we've been better in some areas than others about educating, learning and developing individuals in certain parts of our workforce so the ambulance service are enormously good at it so people can come in relatively unqualified as technicians in ambulances they can become paramedics they can do nursing they can some of them become paramedic consultants and run whole teams I think we're very good at it in pieces I think our social care pathway could do with some work I think you're right that that large swath who come in as care of the elderly workers or early years workers we're getting better at it but I think your career pathway point as well as the living wage I think the career pathway needs to be more attractive and there needs to be moments that they wish to and move through that pathway I think it's a good point Maybe just a couple of points on that so there is a key issue here which is about the quality of the work and the commitment that we've made to move beyond the idea of time and task beyond a scheduled appointment where you need to be at a particular place and then drive to another place the idea that you can work flexibly with your caseload and some of that we're exploring but even two or three years ago we were being regularly approached by consultants whose advice to us was that they could find a way to take 50p off the early rate and that is a false economy trying to push the system a bit faster and a bit harder to reduce the cost which would also take a quality component out of it so people come into caring Scottish Cares reports from the front line about why people go into caring and what they take from caring and what people resource as to what motivates people and there are people who come in and would like to see a career progression but around 50% of the people come in either because it's a job that they do alongside other things they may do alongside family commitments or they may take the value simply in the intrinsic process of caring which I think we need to value so they've identified that around 50% of people see the current job that people do as the job of 200,000 people so there is an issue around career progression but I think we have to not undervalue the basic day to day care that people offer by suggesting that that's a stepping stone to something else Alison Harris Yes, thank you gentlemen I would also like to I would like to leave here feeling more optimistic like Professor Leitch but in the area that I represent I have to say I want to know about the here and the now not the vision in the future but I've got, as Jerry Marra has alluded to as well there are GP practices closing in my area which is Central Scotland being taken over by the health board to be run I am inundated with people complaining that you cannot actually get a GP appointment and by GP I don't mean with associated health worker there is some crazy system where you have to phone at half eight in the morning if you don't get through at half eight you have to phone the next day it's frightening also in 4th valley health board there is a 12 week waiting time initiative to see patients especially in orthopedics ENT orthopedics ENT no, it wasn't urology oh gosh I've forgotten it will come back to me in a second whichever one it was when you actually speak with the doctors involved with that to see when are the patients going to be seen they can't give you an answer they can't tell you is it 20 weeks 15 weeks 19 there is no reply add to that what is a major concern for me is when you actually speak to some of those consultants they have no time limit for a follow up appointment so where you might be seen with your first appointment they actually say to you at your appointment well I have no appointment scheduled for you so my next appointment is in a year what can we do about that we are talking about this model for 2020 we have real problems now where do we start addressing those ok I'm happy first of all to take more specific detail Ms Harris if that would be helpful after the meeting and we can look at that but let me not try to sidestep your question I think first of all to say if a GP practice is unable to fulfil its responsibilities or decides that it's going to close the process is for the health board to take it over and to provide the service now so I wouldn't like to leave the impression that that was somehow the wrong thing to happen that is the fallback that is there no that's fine I just wanted to clarify so part of the here and now of course is if a GP practice cannot continue then the health board has a responsibility to take it over that's partly why I mentioned salary in an earlier response I think in terms of waiting times you're speaking about the 12 week treatment time guarantee John Conaghan who's NHS Scotland's chief operating officer is working with boards including 4th valley who are not currently meeting that guarantee one of the things we've been very clear about is that within any delays patients should be satisfied on the basis of clinical needs so in other words there should be an order but I'm more than happy as I say to pick up if you've got specific issues in relation to a particular health board to understand these a bit more clearly rather than try to give off the cuff answers in this setting about the specific issues I mean it's not that I don't know a bit about NHS 4th valley I do but I'd be happy to provide a more detailed response if that would be helpful I've let the questioning about GP's run on because I think it is very important but I am conscious of time here and I still need to bring in Alex Neil so if you have a final point you want to make, Alison, or you I don't think my experiences and my constituents' experiences are unique and I don't want to get carried away with the exciting models for the future and how we're going to get there I think we have very real problems and that's really something I think we need to look at I wouldn't seek to suggest that there are no problems in the national health service in Scotland it would be a unique health service if there weren't but part of the reason of course for wanting to introduce these new models of care is to reduce the prospects of these current problems recurring but as I say, genuinely happy to follow up in more detail on specific issues That'd be great, thank you Alex Neil The thrust of my questions is in relation to the Auditor General's report on integration but before I get to that can I ask a very specific question which is about a tool that would help not just integration but the health service and patients and the whole thing namely the planned introduction of the electronic patient record which is due to be fully introduced by 2020 where are we with that? So Mr Neil, I'm not going to give you a work in progress answer to that, what I will do is I'm actually asked Professor Andrew Morris to take on responsibility for telehealth and innovation and I will get Professor Morris to write to the committee with a detailed outline of where we are on the electronic patient record we are working towards it there are if I'm being frank with the committee there are elements that I would like to see rather before 2020 there is an ultimate aim of getting there but we've already as you know got some important elements in the key information summary which is used in emergency cases information we can share with NHS 24 subject of course to patient consent so I'm happy to give the committee a detailed response on that because I think it would be helpful for them to have the outline of where we are OK I've got three questions relating to integration I'll just put all three together because I think we're kind of running against the clock a bit the first one is the auditor general makes a point in our report about it's not clear what will be achieved in 1617 in terms of integration I think sometimes given that this is the first practical operational year of integration I think we've got to be realistic about what can be achieved in the first year because obviously inevitably a lot of it is about setting up systems and procedures and policies and all the rest of it and at the end of the day the national outcomes are absolutely what's key for all the IGBs but will you or do you have for 1617 for 1718 and maybe even for 1819 some benchmark benchmarks against which you will measure progress towards achieving the outcomes so that by the end of 1617 there are certain things going to be achieved and if you haven't achieved those in certain areas then that will be treated as a failure if you have it will be treated as a success let's be clear and realistic about what can be achieved in particularly the early years because this is not something that can be done overnight so that's question number one which relates to the concern expressed by the auditor general the second one is in terms of budgeting it's very clear I think from certainly the IGBs I'm aware of not just the ones in my own area that the budgeting remains clearly a key issue and a point of contention between potentially health boards and local authorities can I ask has any thought been given to now that we have 31 IGBs up and running is it not a lot simpler for the Scottish Government now to allocate the budgets for health and social care as an integrated budget to each IGB instead of giving the money to the health boards giving the money to the local authorities and then asking them to agree between them what the budget should be which is all the built in tensions that go with that and my third question is this we now have up and running 31 IGBs they're responsible for 8 to 9 billion out of the 12 billion plus now part of the health service budget and the rest of the health service is responsible for the other 3 or 4 billion but we've got 23 health boards managing that one third of the entire health service budget when are we going to do something about getting realistic the number of health boards we have in Scotland and boil that 23 down to a more realistic figure well okay I will answer briefly on your second and third points that's about budgeting and the number of health boards I'll ask Jeff to give us the detail on what the benchmarks are my main point on your first question about what would be achieved we set out to achieve full operation of all of the integrated joint boards all of the partnerships by this year and we did achieve that that had to be the starting point if we hadn't achieved that we would have had a problem so we've got that far I'm grateful for your remarks about the need not to load too much expectation into year 1 but nevertheless there has to be significant progress and Jeff can talk about that in terms of budgeting I suppose the simple answer is that of course there's a matter firstly for the finance secretary then for the cabinet and then ultimately for the parliament to agree how it wishes the budget to be constructed the point of caution I would put to that is two fold one not all IJBs are the same so in other words you couldn't say that the population of this then the budget will be that because there are things that IJBs must do and then there are things that they can elect to do so not all for example have children's services and my other point of caution is although the process of negotiation is as you rightly say possible points of contention I nevertheless think that an integrated joint board having a budget which has been negotiated between the health board and the local authority means that there is some ownership about the amount of money in that budget rather than simply being able to say that's what we got from the Government and I do think it's important that the IJBs own the budget and are committed to delivering within it in terms of the number of health boards I hope there aren't 23 because I think there are 22 but maybe you're thinking of the care inspector well so that's up to 24 potentially so in terms of health boards so the 22 health boards I'm sure that you have read the SNP's manifesto in which they said that there would be a consultation on the governance of health boards and I would expect that ministers will want to announce in due course when that consultation will be and what form it will take so there's no plan to announce no date for such an announcement ministers have not yet given a date for such an announcement Mr Neil so if how are we for time just in terms of moderating what we say I think you suggested that Huggins might want to add so in terms of benchmarking and progress it is a good point in that we're still in relatively early days at the same time I'm sitting here with the annual reports produced by East Ayrshire and North Ayrshire on the basis of the fact that they were in place on the 1st of April or the 2nd of April in 2015 so they have had a year of activity they are now in the process of producing their report the East Ayrshire report was agreed on Tuesday and is in the public domain and you can see what they have achieved under the new integrated framework within that period you'll see their progress on delayed discharge you'll see their progress on reducing alcohol-related admissions in terms of the question about how we're then looking to bring that together across the piece I'm meeting each of the partnerships roughly once every nine months to sit down and spend time with them and talk about where they are in each case what I will do is I'll meet the chief officer from the partnership and the two chief executives from the parent organisations within that we have a focus on data issues we have a focus on progress and the areas where we're also spending some time is around winter delayed discharge, hospital admissions bed days and using that so if there was an area where we would say that we are doing some comparison and some engagement and working across the system it's probably in those set of issues around flow community response but also the anticipatory and preventative activity but not all partnerships struggle with that so in other areas we will be looking at other things which are more appropriate for them we'll be looking at issues maybe around social care commissioning which is being key in other areas or mental health service delivery so there is some element of moderation going on within that we will challenge we will expect them to describe how they're taking it forward with communities we also bring together the chief officers as a cohort once every two months all of them and again we use that as an opportunity to look at particular horizontal issues that apply across areas and again we will bring data to that with the system we'll talk about the use of residential versus care at home we'll talk about the use of hospital for the over 65s as opposed to the under 65s so we're using that again to give them a conscious understanding of what's happening beyond their patch but also knowledge about what appears to be working in different areas and this is one of the themes of the report in front of the committee today is how you take that learning forward so we're doing that to some degree welcome but it doesn't basically answer my question which is at a national level there are certain benchmarks for progress that you expect everybody to have achieved or the system as a whole nationally to have achieved, I think that's the key issue because the auditor in will just come back presumably and make similar comments every now and again if we don't have something against which to measure progress nationally I think that the absence of that means that none of us know what to expect by the end of this year and how far you intend to make progress in achieving the actual outcomes which are the key strategic performance measurements so all partnerships are required to report against the 23 indicators that are established under the nine national outcomes and that provides a framework under which we can understand progress across the partnerships Why is that, if I could put it that way? So within the role that at the beginning of the summer we took a look at the ministerial strategic group which is where we bring together Scottish ministers with consular leaders, with the voluntary sector with providers with the independent sector and we as part of the rethinking the role now that integration is launched two of the items which we brought onto the standing items to the ministerial strategic group one is around performance and progress so that we can actually look across the system and see how we are seeing change so we can consider whether that's satisfactory and whether intervention is required but also looking at sustainability so understanding the interaction between resource and activity so we have identified the need to do that nationally and we've created a framework to do it in partnership with the other partners who are required to deliver integration I think it would be helpful if once you've done that the committee was informed so that we can see ourselves you know how we measure this as a PAC Yes, indeed, that would be helpful Paul Just a bit of a brief point, convener to remind the committee that it was announced on the 6th of September Sir Harry Burns is chairing the review of NHS targets and indicators so that work will be done with COSLA who are supporting the joint review and we are working closely with them so again by the end of this year there will be something further that the committee can consider based on Sir Harry's recommendations about what we ought to be doing looking forward I think an important point for me is understanding what the trajectories are both in individual integration partnerships so in other words it might be very easy to say partnership A is lagging behind partnership B on a specific issue but actually if partnership B started 50% behind partnership A so I wouldn't want to get too much into league tables about this but you're right to say there ought to be some national objectives and these are set out in the overall indicators Sorry, can I just clarify if Sir Harry's review includes a review of the national outcomes or existing the 23 indicators for this integration So the outcomes are established under by regulation under the legislation and so the focus which has been identified is in respect of the indicators that support the outcomes That is the question Is it part of Sir Harry's review? Were he as part of the review to identify that there was an issue with the outcomes I'm sure we would look at any recommendation he was to make but he has been asked to look at the indicators and to look at the targets and that's the specific thing that he's been asked to look at Some of the and in the context of this some of the data that we're seeing though is quite interesting in terms of the interactions so the East Ayrshire data that we've seen in terms of the progress that they've made on delayed discharge and delays of care alongside that what they've then seen is an increased number of emergency admissions for the over 75s and you can see how those might fall together in that as you free up some capacity that capacity then gets used so it takes us into a broader conversation about how you expect the overall dynamics and again that's why I'm wary of simplistic focus on individual indicators because in solving one problem we then need to move on to try the next problem so it's a more complex system than perhaps sometimes we understand Okay, final question gentlemen from Gail Ross Thank you, convener I've been listening with great interest everything that's been said so far but I feel that I must bring to everyone's attention that in Highland we've been integrated since 2012 and there have been challenges and there have been a lot of things that have worked I just wondered what lessons have been learned and are taken forward nationally from the model in Highland and also just to go back briefly to the point of recruitment and to touch on rural recruitment we have huge challenges in NHS Highland and our problem seems to be that there are too many specialists and we are looking for more general surgeons general consultants we also have problems especially up in Caithness general with anethnotist obstiatricians we also have problems with GPs granted and we are finding now that more and more people are having to travel to Rhaigmoor which for some people can be over 250 miles round journey and a lot of people are finding that they actually travel down to Rhaigmoor only to have their appointment cancelled at the last minute there are a lot of difficulties there I just wondered what can we do in a rural situation to have less reliance on logums which we seem to be spending quite a lot of our budget on and making it more attractive for people to actually have substantive posts The first thing to say is I did last year drive all the way from here to Caithness for the annual review so genuinely I have some appreciation of the challenge that folk face if they have to make that long journey I know that NHS Highlander thinking about models whereby they take the care to the patient rather than taking the patient to the care so in other words I know they have worked with consultants to provide cover in WIC so that people don't have to travel so far in Inverness in October November of last year in November in fact I had a very useful meeting with the GP rural body which was meeting that day in Inverness and one of the things I took away from that was the importance of the new GMS contract taking account of the circumstances of rural general practice that's one of the things I did feedback I think the issue around recruitment and retention in Highland is pretty obvious in some specialisms and I know they're working hard on that both the chief executive Elaine Mead and the medical director are firmly cited on that but what have we learned from that we've actually learned some pretty important lessons about local excellence I've seen it in Avie More I've seen it on The Black Isle it's not just in one place but in many about how you really remodel care for the benefit of rural communities one of the things that we've also learned is that remodelling care and proper engagement with communities is a long time you can't decide at the beginning of the year that it will all be done by the end of the year it rarely works the engagement not just with local communities but with the elected representatives both at national and local level all takes time but when it happens and happens well you have services that are much more closely tailored to the local environment NHS Highland of course is a lead agency model but that means that some of what they do is transferable some not because everyone else has chosen to have integration partnerships would I say that some areas are maybe looking a little endlessly at the prospects of a lead agency model perhaps some are and maybe over time one of the things that will happen in integration is that there will be a more uptake of that as confidence in the principles behind the model so that again as I said to Ms Harris earlier if there are specific issues you'd like me and colleagues to take away about the particular area that you represent I'm more than happy to follow up post the committee if time permits I know that Jason and Jeff would add but I want to be respectful of the committee's time we are running very short of time is it possible to add in written evidence to the committee you probably was not worth it okay so let's just stop okay thank you can I ask one final thing we've covered most of the Auditor General's recommendations quite broadly in some in detail but can I just ask the panel if they're in agreement with all of the recommendations in the Auditor General's report that's not amenable to a yes no answer I accept in principle most of what Audit Scotland says but I would genuinely welcome the opportunity to write to the committee setting out a response to each of the recommendations and these are the ones which are to be found on pages 5, 6 and 7 of the report if the committee would find that helpful I would genuinely like to set out how we're going to address each of the recommendations that would be very helpful Mr Gray I'm particularly interested in the first recommendation about the clear framework by the end of 2016 so your answers on that would be very helpful indeed can I thank the panel very much for your evidence this morning, thank you I'm going to suspend for two minutes while we change over witnesses okay we now move to our second panel on the Auditor General's report entitled changing models of health and social care and I welcome Julie Murray chief officer from East Renfrewshire Health Social Care Partnership and Shona Strachan chief officer of health and social care Clack Maninshire and Stirling integration joint board Julie and Shona will both make brief opening statements I believe Shona is going to go first is that correct? thank you convener this is a short opening statement to provide the committee with some high level background to the partnership as Paul stated not all integration joint boards are quite formed in the same way I'm the chief officer for Stirling and Clack Maninshire I've been in post since July 15 and as chief officer I currently have a focus on the strategic planning for integration and supporting the integration joint board I have no direct operational responsibility for service delivery the Clack Maninshire and Stirling partnership is unique in that it comprises two local authorities and one health board the partnership works closely with the other health and social care partnership in the area in Falkirk and there are a range of services spanning both partnerships including one acute hospital both areas within my partnership have growing older people's population and lower than average levels of unemployment this combined with the rural nature of the communities provides some challenge to the partnership in terms of delivery of services the integration joint board itself was established in October 2015 agreeing the budget and strategic plan incorporating the three localities in March 2016 the in-scope services which form the integration scheme are essentially the community-based services relating to adults over 18 years of age with community care and health needs the partnership did not have an existing integrated community health partnership prior to integration however it has a long and positive history of joint working from the range of single care pathways in place through to fully integrated services such as mental health and learning disability there is strong commitment from staff including those from the independent and third sectors locally and professionals including GPs across the partnership to work in new ways to achieve outcomes services have been designed across all care groups to focus on re-ablement, recovery and rehabilitation there is clear evidence in the partnership of a shift from dependence on things like care home placements to increased activity in the provision of care at home and the development of intermediate care services further supports this there is a major investment just now in the development of the sterling care village which will consolidate the intermediate care provision in sterling on to one site along with the community hospital and some primary care and social care services and this largely mirrors the services already in place in Clitmaninshire in addition both areas have full re-ablement care at home services in terms of the developing work currently underway around prevention of admission Alfie the advice line for you is highlighted within the Audit Scotland report as a good practice example and this is supported by the use of anticipated care plans and services such as closer to home providing multidisciplinary support for people to remain at home avoiding unnecessary admissions and supporting management of more complex care Further work is now taking place to develop the localities supported very much by primary care with a pilot proposal for an integrated model of neighbourhood care currently being developed for one of the more remote to rural areas I hope that you find this statement helpful Thank you Julie, can I invite your statement Yes, thank you convener Again, I just thought it would be helpful to give out more information about the nature of arrangements in the Easter infrastructure and again a wee bit of historical context because although the integration joint board was formally established in August 2015 we have had a history of partnership working to 2006 when we created an integrated community health and care partnership so there's a long history of integration and build up of trust and relationship which I think is really important As chief officer I've got a number of roles I report directly to the integration joint board responsible for delivering the strategic commissioning plan for that board and with that board but I also have full delegated operational responsibility for social care services in Easter infrastructure I'm directly accountable to the chief executives of the health board and Easter infrastructure council for that operational role and I'm also a member of both corporate management teams of the parent organisations In Easter infrastructure the IJB is responsible for all social care services and community health services so that includes adults and older people that includes children's services and community justice services I have an integrated management team I've had an integrated management team for some years and my heads of service are employed by both NHS Greater Glasgow and Clyde and Easter infrastructure council and we do have integrated teams within most service areas Our staff are co-located in the main in two purpose built health and care centres which we are very fortunate to have established over the years one we just opened in August and these are purpose built buildings which we share with GP practices and community health services and social care and they are jointly funded by the council and the health board Our services for older people and people with long term conditions are already clustered around groupings of GP practices we have integrated teams comprising advanced nurse practitioners we have the first advanced nurse practitioners in Greater Glasgow and Clyde district nursing rehabilitation services occupational therapy social work etc and we also plan to align home care in the coming months and also align some more specialist staff around mental health, learning disability etc so that the practices can get to know who their linked person is I think it's fair to say that the shared culture and identity for the partnership has been very important to us and we've put a lot of effort over the years into organisational development and strengthening clinical and professional and managerial leadership locally Given that we began developing services integrated services and management arrangements around ten years ago we have made good progress across a number of areas and I've performed well in reducing bed days loss through delayed discharge and we can also demonstrate improvements in the outcomes of the people we support we measure aggregate and measure talking points which you may have heard of we've also made efficiency savings through the years by developing integrated management arrangements and integrated support structures to reduce duplication and I would just echo what was said in the earlier session we're still in a journey ten years on so integration is not going to be a quick fix our role as a commissioner of unscheduled acute care is still quite new and at relatively early stages of development we operate within NHS Greater Glasgow and Clyde which is a very complex environment there are six partnerships a number of acute hospitals an acute division which is under significant pressure and we are working with colleagues across Greater Glasgow and Clyde to develop a whole system approach because no one partnership can work on its own in that context so I would say that our parent bodies are under financial pressure and subsequently substantial savings targets have been passed down to the IJB or across to the IJB so I think we are optimistic we have a very strong base in which to build we've got strong relationships with GPs which we've built up over the years strong relationships with colleagues in the third sector and community groups we're working very hard to support community developments that reduce demand on formal services and ensure that financial climate is challenging and we're not naive it's not going to be straightforward so very happy to cover anything in more detail and answer your questions to the best of my ability Thank you both very much indeed I now invite questions from members Colin I'm actually just looking at an XB here of the documents we've got and it's the budget information for East Renfrewshire and I've got two questions about that the first is the figure 3 where it shows community healthcare taking quite a big hit how is that? I can explain that an element of that and we should have stripped it out is non-recurring funding in year so it's not really a like-for-like comparison there were some changes made to the way capital capital charges were treated so it's not a like-for-like comparison but to be honest there has been a reduction the reduction in our health budget passed down from the health board which we just found out in July is about 1.2 million it was just a dramatic drop here it's not as dramatic as that that's really our fault for not stripping out the non-recurring and the capital charge changes well whatever 1.2 3.5 minus 1.2 is so that was 1.2, 1.3 is a real is a real recurring reduction okay and the other thing was I'm looking at section 5 and bullet point it says here no mechanism for transfer of funds to primary from secondary care it's not going to work then I think that's one of the big challenges that's one of the real things we're all grappling with the whole point is that the different stakeholders get together and agree that this should happen and what you're saying is it's not happening I think in my introduction I described the complexity of arrangements we have in Greater Glasgow and Clyde we are all getting together as a group of partnerships with acute acute is under enormous pressure they are they are overspending at a rate of not so we are working very hard to collaborate to actually look at our commissioning plans and look at the impact of all our activity to reduce bed days and to reduce admissions and aggregate that into a plan for Greater Glasgow and Clyde but at this point we don't have that mechanism I mean whatever pressures and so on we're under this is not going to work unless we have some sort of transfer of funds someone has to agree to share their budget at some point I agree entirely how are you going to do it well I say we're working across Greater Glasgow and Clyde with the board with the sixth chief officers in the partnerships to try and develop a collaborative plan that starts reducing the need for hospital services over a number of years at the moment it's difficult to see how we can do that with the big pressures on hospital admissions because although we've reduced bed days lost our admissions are still rising so we need to do a lot to try and prevent these admissions I'm not getting a feeling that there's really a solution coming out of this there is not an immediate solution it's very very complex whatever we do in East Renfrewshire and we've been doing it over the years to reduce bed days and to reduce admissions because we share a very complex system we don't have one hospital that we relate to so we're sharing wards in hospitals with Glasgow with Renfrewshire etc we have to collaborate together in order that we can act collectively to reduce the demand in hospital services Can I just ask about the previous panel that we were discussing about GPs and the challenges of maintaining the workforce, recruitment and so forth how are you on that at the moment? In East Renfrewshire I think the GPs are under pressure they're under pressure probably for different reasons than the deep end GPs they're under pressure because of the age and population we have in East Renfrewshire very high numbers of over 85s but we are I don't think that there are particular issues in recruitment locally we're working very closely with the GPs we're now co-located largely with GPs and are doing all we can to work to support them and we're providing as some of the evidence earlier we're providing link workers the advanced nurse practitioners on their more complex patients the people that are more likely to be admitted to hospital although the GPs are very busy we're working very hard with them to try and reduce demand as much as we can Successfully? I think we're beginning to see some success and the GPs certainly have worked because we've worked in clusters of GPs we've had lead GPs from clusters doing some planning with us and we're part of our strategic planning process some link workers who can support people who have got real anxiety issues who attend GP practices very very regularly we can have these link workers who can actually start diverting folk to peer support into community facilities and community services so that was an idea from them we're also supporting them with prescribing support significantly so I think the relationships have built up over the years to be very good and I think we are starting to see some success in our areas of deprivation which we do have in Barhead in particular I think the GPs really welcome integration because we're co-located with addiction services, mental health services and they have really seen the benefits over the years I think we have a variable position with the GPs we did have some difficulties and continue to have a little bit of difficulty within the city area of Stirling the rural area is well served by GPs although the practices tend to be relatively small one to man GP practices and that's an issue in terms of longer term sustainability and we are working with the GPs as a group in and around sustainability around practices we similarly have some GP primary care hub developments locally and some of that has come out of the difficulties that the practices have been experiencing I can only talk about the one in Stirling I'm aware that there are others across the Forth Valley area but again prescribing support has been put in, physiotherapy support the one that is showing probably the greatest impact is the CPN and mental health input which is similar a little bit to what Julie is talking about where people are having mental health issues or are stressed or distressed and being able to deal with that at a much earlier stage to divert into the norm range of community services we've got some GP fellows who are new and young GPs and again trying to focus them on older people's services and giving them the support to do that we've got some nursing staff we've got allocated social workers in and around some of the practices and some physio input again so again it's about I suppose it's about that place based service approach communities what they need and being clear that the GPs are pretty core to delivering health services and social care services need to wrap round that in terms of the rural area I referred earlier to one of the rural pilot areas and that was chosen again with the GPs the GPs are very involved we've got locality GPs in our area for our three localities and the GPs are leading the locality development and there's been an enormous amount of community engagement already in the Strathendrick ward in Stirling and we talked about that taking a long time and it has taken a long time it has come out of concerns about not being able to access services about the acute hospital being very far away about quite often having to use services in Glasgow and we're not very good at the admission and discharge round about that so we already know that it's quite a well-off community in some areas but there are also pockets of quite marked deprivation in the Strathendrick ward and so we've started to look we initially looked at the Birch sorg system and because the principles of Birch sorg with the person at the centre family and communities wrapped round and then the social care and health contribution seemed to make sense to us so we are in mid-discussion just now and we have Highland coming down to help us with some of the learning about what it looked like and felt like for practitioners starting off on this new way of working Just one final question this problem about transfer of budgets and so on from primary to secondary care have you made any progress on that? I think 4th valley is very different to the Glasgow partnerships we have one acute hospital which was remodernised and the community hospitals and click manage so we use community hospitals slightly differently those are the community hubs I described a little bit about the transfer and it is a transfer it's a transfer from sterling council and their current residential establishments into form a community hospital hub arrangement which will have GPs, social care and community hospital health beds based in it so we are seeing rather than a direct transfer we are seeing a realignment of resources and an investment in joint areas in learning disability services slightly different approach in learning disability services we have had integrated services for a very long time we do have some acute beds still which are based in the fall kick area and we are in mid discussion just now about how we reprofile those beds reprofiling we mean moving some people out into the community who are now able to be supported in the community and transferring that resource with them I would like to follow up with Julie this whole issue of the greater Glasgow and Clyde allocation of resources because obviously greater Glasgow and Clyde health boards in a very unique position in that it covers seven local authorities and has got effectively seven I think it's seven IJBs so this you may not know the answer to but the other five local authority other five IJBs in the greater Glasgow and Clyde health board area have their budgets been reduced as well from the health board right so that suggests to me there's an issue here that I think the committee will need to address because the whole point of this exercise is to shift the balance of resources from acute to primary if the health board doesn't do that because they make that primary I don't mean primary in that sense but they make the initial allocation in terms of what they give to the IJBs so I think we should invite greater Glasgow and Clyde health board in to give us an explanation why they're cutting these budgets and where is the money going to because if they don't make the balance it'll be very difficult given they account for about 40% of acute operations in Scotland it'll be very difficult for Scotland to achieve the rebalancing if greater Glasgow and Clyde health board isn't playing its part I think that's a a fine idea Alex I think we can certainly invite the health board in to give evidence on that Do you want to ask a further question Alex, of the witnesses Can I invite questioning from Liam Kerr Thank you, convener I've been very pleased to hear lots about strategic planning I'm concerned it seems to all be rather reactive such that when we talk about admissions rising funding cuts, staffing issues then the strategic plan addresses what is a previous issue if that makes sense so what I'm interested in is what modelling if any has been done for how the world looks in whatever time horizon, 5, 10, 15 years time, so what is the demographic of your area what is the likely need based on changes to public health and the like what is the impact of anticipated results from government health programmes or any interventions such as extra funding and from that do you have review dates for how those scenarios are panning out there are presumably 3 or 4 possible scenarios so Julie you talk about you're still on a journey 10 years on, well a journey where and what are you going to find when you get there that's an interesting question I don't think you ever reach the end of your journey, I think things change demographics change peoples expectations change models change opportunities arise clearly though we do have a strategic plan which we've done a health needs assessment of our local population we understand how that's changing we've got particular challenges around older people and young people with disabilities so we understand what the issues are I think to go back to your point about reactive I think there's always firefighting goes on but actually our longer term strategy is to is to try and reduce demand where at all possible by building up the resources in our community looking at the assets in our community looking at the third sector in people's own assets and how we can support them to to help find solutions for people that don't necessarily mean they get sucked into social work if they don't need to so we're on I suppose quite an interesting journey around that in that we were one of three partnerships in Scotland who are working with an organisation called the national development team for inclusion who've done some very similar work down south and they've actually found that by taking their services and resources out to community hubs so we work with libraries, leisure trusts community groups so we can answer people's questions and direct them to peer support or if they need our services we can do a quick assessment there and then we can actually start reducing our bureaucracy because we don't have big waiting lists we don't have people waiting for ages and ages and we can actually try and divert people who don't really need our services from being sucked in we've also had a huge big focus on reablement which I think Geoff mentioned earlier which means we've retrained our home care staff so that actually almost 70 per cent of the people that they have seen in the last year and gone through this reablement programme actually improve and don't need as much long term services as a long term care plan that they would have had in the past in the past we would have just gone in and been there for 10 years so a real focus on prevention, on anticipation and trying to understand our population Geoff also talked about the information support we're getting from ISD we now understand the people who are very high users of health and care services locally and can get alongside them and work to identify how we can work differently with them and support them differently so if they don't need to go into hospital or they don't need to visit their GP every three times a week then we can work with them in different ways so it's a bit of both we've got some long term plans we twice yearly have performance reviews to see where we've got to we've got a lot of governance around a transformational programme that we have in East Renfrewshire which is about trying to do things quite differently so it's not just more of the same and firefighting but does that because that certainly sounds great for them now the issues that you're having to deal with now has there been any modelling done that says ok we do this now we train up so we heard earlier about training up GPs and that takes seven years so ok seven years time there's an influx of GPs but has there been any modelling done that says ok you've taken these actions now what does that look like in seven years time when we've suddenly got an influx of GPs but do we need them for example do you think we've done that specific workforce modelling around GPs so that we have done some work to identify what is the impact of what we're doing now in terms of prevention and what does that mean later on for example we've got a very comprehensive programme around early years and we're trying to see if we invest in early years and support families in different ways does that mean we won't need as many addictions workers or social workers or further down the line so we're working with some health economists to try and get that answer quite often we don't have that capacity locally so actually we're using the support from the improvement hub and others to help us do that working out cos health economists are fairly rare in the ground but absolutely that is something that's factored into our planning I think it's a similar pattern you would expect me to say it's a similar pattern ISD have heavily involved themselves in our local area we've also used them to upskill our local analysts obviously recognising that that skill will move on and away at some point and I think that's helping us to understand our information is currently calibrated to 2037 2037 and I realised in front of one of the boards one day I was talking about myself right in mid presentation and my jaw just dropped so I have to get this right for me even if it's not for anybody else but we do have to get it right I would argue and I know some of it sounds very reactive but I think there's a real attempt with the strategic planning mechanisms to move it forward and to try and have a forward look as well as we can with the demographic information that we have so an example of that would be in Clickmaninshire one of the smallest county areas in Scotland has quite a different profile to Stirling it has greater levels of preteen pregnancy it's very very high mental health and addictions issues it also has a falling population during that period quite different to neighbouring Stirling where the population will continue to rise and within that population the population spread will be much older so we already know that we won't have the workforce to do exactly what we're doing just now as we go forward so we commissioned from the then jit a more detailed what we called a housing assessment need but actually it was about accommodation and support and what we could do differently and so we are now pretty clear that we can't continue as we are that we are going to have to look at core and cluster systems in order to be able to deliver the support required to the community we will not have the workforce so that's a really really good example of how we can go forward using the information that we've got in the demographics to try and build something okay thank you very much we're running short of time I have three further questions on my sheet if we could have short, sharp questions and answers then we'll get through everyone's points thank you very much I've got Gail Ross, then Alison Harris then Monica Lennon, Gail thanks convener really quickly we've chosen the lead agency model which means that NHS is solely responsible for adult care and a council is responsible for children's services and I heard today that we are the only one in the whole of Scotland that's done that which I didn't know I must hold my hands up what made you choose not to go down the road of the lead agency model and is it something that you would consider in the future I think for us in East Renfrewshire it was an easy decision because as I say we were building on an integrated community health and care partnership which really had all the features in fact our community health and care our community health partnership committee was very similar in make up to the IJB we had integrated services we had aligned budgets the governance has changed and the budgeting arrangements have changed in terms of the structure and nature of our services they are quite similar so for us it was something that we were building on that seemed to work Chini, do you have anything to add to that you don't have to? I don't have any comment to make on that that decision was made long before I ever came into post Alison Harris Can I just ask you a short about the delivery of the sterling care village where are you in terms of delivering that I think we are waiting for what's known as financial closure and please don't ask me the details of that and are currently working on the care models just now a lot of our support funding our integration funding is supporting the current models in sterling so if you look at our care homes the bridge of allen one is a really really good example it is now almost quite an ancient building if you forgive me operating the model that will almost run sfer straight in so it's a dementia and intermediate care model that's currently operating so the staff and everything else are now skilling up for all of that so it's very nearly ready to go it's very nearly ready to go Thank you My questions for Julie you've explained it's been a 10 year experience of working in partnership and you've given us a flavour of some of the complexities involved I just wanted to ask a little about the budget setting process so after 10 years of working in partnership there's still a situation where the budgets are not aligned and there's been a 5 month delay between the council's contribution being confirmed and the health boards is there a quick and simple answer to why that is and have we reached a position where that's not going to be the way forward in the future I think the simple answer is just the historical it's been in the historical approach different organisations have had different ways of approaching things although the health board has recognised how difficult this has been and the finance director has made a commitment to try and start much earlier this year so I think he'll be coming to our meeting in September with some ideas of likely budget scenarios in 1718 so we should be in a position where we're aligning much better for the next financial year any further questions from members for the panel can I sum up by asking you both to refer back to the Auditor General's report do you have similar question that I asked to the previous panel do you agree with the recommendations and do you have any comments on them at all on the whole I would agree with the content of the report I think I would echo Mr Neil's comments earlier we have to be realistic about expectations you don't just set something up on a Friday and by a Monday all of the problems are solved and all of the issues are solved I think this has to be viewed as a long term investment in Scotland's future and in the future of health and social care services however that we do need to pay attention to PACE having said that and the things that are working locally and we have good networks around in order to be able to share a lot of that and the one size doesn't necessarily fit all thank you I think apart from the PACE issue I do agree with the recommendations I think in particular we probably need some national support on shifting the balance of care I mean we've had I'm old enough to remember or be very involved in the hospital resettlement programmes in the 90s around learning disability and mental health where we'd specific bridging finance which was allocated on the provision that we reduced bed numbers and enclosed sites and I think although we've had lots and lots of exciting opportunities through some of the new funds we've been helped to speak creative and innovative I think if we are really going to shift the balance of care there needs to be probably a bit more of a framework around how that will happen okay thank you both very much indeed for your time and your evidence today we very much appreciate it we now move to private session as previously agreed