 Cymru. Fy enw i'r 11 ymdd hashbwrdd ymddian Nghymru i'r Cymru yn 2017, mewn i'r ddechrau'r mawr i'r mowy yn gyntaf dros ymddiadau, mawr i'n ingwydd o'i chi, rôl cymryd o'r mwyraeth o'r opus mawr. Felly, rôl i'n tychwch yn gwrthu o'r ffilmau. Yn yma, ymgyrch yn gwleiffydd cyntaf o'r pwlad y ffordd cyителиwag cysylltiadau. Fy fan y pwlad yw P16 28 ymddiadau i'r mwyraeth o'r sefydliadau mewn gweld, Rwy'r adnodd, ac rydyn ni'n credu i'r cwmwyllt y pethysion. Rydyn ni'n credu i'r cwmwyllt y pethysion yn cymaint o'r pethysion, yn gwerthu'r cwmwyllt. Rydyn ni'n credu i'r pethysion i'r cwmwyllt? Yn rhoi cyddefnydd diolch i'r iawn i'r pethau. Wrthgcrwmrwysau, rwy'n rhoi ymddiadwyd yra, wirwch am y partidwyll yn cyduaith gyflym iawn iddyn nhw i mireddol i webi i gyfer agor. Mae'n ddweud o'r ses manneru hynny mae bydden nhw i ddim yn bwysig o'r pethau. Mae'n ddim yn ei ddim yn ei ddweud o'r effeithio ar y dyfodol, Caerdydd. Rwy'n fawr, defnydd i'r ddefnydd i'r pethau? Rwy'n fawr. Wedyn yn y rai'r pethau, wrth digwydd, I wish to see... I don't mind dismissing the petition as long as we consider the very important issues that it raises, so I do have a particular local issues with it, thank you. Any other members? What's the comment? Okay. Has Collins' course of action agreed? Yep. Yep. Okay, thank you very much. The second petition is P1605, whistleblowing in the NHS. Again, we want to consider the evidence presented and open up to members for any comments. Alison. I'd like to suggest that the committee incorporates and consider this as part of our inquiry into NHS governance. I think that that seems highly appropriate and that perhaps we look at having a session on whistleblowing too, as part of that inquiry. Any other comments? Okay. We all agree that we take that approach, I think that that's a very sensible approach. Okay, thank you very much. Agenda item 2, integration authorities engagement with stakeholders. We have two evidence sessions today, the first is a panel session and can welcome to the committee, Claire Cairns co-ordinator, coalition of carers in Scotland representing national carer organisations. Heather Petrie, future and specialist delivery team leader, voluntary action south Lanarkshire. Linda McGlynn, regional engagement manager, Diabetes Scotland, and Sonja Cottam, director of the Pain Association in Scotland. Thank you very much for coming along this morning. Who would like to ask the first question and get us started, Alex? Thank you convener and good morning to the panel. Thank you for coming to see us today. I wonder if you could start by giving us an overview of the landscape of how integrated joint boards communicate and engage with stakeholders in the current climate. Okay, thank you. Our submission was very much based on the experience of carer reps on IJBs. We've actually been running a project since May last year, bringing together the carer reps from across Scotland. So they've had four meetings altogether and that's been about them sharing their experience and learning from each other and also looking at some of the challenges and the best practice in terms of their representative role. So I would say in general their experience has been mixed across Scotland at the initial meeting in Edinburgh. There was a degree of frustration that they were feeling perhaps that they were unsure of their role, a lot of them feeling quite isolated. I think a lot of frustration was around the way that meetings were conducted. But in saying that, as the meetings have progressed, we have seen a lot of improvements and best practice development and so when we came to write the scoping report, which I think you've got copies of, the experience had changed quite a lot within that time period. In saying that, the carer reps share a lot of similar challenges across Scotland and some of the things would include recruitment and induction, which quite often happened later on in the process. It didn't happen before they joined the boards, it happened perhaps later on. But a lot of them have received training now and have met with key people and so on and so are feeling more that they've been given the support in order to fully participate. There are some variations around the support and resources that carers receive in their role. So for example, with carers we would hope that they would get all their transport costs but also replacement care costs reimbursed and that's not necessarily always the case. Some carers use for example their own direct payments when they're attending meetings and that does reduce the short breaks that they get for themselves. So I think that could be looked at. One of the key things is being representative. In terms of being a carer on an IJB, it needs to be beyond just that individual person's experience because caring comes in many different shapes and forms and so it works well. They've got a community of other carers that they're referring to and going back to you and there's good communication between the two. That happens actually in a lot of areas. Very often they connect to carer forums or their local carers centre and other carer groups, which means that when they go along to the IJB meetings they've already had conversations with a variety of local carers. But there are some difficulties around that. Quite often the timing of the meetings for example or the papers coming out late mean that they can't get those conversations before they attend the groups. I said before, there are some frustrations around meetings like the amount of paper that when you get the paper sometimes it's only 24 hours in advance. They're being quite high level in the idea that you can't contribute because it is decisions which are just being rubber stamped at the meeting. Not as much discussion as people would like so there are again areas where there could be improvement in terms of how the meetings are conducted. And then we would say the ultimate test would be have they made a difference. We did some scoping around that which we could probably move on to but I would say initially it was difficult for carers to make a difference but we are seeing more progress in that area as well. So some really good practice across Scotland but again some challenges that need addressed. Anyone else wish to comment? Thank you from a Diabetes Scotland perspective. We've found involving with the IGBs at a strategic level and at a locality level to be somewhat challenging. We have a network of about 40 local groups and a lot of the local groups found that they weren't accessing the information. Several of the local groups had been involved in local patient involvement forums so they were aware of the processes but many of the other groups were not aware of how to engage with the IGBs or the locality plans. Those that did engage found that they couldn't really see where they had a significant impact. If they had made suggestions there was no feedback to see you said this but we didn't go for that because of X, Y and Z so it was fairly challenging from a national level. We certainly found it challenging in terms of we did significant desktop research to find out where the strategic plans were, what were the priorities, where diabetes set with that, how it sat within the long term conditions and we found it extremely challenging so we did right to every single IGB and every single senior manager to extend an invitation to meet with us to see how we could support the IGBs. Sadly to say that several of those organisations failed to even respond and acknowledge the letter so we did the information of freedom requests and we found a mixture of information that came from that. IGBs were saying one thing about devolved diabetes services and the health board were saying something completely different so we just found out that the communication channels were a bit abstract and opaque and obviously we welcomed the IGBs, we think they're a good opportunity to improve diabetes services in person-centred care and we would welcome co-production rather than just a tick box exercise. In South Lanarkshire my CEO sits on the integration board along with a service user rep and a carer rep. Our CEO meets with these individuals to discuss the papers. That's quite a recent thing to make sure that the information's passed forward. We've also set up third sector forums in each of the localities. We've got four in South Lanarkshire and that is chaired by a third sector organisation who sits on the locality boards as well as a representative from the third sector interface. So we've got that information that we can then pass back. In South Lanarkshire we're talking about just for community groups and organisations. We're talking about 1,600 that we know of so we couldn't expect that all of those 1,600 groups could sit round the table so we see the third sector interface as being the conduit and passing out that information. I would echo a lot of what Linda was saying in terms of for ourselves it's been quite challenging and operating through with the majority of health boards throughout Scotland. For ourselves it's been quite impractical as well to be aware of the way in which a lot of the IA is developing the services and it's been challenging as well to try and find out who are the key personalities round the table who we need to be liaising with especially the people that we've dealt with for example within health boards in terms of negotiating service level agreements. We kind of found out by default that they had moved on and had no way of knowing who we were supposed to be dealing with. So again you're trying to kind of find out all that information trying to be involved and trying to comment on strategic plans which are quite a first size and really quite difficult. I'm very interested in this tension that exists between the idea of consultation and the reality of co-production as I think Linda identified. I think that a lot of organisations and right back through time when they believe they've got somebody at the table who speaks for a sector or a group they kind of tick that box and forget about it or move on to other things and sometimes that can represent a bottleneck as we know there are many many many stakeholders in this field and many of whom may not know what their interface is with the IJB. I just wonder if the panel particularly from the IJB side of things could reflect on what we are doing to broaden the net in terms of getting the opinions of other stakeholders or getting a route for those other stakeholders who don't potentially have a relationship with or even may have a toxic relationship with the reps who are on the IJBs through social media through other events that kind of thing. I think where it works well in terms of the carers movement and in some ways it is I think we have better networks than some of the other stakeholders but where it works well you will have the care on the IJB as mentioned who will then connect with our local carer forum you also I suppose need to populate the other strategy groups and localities with carers as well and somehow ensure that all these people communicate so they are looking at working towards the same aims and goals and that is quite challenging some areas are much further ahead than others if there are resources put in to support those networks and sometimes you might have for example in Perth there is a post holder who is attached to the third sector forum and also the carers centre there who provides support to the carer reps and the service user reps so they have a meeting before they go into the IJB they discuss items on the agenda and make sure that they have all the information they need and they ensure that they have any training or mentoring that they need as well and then they communicate with the carers voice group in Perth which extends like I say the number of carers who are involved but I think as well as that you need another level down too so that would be typically carers who are interested in policy and legislation maybe have some experience in the area and want to contribute it doesn't necessarily involve carers who are just getting on with caring and have other responsibilities in their life they may work, they may have children they've got lots of things going on realistically they're not going to really want to get as involved in something like the development of policy or strategy locally but it's something which really affects their lives and I think the best way to connect with them is again through their natural communities so people from the IJB is actually attending carer groups that they go to or getting involved in social media because carers who maybe don't attend physically groups they very often are online as well and getting support that way so it's not always about the carers going to the meetings it's very much about the IJB and the integrated authority going to there the places where they congregate or where they communicate as well If I may give one final question we've had a number of sessions with the Scottish Health Council around this table who are ostensibly the forum for the voice of patients in the health service whether or not they do that effectively is a discussion for another day but it strikes me that they are well resourced they have potentially quite a large reach and does the panel think that perhaps we should look to perhaps expanding the remit of the SHTC to be the Scottish Health and Social Care Council in these days of integration to better facilitate the voice of stakeholders in the design around integration I'm not quite sure whether that's the model I would be going down from a diabetes perspective I think it's more about ensuring that there's engagement channels up from the local networks certainly from our group so we have individuals that work at a local level as well as local groups and it's about that knowing who to contact and who to speak to and how they would then transverse that message up over so it would work for some people for not for everyone so it's about I suppose a menu of communications from using social media which we do use an awful lot with our young people from local groups so I think you can't just say it's one mechanism and one organisation what we have found with the third sector interfaces that across, up and down Scotland they don't always operate in the same way so it's difficult to know who to get into to the third sector interfaces as well so I think it's about recognising that some people will be quite easily and happily go to local meetings and localities because of the demands on the condition on able to do that but we need to give them the mechanisms to be able to communicate up over and also the mechanisms to actually feedback because what is sadly lacking at the moment is that feedback mechanism to let people know that they've had an impact Can I ask what should happen then? I think currently the model that we have in South Lanarkshire we've recently got a new leader under health and social care she puts out a regular blog and we make sure that that goes out to all social media channels that's through our newsletters and everything else and she's always asking for feedback so anybody in the community can actually come back and ask a question and she's more than willing to sit down and go through it it needs to be more open channels you know as part of our remit of the third sector with the third sector forums all the locality managers are also coming to the third sector forums so that they can sit down with the third sector it's just opening those channels What else should happen? Do you agree with that approach or in other areas is there a different approach that should be taken and if there is what is it? I think as I was kind of mentioning before that we should practice out there already it's just making sure that it's more consistent across Scotland and in terms of supporting that I think most of the support wherever possible should be local rather than national there is a small role for national as well I mean for example we do have our CARES collaborative which allows the CARES reps to meet together four times a year and I think that's been really beneficial for them in terms of previously feeling isolated and not being too sure of their role but I would imagine that group shouldn't last forever because they should be able to more develop their supports locally I think that's better in the long term but it's been good initially as these things have developed but like I say where they have good support and good links locally that's where it works well we've certainly through the CARES collaborative produced a set of recommendations in terms of improving the experience of CARES on IJBs and a lot of that is around those lines of communication making sure there is support making sure they're representative and that is supported as well and I think some of it is about putting some resources in that direction one of the other challenges there is increasingly is trying to populate the many groups so the localities for example as they develop they're looking for CARES to populate them as well and it can be quite a bit of strain there's only one or two in the area who are taking on all of those roles so again there needs to be resources putting in to identify supporting training and recruiting additional CARES to take on those roles some areas are doing that already and like I say quite often it works well when it sits in a hub like a CARES centre and they're able to take information backward and forward and there's somebody there whose role it is to do that where it's done on a more ad hoc basis that's when the communication lines don't work as well I'll not go through the list of recommendations but they are in the report that we have put forward and I've got copies here as well if people are wanting them Any other suggestions from the panel as to how we can improve the situation? Go ahead, concur with what Claire said I think we have to look at what's happening locally what the demands are and putting resources in I think what we need to realise is a lot of the people certainly people with diabetes the condition is quite relentless they can't always commit to regular inputs and meetings the meetings are quite stressful in some instances I think what we need is the resources at a local level from a diabetes Scotland perspective we do support our local volunteers to get involved we actually provide them with training we provide them with expenses, out-of-potic expenses so there is a little bit around where there's a third sector organisation we can work with the integration to support the local volunteers to get that two-way communication Do the boards have identified people who have responsibility for engagement? Is there an engagement officer or someone who's duties within the organisation is to engage with yourselves and others? Certainly NHS Greater Glasgow has an involvement team and they do public involvement across the whole piece for NHS for the boards so there is a model there that works there are community development officers out there within local authorities so it's about how do they do that engagement community development is a good model so it's about putting the local resources from the IJB and working in partnership with the third sector organisations Thank you all for being here this morning and for the written submissions the pain association's written submission I think it's very frank you refer to the fact that engaging with some of those processes is frankly a mystery that you've found it extremely difficult to find out within each integration authority who's responsible for commissioning and it sounds as if it's just making and you speak about it simply being another layer of bureaucracy that's making it very difficult for you to deliver your services and you also speak about three-year service level agreements the challenge of that being reduced to one year I just wondered if things have improved at all if you've managed to find out who it is you need to be speaking to or to develop any of those important relationships yet As of yet, no, we've not seen any improvements. The one step forward we have made simply because we requested a meeting with a representative from the Alliance because we were finding the whole thing such a mystery as to who we would contact and who these people are we asked, can we have a meeting can we have any support and guidance as to who we're supposed to be approaching within each authority who is responsible for this because despite writing to the health boards and saying I'm actually going to people on the ground to clinicians to say do you know within your board who is responsible so that we can approach them to show them the value of the service say this is how we deliver can this service continue and can we provide this and have this continue to your service for patients so that has been our challenge and you're not convinced yet that there's a solution there that there's adequate solution based on an experience with a particular board where we have come across them approaching us to say well come along to a meeting to negotiate your service level agreement you know we were invited along on it to be asked well on it to be told well these are the new personalities dealing with it tell us about your service but we don't actually see the value of self management in terms of we don't see the value of people representing every month to maintain self management skills it's about it should be a one stop shop get them in get them out the door that's not what it's about self management so again we're back to square one trying to put that case forward and convince so I don't see that as an improvement in a step forward I think at the moment there's still quite a lot of fluctuation and change in terms of staff on IJBs and the integrated authorities as a whole so it is very difficult for people to pin down who the best person is to speak to quite often when they do they've moved on or something's happened I know for example one integrated authority the care rep was telling us that in terms even of the development of localities it's kind of come to a bit of a standstill because of the change in staff in the IJB the key chief officers have left they're recruiting new ones there'll be changes after the local council election so it's in a bit of flux at the moment and for example we asked our care reps at the last meeting did they know the care was in their local area and a lot of them didn't know they were care elites and that would be really the primary person they would want to connect in with in their local area who maybe would be responsible for the local care strategy the CARES Act coming in so I think there is a bit of confusion I think as well feedback we're getting is in terms of the meetings because things are being established an awful lot of time is taken up talking about staff issues and in terms of administration the organisations as a whole and also then particular topics will come up again and again like delayed discharge so when CARES told us that really took up the majority of several of the meetings so amongst all that I think it is difficult to get some of the things discussed which actually are more relevant to service users and CARES because other things have been given priority or while things have been established that hasn't really been discussed it's happening more I would say now there is being slow progress in that area so after our first meeting of the IGB we suggested that the CARES reps try to table the CARES Act on to the agenda of the IGB and we did it for a couple of reasons just because we thought it was something that they should be discussing planning towards implementation at that level but also we wanted to see how easy it would be for them to get something on the agenda were they able to place something on and was it then taken up and did it follow through and it has followed through in quite a number of areas I can think of at least five where that's happened not all the CARES reps went ahead and tried to table it so that's not across Scotland but that has led to fruitful discussion and then it's been something which has been a lot more relevant to the CARES reps which has been helpful as well but I would say that would be more unusual and quite often businesses taken up with things which they don't always find relevant so in terms of the decision making process we were saying earlier about things have just been a rubber stamp is there any debate discussion is there any for example you are allowed to propose changes amendments are you allowed to bring alternatives forward or is that just not within the scope of those sitting on the at the meeting I don't think we're there yet I mean in our area we did have an opportunity to get involved with the strategic commissioning and third sector were very much involved in that and we actually waited the items that were coming up so out of the ten thematic areas five came from what we'd put forward very much being like the preventative agenda but I really don't think that we're there yet where we can actually turn round and make that big change because at the moment it seems to be too much of the higher level stuff that they're dealing with at the last carers collaborative meeting we had a discussion around how you can put things on the agenda something so fundamental in your local area some areas had an agenda committee and they were able just to submit and put an item on the agenda that way and some had carer reps on the agenda committee that was very unusual other people were able to put it under other items at the end of the agenda other people even though they asked there was just no mechanism for them to get something on the agenda which meant that they really weren't equal partners so I think that sometimes it's just the process apart from anything else which needs to be sorted out to make sure that carers can feel that they are equal partners around the table Colin on that point do you think that third sector organisations carers representatives should have voting rights on IGBs or is it more a case of being able to influence policy before it gets to the stage of the IGB board actually deciding a paper I think what we found with where some of our representatives have been able to get to look at the strategic plans those strategic plans appear to have been rubber stamped before we've even really seen them and that being asked to comment on them so I think there's a mechanism about before you make the decisions how do we influence those decisions and steer them I think it needs to be a wee bit earlier on in the process We certainly wanted carers to have voting rights and we lobbied for that as the act was going through Parliament in terms of carer reps and sales we had discussions around that and most of them would prefer to have voting rights but a few actually have said that it frees them up more for discussion that's probably a minority view though to be honest with you but I would agree actually with what Linda said it's really by the time not many things go to vote and by the time it gets to vote probably most of the decisions have been made already although we did have one example in one IGB where an issue went to vote had been able to vote the decision would have gone the other way so that is one tangible example where they would have made a difference but yes it is very much about what happens before it gets to the IGB and making sure that things are co-produced rather than just carers are involved in consultation so for example in one integrated authority they were looking at reviewing their mental health services and they came up with three options in terms of what they might put forward as solutions but they only consulted on one so they decided what the best option was and then they consulted on that option and there was a lot of anger actually from carers and particularly the carer reps in the IGB because they felt they hadn't been part of that decision and it wasn't a full consultation when they were only being asked about the one option when they knew there had been two others on the table so you come in at the end of a process you don't own it and also the solution might not necessarily be the best one either I would certainly go for the influence I'm sure that you all know about the national standards for community engagement I don't know if necessarily all local authorities follow those standards Do you think looking at the nature of IGB meetings do you think because you don't have voting rights you're treated differently during the course of that meeting or is the point is that most things don't actually go to a vote so everybody does get their say? I would say that we're slightly higher than just the tokenistic gesture but I still think there is some ways to go on that I don't know if the voting rights I think if we had more say it might make a difference if there was true co-production and maybe it comes down to the fact that if monies that we're going to come into the third sector came to the third sector direct that would give us more of an influence for us to put that money back into the sector and from that point of view we would have more control and they might recognise us as a true partner if that was the case but I know that there was recommendations that went certainly about third sector interface's involvement under health and social care to me because that was guidance it wasn't necessarily followed I know from our organisation that we had no investment under the third sector interface as regarding what we do in health and social care so I really think that the money should actually go direct to the third sector and they would be then putting that money back in the pot but they would be the ones that was influencing that decision and how that money was spent If I can just come in on that as well I think it's important for the third sector to be part of the discussions before it gets to the voting rights and especially if we follow up on the wish of the First Minister at her inaugural speech for health and social care integration in October 2015 when it was her wish and her vision to see the third sector as equal partners In terms of what's there now and what was there previously is the system more democratic and can you influence it more or less than what was there previously Interestingly previously with the CHCP's carers did have voting rights so that was a step back in terms of that in terms of the ability to influence I think it's hard to say to be honest with you I suppose the make up of planning groups has changed probably a lot of the carers have remained the same some of them have come on from the CHCP's and a lot of them are very experienced very articulate people and a lot of the personalities have changed I would say it depends on the area I don't know if there is a significant difference to what happened before but I think there's more opportunity so I think in the future it will be an improvement but we're just not there yet I would say that we've still got a long way to go in terms of integration and the IGB's I think it's an opportunity for us all to work together more positively and more appropriately and I think certainly from Diabetes Scotland's point of view although our experience today has been less than positive we are making inroads certainly at a local level a lot of our local groups are making more inroads as they get the information and communication I think with all these processes communication is the key and we need to get better at that communication if we get better at that communication then we will probably get better at engagement and people will feel that we have a seat at the table whether it's a physical one or whether it's just an influential one I can maybe say one thing which would improve carers feeling like equal partners when it comes up in our report it came up in many of our meetings as I've said this before but resourcing things properly and I think that if a carer turns up to a meeting and they're effectively out of pocket or they're having to reduce the short breaks they have for themselves then that's not really acceptable meetings around IGBs and then some of the other groups that feed into them at our last meeting one of our carer reps said that was in January they said they already had 14 meetings in their diary in relation to meetings around the integrated authority so that is a big time commitment a lot of those people have caring responsibilities already some of them work some of them are retired but particularly I would say the ones who are employed and who are juggling employment as well some of them are self-employed ones on a zero hours contract so they're physically out of pocket whenever they attend meetings I think that's something that should be addressed if you look around the table at an IGB there's a lot of very well paid people there the carers are putting in a significant number of hours and I think that they should be looking at recompensing that there is one example in Oven Scotland which is the Highlands where they have employed a carer both in terms of supporting engagement but also a carer rep in addition to the work he does on the IGB they do employ him for some things on a consultancy basis so it can be done and I think it's something that others should be looking at because really to be equal partners if you're not resourced the way other people in the room are then I don't think that's equality thank you convener and I have to declare an interest in the MSP for Rutherglen so I'm particularly pleased to hear that South Lanarkshire is doing so well in terms of engaging with Faslan and I wonder if perhaps you could give me an indication of if some of the good practice that's been spoken about today if that's being captured and how we're looking at rolling that out across the country certainly in South Lanarkshire we've got a number of events that are coming up where we're looking at community events where we're trying to get the health and social care staff who might not have worked with third sector before so it's a way of getting them up skilled because a lot of them don't actually realise what the third sector do so we're trying from that side we make sure as I said before that all of the information is getting passed through our newsletters and through social media we've got our blog we're constantly tweeting about what's happening so to me the communication levels have really greatly improved I guess I was looking to see if any of that's a good practice has been captured and rolled out across other IGIBs or other care organisations I'm keen to hear from the other members of the panel if that's the case I sadly have to say that I haven't seen any other areas of best practice other than what is going on in South Lanarkshire and North Lanarkshire where I have seen some good areas of practice is how some of the managed clinical networks engage with the service users for instance in the borders they're busy looking at how they can improve the services so what they are doing is they are going to be hosting a series of road shows up and down the the catchment area to engage with service users of the diabetes services to explain to them what the situation is what the challenges they are facing what their proposals are and getting users feedback but that's very much coming from the health board, the MCNs leadership on that from an IGB point of view we haven't really been engaged in an awful lot of involvement best practice there are examples of best practice right across Scotland actually my theory has always been that if you collected all the best practice and applied it to every area then you'd have your solution actually so there's best practice across recruitment, training, engaging carers resourcing it and making sure it makes a difference enabling carers to feed into strategies which make a difference to their lives so there's many examples in our report one area that comes up quite often is North Ayrshire actually for example the carer rep was on the shadow board before the IGB was established which meant they felt part of the process from the beginning they also provided carer awareness training to IGB members and local councillors to make sure they had a good idea of the issues that affected carers and the carer reps led in that training too they've also been very proactive in terms of for example co-producing their carer strategy and involving other carers in that and that's not isolated there are great examples across Scotland there are still areas of challenges and frustration but I think from the beginning of our project last year to now we're seeing that there's definitely an improvement and is there some sort of mechanism to capture that best practice I guess as a committee we've heard over numerous evidence sessions that there are excellent practices in lots of areas of health and social care right across the country but it's about trying to capture that and roll it out so that everyone benefits from that so is there some mechanism or someone taking a lead in terms of finding out where the best practice is looking at how that can be rolled out to areas which are perhaps not as up to speed in terms of just what we've done and it is just for carers so I can't speak for the other stakeholders as part of our project we did a scoping exercise and we also collated the best practice just from what the carer reps were telling us so it is in our report and then we produced recommendations which pulled together how you could look at the best practice and then implement it across Scotland and the next stage is to try and work through the integrated authorities to do that we're working closely with the integration team at the Scottish Government and the carer reps themselves are taking the report and trying to table it a few have done that already to talk about how those recommendations could be implemented locally I think more could be done in terms of putting across those recommendations because we're a very small organisation actually the coalition there's only one paid member of staff myself and we've got a small grant to run this carers collaborative so it's beyond our capabilities to be a much wider effort but I think that it would go a long way to seeing improvements in terms of carers anyway certainly on IJBs although the challenges are probably similar right across the board with all stakeholders I would say and can I ask just finally then how receptive have you found the IJBs to you presenting this works well in another area or this has worked well in this forum this is quite an early stage it was published about a month ago and we actually have a meeting of the carer reps today so I'm going to have to fly out of here and go to that and they're looking at today how they're going to table at meetings but some have already as I've said and we'll hear today how that went so I would be able to tell you afterwards but we're hoping they'll be open to it but we're not sure yet we're also continuing with the scoping work so we'll have another report in January as well on what improvements have been made and whether or not recommendations have been implemented in that timescale I was just going to come in on that that my understanding the only forum that we sit on is within Perthyn Kinross and that was purely by default but my understanding sitting around those meetings who feed in to the IJBs is that the representation from the Alliance was there to kind of support that and gather that information and then all feedback so that could be one way of feeding back and sharing best practice I would have thought I think there's a role for the Scottish Health Council within this to because they do have they have produced standards for engagement and involvement they do do the assessments on health boards they have a lot of evidence on best practice so I think there is a role for the Scottish Health Council within the best practice development formulae in terms of what's being discussed what you've got experience of being discussed is discussions dominated by issues of service improvement or budget budget others resources are a big issue fiscal resource, personal resource information resource there has to be investment in order to have improvement I mean if certainly the feedback I get from constituents is that the discussions are being dominated and the impression I get across country are being dominated by issues of concerns over the financial situation that these new organisations are starting life with which is dominating proceedings rather than how do we improve the health and social care of the local community, would that be a fair reflection in your experience? I think it's certainly what my experience has been it's about getting them to see the bigger picture yes we've got the initial issue sat there of the issues of finance but it's about seeing the bigger picture third sector can actually help, contribute and influence and scope the future development it's about investing the pennies to save the pounds instead of keep focusing on well we're actually spending quite a few of those pennies but it's about getting them to see the bigger picture and looking at person centred services instead of just focusing on the budgets Who is it that's to see the bigger picture? Is it the IJB or is it higher up the JZ Government is it who I think it's one of that thing and I'm so glad that we've moved from instead of the voluntary sector to the third sector because every time we heard the voluntary sector people would think it was free and I've constantly said that we still need to have resources for that so that was my first point and I think it needs to be the bigger picture that all of the partners it needs to be the IJBs but it also needs to be the local authorities to see that as well that we need to be involving all of the communities and all of the stakeholders I think we could do with a greater degree of transparency as well to be honest with you so for example as part of the scoping work we just did a simple look at the strategic plans references to carers and then the minutes swelled to see how many times carers were referenced there was only 17 references to carers across Scotland in the minutes of IJBs not to say they weren't discussed more but their contributions weren't always minuteed and I think from a carers perspective what they'd probably like to see is a local carers strategy very robust strategy which then is reflected in the strategic plan and you can follow the resources across as well they almost all mention carers as a priority but it then doesn't say exactly what they're going to do and what resources go along with it so I think although there may be a lot of discussions around finance it tends not to be discussions which the stakeholders can contribute to can say well this is what we'd like to see happen to resources in an area, this is how they can be better used this is how you might want to do things differently and I think that needs to be part of it where the budget and money need to be discussed but can it not be done in a more open way? Anyone else? Miles? As a Lothian MSP I've been quite concerned for a while with some of the charities who have said to me that potentially some of the services which IJBs pay for but they do not refer or send patients to in the future could be looked at do you have any examples of that because it's quite clear if that starts to happen other IJBs will be destabilising each other I just wondered if from your background if you know of any examples of that we should be aware of as well So in terms of services I've met with a number of charities have expressed concern that currently their patients aren't referred to services which are funded by their IJB and in the future that could be looked at and that funding not allocated and I think when you look across Scotland there's a number of cases like that and I think there's growing concern that if that actually starts to be a deciding factor around finance that we could see IJBs destabilising each other and I just wondered from your background if you had any examples of similar cases From a diagnosis perspective we don't provide services as a third sector organisation in the sense of we don't have them, ISAs but we do provide services and support to the local authorities and the local community where we have found there are issues is actually within the budget allocation from within the health board some diabetes services have not had a budget uplift in several years and yet the numbers of people with diabetes is increasing so it's more from a treatment perspective what we've also found is there seems to be a lack of transparency as to who is responsible for the operational management of the diabetes services is it the IJB or is it the health board so there's confusion there so from our experience it's more within the statutory sector than actually third sector being funded for support services we do have some organisations that provide emotional support and health to people with diabetes and some of those services are having their budgets cut and some of those services no longer know whether they're going to be in operation next year One of the examples that we've been faced with is in sort of all the change around despite for example chronic pain Scottish Government priority if that does not form part of a respective health board's local delivery plan there is no jurisdiction on them to fund it so there's a bit of imbalance there I would say and looking at your sort of other question as well when we attended a primary care conference back in January one of the issues raised for GPs and referring patients on one of the reservations was if we refer a patient on to third sector how do we know that they're going to be there in a few months time given all the funding issues Most of our members are local care support organisations so they tend to be involved in more local negotiations so it may not apply but certainly some of their funding is shaky at the moment some areas for example funding's being cut and quite a lot of areas are looking at putting out tender care services despite the fact that those services have been there for many years are well established and very well respected by local carers so I think it's a different funding environment for people which is always difficult and I would say there is some insecurity within the third sector because of it and when you've got for example the carers act coming in in 2018 it should be a period where you're looking at providing more resources to carers support and building up services in advance of the new duties but we are in some cases saying funding being reduced which is not really the direction we'd want to be heading Certainly in our area the local authority cut quite a lot of third sector organisations funding but we have 19 projects that were funded through the IJB as part of our area and as the TSI we monitored those projects on a quarterly basis and from that we can see the great work that's actually been done I've got one group that received a contribution of 88,000 over two years to develop a meeting place they have 252 users per week and I know that since October and February they had 43 referrals coming through health and social care of isolated individuals that needed that support and some of these are quite elderly people that don't see anybody during the whole week so there's a lot of really good work that's going on there that we've got the evidence to back that up Are you then making That report goes to the IJB so that they've got all of that information and also then use that to lobby those who are providing the grant yes to your organisations but also from a higher up level Out of the monies that was put forward there was quite a lot were not back but I think there was something like 75% that were accepted had matched funding from elsewhere to support OK which spit out the time thank you very much for your attendance this morning and we'll suspend briefly to a change the panel thank you we now move to a round table session also on integration of authorities engagement with stakeholders we will go round the table to introduce ourselves so my name is Neil Findlay MSP for the Lodians and I'm a chair of the health and support committee Hi I'm Claire Hawke and I'm the deputy convener of the committee Sorry, morning colleagues my name is Michael Kelly I'm the director of health and social care in Fife partnership I'm Miles Briggs in service MSP for Lothian region My microphone is not necessarily on I'm Amy Dalrymple I'm head of policy at Alzheimer's Scotland Donald Cameron MSP for the Highlands and Islands Hi I'm Marion Slater I'm a geriatrician and I represent the Royal College of Physicians of Edinburgh Good morning I'm Alex Cole Hamilton MSP for Edinburgh Weston and Lib Dem Health Spokesperson Christina West chief officer for Argyllin butte health and social care partnership Karen Curtis service user representative on the strategic planning group of the Orkney health and care integrator of the largely Alison Johnston MSP for Lothian Hi I'm Joe Gibson director at North Ayrshire health and social care partnership Mary Todd MSP for the Highlands and Islands Andrew Strong assistant director at the health and social care alliance Scotland Colin Smyth MSP for the south of Scotland I'm David Small director of health and social care for East Lothian Ivan McKee MSP for Glasgow Proven Okay, thanks very much Sorry, Tom I wonder if you can open up by just asking about the use of how the engagement process is going is it all smiley, happy and tickety boo or is it not who we'd like to open up Yep, I got it I think the level of engagement phase consistently across the country I think in some health and social care partnerships the independent sector has got a very positive level of engagement in other areas it's sort of tokenistic and what we're there because we really need to be and I think that the main sort of different difference is the personnel that are in post in each of the health and social care partnerships and that can depend on how they view the independent sector as a whole so my brief answer would be it varies considerably Key point being that the identity of personal relationships MDL's care to comment Andrew I'd say from our research and the research of our third sector health and social care support team there's been there's a limited picture in terms of involvement is probably what I would say so we've detailed in our written response people who aren't necessarily involved in the mechanics of the IJBs so people who aren't there is the third sector rep, carers rep or a rep of people who use support and services they've often told us that they find it difficult to source information about what's going on locally and that wider public would maybe have some limited understanding and would find it difficult to engage as well to support that our team our third sector team has produced a range of resources so basic information about what's going on on the boards and about their commissioning intentions and the commissioning plans but that only goes to some extent and there'll be issues for national third sector providers as well which I'm sure Amy will be able to kind of talk to but one thing I would say as well from the start of this that there's inherently an unequal relationship at the IJB governance level between the third sector the independent sector people who use support and services and the statutory sector because of the nature of voting rights but also because of the number of people on those boards at the moment so in some areas you've got eight representatives eight health board representatives and then one person representing the whole of the third sector in that area one person representing people who use support and services in that area one person representing carers inherently and knowingly from the development of this process that's what we've developed but it's an unequal relationship David Thank you very much I think it's probably early days to be fair on the being in existence for a year perhaps a little bit more than a year now so it is early days and hopefully that experience is reflected across Scotland in East Lothian we took an approach of having a broader membership than the minimum required so we have the independent sector the third sector carers and the public there are four seats on East Lothian integration joint board that bring that other voice apart from the statutory members that were mentioned there we're currently reviewing the way third sector membership is input to the IJB so now it's been the third sector interface chief executive they've come forward with a proposal that they would like an election process within the third sector in East Lothian which we're positive about and would welcome and we're just having a dialogue about the feedback mechanisms and how that person would be representative if you like but I think we're very positive about that proposal and we expect to consider that shortly we're developing a new engagement strategy because we recognise that the engagement was for a particular purpose it was about the strategic plan which had to be in place by March 2016 so there's a particular kind of engagement we did around that but we now need a more forward looking engagement strategy which takes us beyond that so we're consulting on our engagement strategy for the future now we do have development sessions as well as formal IJB meetings we hold development sessions so formally speaking our IJB meets every two months and in between we have a development session so the next one for example is going to be about carers issues and how they link into the strategic plan for the future we do recognise, we could do more though our older people's joint inspection report from last year made some recommendations about improving our links with the third sector so we recognise we've got some work to do and the substructure beneath our strategic planning process and the engagement that goes on with that where we would get into the detail of individual strategies and client group issues is perhaps not as robust as it should be so that all of the members both formally and informally on group issues is perhaps not as robust as it should be so I would say in summary it's probably work in progress but I think we're making positive progress on the record the four additional members do not have voting rights no that's right, that's in the regulations that's it, yes I can't call this when it went through but you cannot give them voting rights that's correct you don't have the leeway to give them the legislation's quite clear on board members and the council elected members I think in our area anyway it's gone from being quite tokenistic to still quite tokenistic but with slightly better support in the last few days I've just had emails that have finally recognised the difficulties that representatives and public representatives face and starting to look at ways that might actually be addressed now but it's still as a service user representative I just find my job absolutely impossible I'm not representative I cannot represent I don't have any network to feedback to or to get information from and even the process which on paper looked really good for electing representatives didn't really work because in the first round of seeking representatives nobody applied but I actually got asked by a friend who works in the third sector interface if I would apply I was the only person who applied and because I kind of ticked their criteria for someone who might be a representative I got on so I'm in no way a representative and I think having attended a few meetings now I've come to the realisation that actually my job isn't as a representative my job has to be to monitor public participation and I think that's a really key thing that you cannot be representative at that level but if I can monitor if I can insist that participation happens at much lower levels from bottom up which is really where it ought to be rather than from someone asking questions from the top down then I think I might be able to get somewhere but it is difficult when some of the other difficulties that people mentioned this morning about not being able to put things on their agenda about the strategic planning group not really doing strategic planning but a tick box exercise for things that have been presented with little opportunity for discussion just all those things make life a lot more difficult and I think it's about the whole kind of focus and it really does seem to be too much top down including all the information that we're getting to make decisions on statistics, it's not what people see working at the coalface and that's where all the information should come from that's where the public involvement should start with talking with your health professionals and carers and then that information filtering up to be used as valid information for planning I don't see any of that happening Okay, Michael Thanks I think my summation chair or convener would be that it is a work in progress in terms of our ability to engage and I would agree with David and others on that point, we're in a similar position in five to the one that David explained in East Lothian, we have four seats for the independent sector a patient service user representative a third sector representative and a carer representative and those colleagues are active and vocal around the IGB table Andrew explained that we're a very large IGB so we have eight elective members voting members and eight members from the health board so the IGB table is very large, it's significantly larger even than this table so there is an issue there for us and I know sometimes those colleagues feel that they are challenged to be heard effectively I think in five we've had done some work very well so in terms of the strategic plan that was pulled together before I took up the post there was extensive involvement there and I think colleagues were supportive of the level of engagement there the strategic planning group I think as has happened in other parts of the country thereafter felt unsure about its on-going role and that's something that we've been working with them to resolve we're now at the position, looking forward to getting into the genuine co-production mode with our partners and there's a couple of areas where I think we're beginning to do that we're looking for example about how we implements the Sir Louis Ritchie review on urgent care and Fife we've had stakeholders involved in that process from the beginning but we're at the moment we could take a mix of service users, staff and carers to help us conduct an option appraisal of the options for change around urgent care and more in the co-production phase we're also recently held with Scottish Care with the independent sector a redesigning care together in Fife event at the end of March Donald MacAskill, the CEO there, chaired that event we had 70 people from across the spectrum the conclusions from that event will shape how we invest in new models of care in Fife moving forward so those are examples of how we're moving into that phase but I certainly think as others have said it's a work in progress and I think that would be the case for all IGBs across the country One of the big things that's come up for us is the variability that there is so with that in mind I'll recount a wee anecdote I was at a meeting of an umbrella group of organisations one of the several that we're involved with and one of the chief officers of a health and social care partnership was there and we were talking about the very difficult decisions around shifting resources to preventative and community approaches from acute care and I made the point that we could help we, this group of mainly national but also local third sector organisations could help with the conversations around that and making sure that we were bringing the community with us in that decision making process and the response I got was yes, it would be very welcome if we would help communicate why those decisions were made and it was just a really good illustration of completely missing the point that I was making and I think the point that's been made by people who were speaking in the earlier session and made by some of the other people around the table today it's about bringing people with you it's about doing things with people it's not just about communicating a decision that's already been made a real misinterpretation of the term that you've used in your inquiry around engagement you've also talked about stakeholders and that's very different and we're all coming from our own points of view but from Alzheimer's Scotland I come from several points of view we're a national third sector organisation we have several local services we have local groups around the country of people with dementia and carers of people with dementia as well and so we have a role in terms of making sure that individuals can be involved what Andrew was referring to with people who aren't the reps but we also can be a partner as an organisation in helping to improve care and support for people with dementia and neither of those roles are really something that we're being used to the full extent around the country there are pockets of good practice nowhere is doing everything right though everywhere has got something to learn and so even the places that are doing really well in some aspects I think need to come up to speed on other aspects lastly I'd like to just mention about the need for involvement below the actual board level we've been talking a lot about the IJBs but in terms of locality level and also for us say the dementia leads all the people's mental health groups or wherever dementia is dealt with it's really important that the involvement is not just at board level that's tokenism as well that's ticking a box it needs to run right through the work of the health and social care partnership Christina I suppose in common with my colleagues David and Michael I would share that in Argyllun buta is certainly a work in progress we in consulting on our strategic plan did though make some changes to the configuration of our locality planning groups so we went from 6 to 8 in specific response to community feedback about their local communities and where they wanted to see a planning influence and infrastructure created and we saw things like community transport take a higher priority in our strategic plan which hadn't previously been amongst our list of priorities so over the last year we've been trying to really support our locality planning groups to develop and with 8 across Argyllun bute they all have carer representation they have clinical representation they have third sector representation as well and we've developed health and care profiles which actually say what the health and social care need in those natural communities are and we've begun to provide information about how budgets are actually spent in those natural communities so communities can become far better informed in terms of decision making about how resources are actually spent in meeting our strategic plan objectives each of our locality planning groups have now developed a locality plan which is focused on how the strategic plan translates into local care delivery but they need the information in order to provide that and while we're beginning that journey I think there's not still an awful lot more detail that we can provide on a level of sophistication and the data we're actually providing them with to inform their decision making so that is the level below the IJB in which we are taking the letter of the legislation which was localities with the engine room of integration, we're trying very hard to support that bottom-up growth Mary I mean I think it's clear that approaches to engagement, collaboration, board structure and governance arrangements are highly variable and they're made harder by the scale and pace that's expected some of our fellows have had no engagement at all, others are aware of the process but I've found that it's overly difficult to get involved with barriers to participation those that are involved have found that their role on groups are unclear that there's little in the way of clinical input and there's no real sense that our clinical voice has recognised or acknowledged rather a sense of frustration that some IJBs appear not to value clinical opinion I think opportunities to use staff's knowledge, skill and expertise are being missed and what really concerns me as well is the failure to use data to inform service change many of the proposals lack robust evidence and I think more could be done to improve that and Joe I would echo a lot of what's been said this morning we in North Ayrshire are a year older than most of the other partnerships although I'm sure it doesn't show so we did do a lot of work at the beginning to try and create an inclusive ethos and we heard from colleagues from the carers coalition this morning about the carers have been involved as well as the third sector interface as well as service users and as well as the independent sector from our shadow state into where we are today we have focused as many have described initially on those very senior structures so involvement in the IJB and the strategic planning group we did that not only through the mechanism of the meetings themselves but also with a lot of development and support behind the scenes a lot of development days together where we shared information and got a shared understanding about what each colleague was bringing to the table since then I think we've only seen the tip of the iceberg in terms of the potential so with now developing the locality planning structures that gives us architecture in each community and the chance to hear the voice of communities it also has opened our eyes up to how we can involve people in designing our services in a way that not only benefits citizens in that way design more efficient and effective services but it benefits the citizens themselves and being involved and we've seen lots of positive outcomes for individuals and groups because of that the other thing we're seeing is people are beginning to mix up the hats they're wearing so initially our third sector interface colleague represented just that view now we're using those skills and those individuals to do different roles in the partnership so one of our locality forums is chaired by our carers rep from the IJB one is chaired by our third sector rep when we have commissioning decisions to make we have set up small groups which are populated by that range of individuals to make those decisions and bring back recommendations to the IJB so we're blurring those boundaries between the organisations and creating greater understanding because of that Marion suggested that the people's views were not being listened to and the input wasn't sufficient in terms of the previous panel we heard about the dominance of issues around finance, dominating proceedings and the rest of it so is there, or are there enough people involved in rolling out the engagement in this in order to capture those views is it a financial pressure that's preventing that or is it the culture of the new organisations that's preventing that I think it's the culture of the organisations I mean I've been quite shocked really at the difference between the national health service of New Zealand and the national health service in the United Kingdom just in the way the patient's views or the patient is respected as a person with information and knowledge about their conditions and their ability to talk to the professionals involved in their care so I think it all kind of starts from that but looking kind of wider at a policy level I mean I've been looking at a number of different documents and one of the ones is the New Zealand health care better, sooner, more convenient now that's about integration and it's about integration between primary and secondary care rather than health and social care but kind of fairly similar but when I look at changing models of health and social care which is the Scottish document here the one thing that really kind of strikes me is that all the best practice examples in the Scottish document seem to be based on other people's best practice documents like we have lifted this model from Alaska and we're trying it here we have lifted this model from somewhere else and we're trying it here whereas the New Zealand one starts with we saw what was happening at primary care level and we have done something about it and I think that is a really big change for the UK generally but for Scotland I agree that the focus has been initially and I take it with the IJB chief officers and the representatives around the table you're all saying early days it's a work in progress so it will help your progress but the focus has been so far on resources issues and structural issues as well it's been a big structural thing and partly and you've seen the clash of cultures there the NHS is frankly one of the most hierarchical organisations I've never come across when I first read the Royal College of Physicians submission I was intrigued because our take on it is that actually health is very dominant as a sector in the health and social care partnerships and it's very much driven by health decisions and I was kind of well how can the Royal College of Physicians their members not feel that they're being listened to and then I realised it's because of the hierarchical nature of it and that's a very different culture to the one that I would come from in the third sector and in community development and I think that that's a big cultural issue for us who are from that sector in terms of getting involved because there isn't there are all these levels and the levels don't speak to each other in a back and forth way they issue instructions to each other or information to each other as requested and that actually makes it harder for us to be involved let alone when the focus is not on is not on collaboration, is not on co-production and is not on improvements and services because they're busy trying to make sure that the IT system speak to each other Please don't start with an IT Yeah, you're a Lothian I know Marine I think that the issue is more cultural than financial I mean certainly my experience is that the approach from the the IGB where I work has been overly top down and you know as it's been alluded to in lots of the submissions and priorities seem to already have been decided beforehand with a little scope for discussion or change we've been asked to develop a hospital at home service and I think there's really very little evidence of that there was a large Cochran review in 2016 which suggested that when compared to in hospital care hospital at home services probably make little or no difference to the likelihood of admission or patient health outcomes and the evidence of effect on length of stare cost of the health services also lacking and yet that's what's being pushed and there's plenty of resource to develop that it's caused a lot of friction and tension within my service because there are those that support the proposals and those that feel we really need robust evidence to support this and yet that finance isn't available to us to develop other services so I think that comes back to the point that you were making Amy that although health is a large part of this actually the experiences that frontline clinicians aren't being allowed to influence this I mean our acute services are over stretched as they are without expecting the same service to take on more developments and the other issue that I think is often overlooked is the pressure on staff and we've got huge vacancies particularly in community nursing and I don't think that that is taken sufficient account of in many of the proposals that have been set out David I think that this issue of clinical engagement is really important and I guess it maybe depends partly on the services that are provided under the authority of each IJB so for example in East Lothian I think that we might have one consultant who is a member of the Royal College of Physicians but we might have 100 people who are members of the Royal College of General Practitioners so we have a GP on our IJB which is in addition to the statutory minimum of having the clinical director who is also a GP but we do have a consultant physician a cardiologist from the Royal Infirmary of Edinburgh we also have the chief nurse and the chief social work officer so that whole professional input to the IJB is what we do so we have deliberately gone for as broad a professional input to the IJB as we can again back to the point, these are non-voting roles because of the statutory basis of integration joint boards but it's important to have that diversity of input we also have consultant psychiatrists in putting to our strategic planning group and the issue of hospital at home is a really interesting one because I take your point absolutely but I think most of us are trying to develop some version of hospital at home with dementia or delirium where it might actually be the worst thing for them I appreciate there's evidence both ways but I think it's one of the key tools we will have in the future to meet the aspiration to reduce unscheduled care bed days under the health and social care delivery plan Based on evidence that you have It's based on practice from across Scotland, I think South Lanarkshire and Fife were one or two of the early areas before IJBs even who introduced hospital at home services and they have produced evidence of admissions, shorter length of stay etc Michael? Confirm what David said that hospital at home has been in place in Fife for some time and it's a key part of our kind of armory moving forward around shifting balance of care and keeping people at home wherever possible but I take the point that Mary May is a fair point there is genuine clinical difference in clinical views again like David I think the ensuring effect of clinical involvement is a really important issue we have a similar arrangement as David describes around clinical voices around the IGB table itself but also in terms of the senior team that works with me in the health and social care partners I have an associate medical director an associate nurse director we have a qualified social work around that senior team as well and that's a very important mix and ensures, I'm not again I think it's a work in progress the clinical voice and the professional voice more broadly described so housing professionals social work professionals are heard around these tables the other point that I wanted to make I think the discussion in the previous panel was interesting around how much time IGB spend on budget and procedural and structural issues as opposed to dealing with substance I suppose and I think that's been a real challenge and it's potentially a factor of the relative infancy of IGBs but we have spent a lot of time in Fife thinking about our budget and budgetary challenges but just thinking back over the last few IGBs we've discussed home care we've discussed new models of community care we've discussed mental health issues and looking forward over the next couple of months we've discussed urgent care community hubs as a prospect but also implementation of the carers act so straight striking that balance between having necessary discussion about difficult issues like budget but also thinking about the substance is something that will be an issue Andrew Just on the point about culture change really and reflected on the language that was used in the development of this legislation were words like co-production which Michael used earlier on it's heartened to hear that in Fife there's developments around that and transformational change and I think this inquiry that this committee is doing is very timely in terms of that but what we really need to look at is beyond consultation we can't just be talking about consultation in this regard we need to be looking at some of the examples that have been used during the table and how they can be rolled out elsewhere the idea of co-production underlying the guidance is one which we wholeheartedly support and we want to see more of in the coming years and take the point that we're in early days in terms of the development of some of the health and social care partnerships we want to see more of this going forward one thing I would also say is that at strategic planning and locality level we're probably more likely to see those things happening than we are necessarily at the top governance level with the IJB and then feeding into that and that links to some of the points that have been made so perhaps the committee could think about what it's doing in terms of asking questions of IJBs around those levels and what's happening in terms of co-production there so I just wanted to make that point in terms of culture changes I think the independent sector is the biggest provider of social care within Scotland but it's very disappointing that we've only actually got a seat on seven IJBs across the country the areas that we do have seats on like Fife, which Michael's made reference to some of the innovative work that's taking place there to North Ayrshire and Argyll and Bute and really good partnership working we're seeing some innovative approaches to service delivery which is undoubtedly benefiting the people living in these areas so I would rate one of the things that Scottish Care is really keen to have is having a seat at each of the IJBs where we've got presence in the country You need to bring in any of my colleagues who want to add any additional questions Colin Can I just ask, one of the recurring themes is that there's lots of good practice out there to make sure that good practice is spread across Scotland what's the mechanism that needs to be put in place either at government level or at some other level that will make sure that best practice is shared across Scotland and is implemented across Scotland where it's relevant I think the best practice is more about the how than the what so it's more about where those ideas for innovative projects come from about where they came from how people actually engaged at the bottom level to get those ideas coming up so it is more about the liaison between the services and the people that use the services and I know there is a lot of difference in the various areas around the country of engagement practices I mean I know in Orkney we have a public engagement officer in the health board anywhere and public engagement has been devolved to manager level of each area but nobody is monitoring that so nobody is actually seeing if that really happens so I think something about looking at how engagement happens at all levels particularly from the very lowest levels upwards rather than from the top down would be one good thing and showing people how to go about developing these innovative projects rather than replicating ones that already exist I think we have a lot of the solutions between us already but the job in these new integrated joint boards is relentless and it has been from the start so it does get very difficult to free up time to go and study elsewhere and what's happening and then begin a discussion about how you might apply that in your own patch but I do think we have opportunities to do that through both colleagues in the alliance and through what was referred to in the earlier session around the role of the Scottish health council so we do already produce narratives about what we've achieved and what's worked well it would be helpful if one of those national bodies were able to compile that in a way that's distilled for all of us to use and I have a geographical link with the alliance who are beginning to do that and we have a geographical link with the Scottish health council if it was clearer that that was the remit to share that information that would be helpful the other thing that each partnership will be producing is an annual performance report we get guidance from the Scottish Government about what should be included in that it would be helpful for that to ensure we also reflect how engagement is working and that extracts from that is distilled and shared so we all have something like a go-to toolkit Andrew Cynas, is that something the alliance is working on or do you have funding to do that? Do you have a remit to do that? Our third sector team is funded to provide a clear understanding of the integration landscape mainly around about the third sector's role and enabling the sharing of the sector's experience and creating connections between the third sector it's not technically within that remit but it does in some cases we are looking at what is happening innovatively and trying to share that with our networks so we have monthly integration forums with the third sector to share what's happening locally we're hosting a range of strategic commissioning events at the moment and 115 organisations are currently signed up to that across the country and also sharing that through regular newsletters but we are attempting to do that I think it's a very important issue and it's not an easy answer I think the alliance has an important role as Andrew and Joe have described I also think there's a role for the national statutory bodies David, Christine and I were at we have a regular meeting of chief officers every quarter and we were at that meeting last Friday and healthcare improvement Scotland came along to talk about the work of the i-hub they've put together a relatively new development about supporting improvement across health and social care and one of the issues there they talked about is how they capture and spread best practice and work with the Scottish health council and work with our voice initiative which I'm sure the committee has heard of in the past to try to capture some of that best practice so I think but I also think we as IGBs and as chief officers have a responsibility ourselves to exchange information and make sure we follow best practice because the i-hub is busy and relentless but taking the time to do that is important I think also there's a role for the Scottish Government who understand that I've been involved in the Steane group for the NHS event the one kind of two day big conference that the Scottish Government organises in the CCC in Glasgow and I know that quite a lot of the content this year is about from IGBs around best practice so that's one practical example of how best practice is spread to be a constant issue for us moving forward If it's worth doing at all not just because it's in the legislation but if it's worth doing because as I firmly believe you can use this to improve services, to improve outcomes for people then it is worth putting the time into and it is worth doing it properly and it's worth prioritising in terms of resources and in terms of attention a slight disagreement with Colin but there's some good practice I wouldn't want to kind of like there's not huge amounts around but there is some organisations like my own can support good practice we have a network of local groups but we've got a national Alzheimer's Scotland infrastructure behind that and one of the issues that we have in terms of engagement with the third sector is because it's done through the TSIs and there's great variability around the capacity and and even willingness sometimes of the TSIs to work with their members and particularly to work with those of us who are national organisations I think that there could be an improvement there and in terms of the accountability that there is within the TSIs I was very intrigued to hear about what David was talking about what you're talking to your local TSI as it strives around an election process around how the third sector is represented on the IJB because I think that that's a really important issue and certainly one that I've talked to people who do my sort of job in other national organisations about that there is a problem in some areas about can we actually engage with the TSI not Southland nature I have to say noting that the witness who was speaking earlier is still in the room I think information transparency greater information transparency would really help that as well so as well as using using the national networks we can do our job better as in we can help share good practice the information is there about who to share it with it is very difficult in some areas to know who the most appropriate person is to contact and chief officers sitting round this table do not want to be bombarded within appropriate information and suggestions from organisations like mine or others who have been speaking today but if it was more obvious who the right person was who was making particular sorts of decisions then we wouldn't be bombarding you we would be making sure that you had relevant information to your role and that others had information that was relevant to their role as well there is a lack of transparency in many areas around who is in charge of what and who is accountable for what not just about who is in charge of engagement but also who is in charge of particular areas of care that's not always accountable sorry that's not always obvious there was one voluntary organisation that put in a series of freedom of information requests to find this out because it's just not available anywhere obvious so we can support the process of spreading good practice but we can't do that unless we have the information available to let us know where that needs to be spread Alison, did you want to? Yes, thank you convener I probably feel somewhat depressed during this evidence session having read the submissions and listened to the various contributions I think if we have a situation where a service user representative has said I'm not a representative I'm monitoring public participation because it's simply impossible to engage more fully there's an issue and we're hearing a very similar message from the Royal College of Physicians and from the third sector so it seems to me that this is cultural and structural now I am hearing some positive suggestions that just because time is moving on relationships are developing and it's getting better but I'm just concerned about the length of time it's taken and I just wonder if there's anything that we could be doing now to ensure that greater collaboration and engagement is taken seriously I don't know who would like to respond Can I give an example from my experience in New Zealand I was involved in a number of ministry of health working parties they were looking at primary healthcare guidelines but I think the experience is the involvement as a consumer representative I was called there I was an equal partner on that I had full voting rights equal speaking rights which was a little bit of a problem to some extent because then the decisions that might have been made at the end I was tacitly in agreement with even though I may not have been but I think I was definitely treated as an equal I was actually paid as an equal because I wasn't being paid by my workplace I was getting a day rate for attending the meetings and I think that's kind of important as well especially for things like carers and service users who like me may have considerable disability that puts them at a disadvantage I can't work full time and yet I am spending time on this voluntary position which takes away from my ability to do any more paid work that kind of thing so it's about kind of respecting it but I was on those committees to give my kind of perspective on issues not to represent the views of people or the opinions of people but to give a perspective from that point of view but also it was about having really robust data I've been absolutely horrified the lack of data that's come through the strategic planning group we've had this really broad level statistical data no analysis at all of how it relates to the local level no analysis at all of some of the projects that were being expected to say yes or no to no analysis of what's gone on before no good estimations of how much money this might save or what it might be doing differently so there's been no real information to make a proper decision on now I may not have understood that on some of the New Zealand committees but we actually had a researcher who read through all the stuff who graded evidence who pointed out stuff to us as we were discussing well that fits with this that doesn't fit with that really good but we don't actually have good quality evidence to show it that kind of stuff we had it accessible to us so you didn't need to have this high level understanding of things in order to be able to discuss it at a high level Is that peculiar to your area or is that happening across the piece because if it is then we have a real problem if major decisions about the use of public funds are being based are being taken with no evidence base then that flies in the face of the whole approach that's supposed to be being applied to public services which is that we have evidence based policy David I was just reflecting on what you were saying and the East Lothian strategic plan can find it online if you're interested does have all the data is down to the two locality level that's obviously very different to Orkney's I appreciate that and we've gone for two localities east and west so you'll find that it does analyse down to east and west locality level and things like use of medicines, disease prevalence length of life etc all of that is in there but I do think we've probably got a bit more work to do on developing meaningful local plans because quite a lot of our services are provided across east Lothian and don't distinguish between the two localities so it's what do we build bottom up based on this data that we've got and how can services be responsive to the differences between east and west because they are different, the town of Musselborough is very different to the town of Dunbar and the needs are different and the problems that service users experience are different so I think we've still got some work to do so if this was part of that context of work in progress and we're all trying to do the right thing to improve engagement, to improve our services then I would go with that point perhaps on a general point across Scotland hundreds of people involved in integration joint boards and strategic planning groups from all sorts of backgrounds, members of the public members of local third sector organisations national ones, Scottish Care etc members of professional representative bodies there will be hundreds of them across Scotland and I think it's back to that question of how do you get the breadth of that experience across Scotland to get a general feel for how it's going across Scotland because I think it is early days and I think we will find there are areas that are good, areas where it's better even in one partnership you'll find things that are not going so well and things that are going very well so I do think there's a challenge in bringing all that together and I did like the suggestion of perhaps on that national annual report from IGBs which will be coming up soon there's maybe something about how we include engagement and get the voice of those who are engaged as well as the voice of people like myself and Michael writing stuff in a performance report in that Do you recognise Corrine Senor I don't I don't recognise that for Eastwood then I'm sure there are some excellent examples of data collection but the feeling overall is that it isn't being used properly I was quite astonished by the Care Inspectorate's response and the examples that are given none of them have any evidence associated with them not even qualitative evidence it's just a wellbeing officer went in here and we feel that this is a truly innovative use of service and it maybe is and I'm sure it's making a difference to people but then they should be measuring that sorry I think it was you Joe said about what can we, oh no sorry it was you that said what can we be doing now to improve things and I think we can start collecting data now to evaluate these projects that's something we can do today each of these projects that's started each of these projects that's taken forward we need to start collecting the data to show whether it really is making a difference to service or not and just to briefly come back to the hospital at home in relation to that I'm not against hospital at home at all and I think we've got some excellent examples of how that works it's just the whole reason for the data collection is that we have to bear in mind that expanding services outside the hospital can mean uncovering previously unmet need providing extra services that people are going to use on top of those that already exist and we can't assume that preventing admissions means that all associated costs can be chalked up with savings and that's why we really need to be getting robust data because as you say it's public resource and we should be utilising that in a responsible way Andrew my point was less about data although I think the point that's made about monitoring and evaluation going back to the point about budgets I think that there's an issue there around about budgeting to make sure that monitoring and evaluation of key projects actually happens because the budget what usually happens in times of austerity is that things like that fall away but my point goes back to what Corin said at the start of the contribution around accessibility of boards and planning mechanisms etc and I thought you hit the nail on the head that if we truly value public involvement in some of these boards we need to pay for it and we need to budget for it and we need to make sure that people are able to attend that they're financed to attend and I think that actually applies as well to the sector interfaces and their role in this because they don't get the level of financial capacity to be able to complete this role in my view and that's why we've got such a patchy picture in terms of accessibility, RNIB Scotland have recently made some asks of integrated boards around accessibility for people with visual impairments and that will go for other organisations as well and if we're taking a human rights based approach we need to make sure that things like respite are available for carers to be able to engage in this that disabled people get access to the meetings that they get supported to and from meetings and that we budget for things like expenses and overnight stays those are the kind of mechanics behind good valuable involvement in these things we need to make sure that they happen it comes back to the point that was made earlier on as well about the Scottish Health Council's participation guidelines and those we really need to make sure that those are put in place for some of these boards that that actually happens in terms of your own organisation to the people who are involved in your own organisation that are compensated or paid for their involvement in your organisation yes Michael just a couple of comments on data I think that as colleagues have said consensus around the table that's really important we're in a similar position to the one that David described we have seven locality areas in five and that's relatively recent I have to say developed detailed descriptions of the health and social care issues and around those individual communities we're not as advanced as Christina is in terms of putting those locality groups together but when they are and that's an immediate priority then there will be really valuable data about the particular issues in each of those communities so that's in place I also think though as a colleague from the Royal College said that we need to have data around policy developments to understand whether they're worth rolling out and that's something certainly in Fife where we're very keen on we've put in place a new model of home care reablement over the last year called START which is designed to support people getting out of hospital quickly to assess their needs over a short period of time and to where possible if that's appropriate ensure they get the right level of support not just the level of support that they were initially provided with and that's beginning to show real benefits but that's because we're monitoring we're evaluating and we're recording that data and that will inform it's own word development The only other thing I want to say, I think that Alison's challenge around this feels quite depressing is a fair one I suppose from my perspective the real light at the end of the tunnel here around engagement has to be around we need to get it right at the IGB level and we need to take into account what people have made today but the real opportunity here I think is at the locality level so in Fife and those seven localities David's 2 and Christina's I think you said you had 4 8, sorry localities Christina and that's where as Christina said there's the engine room of integration was designed to happen and that's where I think there's real opportunity for service users, carers, patients, families those providing services shape and inform the delivery of services moving forward and that's where I think the real opportunity for co-production is and so for me that's the light at the end of the tunnel that we need to keep our eye on moving forward Joe Just a couple of points I would like to say that I don't recognise what Corine has described about her experience at the strategic planning group and I very much hope all my colleagues on our strategic planning group would agree with me our first strategic plan was based on a very detailed needs assessment that was available to everybody but that was brought together by a range of professionals so we clearly based decisions on what we understood where the issues in the population at the time since then the strategic planning group has received they receive our quarterly performance report and consider in detail what progress we're making against our strategic plan we have also shared with the strategic planning group the locality profiles that others have described where we've built up a document detailing everything we know about each locality so we try and enable the strategic planning group to be as informed as us so that when we make decisions about commissioning everybody has the same amount of information we've recently brought forward a medium-term financial plan and that has very much helped us in the last budgeting round because that has laid out the scale of the challenge before us over the next three years we spent some considerable time with the strategic planning group a few weeks ago going through the detail of that medium-term financial plan so we all have that shared understanding of where we're going in terms of the question about data and evaluation I totally agree and I'm sure you have rehearsed many times some of the complications around information and information governance we did early on decide to invest some of our integrated care fund money a group of people that we called the change team and in that group we ensured we had skills around information analysis evaluation project management and OD support what that's meant is when we've embarked on a change we've taken the time to study the data both quantitative and qualitative beforehand and then we could see changes as we move forward and one of the things I'd like to share with the committee that has enriched this greatly is we've used peer researchers to help us understand the impact of that service for both service users and their families and we've trained and supported peer researchers and reimbursed them where we could to do that that's worked well in a number of projects so far and we're working to train a larger cohort of peer researchers over the next year so we can build on that Christina I was going to pick up Alison's specific question which was what can we do to enhance greater collaboration and engagement that my own IGB have raised over our first year we've embarked upon a series of ambitious changes and some of those in terms of our communication and engagement have gone less well than others and that's a lesson that the IGB have sat down and considered very carefully and as a result of that we are going to be investing more dedicated resource in communication and engagement resource but specifically to target and support our locality planning groups getting the case for change out there and being well understood by communities is a real challenge for us we've had very fair accusations levelled at us about our use of jargon about our use of data and analysing it and making it easily explainable so the IGB in turn have used that and I think our lessons learned over the past year hoping that going into this year that investment will actually help us focus in a more meaningful engagement process we've got that locality infrastructure but the feedback that we're getting is that the message still isn't understood about the case for change people understand that there is a fiscal challenge and that that's something we need to address but actually the other challenges in our Gailin butaure about a diminishing population they're about a significantly increasing population with an over 74% increase in our over 75s by 2035 we know that our workforce will decrease by 14% and we're already beginning to see recruitment challenges the totality of that is actually what is facing us as a health and social care partnership not just the budget and so it's really important that in our communication and engagement that we're letting communities understand actually what the challenges we're facing so that together we can decide what the future looks like and I think that's really what the focus is on Donald I want to pick up on that final point because obviously we talk about stakeholders the general public is one of the key stakeholders in all of this and just firstly an observation there was talk from Marion and also from David about the role of clinicians internally I actually think that that can be taken one step further and clinicians have a role a public facing role when change is necessary and often I think people trust a doctor or a nurse when there's a case for change more than they will someone in NHS management or even an elected politician because they are able to provide clinical or medical reasons for change and I think that's a very powerful role so I think that that can be taken further I really want to ask about there's a petition that's before this committee petition 1628 which is about a care home principally initiated by a care home in Danun which Christina will know about Stuart and Lodge where many of the issues that we've talked about this morning are encapsulated the real problem is that there is a lack of engagement and this is especially in I think rural areas I don't think it's confined to that but there is a lack of engagement with local communities and this petition and I should pay tribute to Max Barr who is the petitioner reveals this to put it bluntly the local community don't feel involved they feel that the engagement that has existed is superficial they feel decisions are predetermined the community health forum don't feel informed and often as is often the case it takes the formation of an action group or a local media campaign or involvement of local politicians to really ratchet up the pressure so my real point and I'd be grateful for people's views on this is that there is a gap and all the good work you talk about internally about strategic planning and locality planning and co-production all of which is important there is a real gap between that and the general public and how that changes are achieved with the general public support and I think the petition about sure and loss just focuses a lot of that and I'd be very keen to hear what the solutions are because a general public will only hear that their local care home is closing that is the message that is coming across how do you advocate and get support for controversial change in these areas The points you raised were covered when we had the sessions with Scottish Health Council as well they came up as well about service, redesign and change and we want to begin on that, Amy When the public the first thing the public hear is that their local care home is closing that's I think where the problem is if the first thing the public had heard was that there were difficult decisions to be made because of a decreasing a decreasing population and a pressure on resources and we needed to work together to figure out a solution then there might not be there might this area being uninformed it requires a real culture change to work like that I referred to the NHS being hierarchical it's also it's government isn't it and so are local authorities and health and social care partnerships IJBs are creatures of both and neither of the institutions that have come together to create these bodies are really used to stripping back and letting the public see the mechanisms of how they work and that means that you get a fit of complete you get a decision that has already been made you get the public hearing that the care home is closing you don't get a feeling of involvement so having the courage and this is what co-production is about it's not about consultation I've seen in a report by I genuinely can't remember where it was a health and social care partnership saying we co-produce this consulting people the two things are entirely different co-production is actually about going back not to when you make a decision but to before you even know what decision you need to make before you even know that a decision needs to be made but saying here is our locality here is our community and what are the issues that we need to address in it and what are the issues the data helps absolutely but it's also about what the members of that community feel that those issues are there may be some aspects that actually the data would present as a problem but actually the people in that community feel that they manage together quite well if they're allowed to get on with it and do things the way that they want to and I see my fellow panellist in particular nodding at that I think that's something that I've seen in Ireland and rural communities in particular so it's actually about going right back to the beginning there and involving people and that is going to take courage and that is going to take culture change and that's something that from our I'm not going to say side of the table because we're all interspersed but from our side of things we're well aware of the massive change that that is going to be but we are here to support that to happen and national local third sector organisations community groups all kind of individuals individual activists are here and can make a contribution to that and can support these big organisations with that change and with that culture change but it's about admitting that that needs to happen and having the courage to strip back and expose the bits that may be a bit mucky and need a bit of oil to stop them creaking I'll respond to the generality of the question that Mr Cameron has asked I do think that a particular challenge we have as I've already said is getting people to understand the case for change the difficulty I think specifically when we look in localities that we need people to understand the whole system and while we're trying to shift the balance of care what we will see is individual buildings and beds become the focus of the discussion of local communities and that will be because they have a genuine confidence in that service they have had good experiences of that service and any change in that service they see as a reduction or a diminution of that service so having a conversation as Amy says about increasing bear the facts that we're facing which are actually we cannot continue to deliver services in the way that we are not just for financial reasons but because actually we don't have the workforce to provide the service and we can't meet the increasing demand based on our current models that does require a very different kind of conversation so I think having getting people to understand the enormity of the challenge is really important but the currency of buildings and beds is also a really important issue for us because we are charged with shifting the balance of care therefore we need to develop confidence in our community services and an acumen service user said to me recently Christina, we need communities to have sufficient confidence in their community services the type of confidence they have when they see a building with a front door and I don't think we're there yet I don't think we're there and I don't have confidence in communities that the service that you can receive in your own home can be as safe and as effective and as high a quality as the service that you receive in a building and so people will fight tooth and nail to save the service in the building so that is a particular challenge that we're facing certainly when it comes to care home capacity across Argyllin butte we have a very mixed economy and we have a huge variation in the cost of care provided in our care home sector whether that's our own local authority provision or independent sector and so while we're talking about shifting the balance of care people often think about acute to community services but actually I'm also thinking about bed based care in residential care homes and whether or not we should actually be supporting more people to be actually cared for in their own home so we need to see that shift not just from hospitals into community as well without a doubt the timing our engagement around student lodge I personally and the IGB have said to the community we've apologised we didn't get it right there was an absolute error in judgment in terms of making decisions that were very focused on budget due diligence had identified a £1.58 million deficit in May we'd already agreed our budget in our savings plan and then we had £1.58 million that we needed to identify related to social care and so changes were accelerated in a way that I don't believe the IGB will ever do again and I suppose that's the learning that we've had this year we accelerated decision making we didn't take the time to go out and communicate with our communities with our stakeholders we didn't take the time to actually explain a case for change and why this needed to be happening lessons learned for us without a doubt I suppose going forward they're very valuable if not painful lessons yes we did respond to that feedback that we got from communities we agreed as an IGB in November to take a six month pause in the changes that were actually being put on the table for student lodge and we undertook 19 community engagement events 190 people turned up 45 questionnaires were responded to and the student lodge development group have come up with an action plan of different proposals for how student lodge might be used in the future we now need to consider the totality of that feedback because there's no consensus and as you would anticipate with any community there are a range and diversity of views that have been expressed which see us either disinvesting from those 12 residential care home beds and using that resource as a community hub which was what the proposal was which was having a hub for support for carers, reablement services signposting people and actually using the available infrastructure locally through independent sector to provide residential care or whether or not we actually maintain that local authority provision in Dunoon so that's still a discussion that's being, it's still a discussion to take place at the IGB we will absolutely take account of all of the feedback that we've had but with engagement comes a diversity of views and the IGB will need to consider that in the round at its meeting in May I mean, I'd actually be grateful to you for that explanation and I do hope that when the IGB considers it in May they do take on board the very strong feelings that are apparent here I think what Amy said is very right often the public feel that a decision is taken and then everything therefore that follows is tokenistic I think the phrase has been used and I think the challenge is to reverse that process as you say and to start with an open book genuinely with an open book and bring people with you and I'd be grateful to hear what others around the table is doing I have some quite strong views on consultation having been involved from both sides I mean, I have been used as a consultant to get consumer views on things as well but I hear a lot of different things one thing I hear is consultation fatigue we don't bother asking people because there's too much consultation fatigue out there to my mind consultation fatigue happens when the public gets asked so many stupid questions it's things like please comment on the 64 page strategic plan no please give your views on one aspect of it maybe but not that so real questions really gets real answers another example of that was what was deemed as a quite successful social media consultation where apparently 125 people were involved I think the person that was counting forgot about spiders and bots on Facebook that boosted the numbers for that there really wasn't 125 people involved there was about four people that actually said anything real and that was in response to a general question from the person leading the discussion on what would you like to say about the strategic plan again, sorry, too big a question and then when you did say something that's really interesting that where did it go, I don't know so I think just that kind of thing people need to understand what real communication actually is and what real learning from the people they're consulting with is and I think we're missing a huge big opportunity I look on patient opinion every now and again from my local area to see what people are saying well actually they don't say much because they've learned that you give your opinion on patient opinion about a service and what you will get back is a really stock standard response I'm sorry you had this experience if you contact me directly we'll see what we can do to make it better that doesn't do anything what you should be learning all the people that are looking at these responding to these sites is okay this person has an opinion a problem with the service here does anyone else have that problem, is it a systemic problem what can we do about that problem generally instead of just seeing it as one individual has had a bad experience we're sorry about that those are the ideal opportunities for actually finding where changes could happen I could give you dozens of examples of wasted services in Orkney particularly where people have had to either travel from the Isles to the mainland for something or have had to travel from the Isles to Aberdeen for something now the number of wasted trips to Aberdeen it's just shocking it really is and all of those from my island also involve an overnight stay somewhere because you cannot get down to Aberdeen in a day and back so I think learning from people's experiences of that but I don't know where to point people to get those recorded even let alone acknowledged and done something with I think there's huge numbers of that kind of experience that you could be learning from in order to make plans about what's working what isn't working where we might want to shift resources the other point I wanted to make is just about the whole kind of service user role I don't think it is to help you make decisions I think it's to give the information to help the professionals make the decisions I've come to that from an experience in New Zealand where it was the beginnings of the mental health service user movement in New Zealand and the professionals were starting to listen to the experience of people who'd used mental health services and I was working with a patient organisation who realised that it wasn't about telling the services what we wanted in the way of services it was about actually just saying what our experiences of using the services were and then that would give the clues for the people making the decisions about where things needed to change and I think that really telling the stories made the biggest difference rather than giving recommendations I'd just like to build on a couple of points that both Christina and Corine have raised I think in our existence to-date as health and social care partnerships we have not done a lot to promote our existence to our public and neither has that message gone out nationally very strongly so the fact that we exist and that our responsibility is to shift the balance of care I think we could do with some help in informing the public that that is the case I think we have a responsibility to do that locally but I think a national campaign to support us would help I think then secondly that the skill of that challenge we are trying to gain understanding of that locally but again if that could be supported nationally that would help but I just want to share one little story about how I think we are beginning to stop thinking these are the problems that we need to discuss with the public and instead try and create the context where the public identifies the problems and we work together to address them so one of our locality forum members shared a story where she was in her kitchen and her daughter was sitting at the kitchen table with seven friends and one of the friends identified that she had recently started to take antidepressants and slowly over the course of the next half hour I think seven of the eight young people admitted that they were on antidepressants so our locality forum member was unsurprisingly shocked about this she brought this to a discussion at the locality planning forum where the local GP was able to say I'm not surprised in fact we feel like we meet person after person who's describing anxiety and stress and we feel that we have little option but to prescribe antidepressants once that conversation had happened in the locality forum we took that to our locality forum network where all six locality forums were present six lead GPs as well as six IJB members we had a discussion about that then we looked at the data and that was actually confirmed in the data in our prescribing data research about the levels of stress and anxiety faced by young people in North Ayrshire then we were able to make different decisions so already we have put community connectors in surgeries providing advice on mental health and wellbeing we worked with Scottish Government and set up a participatory budgeting event on mental health in that area and allocated £50,000 to community groups and individuals who had ideas about that and we've commissioned the third sector to develop a specification for us about what a low-level effect of mental health service would look like for North Ayrshire so I think that's an example about shifting the conversation to letting the public and community identify what matters to them and we respond with them I'm hoping that is maybe slightly less depressing than where we began Reflecting what Christina was saying I think we've had an experience in East Lothian which actually started in 2011 long before the integration joint board when we were reviewing the future of two community hospitals and it was actually before my time as well there was a proposal to close them and the negative reaction that came from that is still with us now in 2017 I think we're only just now getting over the history of that negative reaction and starting conversations with the communities again about those two facilities and what they could be in the future and how they can be not just health services but joint health and social care services all that is now back on the table but it's taken six years to get that trust back that we can have those conversations and even then it's still very difficult and there's a lot of suspicion so it takes time and I think that the lesson for me is to start early start before you even know exactly what the problem is and certainly before you think you know what decision needs to be taken Wind up just now but I just want to take the people in the IGBs to confirm whether they have set their budget for debating this last about last year's budget so we're now at this point in the financial year have you set your final budget for this year? I'm happy to go first we've received the council's budget it's been accepted by the IGB that was accepted at the end of March the health board set its budget on the 5th of April so we had an indicative proposal from the health board that we discussed at our IGB meeting at the end of March which was agreed we don't anticipate the final offer to be any different yes sorry chair I'm pleased to say that we're in a similar position so our 1718 budget for delegated and managed services was approved by the IGB on the 23rd of March the total budget for 5th IGB is £475 million the budget doesn't quite balance I should be clear we have a remaining budget gap of 2.1 million that we have to manage in the course of the year there are clearly pressures on the budget that we debated and acknowledged during the budget setting process but the budget was approved on the 23rd of March we have notification of both delegations of budget but the IGB have not yet accepted the budget as we do not yet have a plan that allows us to deliver all services within the delegated budget that we've been provided with at the moment what we have is a quality and finance plan over the next two years which has a £20 million funding gap of that gap and £9 million in year 2 and we haven't yet identified all of the service redesigns, savings, proposals etc for year 1 so there will be a further discussion with the IGB at the end of May around that and those that will be the IGB identifying what you view as the savings rather than the community identifying what should go into that plan we'll be informed by some of the look at the budget setting process we actually asked our LPGs to come forward with ideas of redesign which would fit with the strategic plan so our quality and finance plan and developing it over two years started in October last year where we asked our communities what are the priorities, what are the redesigns you want to see in localities the ideas that they came forward with did not meet the budget gap that we had so we've had to obviously work with LPGs and we've obviously had to work as a management team for the redesigns that can allow us to meet that budget gap just to be clear we see those redesigns being driven by budgetary process rather than service delivery and service improvement all of the savings we've identified thus far we are confident a complete alignment with our strategic plan we're very confident about that which is why the IGB we're happy to agree them at the last meeting the issue is we have a £2.8 million gap for this year and any proposals coming forward haven't yet been aligned against the strategic plan which is why the IGB haven't made their decision yet and I suppose that will be the decision in your view then you think you can implement those cuts I will call them with no impact on service there will be an impact on service without a doubt thank you Joe our IGB agreed its budget on 9 March based on an indicative budget from the NHS and a council meeting on 1 March that budget did include £5.3 million worth of savings which have been identified and approved we do still have a £1.2 million gap in terms of savings on the NHS side we've brought forward some proposals about that on palatable to all concerned and so we're back to the drawing board on that but any the only place we can go to for savings on the NHS side is on community services because we can't reduce funding in primary care and we can't reduce funding in mental health services anything we do to reduce service in community care flies in the face of shifting the balance of care and our strategic plan so at the moment we're in a very difficult position negotiations continue I have no further information you've probably observed this committee before and you'll be familiar with this but if they were savings then why would people object we needed to make a 4% saving on the NHS side we have achieved much of that but there's still a gap because of the ring fence nature services and because of the essential need to develop community and primary care and mental health services we are in a very difficult position as other boards will be also those who are being affected by those savings do not perceive them as savings so the ones like Christina has pointed out where we have made savings that's been in redesign so actually we're going to provide a more effective and hopefully more appropriate service for people and they have all been in line with the strategic plan and have had wide consultation and involvement the remaining £1.2 million we're not clear where that's coming from and conversations will continue I foresee that unless something changes that does mean service reductions in areas that are crucial to our communities doesn't sound very much thick savings but anyway could I thank everyone for their attendance this morning's been much appreciated and please keep an eye on the further developments in this area that the committees work thank you very much we suspend for a short break agenda item 3 is an opportunity for members to discuss the main themes arising from the informal evidence session with NHS senior managers held last Tuesday could I invite any comments from members on that session please you are not usually this shy and reticent Alison the group that I was involved in discussion with were certainly off a view that raising concerns was difficult that they didn't want to speak out that it could be perceived negatively and perhaps have a negative impact on any career progression and potentially with relationships with other colleagues so it certainly didn't feel like an open culture in which issues could be discussed without an element of concern I think that's the impression I had from the group that I was with anyone else like to contribute just a background question if that's okay can we hear what was the rationale behind using that union in particular was it just because it represented people in management level in healthcare or union was that? the union that everybody well I think it was at MIP sorry sorry so on the papers last week it said sorry just that it was a few trade unions represented in that so I was just right so why that union just because they're healthcare managers is it were because their membership UK level was 6,000 but in Scotland they've only got well at the last time at the last count was about 500 members that were well represented in Scotland so I just wonder how representative they are of healthcare managers more broadly I'm not sure probably because an organisation has got a collective voice if you like we might have struggled to get others one of the things that stuck me was some of the people that I was talking to had a remit that was UK-wide and they spoke very positively about NHS in Scotland in comparison to the rest of the UK and particularly about privatisation of the NHS in England in particular and their concerns the impact that that had on staffing there so they wanted to they did ask to draw the contrast between the two systems the group that I sat with were all staff members and they were raising quite significant concerns about the kind of culture that goes from world level up through the system and the way in which it stifles and their view stifles innovation and stops people taking risk that's positive risk and developing service and that type of thing in the way in which there was one individual who had been a manager and had experienced quite significant what would I call I suppose in the terminology now would be building an harassment in her role having raised a series of concerns but the overwhelming thing I think they wanted to about pressure felt having to deliver targets that was the main thing that they felt that the pressure to continually deliver those targets took over everything else and that some common sense things that they would like to have seen brought in in their service area or in their ward or whatever or the area in which they manage put aside because the overwhelming pressure is to deliver the target to deliver the numbers and I think that was they seen that as a negative on their experience I think that as we take forward report or whatever it's going to be quite difficult sometimes to make these voices heard especially those who maybe approaches as individual members or as MSPs to express real concern about bullying and harassment sometimes by senior advisers within the health service in Parliament here and I think I would put on maybe the table here we're going to have to really look at how we can make those voices heard because in some cases they're using us as their complete system I think that's something which is a committee I want to make sure we get right that that voice is actually heard in our final piece of work Marie What you were saying Neil, I think some of the people that I spoke to said that about the level of stress and they said that when people are under stress to make cuts what the rules revert to maybe not very effective managerial styles so whilst they all had very positive things to say about for example the patient safety programme and how excellent that was at empowering people on the co-face and delivering bottom up change, they said when people are under pressure they just revert to top down this is what you're going to do in bullying I think that was definitely what came across Any other issues people want to raise? If people took notes, I took screeds of notes or passed them on to the committee clerks, but if there's others please send them on so that we capture some of the themes that came forward Okay As agreed at the previous meeting we will now move into private session