 We have a good morning and welcome to the 19th meeting in 2015 of the Health and Sport Committee. In the room, I have been asked to switch off mobile phones as they can often interfere with their soundsystem. We also notice that some of us are using tablet devices instead of a hard copy of the papers. Our first item on the agenda today is an evidence session with directors of finance Felly, mae gennym ni—fiddiw, maen nhw'n gweistin. Mae'n osart hon yn gweithio. Mark White, director of finance, NHS Greater Glasgow and Clyde. Derek L compartment, director of finance, NHS Ayrshire and Arran. Lynse Beddford, interim director of finance, NHS Teaside. Katie Lewis, director of finance, NHS and Freeson Galloway, and Marian Fordham, director of finance, NHS Western Isles. Welcome to all. We appreciate your attendance this morning. We delayed you a bit this morning. We were in a pre-brief and we were struggling with our papers over the weekend because there seems to be such a lot of performance targets and data. We were struggling with it. You deal with this on a daily basis. We were struggling in our brief discussion this morning to have something that you may be able to help us with, to have some evaluation about how useful this data is, how it drives improvement, what is useful, what is less useful. For us, in dealing with our papers and papers that we had and the questionnaires coming back, there seems to be a lot of data collection, there seems to be a lot of performance targets. Some of it is important because it drives the way it acts. No, it would seem always in the interest of a business plan because it can drive the directions that take you away from your business plan. After that round robin, the question is performance targets, how important are they, what ones are important, what drives your performance, what drives improvement, and the data that we collect useful to ourselves and is it useful to the general public and politicians to try to establish what is going on in the service. Anyone who wants to take those 15 questions, I would appreciate it. Derek, you blinked first. Yes, there are a number of performance targets, although the main ones that boards are measured against, and indeed our local delivery plan is based on, used to be called, heat targets, and there's a limited number of those. It does drive to some extent at least the investment that's required. For example, the treatment time guarantee, which was introduced a couple of years ago, in Ayrshire and Arran we invested about £1.8 million additionally in that because that in orthopedics, which was the main area where we had patients who were breaching the treatment time guarantee, so it does drive performance in some areas. For example, more recently around the accident and emergency and the four hour target there, again there has been significant investment. There is increasing demand and we've had to invest to manage that. I would say that performance targets do have a direct relationship with some of the areas of investment for boards. Anyone else? To add to Derek's comments, I think that in trying to answer your main question, Cymru, are these performance targets useful? I think that they absolutely are. You did touch on the fact that there is a huge range of them, so invariably some of them will be more important than others. We do base our investment decisions as a business and in terms of our day-to-day operations on the ones that are deemed to be more important and as Derek touched on over the past several years, that has tended to be the TTG waiting times at A&E waiting times to lay discharge, all those kinds of targets. To answer the question, yes, they are useful. I think that they're useful to the public and I think that they're useful to us in terms of making our investment decisions and in terms of the day-to-day running of the operations. Not necessarily to you Mark, but do they dictate your investment decisions in a reactive way or in a planned way? I think that's what we're trying to get at. We're part of this problem about A&E and if you miss a target, there's all of that pressure and public pressure and politicians jump up and down and whatever, but probably the politicians know that if we reduced the demand going in the hospital and speeded stuff coming out of the hospital, and we're talking about community investment here, it would reduce some of that demand on you, so is it reactive or does it necessarily meet our business plans over a longer period of time to continue in this way? I'm happy that the others will come in and I'll give them an opportunity. Most of the targets do tend to be focused on acute services and therefore shifting the balance of care may not be the major focus around those types of targets that I've mentioned. I think that there is something about how tight the targets are and the flexibility within them, because you have a law of diminishing the turns and in order to get to 100 per cent of something, you have to invest a disproportionate amount. An example I would use relates to waiting list initiatives. Our normal capacity and our workforce, etc., is able to deliver and hopefully is staffed up to a level where we would normally expect to be able to deliver the targets. However, if we have unusual levels of staff sickness or operational difficulties, we then have to invest a disproportionate amount to catch up again through things like waiting list initiatives and therefore having flexibility around some of the targets. Either you don't need to meet them all the time or it's maybe only 90 per cent target level that you're aiming for rather than 100 per cent means that you're not having to invest at a premium rate to catch up on some. I just wanted to say that when you're considering the benefits of doing something new or differently then it has added impetus if there's a benefit in terms of achieving one of the national or heat targets. It can actually lend weight to the argument for doing something but it's not necessarily the only driver. The other thing from the western ars point of view is of course with the targets we're often affected because we're dealing with such low numbers that it doesn't take very many, you know, differences to actually make a big percentage difference and then it will look like an outlier when really it's maybe one or two patients. Yes, I see that point made in the papers Katie. I suppose I just wanted to reflect on the Dumfries and Galloway position and whilst it affects some of our investment decisions, particularly I think Derek reflected on TTG and also around our unscheduled care pathways within emergency division. I think one of the things we've been endeavouring to do is to get a balanced acute systems to ensure that our demand and capacity are managed so that what you don't see are the sort of peaks and troughs in demand within the system and some of our investments that we've made are looking to get that level of sustainability into the system and I think that's certainly what the ambition of acute systems should be is to get that balance both in terms of managing demand somewhat downwards in some instances but also ensuring that we've got the capacity to do that. I would just add to Derek's comments. I think it is about that flexibility about achieving the targets 100 per cent of the time. I think we all recognise the pressures that we, all boards, face over the winter period and that certainly puts additional pressures on delivering and sustaining the treatment and time guarantees over that period. Anyone else? Can I ask one question of what you all know because I think it is an area that the committee is interested in in terms of, I think you mentioned that, this proportional investment to, you know, so what does it cost the boards, you know, to get from the 90 per cent to the 95 per cent to the 95 per cent to the 100 per cent, you know, you mentioned disproportional cost there to get to these figures. You know, what is the difference I sometimes ask myself in cost from somebody getting that elective procedure done on a Friday rather than the following Monday? You know, I think the committee would like to have some idea about the impact and cost of that, you know, that we don't always hear about when we talk about targets. As a general thing for waiting list initiatives, consultants are paid about three times the normal rate to do a waiting list initiative. So if you have a consultant working the normal working pattern and then ask them to come in and do a waiting list initiative, it can be about three times the rate. Clearly private sector and using the private sector to increase our capacity is also more expensive than having our own in-house provision. So I don't have figures to say how much would it cost to be 90 per cent or 95 per cent or 100 per cent, but as a general rule, that's the kind of scale of difference in salary costs. What is financial directors? You must know what it costs you on your board to meet those demands. Within Ayrshire and Arran, over the last few years, we've spent about £3 million per annum on waiting list initiatives. Now some of that won't necessarily be specifically for things like orthopedics, it could be about radiology capacity because we have vacancies and so forth, but roughly three million pounds a year we are spending on waiting list initiatives. Anyone else? Mark? To Derek's comment, I think we've been very focused on our area waiting times and to give you an example again is very difficult to give you an answer, direct answer to how much does it cost to move the percentages, but as an example we spent an extra £5 million over the winter to try and you know give ourselves that breathing space to try and meet the target. It's not always a case of being able to split the cost down because it can have an impact, to achieve very easy waiting times. You've got to have support beds, you've got to have the staff, you've got to have a whole range of things in place, so it is very complex and very complicated to be able to work out exactly how much it does cost to meet the target. It's a far wider picture, but as I say, you can break it down into particular initiatives, as Derek said and as I said, so you can put sums on particular drives or particular areas of it and for Glasgow that was an extra £5 million just to get through the winter. The incremental costs for us if we look like we're going to breach the TTG for instance can be enormous because we might end up having to send patients away to another board where we don't have a contract so that we end up paying quite a lot for that. I suppose it comes back to my original question, if you don't understand what it's actually, that detailed cost now. It makes it difficult for you to make the argument that we get that flexibility that would allow you certain savings. It may be invested in other areas in the community that would result in preventing them for next winter, that if some of that money was re-diverted to reduce the demand so you didn't have to pay, would you repeat the figure that you said, Mark? Was it? Yeah, it was £5 million just particularly for a winter last year and I've planned for a similar amount this winter. Right, just additional, on top of... That's on top of my day-to-day and, you know, I could spend. As I say, that's put on me in Glasgow, that's focusing on our A and E waiting times and it is very challenging as a demand-led service, you know, very much it's hard to predict what your attendance, pattern of attendance is going to be so for us in Glasgow, the TTG waiting times has been more successful, we've been successful at achieving them, it's our A and E waiting times and that's where it's very difficult to put a range of spend on them, you can allocate some money to it and that should hopefully have an impact. I've got Mike McKenzie followed by Richard Simpson. Thank you, convener. What strikes me in looking at this overall area is both in terms of the targets and some of the health outcomes. With some exceptions, there seems to me to be a remarkable convergence of the data, so much so that some of our papers in terms of the graphs we're looking at and so on have had to expand the scale to amplify the differences. That seems to me to be remarkable. I wonder if, in deciding allocations within your budgets, if finance directors don't say actually we're doing really well in this particular area against the Scottish average, therefore we can reduce expenditure a bit and put it into another area where we're not doing so well and that that over a long period is what's driven this convergence, the remarkable convergence, despite the fact that in some areas, Western Isles, we know huge incidents of fuel poverty and we know about the health effects of that. What I wonder though is, and this is just a general question, if that's the effect that there is, is that not driving us in a kind of race to the bottom to the lowest common denominator rather than a race to the top so that health boards that do particularly well in certain areas set a standard that the others strive to get towards? So, is the average a kind of lowest common denominator? Are they comparable across the health board with this data? If they're not, why not? Could I maybe start off by saying we all have the same targets so I guess that's the first thing that would drive us all towards being similar in terms of those and where we are not meeting those targets, the performance management aspect from the Scottish Government would be coming in to say, you know, why aren't you getting your performance up to that? We can have support teams that come in to do that and there is a sharing of best practice so that if one board is able to deliver good performance in an area through innovation then we would try and share that. So I would hope that the drive is towards best practice in learning rather than a drive, you know, a race for the bottom. Yeah, I suppose just reflecting on the D&G position, I mean we've over the last year or so had quite strong performance around our emergency department and our A&E weights. We've certainly been above the sort of the 95 per cent and I think one of those things around that is about ensuring that we've got a sustainable system, you know, we have brought down our emergency department weights and I think what we're trying to do is get a system where, you know, it's not just fixed for today, it's fixed for the future and I think the achievement and the movement up to the 98 is going to be really challenging but I think it's right that, you know, we sort of set a standard and that we all aspire to that because that's, you know, we can't set the standard too low because that's in conjunction with clinical teams, with patients and the like because we wouldn't want to move back from that standard in terms of the four hour weights for patients within our system. Thank you. Lindsay? In terms of take side, take side certainly has been a frontrunner in terms of accident and emergency waiting times. It's probably regularly attained the 98 per cent level, not the 95 per cent over the years and certainly we've had a significant number of visits from boards over the years. Looking at the model that we have in take side, clearly we did invest two or three years ago in accident and emergency. For take side, we certainly have challenges around the treatment time guarantees and I guess we, as a way, look to all of the boards to see what they're doing to see if we can improve our performance. I mean, I perhaps didn't articulate that question as well as I might have, but, and I'm not just solely talking about targets, I'm also talking about outcomes because the committee inquiry and the, you know, the questions that you've responded to in your written evidence touches on outcomes as well as targets and what I struggle to come to terms with is that each of you are dealing with different social demographics, different social economics and matters that are often largely out with your control, driving health problems that are different by their nature in each area and yet there's a remarkable convergence of when we look at outcomes and target achievements and I just wondered how you felt about this general approach. Is it contriving to create a situation where the good becomes the enemy of the best? You mentioned as one of the three that you've picked us about emergency admissions and that's noted in the reports and there is a graph which actually you can see a trend that the west of Scotland boards have higher levels of emergency admissions per 10,000 or 100,000 population than other boards in Scotland. So I think there is a factor in there about socio-economics, about deprivation, about just patterns of presentation at A&E departments and so forth. There will also be something, however, also about the model in which how we deal with patients and, as Lindsay mentioned, in relation to Tayside, their GPS assessment model is certainly being followed and copied by a number of boards, including my own. So there is a factor about socio-economic but there is also how we can respond to that demand. So that would then take me neatly on in my last question, convener, with your indulgence, is that it takes me neatly into that direction so that the kind of wider approach towards these health problems indicated by the integrated joint boards. How far, and I notice that there have been a huge range of percentage different contributions from various health boards into these integrated joint boards. On what basis do you make the calculation of what proportion of your budgets that you put into the integrated joint boards, because there really is a big, big spread in the range of contributions from health boards? I know that we are quite different to some of the other boards in terms of the approach that we have taken and my health board decided that it wished to put the minimum it could into the integrated joint board. What I can say is that the figures that you had in the response have now changed because following feedback from the submission of the integration scheme, we have now included some further services. So actually now our percentage contribution is very comparable with some of the bigger boards, though not as much as places like Dumfries. On what basis did you make the initial decision and on what basis did you change your mind? I think that there is an apprehension about losing control over some of the acute services that we manage. Kate, I'll get some other responses, mate. Anyone else in terms of this? In terms of the specifics of the Dumfries and Galloway position, we've got both the entirety of acute services and a range of other clinical services included within the integration joint board. In fact, everything that currently sits under our chief operating officer within health, who is also the chief officer designate for integration. I think that one of the reasons behind that is that we're coterminous with our local authority, so that allows us to do that. That's something that not all boards are able to do because of the way that partnerships are created. One of the things that we were keen to do to maximise the integration across the whole of the patient pathway and to not break down acute into sort of unschedule care and the like. We were concerned really that we would get the best benefits out of integration by having that full integration, but, as Marion says that, that's maybe a bolder decision than other board areas have chosen. We took that decision in discussion both within the health board and within the local partnership about what we thought was the right thing to do. Remembering, I suppose, that the focus around integration is improving the services to patients on the ground. I guess that for both Tayside and the Urshire and Arran, we have three health and social care partnerships within our area and Glasgow has, I think, five or six. There is something for us about the synergy of acute services that it wouldn't be appropriate to split in three ways the whole of acute services. There are synergies around the way in which they are delivered. In fact, we have two district general hospitals within our three council areas. It is perfectly understandable for Dumfles and Galloway to look at that in totality whereas, because of the local authority boundaries in some other boards, it's more difficult to look at splitting that up. From an Urshire and Arran perspective, we have devolved the whole of mental health services, all of primary care, all of our community hospitals to those integration joint boards, but the main district general hospitals are retained within the board, with the exception of some of the emergency services that are in what they call the set-aside budget, which are subject to the strategic plans that are prepared by those integration joint boards. Those would allow some movement of money between hospital and community there. Lindsay Lylew. Tayside follows a similar position to Urshire and Arran. I think that it probably reflects out in the report that you got that Urshire and Arran's percentage is 52 per cent of the overall budget and Tayside's is 54 per cent. As Derek said, in Tayside we have three local authorities and shadow integrated joint boards that we're dealing with. For the exact same reasons as Derek has highlighted, at this stage, given the complexities of acute services within both Dunia and Wales and Perth Royal sites in particular, we've focused on delegating down the older people and adults budgets that sit within our current community health partnerships, which also brings in mental health, as well as community hospitals. In answer to the initial question, it's interesting because we're still finalising our budget, so I've been looking at those percentage splits to find out where Glasgow sits on. In direct answer to the question, I think that it has very much to do with the mix and the range of services that every board is delegating to the IGB, and that does vary across each board. That's just when it's in primary care situation as well. I think that the larger part of complexity comes in your acute services because that is the challenging part to determine the range and the boundaries in the spectrum of services to which each board is allocating. It's difficult to compare like with like. There are common themes, but it's a difficult situation. As accentuated in Glasgow, we're trying to get to more than six of these, so I understand the question, and I think that's the broad answer to why it's so different. I suppose the other question that we discussed earlier is your understandably cautious approach because you've got to deliver all the acute services and worry about all of that, but we have a policy that is generally accepted by this committee. We've got a 2020 vision that more people will be treated at home or closer to home or within the community. Now, is that cautious approach that you're demonstrating here consistent with a plan that's going to see more and more people delivered their healthcare and community settings rather than acute hospital settings? What type of planning is in place to get us there in that five years or beyond? Or is it just year-to-year that you're doing this? There are strategic plans that are being prepared by each of the three integration joint boards in consultation with the health board, and they don't just focus on community services, they also look at the emergency and elderly services that are delivered within the acute hospitals and the opportunity then for that integration joint board to propose a shift in the balance of resources. We have the three chief officers from the health and social care partnership sitting around our corporate management team as well, so they have a significant input to discussions that we have. They would reflect on, however, the increasing demands that are going into our acute hospitals because of demographics, and, perhaps initially, the thinking was that we'll be able to take money out of acute services and transfer it to community services. First of all, we have to prevent people going into those acute services because it is demand-driven at the moment, so there is a balance that has to be struck about investment in community and in the increasing demand in acute. Anyone else? My question is directly mentioned, the strategic plans for each of the IGBs that we drafted just now, and in answer to your question, yes, they very much are focusing on the themes of 2020, which is early intervention, treating people at home or in the right community setting, so that is very much exercising that process at the moment. It is complex in that situation in terms of moving funds from acute and elective and emergency surgeries into more preventative methods, but that is very much the purpose of IGBs and very much where the focus is at the moment. I think that the challenge will come in how we measure the outcomes from the IGBs, and that is, again, something that is very much entrained at the moment to get that suite of performance indicators. However, many years time, we can look back and determine that flow and the allocation resources around that is working. I think that if I reflect on the kind of forerunner through the integrated resource framework, and I guess that that was part of the way of developing the data sets that would at least allow local communities and local areas to understand the resources that they were consuming. Although the integrated resource framework has been around for a few years, I still think that there is that bit about understanding the data and understanding how each individual area actually uses the health resource, because it does vary across the party, depending on clearly where the TSI is at, both in urban and rural areas. Health populations use of health resources vary significantly across the whole patch of it across TSI. Well, yes, and I'll let you know just if Katie and Marnie don't want to respond. We actually do quite a lot of joint work in terms of making sure that we try and keep people out of hospital and keep them as close to home as we can, and notwithstanding the integration process, we've certainly got a project underway in Barra, for instance, to try and re-provide St Brennan's hospital and care home in an innovative and joint way. I think that we can point to a lot of joint working that's designed to try and keep people at home, but it almost runs in parallel with the integration process at the moment. I mean, you know, it goes back to those targets on what drives the service. We heard earlier they're breathing down your neck about getting those waiting times at E&E down and waiting times, then it's, you know, you're not going to get to some of that earlier preventive, sir. Richard. It was really the integrated resources framework that was the thing that interests me. It's been around since 2009, and Tayside are actually, in your Perth and Kinross division, are the most advanced in this in terms of actually what it's delivering, and it's just to ask you all whether that is, you know, we've been at it six years now. You know, refining that data is really critical to integration, in my view, because it does range across the whole field from general practice prescribing to Sparra data, all these things, the amount of care home use, et cetera. These are all fundamental if we're going to look at the variations. So, to take Tayside, I'm sorry to concentrate on you, Lindsay, but Perth and Kinross are furthest ahead with IRF, but interesting enough, Angus has one of the highest levels of care home provision, you know, which shows you the variation, and understanding that and the costs involved in that seems to me to be fundamental to the integration process. So, I'd just like to ask a question about whether you're using IRF, whether both the health board and the local authority partners really understand what that's about, and what effort is being made to actually ensure that that data is available, because unless we get the data right, then, you know, going forward, we're not going to be able to understand the variations, which may be justifiable, but we need to understand them. Kitty, yes. I mean, Derek talked a bit about the strategic plans that are being developed as part of, as we move to integration, and within that, there is also locality plans. So, in Dumfries and Galloway, we've got four localities, and supporting the strategic plans is a whole wealth of data through the strategic needs assessment and also a financial plan. And that's certainly one of the main areas where I would see us using the IRF to really influence some of the decisions, particularly at locality level. I think we have been challenged over the years, although it's been around for a while, the quality of the information that we're getting through the IRF has improved significantly over that period of time. And certainly one of the things that we've been working around in D&G is around looking at how we involve that in the localities, at how we get the locality management strong, so that it's the localities who are empowered to make some of the decisions as we move forward. So, you're absolutely right, they need to understand the resources that they've got, whether it be people, hospital, money, and to be able to have an influence around that. And that's certainly one of the principles of the model in terms of the way that we've set up integration in D&G. I would say it's fair to say we're still in early days, so we're still working that through, but it's one of the work strands that we're taking forward as part of our implementation of integration through the shadow gap. Lindsay? I'll have to come in just a bit on Highland Perth and Canos. Highland Perth was the pilot for the integrated resource framework that we spent a fairly significant amount of time collating the data, refining the data over that period. Where we got, I guess, we did start to have the discussions with, not only the general practitioners for them, to help us to understand the resource profile, but also with the community as well. I think that where we've always suffered, and Katie has touched on it, there is significant amounts of data held nationally for inpatient activity down to individual patient level, for new outpatients down to individual patient level. At times we've always struggled with the community data and clearly to understand the full resource consumption that we need to understand. At a bit more granular level the community spend, and that's a bit that's in part always challenged us, although we continue to take work forward in that. Similarly, from a social work perspective, they're not used to collating data in the way that we were looking to manage it, to corral the data. We use that Perth and Cynos experience as a learning curve. Moving to Angus, we can certainly transfer that knowledge to Angus. We certainly have the significant levels of health data from the ISD database, but I think that we can provide the data and demonstrate the data in however many manners we can. However, we need to think about how we would take that discussion into the clinical fraternity and primary care, as well as the public, and that will be a challenge to take, the significant amount of data and help people to understand. Derek Rennart, you've had prescribing budgets down to GP practices for a long time, and there's a good visibility of that. I guess what then the IRF brought was a visibility around the spend on acute services for populations within the three local authority areas. One of the things that we did was having identified that, compare that to the NRAC share of that, which the NRAC is flexible enough and detailed enough that you can go down to that level. That showed some apparent overuse by some areas of the population and underuse by others, which led to some debate around that issue. In moving to the integration of health and social care, I think that it was a useful starting point. One of the things that we are now doing is being supported by the information services division of national services or the Scottish Government are dedicating data analysts to come out of each of the partnerships to help support the use of data. One of the areas that we wish to use them on is what we would call high-resource use individuals. There are a relatively small number of people who have frequent admissions to hospital and if we can identify how best to support them to not have to be admitted to stay in their own home to get the support that they need, we think that that will help with the demands on the hospital sector. The other question that I have is about general practice, because I am really very concerned about what is happening in general practice at the moment. I do not know whether the boards that we have got in front of us today have particular problems, but certainly in my health board area 4th valley we have now got 23,000 patients and three practices where there are no GP partners anymore and the likelihood of at least one more occurring. We know that there are 26 practices in Lothian, the city of Edinburgh anyway, which have closed their list of new registrations. Sterling, all except one practice, has closed its list of new registrations. If we are going to get this integration and the shift, continuing to shift things to general practice when clearly general practice is actually struggling seems to me to be a major difficulty. We also know that the share of money going into general practices or primary care has actually reduced and the colleges bang on about that all the time and the BMA bang on about it. As part of this integration process, how are you going to tackle the fact that we have a really serious developing problem in general practice? Do you recognise that as being reality or am I just extrapolating from a couple of areas to saying that this is not happening elsewhere? Just commenting on the D&G position and the facts that you have laid out there, Richard, we have got around about 11 vacancies currently within GP practices and we know that within the next 18 months around about 10 per cent of our GPs are planning to retire and it is something that we have had considerable discussion around our management team and our board around what are the options moving forward, not just in terms of daytime general practice provision but also our out-of-hours because obviously if GPs are struggling to meet their commitments within daytime then the out-of-hours is inevitably going to suffer and we have had to invest significant amounts of money in locum costs to support that. Not only that on GP training posts, we are not able to recruit the same numbers that we would like. I think that the latest we have got four out of 14 and I think that the reality is that certainly there are no easy solutions for this. We have looked very much at different models of provision moving forward, so looking at advanced nurse practitioners and looking at other professionals to be able to support models and we know that we have a really good GP community within Dumfries and Galloway who are committed and so I think the challenge for us is when we are seeing those really committed and enthusiastic individuals getting really challenged with things then the reality of that hits us and certainly the sustainability of our system when we are talking about things like the impact that they have on emergency admissions and being able to manage people in the community is absolutely critical. The key things that we have been doing within D&G aside from looking at the different models is almost fundamental review of our services, particularly out-of-hours looking at the national work that is on-going. We have been looking at our medical recruitment process and really supporting GPs with that, so looking at how we advertise and how we maximise the intake that we can get locally and even looking potentially at international candidates. Which is quite key in a rural area is ensuring that if we recruit people that if they have got spouses or individuals that we try and work with our local partners to kind of find jobs for individuals, particularly in the more rural areas within Dumfries and Galloway. I suppose that I do not have a final answer for you on this because I think that it is one of the challenges that we have got and I think that it is something that we need to be thinking about how we take things forward. You asked about the overall picture in Scotland. I think that Fourth Valley is a particular hot spot in terms of vacancies for GPs and some of the rural areas also may be particular issues, so Ayrshire and Arran do not have as many vacancies as Fourth Valley. We do, however, looking at an age profile have a large number of GPs who are over 55 and therefore will retire in the not too distant future and therefore making provision for that. There is, in terms of the investment for 2015-16, £100 million of an increase in the integrated care fund with £40 million of that identified for primary care. Therefore, I think that that has been recognised as a national issue to see some investment in that area. Those two funds are not separate then. £140 million of it is for general practice. No, so there is £100 million that has come out to boards for integrated care funds, which is prioritised by the integration joint boards. In addition to that, there is £73 million, which was retained by the Scottish Government of which out of that £73 million, £40 million is for primary care, so there is a total of £173 million. However, I was just going to give one example of an airshire and Arran issue around GP out-of-hours, where there is significant pressure and it relates to the Isle of Cymru, where we had issues about getting a GP for there, and in particular if that GP then has to do out-of-hours. We are using advanced nurse practitioners, a team of them, and they are not just based on Cymru. They rotate between Crosshouse hospital and Cymru, so that their skills and experiences are kept up as well. I know that we visited, I can't remember if it was Orkney or Shetland, to look at the model that they had using advanced nurse practitioners. Actually, they took members of the public from Cymru up to see that, so that they were satisfied that the service that they would get would be appropriate, and that's now been working for over a year. Can we broaden the responses out a wee bit? Who's responsible for the overall workforce planning for the health and social care? It all seems to be local and in the moment. We've got a shortage of cover for out-of-hours care for flying people in from South Africa, as it happened in my neck of the woods or whatever. Given the context that we're talking about this morning, the planning and the spending, whose responsibility is it and who's driving the thinking about workforce planning and what the workforce will look like to deliver more healthcare at home, closer to home and in the community. Who decides whether it's 50 nurses or 100 home carers? Is there any of that going on? I would say that each individual board produces a workforce plan by the end of June, which will all go into the Scottish Government, so there is a consolidation. The issue around workforce planning is that it can take five years, ten years to train up a workforce to meet a future need and, therefore, the crystal ball that is required to know exactly what is required in ten years' time. There are national workforce planning arrangements for things like medical workforce, I guess. There are deans of colleges and so forth. There's almost the inputs that are required into the education system in order to produce the outputs of qualified staff at the end of that. It can take a long time. We do this on leaflets—a thousand more nurses of that. It doesn't meet the requirements that we're looking forward to. We're still recruiting for hospitals rather than it's a clinical workforce, but is there any workforce planning that looks at the value of right-down-to-care workers or physiotherapists that can bring about some of this preventive stuff, can reduce admissions? Who's doing that? It's done. As Derek said, there's workforce plans being developed just now on the health board side of things, and they will contain both acute and primary care staffing quotas, so in many ways that will involve what we have in the current primary care system, and it's all about making that better and improving efficiencies. In answer to the question, it's sitting with the health board just now, and social work will also be doing their planning when the IGBs are up and running next year will become a joint process. No, we're just drawing that out. It's not—you're dealing with the demands that you've got to deal with. I'm just looking for a wider approach to workforce planning. Richard, you moved swiftly, convener, on to my—I think, because it's partly about general practice, but the responses being advanced nurse practitioners are coming in to do it, or physician assistants are actually being considered as well. That's great, but if we look at what's happened, we had a really quite substantial cut in student intake and nursing. It's been going on for seven years now. There's been a reduced student intake, but whiffery student intake was reduced. The FY01 levels in the doctors was cut. The specialist training grades were going to be cut by 40 per cent, and that was all around 2011-12. The numbers actually in the health service dip were 2,500 fewer nurses, far greater cuts than occurred in England, I have to say, proportionately. Then, within two years, we're back up. I just think I look at this and I say, well, where's the workforce planning in that? Because, as you said, it takes—you know, you have to plan years ahead, so the plan in 2011 was actually five, six years ahead to have a smaller workforce? What was actually happening? How did the workforce plans that you're feeding in locally, could they possibly feed in to a situation that we've got now? Specialist nurses, not just advanced nurse practitioners, specialist nurses in neurology, specialist nurses for heart failure, all those specialist nurses that can keep people in the community, COPD nurses, all those specialist nurses, you can't just create them and not have more nurses coming in at the other end to do the general nursing, or to do nursing in general practice. So how on earth can we say that we've got a workforce planning system that is anything like functional? I don't think anybody said that, but Derek? I think—and you mentioned 2011 and thereabouts—you'll recall with the austerity and the budget projections that we had, although health would be protected in terms of real terms increase. We were looking at very straight-in-times with funding uplifts of 2 per cent or thereabouts. In terms of the financial plans, looking at, for example, we've seen increasing expenditure on drugs of very significantly over the last few years. And our other—or our main cost is staffing cost. So if you're balancing between—we know that these costs are going to go up there for—and our funding available is going to be pretty static, then you have to look at the balance there. So I think that was probably the driver for any reductions in the numbers of intake into the professional qualifications was because the years of austerity that were lying ahead of us looked as if that would be required. Clearly, other issues around the introduction of the nursing workforce tool, the patient safety focus and the staffing levels in wards has resulted certainly in Ayrshire and Arran in a significant increase in staffing as a result. So those are perhaps factors that are contributing to that dip and then the increase that we've seen in recent years. Any other comments? Lindsay? Maybe just say in terms of workforce. I think what we've talked about in Tayside is kind of growing our own workforce. So perhaps not looking to the primary care and community aspect, but certainly if I think of the theatre environment. So we've recognised that we've struggled to recruit to band 5 nurses. So we've looked at opportunities to develop support roles and expand the labour market. So we're looking for a completely different profile of workforce. So we're potentially giving the opportunities of band 2s and band 3s to become assistant practitioners through education and I guess also opening up new potential employment markets as well. So we do recognise the challenge in particular areas, but we've had to think differently, recognising that we can sustain the position that we're in. Thank you for that. Bob Doris, followed by Dennis Robertson. Thank you. It's perhaps worth noting that just in the context of workforce planning and nurse and midwife numbers that last week the Government used a nice record levels of staff within the NHS including nurses and midwife. So maybe just put that on the record and we can scrutinise some of the figures put on the record elsewhere this morning a bit more robustly at another time and place. I would like to absolutely convener that that would be a well-rounded discussion we would have, but I want to look at the budget scrutiny which of course which is the principal function of this morning and my apology I think to Mr White in advance because I've looked particularly, as you'd imagine, at the Glasgow submission, but I was doing a bit of comparing, so I was looking for example on emergency admissions through A&E and looking at that I saw absolutely the air shun arm, I've got significant challenges as does Glasgow and some others fearing a bit better. I've taken board the demography and ageing population issues around that, but it was in relation to some of the answers we got in terms of that and I just want to make reference to them. So for example when Glasgow was asked what factors can help to explain any observed differences in performance he said key factors are like the managing population and levels of deprivation across NHS greater Glasgow and Clyde. The other health boards including for example air shun arm identified routes for improvement and I won't list through them because it's all within evidence. Glasgow didn't seem to do that and if I go and look at others I'll come back maybe some more information on that would be quite helpful in a moment, but I just wanted to get specifically in relation to the evidence but we were also asked about how does this performance against this indicator influence budget decisions and we got this is important performance indicator significant recurring and non recurring investment in this area has been made in 2014, 15, 15, 16 but no numbers behind it. If you look at other evidence we received we get numbers behind it. Mr White in the final thing I'll refer to is what programmes or services are specifically aimed at improving performance against this indicator. Preve provides three main areas and Glasgow says it's not really possible to give meaningful responses it could be argued significant elements of community services expenditure, district nursing, rehabilitation etc are geared towards achieving this. If you look at all the other responses you'll find it's one of the boards Dumfries and Gallow said it's a complex issue provided two pages of information and they did actually pick three areas where they'd identified budget and budget increases as did every other board. I know there's good things happening in greater Glasgow and Clyde convener I just feel the information we've been given in terms of to enable myself as a Glasgow MSP and his deputy committee of this committee does not allow me to interrogate those figures so I suppose it's an opportunity maybe for Mr White to put something on the record of what Glasgow's actually doing to align its budget to improve that particular performance which is very very challenging and maybe for some of the other witnesses to talk about how they prioritise budgets to meet that target also so sorry to get on at length but it is budget scrutiny we have been given significant amounts of information by some of the witnesses but not very much by others and I'm trying to scrutinise and compare in relation to this so I suppose over to yourself Mr White. Yeah I can give you an answer in two parts of that in terms of the submission for Glasgow can I just point out I've been in post just under two months and this submission was completed and submitted before I started so can I just say having read it myself over the past few weeks had it had I been in post earlier it would have had far more detail in it so I do appreciate your comment and can I promise it next time the submission will be far more comprehensive. In terms of where we are with the emergency admissions as I said at the start it is extremely challenging position and Glasgow has struggled with it. It's not all bad news we have achieved the emergency admission targets particularly around the Royal Hospital for Sick Children across our emergency care centres at the Victoria and Stop Hills we have we have had pockets of good achievement along the rest of it yes we have significantly invested in in every other site we have we have a number of initiatives going on particularly at the Royal Alexandra where we have had a real issue and we've had the Scottish Government support team out there to visit and a number of other sites as well and we've taken on board some of their comments and we've allocated specific directors to specific sites to support managers that are involved in dealing with emergency care. We've just spent money at the western and at the Royal Alexandra around discharge lounges so again we're taking the steps around that and obviously we've got a new surgical assessment area at the Royal Alexandra as well that should hopefully help us to achieve those targets. In terms of overall Glasgow picture we have obviously the new hospital that's just opened at the Southern General that has involved significant investment as I'm sure everyone is aware and we are looking to significantly improve our performance particularly around the businesses missions with the opening of the new hospital and we have a number of cutting-edge initiatives if you like and ways of working at the new hospital that we are very confident will bring those figures down. I'm sure it will bring us up and address the challenges so I don't have exactly specific numbers I'm happy to provide them if that's the committee's request but yes to satisfy or to try and answer the question we have taken real heed of that issue and are spending significant money and huge amounts of attention to resolving it. I really did just want you the opportunity to put some of that on the record because I'll have it in grumpy sometimes on a Tuesday morning Mr White. I'm just genuinely trying to scrutinise the information available I suppose Mr Lindsay did mention challenges that your board's got but been quite proactive in trying to tackle those head on. And could I put on the record as well the way in which I completed the form that was here about investment. I showed additional investment each year and that appeared then to show a reducing level where in fact it was investment in year one and then it was further investment in year two and further investment in year three but the report that you received notes that for most boards there's a planned increase in the expenditure however for rare serinarum the reduction reflects lower spending on local and schedule care action plans that's not the case. In 2014-15 we invested about £1.7 million to provide things like GP assessment. I mentioned the Tayside model we learned from that. We also introduced combined assessment or clinical decisions unit to allow the flow of patients through A and E. So there was significant investment in 14-15. In 15-16 we're investing another £700,000 and in 16-17 a further £2 million pounds and most of that relates to new builds at the front door of both A and cross-house hospitals of combined assessment units. The capital spend on that's about £27 million pounds. The cross-house one will open up in February or March of next year and there are additional staffing resources as well as the facilities costs there. So actually for rare serinarum our increase in spend over those three years around unschedule care is about £4.4 million pounds. I'm just interested to know because both facts and Mr White didn't have it in his written submission but the two pieces of evidence we've had in relation to emergency admissions at A and E shows that your budgets are aligning to a strategy to reduce emergency admissions. Do the other three witnesses have specific budget alignment to achieve progress in that area? From a D&G perspective I mean we've spent not just resource but also a lot of time essentially redesigning our systems to really improve our resilience over the winter period because that's obviously where we you know if a system is going to break or is going to be fragile that we'll do that. So we have developed our local unschedule care action plan and that's been developed in partnership with our local authority and despite the fact that over the winter period we saw you know kind of higher levels of admissions we have sustained the A and E performance that we've had. Although we've seen an increase in emergency admissions it's lower than the the Scottish average and we've also particularly over recent months seen reductions in our delayed discharges and so we've invested resource both the money that came through the Scottish Government towards the end of the year on delayed discharge but also additional resource in year to manage some of the challenges that we've had locally and some of the particular ones have been around care home closures and some of the challenges that we've had around that. So I don't have specific figures for you other than what's in the return but we have invested more money than over and above what's included within the information you've received. I'll maybe just mention the Enhance Community Care pilot. So this was an attempt to try stop the flow into accident emergency and medical admissions beds. We started a pilot using our unschedule care moneys not last time but a year before over that winter period. What that demonstrated over that pilot period for four practices that were involved in it, it actually demonstrated a 17% reduction in admissions towards as well as demonstrating a reduction in length of stay for patients. We've continued with those four pilots over last winter and we've now extended that into two areas, both our Angus south locality in our broth and also into an era within Persia. Clearly it's an era we do continue to believe that will benefit not only patients but also the flow into the acute hospitals and that's where we're certainly looking to invest further resource. Finally, from Western Isles, we've been doing quite a lot of work on a much smaller scale clearly in terms of, and I know this isn't new particularly, but initiatives with Scottish Ambulance Service, our GPs have been training up paramedics so that they can actually do more assessment of patients at scenes and make decisions as to whether to admit or not. We're working with nurse practitioners also to try and take some of the pressure away from GPs, but I would say that in terms of actual investment it is caught up a little in other areas of work that we're doing so it would be reasonably difficult to tease it out, but I don't have them with me, I can try and provide that for you if you wish. Really from our point of view, it's more around the pressures that we're facing that Richard was referring to earlier in terms of GPs and supporting the out-of-hours service, the pressure that delayed discharges are bringing to us, actually all converging to provide a focus in terms of working to reduce A&A admissions anyway we can, but it's more around service redesign within the resources we've got rather than additional investment. Okay, thank you for all of that and it gives us a real sweep across the country of what's going on. Just in terms of emergency admissions themselves, yes, we can prevent them, slips, trips and fall strategy with older or freeloader people at home and that kind of thing. Do we track, when we get emergency admissions about, would we count someone who's in there for social care needs rather than for medical needs? Would that still be counted in emergency admissions statistics if someone comes to A&E, they feel the place of safety for that individual would be an admission, but the emergency might be a social care crisis rather than a medical one? Would that still count in the stats in relation to emergency admissions? Would that help inform health and social care integration boards redirecting of funds going forward with integration? My understanding would be if they go from A&E and are admitted to a bed then that will be included for whatever reason. I think sometimes the reason for admission can be as you say for social reasons. We have tried to, in Ayrshire, we had something called the Freely Elderly pathway, which was having a geriatrician at the front door to try and redirect supported by social work. We've also involved Red Cross in allowing people to leave A&E without being admitted into the hospital so as to be able to go and buy some milk and bread or whatever and make sure that the person is settled in their own home. I think that there is working with voluntary organisations and others, and social work is crucial to reduce the number of emergency admissions, but I would flag one other issue, which is in relation to the seniority of people reviewing, the medical staff etc, reviewing people when they arrive, because often it would be, while we will admit, in order to carry out tests and decide if that person is safe. Whereas if you have a senior clinician at the front door who has a tolerance for taking a bit of risk, I mean that very defensive practice is the opposite of that, but who can take a judgment to say that with the appropriate support this person can go home and they don't need to come into hospital for safety, I think that's an important aspect as well. Does anyone else have anything to add to that? My understanding is that those people would be included in those statistics. I think that that is part of the process of moving TIGBs, because that part of the acute function is to transfer TIGBs so that people can then be dealt with in the proper way. I think that, to reiterate Derek's point, we've also taken big steps at the new hospital to get that joint medical and surgical assessment at the point of admittance to try and get our turnaround rates and discharge rates up to about 40 per cent to prevent exactly those kinds of admissions within the safety and within the mentioned patient quality, so it is a big area of focus. I probably just add a couple of statistics. If I talk about the initial pilot that we did that saw the 70 per cent reduction, so for the enhanced community care model, 17 of the referrals into that service, 24 per cent of them were to do with falls, 26 per cent were to do with infection, so it ties in with the strategy that we're following around, slip, strips and falls. Thank you very much, convener. I think that what we're hearing is that we have a very complex issue in terms of probably setting your budgets. Other clinicians themselves are probably looking at the outcomes in terms of patient care. Are you driven by finance rather than the other aspect? Are you able to divorce yourself away from the outcomes of direct patient care and look at the budgets in isolation? If so, how do you prioritise that? I would say that an important role of the director of finance is to be able to bring our professional judgment to bear on what the value for money of different aspects are. We spend about 66 per cent of our budget on staffing, about 22 per cent on drugs and about 12 per cent on other things. Is that the right balance? Can we evaluate what the outcome associated with any of that expenditure is? We are assisted in that by people such as health economists or some of the research work, which would say that by investing additionally in this area you can get a better outcome. As I mentioned at the very beginning, we are also influenced by the targets that were set in the achievement and the demand that comes from population and demographic changes. I think that finance director's role is primarily about looking after the budget but also how best to achieve value for money in the right balance of spend. There was a report that came out in November this year from the Academy of Medical Royal Colleges, which is probably the first time that I saw the clinicians getting involved in the debate about how we use our resources effectively. That report talked about 20 per cent of mainstream clinical practice that provides no benefit to patient outcome. That is through the excess amount of tests, investigations and diagnostic investigations. I think that through that report, it was the first time that I saw a report that allows us to have a better dialogue with the clinical environment, not only in secondary care but also in primary care, talking about referral levels. For me, that is certainly a route into helping both the clinical side and ourselves as directors of finance to understand the resources and how they are being consumed and to be consumed more effectively. You are obviously working with the other directors of finance from local authorities to look at the integration of the integration of the joint care aspects. Together, are you setting out a five-year plan, a 10-year plan with regard to that integration, in terms of, if you look at the efficiencies that you have to have as well, whether it be in prescribed drugs or in staffing? Are you working with those other directors to see where you can both have efficiency savings but also protect the level of care, whether it be direct to a patient or within the community, through social care? Do you have those discussions with local authority, directors of finance? I have been meeting with the local authority, directors of finance on a monthly basis for at least a year or a year and a half in preparation for the integration joint boards and the shadow arrangements that we had in place last year. The strategic plan that I mentioned earlier, prepared by the integration joint board, has a financial strategy attached to it with projections for spend. We have inherited efficiency savings programmes from both a council and a health perspective, which have to be reflected in that strategic plan. We meet and reflect that in the strategic plan. What I would hope out of the integration joint arrangements would be that there will be some synergies, rather than us having to look after our own interests. There may be opportunities where, by working together, we can do things more efficiently. I have had conversations with region i5, the department of directors of finance, around a number of issues on the IJBs. We are trying to get people to spend posts, we are trying to work out the strategic plans, we are trying to work out a kind of control framework. There is a whole range of consultation and negotiation going on at the moment. I think that Derek said that the focus has been on working out how we can do things better. We are both going to—there is no denying that we are both in a period of real restraint, so we are both parties that are always going to have their own savings initiatives, but the crux of it has to be on efficiency improvements and being able to drive out those processes through to the end outcomes and make sure that the IJBs achieve what they are set out to. The focus is more on improvement and efficiency, as much as joint savings. Are you looking at year-on-year, or are you projecting into a five- or 10-year plan? It seems to me that it would be more sensible to have a long-term view. I am just wondering if you are actually doing that, or are you just basing it on a year-on-year budget? You can conclude your remarks on that. Yes, I mean the plan certainly that we are looking at are probably around a five-year plan, based on year-to-year budgets, but we have got to look long term. The IJBs will be—there are longer term goals in terms of what we can achieve. It will take time, so that is probably the timescale that we are going to base our strategic plans on, although they are still in draft at the moment. Is that common? Five-year plans, year-to-year budgets? Delivery plans as a board, certainly for D&G, are five-year plans, so we will be developing plans within that sort of timeframe, really assessing both what opportunities there are with integrating budgets, but also recognising that there will be challenges and risks around that. How public are those plans and those discussions? That is the information about the objectives, the finance, and are they in the public domain? Katie, Maureen. Derek reflected on the strategic plans and the financial plan that will go alongside that, so commenting from a Dumfries perspective, we are still in development of that plan, so they are not in the public domain as yet, but they will form part of the strategic plan that will be consulted on widely within partnerships. That is what I was going to say. That is common. That is the common approach. Is it Government guidance on how you prioritise that, or are you just doing this within your own localities? The timing issue is partly down to when the integration joint boards are going live, so, in the case of Ayrshire and Arran, our schemes of establishment were approved around the beginning of April. The first meeting of the integration joint boards happened in April and they considered their strategic plans, so I think that the Ayrshire strategic plans are now in the public domain, whereas other boards are at different stages during the course of 2015-16 of having their schemes of establishment approved through the parliamentary process. The first thing that makes the integration joint boards live is the approval of their strategic plans. All boards will go through that during the course of this year, but on a staged basis. I see the process as being an iterative process. We are developing strategic plans at the same time, developing locality plans, so there will be a bit of bottom-up from the localities in terms of the developments that they may want to take forward, the things that they think might impact on the service areas or any service changes that they want to take forward, and also from a partnership perspective, things that we want to commission or think are the right things to do. I think that because we are in the first year of integration, they will evolve over the next two to three years as we develop as a partnership and know a bit more about what it is that we want to do and where we want to get to, recognising that there is a performance framework that sits around integration, so there will need to be a linkage around some of the performance outcomes that are expected as a result of that. Is the priority to get more people into the community rather than acute services? Therefore, you have your savings in terms of your efficiencies, which might not result in maybe reduction of staffing, but keeping people within the community is a primary objective? Absolutely. We know that the models of care that we take forward in the future can only be sustained on having the resilience within the community, and certainly a lot of the work that we have done so far through the change fund, the resource that partnerships received over the past three to four years have been looking at what those models might be and how we can develop sustainable solutions at local level. I follow on from Dennis Robertson, particularly with the last six months of care, as people near the end of life. I was very interested in Tayside's approach to the rotational scheme for nurses having them within the acute sector and within the community setting to get a grasp of the whole picture. I think that this is quite innovative, and I think that it is the sort of thing that will probably have to happen in all areas as the population really does get older. I would be interested if Lindsay Bedford could tell us what drove you to starting this strategy and what sort of challenges you met during it, and have you worked out the cost benefit of it? I am probably not in a position to respond to that question today. The response that came really from the clinician that has been directly involved in driving our palliative care strategy forward, clearly we do believe that it has had significant benefits for patients. In terms of cost benefit, at present, there is no analysis that has been done, but I can go back. That is a very interesting approach. I would love to hear a bit more about that at the time to come. Is there anyone else who has any comments about that? I think that it is an interesting statistic. On its own, it has got to be looked at on a broader basis. Are we making sure that people are in the right setting rather than just the statistic itself? Are we making sure that people have their choice? It is back to some of the initial discussions that we had at the start of the session around some of those performance indicators and how useful they are and how much we use them. That is a perfect example of one that we have to look more broadly at some of the underlying issues and factors that dictate that statistic to make sure that we are doing it right. I am just as well to say that there is not really any indication of quality of care in the statistics being looked at. Is there any comment about that and any alternative way of approaching it so that quality of care can be judged as well? I will reflect on the fact that one of the things that we included in our submission was our putting you first programme, which was the change programme that we took forward through the integration results that we had previously. As part of that, we had a full qualitative assessment done to really look at how the patient experience had been impacted by the initiatives that we have taken forward. It was much broader than the end-of-life care example that you have pulled together there. It has to be around understanding both the patient and the family experience of the care that we receive and being able to measure that and understand that and also do something about it. Certainly within Dumfries and Galloway, we have had a much increased focus on absolutely acknowledging that within teams that are working with patients, the impact that their interactions can have with the patient can have on the quality of care that they receive. Ken Donaldson, who is our acute medical director, has taken that forward across the organisation. It has made a measurable impact on what we do. My feeling is that that sort of qualitative assessment will be quite important as integration beds in and to see how it really is working in the interest of patients. I am sure that you will agree with me that we have to look at the outcomes for patients in regard to the whole integration. That is why we are doing it. That is reflected in the national outcomes that are set around integration and will be measured as part of that process. It is not just the hard numbers and facts. On that subject, I am quite happy to take for five minutes or so some supplementaries on that issue because of what the committee are planning to do, some work on the end of life and palliative care. In terms of the briefing that we have got, there is a different approach to whether board use, hospice services, how they are funded, and the funding model between local government and yourself is around 25 per cent. Some areas of meeting that from the boards is around 12.5 per cent of the hospice funding, some are meeting that, some are not. In terms of the charge and the children's services there, there is a particular responsibility. I do not know whether we can explore any of them and I am happy to take brief supplementaries from the committee over five or ten minutes of this, if it is necessary. Yes, Derek? Just on the point of funding, there is complete consistency in terms of the children's hospice because it is done on behalf of all boards through Tayside and the contribution, which I think is about 12.5 per cent. In relation to local hospices, the target for that is 50 per cent. Most boards are certainly close to 50 per cent funding of hospices. In terms of the quality of services, the person-centredness, the small scale of them, they offer a very high standard of care to two patients. That joint working with the voluntary sector is important in palliative care. For Macmillan nurses, for hospices in local areas, there is real value added about working with the voluntary sector. I will wake up the point around CHAS, the Children's Hospice Association Scotland. The table that we provided shows the level of contribution from territorial boards as well as the contribution through the Diana nurses funded by the Scottish Government. The figures that we obtained from CHAS' percentage of their charitable activities—I guess charitable activities from their perspective—is the hospices, the care at home, as well as the outreach facilities. If I think of the contribution that health boards currently make, probably going back to 2009-10, there used to be a fairly detailed piece of work that was undertaken each year to reach an agreement on the agreed hospice funding level. That was a fairly bureaucratic process and it certainly took a significant amount of time from CHAS to provide that. At that time, both parties agreed that we are looking for a more pragmatic solution. At that time, agreed that whatever baseline uplift that health boards received would flow directly to CHAS. That gave them certainty around the planning cycle and the level of budget that was going to be available to them accordingly. No efficiency savings has ever been applied to the resource that went to CHAS. I think that probably both parties do now reflect that CHAS do now have a significantly expanded service. I think that we all recognise it with medical advances that children and young people now need much more complex clinical care, which has led to CHAS having to employ more specialist medical and nursing staff. I also reflect on the CHAS at home service. Way back in 2009-10, that was a support worker-led service. It is a very different model now. It is a nurse-led service and is certainly integral to the care of palliative care services. Many roles undertaken by staff in CHAS are not within the hospices themselves, they actually go out into the community. We recognise that with that significantly expanding service. We probably need to go back and revisit the baseline. We might not do it every year, but perhaps every three or five years it is appropriate to reset that baseline so that we can get an agreement on the agreed level of hospice funding. The initial discussions that I have had with the chief executive of CHAS and the director of finance and the administration of CHAS are both in agreement to that outline proposal. I will be looking to work with the senior officials of CHAS during this year to revisit that baseline and to confirm what the agreed hospice funding costs are. The majority of palliative care services for older people, and I know that we are talking about CHAS. In fact, CHAS has a conference this Friday in Aberdeen on palliative care services. I am just wondering, should you all be looking at not just the hospice but in terms of the community support that is there? Are you able to look at the specialist and general services in terms of working out how much it actually costs each board? I noted that Tayside was looking at a 0.7 reduction in palliative care services, which seemed extraordinary given that we were looking at probably expanding palliative care. It did seem a bit extraordinary. I have another supplementary on this, Rhoda, on this issue. I will get the panel to respond to both, or if anyone else wants to come in. It is more about how we grow palliative care. I think that what we get as a committee and everyone who speaks to those who are in receipt of palliative care have really good outcomes and have no complaints whatsoever. Where we do seem to get the problems is the lack of palliative care. It seems that in our discussion we are talking about a third sector charities providing most of palliative care hospice, CHAS and the like, but we really need to look at mainstreaming this, especially at close to home and in the community. Are there plans to do that and what is the cost of that? How would that impact on budgets and would good quality palliative care actually provide savings, because a lot of people at the end of life are admitted to hospital needlessly and indeed in a stressful situation for themselves and their families? Anyone else? I will just supplementary on that and start that sharp point. Some of the health boards were unable to give us any information about the cost of general palliative care that they provide. Is it feasible to ask for that and how could that be done? I think that I just referred earlier that that broad information set that says more people are dying at home is not necessarily—it does not give us any sense of quality or an indication whether that happened by accident or choice. Are those issues that we are exploring? Derek, please. I know one thing that we have worked locally with care homes in particular, because there may in the past have been a tendency if somebody was nearing death to say, well, we will take them to A&E and get them admitted to hospital, and therefore to upskill the care homes to provide support to them training how to support people who are dying and to die with dignity is something that we have done locally in Ershire and Arran to try and minimise the number of admissions to hospital, but also to really not take people out of their home environment and into a very acute type of environment there. I think that somebody also mentioned earlier that they are on in terms of the outreach service that is provided, and I know that in Ershire and Arran the Ershire Hospice has outreach workers who work very much in the community. Again, we fund 50 per cent of that as a service to outreach, so it is not just about people coming into the hospice to die, but they can be supported. Well, before that, they may come in on a day-case basis as well to the hospice. So I think that there is joint working that goes on with those third sector organisations. Anyone else? I see Lindsay and then Katie. I think that I may respond to the palliative care resources in Tayside. If we had to look at the recurring budgets for palliative care services in both 14, 15 and 15, 16, you actually wouldn't see any differential. Tayside has invested in palliative care services over the past few years. The differential that you are seeing today is just the actual expenditure that was incurred in April to March 14, 15, recognising some of the operational challenges that they had, I am guessing, around supplementary staffing. That is why there is a differential between that and the recurring budget that you see. There is no reduction in the recurring budget that is available to the service. Just to comment on the specific question around how do we cost and understand the cost of palliative care services, what we have included in the D&G return is the specific specialist services that we provide, so specifically the inpatient facility within the infirmary that operates as our hospice, and also services that we commissioned through Marie Curie to supplement the community support. What you will find is that within all of our community teams, our district nursing teams, an element of their role will be supporting individuals who are end of life. It really is difficult to say how much of their D have they spent on that. Similarly, we are dealing with individuals not just in our community hospitals but in other areas of the main acute hospital and, again, it is really difficult to disaggregate that cost. One of the things that we can do is have a discussion and take that away, but it is just because we do not, I suppose, count activity in exactly that way and we can certainly have a look at it, but that is why most of us struggle a wee bit to pull that information together. I suppose the following question is, would it be worthwhile, would it be worth the effort to establish the cost of that pallent of care within a hospital setting, would that drive any other initiatives that would take you out of the clinical setting and pay a greater focus to end a life, as I suppose? I certainly think that the fact that we are moving to IGBs and joint working, then I think that to try and put a cost round it, yes, it probably would be helpful. I think that we might end up with some disparities, we might end up with equations on how accurate that is, but I think that it would be valid, I'm certainly, if that's a request from the committee, happy to go and take that away. I've got Rhoda Grant, followed by Richard Lyle. Yes, an issue that just really flagged up last week with regard to patient travel to hospital and the impact that has on budgets used to be paid centrally through the Scottish Government, if people had to travel distances to hospital. I noticed that that's no longer happening and NHS Highland has put huge cuts to the patient travel budget in that someone needs to drive for about 70 miles before they get any of that cost met and when they do beyond the 70 miles it's at somewhere around half of the cost that the inland revenue sees for mileage. They've also told people not to take flights, to take ferries instead, coming in from islands and I'm just wondering if other health boards are facing similar concerns and how has this budget been devolved and how is it funded? Well I think that NHS Western Health is the biggest recipient of patient travel funding, which has now transferred to our e-marked recurring baseline. We get something like £3.2 million in 2015-16. We are quite concerned about the volatility of that budget because we can have issues in terms of suddenly having to take cohorts of patients to the mainland for instance in order to meet TTG targets and so on. So there are significant vulnerabilities around that budget. I have to say that we have included in our efficiency plans this year a small reduction at something like £25,000 to try and make a contribution towards the total savings target that we have from that budget. I don't imagine at the moment that we'll be making quite such swathing reductions as Highland but I have to say that I can't either rule that out because we are struggling to identify the rest of our efficiency savings target. It is a real issue for us and we're very worried about it. I think that the biggest thing though is that actually the people who live on islands do tend to have an expectation that all their travel will be funded. I think that there is a question to be asked about the equality of that when you look at people who live on the mainland who are expected to make their own way to their appointments and sometimes their journeys can be equally difficult. Any other comments on that? Derek? Just to say, I think that Highland and Islands travel scheme only applied to maybe four boards. So, although Ayrshire and Arran and Cymru, we didn't receive any funding from that. Richard Lyon? Most of the questions are going to be answered but I was having a look over your submissions, cost pressures and efficiency savings. We all know that most of the cost are staff, energy costs and drugs. In regards to cost pressures, you put in hospital drugs, anticipated price and volume changes 2015-16. I'll give you a flavour, convener. Ayrshire and Arran assumed price uplift 2 per cent, assumed volume uplift 22 per cent, and Dolce and Galloway assumed price uplift 8.7 per cent, assumed volume uplift 2.5 per cent, and Tayside assumed price uplift 3 per cent, assumed volume 5.7 per cent. Some of those Ayrshire and Arran is not the highest, but it is quite high. Moving on, we come to efficiency savings. I don't square what you are saying to me. Ayrshire and Arran, Dumfries and Galloway and Tayside are planning to achieve around a quarter of their savings from drugs and prescribing. You are telling us that you are going to have a volume uplift, you are going to have a price uplift, but in the next step you are telling us that you are going to achieve your financial savings from reducing drugs. Now, maybe you could explain it to me. It could be the factor that some drugs are dropping off patent or whatever. You may want to pin your mask to that one, but how do these two square? You are saying that volume and price has gone up, but you are going to save because you are reducing drugs consumption. You have got your answer for that, haven't you, Katie? No, we just get an answer. I will explain a little bit about how we establish budgets. We would establish a drugs budget in conjunction with our clinical teams and our pharmacists at local level. What we would reflect in that is the gross cost of that budget. For DNG, 8.7 per cent and 2.6 per cent will have been built up from our previous experience of what volumes we have seen, from new drugs that we know have either been approved or are going to be approved through the Scottish Medicines Consortium and any local investments or developments that we have made in drugs. We have reflected that gross costs within our financial plans and our budgets. What we are doing at the very same time is looking at how we can deliver efficiencies as a board. As part of that same piece of work, we would look at a range of areas where we can look to make efficiencies. If I use volume, for example, we might have seen quite significant increases of volume year on year, but that does not mean to say that we would not target that as an area that we want to make efficiencies. Certainly within Dumfries, part of our level of efficiencies that we are looking to deliver in year will be about trying to reduce that volume level from the 2.6 to a lower level. That is not an unreasonable approach to take. What we also are doing at the same time is looking at drugs that are coming off patent and the normal drug switches and any other things that we can do to reduce our drugs budget. Again, the principle that we have taken forward in DNG is about maximising efficiencies that we can make from drugs and procurement savings without impacting as much on staff savings as we can. What we are saying is that, speaking to my chief pharmacist earlier in the week, two or three years ago, the list of drugs that we were looking at for efficiency savings was probably about a dozen. We have now got maybe 70 to 100 of different drugs that we are looking at at switches and coming off patent and looking at different ways of delivering that. The whole environment has become much more complex and it is an area where, while we are still targeting it for savings, the level of savings that we know that we can deliver from there will become reduced over future years. You mentioned how high the Ayrshire and Arran figure is and I would just flag up that it is hospital drugs that are specifically in that table. In terms of primary care prescribing, Ayrshire and Arran, over the last two years, has seen increases in costs. This is from our statutory annual accounts averaging about 4 per cent per annum. However, over the last two years, the average increase in other drug costs, which are mainly hospital, is about 15 per cent per annum. There are new drugs such as Hepatitis C, which are very expensive and are being used more. We also know that a policy initiative has been to increase access to end-of-life drugs to ultra-orphan and orphan drugs, which again are very expensive. Therefore, we know that our costs are likely to go up by about 20 per cent or so on that category of drugs over the next year. Between price uplift and volume uplift, that is a bit subjective. For example, Hepatitis C is a relatively new drug. We will have increasing numbers of patients utilising that drug, so we have categorised that as volume rather than price. However, if the cost of a Hepatitis C drug went from £50,000 a year to £60,000 a year, we would say that that was a price increase, so that is the reason for the discrepancy. On the hospital drugs, what our uplift focuses on is the growth in established agents and the new medicines that are likely to come to the fore in the year. That is advised through the forward look submission through SMC. We work extremely closely with our clinical pharmacist so that this is not financed coming up with figures. Over the past couple of years, it probably used to be that secondary care drugs were never looked at in terms of driving efficiency unless there was a drug that was coming off patent. However, through the hospital medicines utilisation database that has now been developed, we all have the opportunity to try and compare our secondary care spend, which is something that we have never been able to do before, apart from at a single line level. We have now got the opportunity through this database to see where is the variation in secondary care prescribing, and we believe that there are potential efficiencies in there that we can pursue. On primary care, primary care will always be a focus, in case I would spend about £77 million on primary care drugs. As ever, we will continue to look at driving first-line formula compliance. We will continue to look at the variation, or the waste, the harm and the variation between our respective practices, and through the locality pharmacist that we have in each of the practices, that is where we continue to look to drive down costs. One more question. Politicians during the last election were talking about a seven-day service in hospitals. If I caught one of the comments earlier, you were saying that if you brought in a surgeon at the weekend to do an operation, you are paying him or her three times what the normal period is. Most workforces have had their days of working amended over the years. Most people now work at the weekends. That is the normal week of working, and conditions have changed in the last 20 years. Although that is mainly down to hospital managers, from your end of the costs, what discussions have you had with any of your chief executives in regards to looking at how differently we do things in the health service if we are trying to get a truly seven-day service that people can be operated on on a Saturday and Sunday or other things that did not take place before? There is a national group that is chaired by the director of HR from the Scottish Government, but I know that my chief executive sits in that group. It has been meeting for about six months to look at seven-day services. They have produced an interim report, but the work is on-going. From my perspective, the nursing staff already work seven days a week because they are looking after patients and wards all the time. The main impact is likely to be on medical staffing and the change in working patterns around that. We have already introduced that to some extent around ward rounds happening at weekends. That will be the main cost that is associated with changing the working patterns of doctors to a more seven-day pattern. I will reflect on one more thing on what we have done in Dumfries and Galloway today. Particularly through the winter period, because we know that a Monday is always a really high activity day, one of the things that we have been piloting is enhancing our AHP support over the weekend period, particularly physios and occupational therapists. That has had an impact on how busy Monday is, which means that when you are starting the weekend, particularly through the winter period, when there is reduced bed capacity, that has had an impact on services. We are thoughtful about what that might look like moving forward, particularly when we need to be clear what our vision of a 27-day service looks like, because it might not necessarily be that we do everything that we do during the weekend. It is about managing some of that activity a bit better over the week, so that, because a patient is admitted on a Friday afternoon, it does not mean that they automatically have to stay until Monday. It is an area of work that we really need to explore and develop. We need to await what comes out of the national review and look at how best we can implement it at local level and what fits each local system. One final question that takes us almost full circle about priorities being set out with the boards and targets being set out with the boards. In our report in 2014 to the finance committee, we suggested that we needed to place more attention on analysing the performance of targets in the sense of those targets that are more urgent for change and leaving a longer period of time, I think that we said, for revision to targets that have a lower priority, that prioritisation. Do you have any views on that type of approach that would be analysing those outcomes and priorities and de-investing in some of them or pulling back in some of them and concentrating on others? Is it an approach that you already adopt, as some targets are seen as a lower priority than others? Is that a process that takes place to agree with the committee's view that we need to analyse outcomes and prioritise efficiently, drawing back and having that flexibility drawn back, I suppose? Derek? I might just reflect back comments from clinicians that have heard around targets and particular waiting times targets. Clinicians would always prioritise the greatest clinical need as being what should come first and sometimes they do feel frustrated that someone with a relatively minor need has to be treated within 12 weeks from them seeing them or within the 18-week referral to treatment time where someone with greater needs means that they have to wait the full 12 weeks or the full 18 weeks. I think that there is something about differentiating between the urgency and the clinical need that is identified by the clinicians as opposed to having a blanket for everybody requiring to be treated at the same time. Has there been any work done on or any analysis done on? We assume that that happens, but has any analysis been done? Clearly, clinicians on a case-by-case basis are assessing if someone needs to be an urgent or a routine and they do a degree of prioritisation. I am not aware of something being done on a national basis that tends to be more anecdotal than individual. Is there any work happening locally at the board, Mark? No, I think that Derek touched on it at the beginning. In any organisation, you have a suite of performance targets, some of them will be more important than others and some of them will take up your attention in a larger part of your resources. I think that the question of whether we should de-invest or divert resources from certain targets on to others is a question that is a broad question rather than a direct to finance question. We follow our clinical strategies before our local development plans and they set out a whole range of targets to which we allocate resources, so there may be an argument for it, but I think that it would have to be wider than the direct to finance that makes that decision. Some boards suggested in their evidence that guidance and priorities should be developed. Is that the justification for it? That you are not best placed as financial people to set that guidance and priorities? Is that what you are saying? Should there be guidance? Who mentioned the evidence? I think that there was some evidence that we received that we need to have some guidance on. Katie? I am not sure if it was me who said that, but certainly from my perspective we need to make sure that the targets that we are focusing on are the right ones. We talked a wee bit earlier about the flexibility around some of the targets and one of the things that I reflected was making sure that if you use the access targets and the TTG that what we do is we get a sustainable, balanced demand and capacity model for all health systems and sometimes targets can skew that a wee bit in terms of the flexibility that we have around that. I think that we have got some of the focus right because we are looking particularly at partnership level around things like delayed discharges and things that really have a bigger impact on the whole system not just our acute system and I think that one of the things that we have talked about is not just focusing on what we can measure but actually focus on the whole system and I think that as we move into that integrated world and we get more sophisticated in the performance targets that we have that sit around that, we need to be thoughtful about the basket of targets that we use to measure overall board performance and as you see it probably is not us as individuals who are best placed to see exactly what those targets are but we need to think about how we take that forward. Okay, but none of those ideas appear in your efficiency target. We have talked about flexibility or about how savings can be made but none of it unless it is in the productivity savings that we hope to give them but none of that type of thinking appears when we get to the stage of proposing efficiencies. None of that flexibility seems to appear there. Is that a no go area or Derek? I mean there are things and have been for quite some time around advice we would get from clinicians or public health or whoever around what are low value procedures so you know adenoids and gromits and you know certain things that they say well we really should be doing less of these and therefore we can monitor and that may move to the extent while we're going to issue advice to ear, nose and throat consultants we shouldn't be doing any more gromits but there will always be exceptions so there are some clinical advice that we have and have implemented over a number of years in those areas. Okay, I don't think there's any other questions that remains for me to thank you all for your attendance here and the time you have given to written evidence. I think we continue next week with the director general of health at NHS Paul Gray and thank you all for your time today to spend at this point until we set up for the next panel. Thank you all, thanks. We now resume our committee meeting by moving to agenda item number two. Sorry for delaying our witnesses there, we've had a long session. The second item of course on our agenda is the evidence session on smoking prohibition children and motor vehicles Scotland Bill and this is the first panel of witnesses that we've had to give evidence to the committee on this bill so we welcome Dr James Kant, head of British Lung Foundation Scotland in Northern Ireland. Sheila Duffie, chief executive of Ash Scotland and David McColligan, policy and public affairs manager Scotland British Heart Foundation. They are all members of the Scottish... Oh, Celia. I have Celia, what I'm doing, I just noticed you there but according to my brief I'm introducing all of the others here as members of the Scottish Coalition on Tobacco and of course we have Celia Gardner, health improvement programme manager Tobacco NHS Health Scotland. Welcome to you all. I'm going to proceed to questions immediately by taking the first question from Richard Lyle. I have a mission to make. I'm a smoker. I smoke in my car. Basically, if we go back 20, 30 years ago, maybe not the done thing nowadays but 20, 30 years ago most people, I smoked my car when my kids were in the back. They're now growing up but my daughter doesn't smoke, my son doesn't smoke and now my wife doesn't smoke but basically the situation is that this bill will, as far as some people are concerned, invade their privacy, invade their sitting in their car smoking. I actually am leaning towards this bill and don't smoke in my car now when my grandson or granddaughter's in the car but still what effect do you think bringing this bill in would have in order to help children, what effects at this moment time are there on children and also what would you say to the person who says it's my car, I'll just put the windows down and the air will blow through and the smoke will go out the window because in one of your submissions someone put, I think it was the British Lung Foundation, maybe not, will exempt convertibles because the people have put, if it's going to be no smoking in the car when children are in the car why shouldn't it be that there should be any smoking at all when children are in the car rather than exemptions for convertibles or whatever. I'll start on this one, can I just begin and for the record make a declaration of interest that neither myself nor my organisation have had any contacts financial or in kind with the tobacco industry or any similar vested interests. What I'm about to tell you may surprise you, I have been in post with the British Lung Foundation for five and a half years and I have not yet told a single smoker to stop smoking and I never will because it's not my job to judge in any way, shape or form and had it not been for a slightly different twist of fortune as a teenager I would probably be smoking in my car as well at this point in time. This is very much a case of working together with adults whether they smoke or whether they don't smoke, this is absolutely not an attack on smokers and again this may surprise you, I have on a personal and organisational basis defended the rights of people to smoke within the confines of their own environment and you have an absolute pledge from our organisation that while we want to work together to protect the next generation's lungs we were always always there to support people whose lungs have been damaged for whatever reason without any prejudice or judgment involved there. In terms of the convertible you may not be surprised how much esoteric thinking went into whether or not there should be a ban on convertibles or not and I would like to think that the approach that the BLF is proposing is a pragmatic one and we are trying to have something that is seen to be enforceable and sensible and one of the things that encourages in that respect is that the most recent figures show that 85 per cent of the adult population are in favour of this control and crucially 72 per cent of those people who smoke are also in favour and we would not want to lose that level of support and consensus if we were being seen to be particularly dogmatic when it came to something like a convertible it's absolutely crucial however to differentiate between the impact of second hand smoke in a convertible or lack of compared to for example the impact of second hand smoke in a car even when the windows are wound down and we're in a very fortunate position nowadays because we actually have the ability to have precise measurements of the level of pm 2.5 within a particular environment a Dr Sean Semplin his colleagues at Aberdeen University are world leaders in this and what their long-term studies have shown is that even when the windows wound down you would still be any passenger within the car but it would still be encountering average levels that would be more than 10 times the whl safe level of pm 2.5 exposure and a crucial point to get across to what i finished is that it's important that we realise there is no safe level of exposure to second hand smoke given the number of toxins within the chemicals themselves I would like to make the same declaration of interests for the record as Dr Kant made and also to say that we are not anti smoker but that we believe that this legislation is proportionate and needed because of the level of damage that tobacco smoke does and it does particular damage to children there is excellent and substantive evidence on that but we were encouraged when we commissioned YouGov earlier this year they did the field work in late February early March among adults in Scotland and they found that 85 percent of Scottish adults overall and 72 percent of smokers supported legislation to end smoking in cars with children under 18 and the research shows us that both that there are very high levels of tobacco smoke in cars where someone's smoking it builds up very quickly we know from other research that short term rapid exposure does create damage disproportionate amounts of damage heavy damage and we know again as Dr Kant said that just winding down a window putting on the air conditioning blasting the air through the car does not sort that damage now in ash scotland's response we suggested that any car that was 50 percent or more open could be exempt because that was in line with the principles that were put in place for enclosed public spaces David on behalf of myself from the British Heart Foundation Scotland I'd just like to echo Dr Kant's declaration at the beginning there I just wanted to pick up on Richard's point about what's the effect on the child there's been a number of studies into this related to cardiovascular disease a systematic review in 2011 showed the children had altered cholesterol profiles and had lower EDL which is a protective HDL protective cholesterol when exposed to second hand smoke also in a study of 11 year olds it was shown that they had endothelial dysfunction which is a effect in the inner lining of the blood vessels which leads to atherosclerosis which is the thickening of the blood vessel which ultimately leads to coronary artery disease which is your heart attack went to happen essentially so you know clear evidence here that second hand smoking in children leads to cardiovascular disease and in that study of the 11 year olds it was shown that this was already occurring and kids it only had moderate to small exposure to second hand smoking I think I would just echo Dr Kant's comment as well that I think this clearly shows that there's no such thing as a safe level of tobacco smoke I would also echo the statement made by my colleagues about not having any links to the tobacco industry I think the important thing about this legislation is it's about protecting children it's not about getting its smokers which is what my colleagues have said and the important thing is that the children a car is a confined space and when children are in a car where somebody's smoking they breathe faster they absorb they have smaller airways they absorb the smoke much more quickly than an adult does and I think there's a bit of a general misperception by the public that if you wind down the window it's safe that there's fresh air coming in but we know it's in the chemicals that are in second hand smoke as others have said there is no safe level of second hand smoke so it's important to put this in place to protect our children it's not about having any baggage with smokers we need to do that to protect our children and smoking second hand smoke exposure in cars can just build very rapidly and to get to very high concentrations and so we we mustn't expose children to it I've got Mike first then call and then I'll take you in calling and then Dennis wants him. Mike. I'm a former smoker and I use e-cigarettes and I'm very pleased that I've been able to encourage a few colleagues to take that route out of smoking and I'm very pleased also that my just like Richard's my children who are adults long since don't smoke but I'm and I have to say I'm in favour of the general principles of the bill but if you allow me to play devil's advocate just for a moment isn't this the thin edge of the wedge isn't it the case you've just said that there are no safe levels of smoking so the logical next step for this bill is to move from cars and enclosed space to homes another enclosed space because there are no safe levels and then pretty much to a complete ban altogether now I'm not so sure that I would be absolutely against that but isn't it the case this is really just the thin edge of the wedge Sheila I think I caught you shaking your head there so you're first up this time I have not been aware of anyone calling for legislation in domestic settings this is about legislation in vehicles where you have other forms of legislation that apply for example to do with wearing seat belts installing car child seats not using mobile phones while driving that kind of thing so we are used to legislation within vehicles it is legislation that is aimed at protecting children in a very enclosed concentrated environment and it is warranted by the high levels of evidence about harm from tobacco smoke as you know better than I do politics is the art of the possible and this is possible this is achievable this is something that already has significant support I can I can assure you that as Sheila says there is not an organization that I have worked with and certainly nobody within my organization who imagine it to be conceivable or at all going to be happening that we will be moving towards banning smoking in domestic properties I think at that point from a civil liberties point of view it just would not be feasible and it would not be supportable here we have a situation where the minute any of us get into a car we immediately place ourselves under quite a significant list of restrictions and expectations to keep other road users safe and also passengers within our own car as well and Scotland has set a phenomenally ambitious target to go smoke free by 2034 so that's defined as five percent smoking or less and what we need to do to achieve that is we need to actually mix suite of activities most of it the vast majority of it is going to be the change of behavioural norms there are very very few situations where specific discrete pieces of legislation can encourage that change in behaviour but as Sheila says also crucially provide that protection so I would I'm glad that you've raised the issue because I think it's a very very important one but I would assure the committee that I see this as no way at all it's been at the beginning of a creeping science of legislation this is a specific carefully targeted and measured piece of legislation I should be seen in that light I should be seen against the wider campaigns being undertaken in partnership between ourselves and Scottish Government and NHS Scotland to increase awareness of smoking in the home take it right outside is an excellent example there we're we're not telling people not to smoke we're telling people that if you will smoke smoking away and in a place that keeps our family safe you'll forgive me as a now a non-smoker a bit of a zealot now in this cause I'm enthusiastic but I have to say there's a logical inconsistency here the the damage to our lungs through smoking is a function both of the size of the enclosed space and of the amount of time we spend in that enclosed space so you know and the logical inconsistency I would put to you is that your position on on an outright a ban for instance in homes is scientifically and logically unsustainable and there is another argument about public opinion and about public and civil liberties and public freedom and so on I think by pretending that argument doesn't exist you're doing this cause an injustice and you're attempting to be um not explore the issue fully and in the round and therefore I'm disappointed at the answers that you've given but maybe you want to reflect on that and add to what you've said I'd like to add please um I think one of the benefits of having this debate and having this legislation up for consideration is it will raise public awareness that tobacco smoke is in itself a harmful damaging substance and we have evidence from other countries that people have voluntarily introduced additional restrictions when they have got that message we know from the refresh work that Ash Scotland did with the universities of Aberdeen and Edinburgh that parents and carers want to protect their children but they don't always know what's effective to protect their children and the overall aim as James said is to put tobacco out of sight out of fashion out of mind for the next generation so we would like to raise the awareness of the harmfulness of tobacco smoke it is always harmful but this piece of legislation is timely and it's possible the Republic of Ireland has introduced it England and Wales are on track to introduce it in October and and it's on the table here so we are supporting this legislation thank you i'm now half calling here thank you convener and since we're all only obviously i'm not a smoker never have been and personally i hate the things that said and there is this touch of similarity between what mike mckenzie said you know i think is a degree of devil's advocate we have a situation where a child grows up in a home with two heavy smoking parents what would how how would you be able to measure the the damage done to that child who's living in that environment all the time to the point where they get in the car and actually sort of drive away how can we justify taking this action and what sort of measurements would you see and how would we measure these outcomes david i'm from a cardiovascular disease point of view i mean the figures are fairly stark i mean the exposure to second hand smoke increases your chance of stroke by 25 percent increases your chance of coronary heart disease by 30 percent so i think you know the message here is very much around a child protection message this is about making sure that children during car journeys are protected and and i understand the devil's advocate argument here of is this not the next step in the house and i think you know british heart foundation scotland like ash scotland and blf would would say that we're here today to talk about the exposure in cars and that's the bill that's on the table and we equally supported the scottish governments take a right of south campaign and someone once said to me that it's easy to take it outside in the home but you can't take it outside in the car because it's moving and i think that's a very valid point that if we're on long car journeys or short car journeys and someone lights up a cigarette you can't take it outside it's a confined space that people are all you know trapped in and have to take part in the second hand smoke if you would but the i think the interesting point about the take a right outside campaign as well was it challenged the conception that you can hang out the window and have your cigarette or you can open up the kitchen window and smoke in the kitchen that doesn't work in a home it doesn't work in a car and and that is why we are calling and supporting this bill to to ban it outright in cars when there are children present yeah my question is still the same though if they're living in that environment and maybe the parents are not you do you're going out the back garden or you know for living a flat or somewhere like that to go outside and have a cigarette how do we how can we measure the there's always damage being done in the house how can you measure this taking it into the car what makes that so much more dangerous than living in the environment all the time i mean i think um i think to measure the exposure from in the house and then moving into the car it would be a i think would be a challenging one i mean i suppose my my argument would be that at least it's given the child to break when they're in that confined space and not exposed to those such high levels from a british heart foundation point of view we see it as a almost a status of of that that you can't smoke in the car i think sheila pointed to earlier that is another opportunity for us to educate people on the harm of secondhand smoke and that was what the take a right outside campaign was trying to do as well wasn't telling people to stop smoking in that but educating them and i think i think that's a real root cause here we're not telling people that it should stop smoking completely much like the british lung foundation we're saying we're saying here that you shouldn't be exposing people to secondhand smoking and quite often that's a challenge people will understand that if they smoke they're consuming the smoke and the chemicals are involved in it but actually it's about understanding that the people around you are being exposed to that as well and i think an adult would have the ability to say to someone in the car don't do that please don't do it may even have the respect of the driver but you know a child may just sit there and take part in our journey so it's about giving this child an opportunity to be protected in this space i think there you know i would argue that it's hard to differentiate between smoking home smoking the car if a child's going from the same areas and experiences but i think what we've got to look at here is where children are protected and educating those people who are smoking the car that the second hand smoke is bad it doesn't matter if the windows crack down a little bit and some some other people might have views on that as well. I believe there are two recent studies from New Zealand that showed an increase in voluntary restrictions in the home following smoke-free legislation and some evidence of protection for children from that legislation but i think also in this legislation you would be listening to the voices of children because there is documented evidence that children say that they feel choked and nauseous in the car that many of them would like to ask people not to smoke in the car but much fewer of them have actually been felt able to do so. That should be seen as complementary to the the on-going advertising campaign to take it right outside and the beauty of the narrative of that particular advert was that the parent was trying to do the right thing she was at the back kitchen window she shewed her husband to shut the door when he came in because she thought she was doing the right thing to help protect her child what it helped to convey was two absolutely critical things more than 85 percent of sector and smoke is invisible and has no smell and the reason for that is because it's caused by particles that are one twentieth of the size of a grain of sand and that's so there's a huge education programme that has to take place as part of this as well and this would provide a wonderful opportunity to dovetail those messages the child you describe there's a very good chance the child you describe in your scenario would be attending the local sick kids hospital because the figures from royal calls of physicians of Edinburgh indicate that over 4,000 new cases of asthma, wheeze, glue ear and the like will appear in Scotland every year almost certainly as a result of second hand smoke we can't differentiate for ethical reasons to what extent that took place within the home or within the car but what we do have is an opportunity to make a clear statement and I would see this in something within a couple of years time or sooner than that even where people look on this in the same way that you look on putting a child in the car seat you have to put the seat belt on because that's what you do to keep the child a young person safe during that journey and as Sheila says that the emerging evidence that we have particularly from Australia over pioneers on this is that there is a knock-on a very positive knock-on effect because to come back to the devil's advocate question the thing that we face most most often is the allegation that we want to help you to become the nanny state this is not what this is about this is engaging with the population of the adults in scotland today to ensure that the next generation they're able to break that chain in the way in which your family have done already can I just ask one more question I think you mentioned something about 50% open space in the car I know that sounds really odd you know we all kind of know what a cabriolet is and whatever but how is it defined and how would you expect it to be defined in terms of practical enforcement this was just a rule of thumb and it was to bring it into line with the rules that being put in place for enclosed public spaces because what we do know is that opening windows in your car and turning on the air conditioning will not sort the problem of tobacco smoke there is still their insufficient quantities to be considered harmful and so that was really just a rule of thumb that we suggested I mean I just say this because of the fact that I'm a normal cabriolet he would have a fold down by group for instance and then you have something like a two cv that has windows up on the front the sides and perhaps the roll down how do you how would you there's got to be a difference in air circulation around about there as well I know this sounds really mundane but the the fact is you know these different designs exist you know I mean what I liked about smoke free enclosed public spaces was the simplicity of the guidance you know it was it was very clear and simple and and then perhaps working out what fitted and didn't fit was less clear but I think you know to me that's in line with the existing legislation I presume there's no support for exemptions for convertibles from the panel and the bill if it's more than 50 percent or 50 percent or more open we're relatively relaxed as to whether or not the eventual legislation contains cabriolets or not my experience of going through Easterhouse in our recent summer weather has not indicated many two cvs or cabriolets certainly not with the roofs down so for us that that's that's a relatively minor detail we're much more focused on the more significant message and we would we would from a BLF point of view we would certainly defer to your wisdom on the cabriolet question I just think in terms of enforcement it's this is just a problem for the poor to identify well increasingly increasingly exposure to second-hand smoke will be very much will have a social and economic element to it because what we've seen in terms of the smoking rates is that Scotland is doing very well in terms of encouraging reduction of smoking within the more affluent communities that this is an absolute inequality issue as well yes how have they reflected their opinion and how they view this this legislation as they view recent legislation and smoking in public places that's an absolutely critical element and a lot of our work has been geared to working with children in some of Scotland's most deprived communities where we've done some work in in Easterhouse to develop some messages she'll mention previously that very often children feel disempowered they feel as though they don't have the authority or the voice to be able to speak in that way so we've actually done some extensive work across some of Glasgow's more deprived areas and we're currently doing it in Forth Valley as well because for us it's absolutely crucial that children are given the voice but that entire communities are taken along in this way because I think you're very right to highlight the danger that many people do feel as though health is done to them rather than with them with the smoking ban that's certainly the case isn't it it hasn't significantly we see evidence of that every time you walk along the street outside pubs clubs whatever whatever it's been exclusion for their point of views or not so how do we know that that group of people who this would by by your statement directly impact are they in favour of that have we done any work you know quantitative surveys or anything like that with that group of people who were targeting here I think there was quite a lot of work done with the take it right outside campaign last year a lot of promotional activity was done targeted at parents and more deprived communities they did it outside you know little and supermarkets like that and this was basically kind of educational work and what was reported back well a lot of the parents were saying I didn't realise that the you know there were all these chemicals within secondhand smoke and it's this perception that if you ventilate or open windows and you can't see the smoke there's no harm whereas what we're talking about it's it's invisible to the eye it's there in the atmosphere and people breathe it in you'll have also had submissions from the University of Aberdeen and all the work they've done with the dialos meters that can actually measure the amount in the air and James and the BLF have done a lot of work in this and placing it in deprived communities so we know that there's a real educational need that there's a misunderstanding about what the harm is from secondhand smoke and it'll be really important if this legislation comes in to build on that education and make sure that parents are aware of just what harm and how it's harmful for their children and about what they can do to protect their children because most parents they want the best for their children they don't want to knowingly harm their children and so there's a kind of gap in knowledge here and we're working at breaking that down and I think once this is generally better understood the difference between not seeing smoke and the harm still lingering there in the wake and dissipate throughout the house very quickly then we'll be making progress. I think we've got to accept that that message hasn't get through to that group so that takes us to enforcement so they're not listening, they don't understand, they won't listen, so we're legislating now. So how do we enforce that legislation? I still think there's a big education need here, it's not that they're not listening. We've failed in many respects, I know there's a change of behaviour but that's the group where there's still the most amount of people smoke and that'll be related to social economic problems, you know, that's, you know, if you're living a sad life, you know, having an extra five years in that life isn't something they're going for and they're not receiving the educational messages many of them are still smoking, they're smoking when they're pregnant, they're smoking at home and with children around, they're smoking in cars and that's the target group. Can I, there's several different things in there, what I would say is we're not targeting an educational message that's about stopping smoking, the message is about protecting the children and I think that's a different message from giving up smoking yourself, it's about how you do the best for your child and I think people are open to hearing that message. I don't mean, maybe I'm not too speedy in this but in those hard to reach communities we are struggling to reduce smoking prevalence while they're pregnant. Oh I know that. So just saying you know that, you know, that's when you would think that we would be more responsive to the message about the protection of the health impacts of their child, not when they're there in the back of the car, so not necessarily run that this will have an impact on this community. Is it, James? I would be very happy to invite you out to some of the community work that we do and I think you would be actually very heartened at the impact that these messages have upon the young people themselves, the parents generation and crucially the grandparents generation because as we all know grandparents have huge influence and also have huge practical significance in terms of childcare as well. This is something where when we go into work in a community, we work with the community but we seek to work with families across the generations. I think it's very important to differentiate as Celia highlighted, this is not about us trying to stop people smoking, this is not what this is about, this is about protections for the next generation. The point that you raise about smoking in pregnancy is of huge importance. I would actually say that that increases the priority importance that should be given to this particular piece of legislation. It also increases the importance of making sure we get across key messages. So for example, many of those who will be smoking while pregnant in deprived communities may have a sense of fatalism or despair. A critical message to get across is that if you smoke during the first trimester, the stats tell us that your baby should be born unaffected by the impact. So there's an imperative there to give up within that first trimester. So the messaging is absolutely critical but the work that we've done with communities is actually encouraging and I think what we need to do, if Scotland is going to achieve its ambition by 2034, we need to take this on as a society, we need to see this as something that's empowering, we need to recognise that if you as a couple are smoking a pack of 20 a day each, then by the time your child reaches 18 or 21, you could have had £100,000 that you could have given to that child. That's how Scotland needs to address the matter, but to come back to the specifics of this, what attracts us and the reason we're so supportive of this is because we see this as being a particular piece of legislation which has immediate and long-term impacts in terms of safeguarding children's long health and has very, very significant support, not just from the population as a whole but crucially from those people who smoke. Yes, but we're at the stage, the bill's about legislation enforcement. So if it had been all wonderful and the messages we're getting across, we wouldn't be at a stage where we're legislating and enforcing. As well as the legislation, there's a continuous hope of that educational message, refining our public messages and specifically targeting those people who we're talking about here. It's not the wider population that we're talking about, that's the point that you made and I agree with, but we're talking about legislation and enforcement. We anticipate that some people will not listen to that message, so how do we ensure that this is enforced effectively in terms of the bill? I think that you're right to flag enforcement. Our belief would be that the police, because they routinely are out-checking vehicles, enforcing other legislation would be best placed to monitor and be part of the enforcement in this. We're aware that environmental health, the Royal Environmental Health Institute for Scotland, has also said that they would be happy to work with the police to enforce this properly in Scotland. I take you back to the two pieces of New Zealand research that I mentioned previously following the implementation of smoke-free legislation. They concluded that there was a drop in the likelihood of children going on to take up smoking as a result of smoke-free legislation in vehicles, which was independent of smoking in the home and other areas. I think that this legislation looks like an investment in the next generation. Do you believe that you'll have the support of those hard-pressed communities who are enforcing smoking legislation in cars rather than scarce police resources being used to tackle the money lenders, the violence and the drug dealers in the street? We would divert people police away from that to enforce smoking in cars. We would hope that it could be done as part of their regular traffic duties, rather than be an additional significant burden. The parallel that I look most closely to is in terms of seatbelts. What we found was that when legislation was coming through, it gave a priority and a significance to the element of parental, grand parental safety, which it may not otherwise have had. It also allows an opportunity for advertising campaigns, which really get the message across. I do not think that we would, for a moment, anticipate diversion of actual police officers to this. I very much agree with Sheila's point that we would see it as being part of the on-going police activities in terms of road traffic offences. You would accept, as a very nice resource, the number of police officers that we have, the others, who could carry out similar work. If we are not for the fact that this is something that causes permanent and sometimes fatal impacts on children in Scotland on a daily basis, I would not be pushing for that. I accept your position on that, but in terms of drink, drive, seatbelts, mobile phones, they are all specific, in many cases specific, campaigns in and around Christmas, or summers, and on particular roads. Those initiatives are usually information-led. With the back of legislation? You are. Unless, as you are saying, it is just an add-on, that there will be no specific campaigns to do this, it is just when they are out doing a road check or a seatbelts campaign or a drink, driving campaign, then that would be added on. Is that what you are suggesting in terms of the police enforcement? British Heart Foundation Scotland does not have a position on how that should be enforced, but the examples that you gave there, I suspect Police Scotland and whoever runs the campaigns decide when to do them, drink, drive and sitbelts done around the Christmas period. I am sure that it was not thought of in the very first instance when we imposed drink, driving that it would be a Christmas campaign, so there is no reason why Police Scotland might not decide to say, we will have a week at the beginning of the summer holidays to crack down on this. I think that the point that James made is a really valid one that gives us an opportunity to raise the profile of this issue and educate through the legislation. The things that you mentioned in terms of mobile phones, seatbelts and drunk driving are all legislated for, so they have come up with ways of enforcing them, and I think that Sheila's point of it being part of the regular road traffic duties would be a sensible one to take. They do require resources and they do require police resources. If you have more responsibilities, they do require police resources, which is a resource on the week. You could, for example, I suppose decide that tobacco and alcohol would be dealt with together as issues at the same time. Thank you, convener, and good afternoon. I will try and be brief, convener. I should declare as well that I am the convener of the cross-party group on heart disease and stroke. I have no qualms at all about the evidence regarding psychinhand smoke. I just sometimes thank you because we talk about smoke. When the smoke dissipated, there was no smoke and we were really talking chemicals, and this is maybe part of the problem of getting that information across. I have heard from everyone on several occasions in the short space of time that we have been talking this morning about education awareness. Do we require legislation? Is it about education and awareness? I would contend that we do. The most recent Salsa stats interviewed 12—excuse me—13 and 15-year-olds within Scotland, and that indicated that 22 per cent of those young people in Scotland are often or regularly travelling in a car and where smoking is taking place. Sheila has already indicated the fact that there is a certain powerlessness. I felt a powerlessness myself as an adult who just needed a lift to work, but certainly when it comes to the context of a child or a real person, there is a powerlessness to intervene to protect themselves in that way. When I put that alongside the scale of the immediate and long-term medical threat that this causes to children and young people, my conclusion is that, yes, there is. I have no plans about the evidence and the medical effects that impact that. I think that that is a given, to be perfectly honest. I am taking up the convener's point about enforcement to some extent. What I am saying is that it is still about education and awareness. We are accused sometimes in Governments and Parliaments about taking forward legislation that is not necessary and where it should be a different approach. Is education and awareness—do we need to have this absolute—do we need to be more smart? Every time a car is sold with a handbook, does it have a no smoking sticker attached to it, no smoking children in a car? Should there be a sensor built into the car so that, when someone lights up, it goes off, just like you have seat belts? If you are not waiting a seat belt, you will get a sensor going off. Are there other things that we should be doing, rather than taking forward legislation? Generally, we have to do a number of things and we have to do them repeatedly to be able to raise awareness and change practice. I saw the public attitude to tobacco smoke revolutionise itself over the course of six years in the debate on smoke-free public places. Now, if, as a nation Scotland had unlimited resources, we might be able to do the sustained level of education and awareness raising that would be required to change culture, but my experience would be that there would be significant media interest in this legislation and that you will get free education and awareness raising that would cost a lot of money from the public funds in any other way. Yes, David. From a British Heart Foundation point of view, we have looked at international examples in Australia and Canada and where it has been brought in and legislated for and seen that it has a substantial impact on the reduction in children going in car journeys. James alluded to the 60,000 a day that is happening. I think that the scale of the problem, the health impact that we are talking about here, begs the question of why we have not done it already in Scotland. We have a history of being progressive on things such as smoking in public places. The time has come that Scotland really needs to act on this. We are not talking about five or six kids a day that are doing the 60,000 journeys that are happening. That is one of too many really, but I think that that number and scale is massive and it is something that we really should be acting on. Richard, I am not against taking forward legislation. I am just asking if it was necessary. My other point, if I may convene, is that it is maybe something that those witnesses may not have a particular view on, but it is about the adult age limit, the 18. You can hold a licence at 17. My other point is that if you have a young person smoking in a car who is 16 and there is no adult there, they are just sitting in a car and they are smoking. The legislation does not seem to cover that. It is just the adult age of 18. That is a peculiar age limit for me. Do you have a view? My understanding is that 18 is generally an accepted age for child protection internationally. When you are talking about child rights, like to learn to drive or whatever, 16 tends to be preferred? We have a different legislation in Scotland in terms of the age, in terms of children, transitions, duty of care. I am just wondering if that needs to be looked at. That is to do with supporting children and children's independence and rights. The age of 18 is generally, I think, internationally accepted for protecting children. I think that, from the BLF point of view, we could see no clear definitive correct age because of the complexity that you mentioned. From an organisational point of view, we would be quite relaxed in terms of where that went and where the legislature thought would be the most sensible cut-off point. Sheila, can you come back? I suppose that, in terms of underage sales and so forth, having a higher age range makes it easier to distinguish when children are younger. There is less argument if the cut-off is 18 rather than 16. That was the point that I was going to make. 18 is the age that you are legally allowed to purchase cigarettes. Technically, we should not have 16-year-olds sitting smoking in a car, though, in reality, we probably do. I want to ask about a slightly different issue. That is the level of accidents that occur in cars with drivers who smoke. I understand that that is considerably higher than the cars that are non-smoking. Is that the case? I mean, my understanding is that it is noted as a factor in road traffic accidents and it is probably significantly under-reported. It is not always put down as the cause of the accident. I think that that may be covered under existing motoring restrictions. Because I am just wondering whether we should not, you know, why, as Mike McKenzie was saying right at the beginning, I mean, slippery slope but, you know, a slope upwards in this case, why don't we just ban smoking in cars completely? Because if the accidents are greater, you know, I think anything you do with your hands, apart from actually having them on the steering wheel, is not good. I mean, and smoking is really unnecessary, so why don't we just ban smoking in cars completely rather than just the more reasonable thing of protecting children? I suppose that this legislation for us is about protecting children and we would like to see that secured. We are here to examine the bill that did not propose the area for that. E-cigarettes in the car wouldn't be covered with this bill? That's not the proposal that's on the table and there isn't the same level of established evidence of harm that there is for tobacco smoke, which is really irrefutable, although I wouldn't be surprised if you didn't get challenges on that from some of the tobacco industry representatives. Is there any other questions? Thank you very much for your attendance today. We look forward to going on this journey with you over the next few weeks and seeing the further evidence. Thank you very much indeed, thank you. I think that concludes our business for today, but I didn't.