 The first item is to decide whether to take items 4 and 5 in private to consider the evidence heard in the stakeholder session and to consider the committee's approach to pre-budget scrutiny. Our members agreed. The second item today is around table with stakeholders on social care, and this is intended to inform the committee's future work programme discussions. We have our panellists joining us online. I would like to welcome Derek Feeley, the chair of the independent review of adult social care, Professor David Bell, Professor of Economics University of Stirling and COPI Healthy Aging in Scotland, and Fiona Collie, the policy and public affairs manager for Careers Scotland, Henry Simmons, the chief executive for Alzheimer's Scotland and the co-chair of the Fair Work Convention's social care inquiry, Judith Proctor, the chief officer of Edinburgh integration joint board and chair of the chief officer group, and Professor Nick Watson, director for the Centre for Disability Research at the University of Glasgow. I would like to ask the first question of Derek Feeley on the independent review of adult social care. Obviously, the review itself was focused on adult social care. I guess that I really want to ask whether there should be a similar review of children's social care and about that transition period to adult social care as an issue, not obviously just a transition from children's to adult services, but also, at the other end, to older person services as well, and whether you have some thoughts on those things. Thank you, chair. As you quite rightly say, the terms of reference for our review are specific to adult social care. The thinking behind that was that there had been an earlier piece, which resulted in a report called The Promise, which looked at children's services in Scotland, including social care support for children. I think that there was a desire not to go over the same ground again. We had a number of conversations as we did our work with the team that did the work on The Promise, and we tried to do the best that we could to identify areas that should quite rightly say that transition is one of them. There would be some overlap and that these things would have to be taken into account as any implementation of our independent review got under way. There are some additional issues around social work, for example. Social work with caseloads will often be with children and adults. We will need consideration in due course. The promise was published about six months in advance of our report being commissioned. In terms of the review itself, do you feel that the recommendations that you have made—and obviously you have done an awful lot of work in reaching out to people who use the various services of adult social care—do you feel that, even in the early stages of looking at the national care services, the voices are being heard and that there is an opportunity there for those people to be inputting into the formation of the national care service? We certainly did everything that we could during the pandemic period to hear as many voices as we could. The vast majority of what is in our report came from listening to one of the promises that we made to the folks who engaged with us was that they would see their reflections and their thoughts and their ambitions and aspirations reflected in our report. Most of the feedback that we got from people afterwards was that we had done so. We set ourselves some ground rules. We said that we would refuse no meeting, so we had over 200 of those. We said that we would listen more than we talked and we said that we would make it as easy as we possibly could for people in the language. Those would not be bad ground rules for the implementation process also. We said that we would refuse no meetings, listen more than we talked and make it easy for people to engage. I am now somewhat on the outside looking in, but my early sense is that the spirit in which the work to implement the report has been taken forward. I want to highlight a couple of things that certainly jumped out at me when I was going through the report, but they are also completely reflective of my experience as an MSP speaking to constituents on the issues that they have with the social care services. One of the first things that you highlighted was that the access to care and support is too complex and too variable around the country. How do you see that being addressed by the idea of a national care system? I guess that the point that was made in the report was driving the idea of something nationally where the variability was able to be tackled and the accessibility was not something that people who need access to care had to wade through TRIQL to get it. There is a saying that goes that every system is perfectly designed to get the results that it gets. Our current system is perfectly designed to get us variation. As you quite rightly said, one of the major drivers in us recommending a national care service was to try and remove some of that variation. People who we spoke to who received social care support described us as a post-court lottery. Removing some of that was definitely some of what we had in mind when we recommended a national care service. We also wanted to see social care being given the same regard as the NHS. We wanted parity with the NHS. We wanted to clarify some of the accountabilities. We wanted to give national assurance to ministers, Parliament and the public about the standard of social care in Scotland. We felt that it was important enough to have national strategy, funding and direction. We wanted a national care service to be a vehicle for fair work. We wanted to be able to set national improvement priorities. There are some real pockets of excellence in social care support in Scotland, but we wanted to have a way to more easily spread those across the whole country and scale them up so that everybody got the benefit of those. That combination of things, chair, were the reasons and why we recommended a national care service. I want to point to another couple of things that resonated. The threshold for access and support was too high. A lot of people said that. I did really like the quote that a care system should be a springboard, not a safety net. I thought that that absolutely encapsulates that. Can you give us a little bit more information on the issues around that that you were hearing and that you put into the report? I cannot take any credit for that quote. That was a young man with learning disabilities at one of our meetings who shared that perspective with us. People described us finding the process of assessment and eligibility as complex, as bureaucratic. One young lady described it as brutal. One of the things that has happened over recent times as resources have become stretched is that eligibility criteria have just been ratcheted up and up. Now, the only way to access social care support is if you have a real crisis in your life. By that time, it is often too late. We wanted to simplify the assessment and eligibility process to standardise it across the country. No matter where you live in Scotland, you could be sure that you would be able to get access, but we also wanted to get more people into the system of social care support. For social care to be seen as something that was not necessarily just about a crisis, but was preventative and proactive and available to help people to live the kind of lives that they want on that. I am sure that Henry could speak to that, but one of the things that we had from his organisation, for example, was that he had done some really great work around more preventative approaches to supporting people who had Alzheimer's. That has been incredibly difficult to scale up across the whole country. Lots of opportunities in simplifying the process of assessment and eligibility and making it easier for people to access those support. I am with a bit of investment to get more people into the system earlier. I would like to open it up to the other panellists. If they want to come in and say, they just have to put an R in the chat box on the BlueJeans function. I guess that the actual opening question that I would like to ask all of you is what you see as being the most pressing issues for social care that we as a committee should be looking at and that perhaps need to be tackled by the idea of or the reality of a national care service. I will go to Fiona Collie first. I want to just to quickly feed back a little bit on what Derrick had been saying on that issue around children's services. I think that what we hear from carers very often is that transitions are particularly challenging time. However, there is a wider picture of children with additional support needs and with complex needs and how they have access to the support and services that they need, issues around employment levels of carers and the difficulty in juggling work and care and how to incorporate children's rights in any of the problems. Certainly for carers, I would reflect that the idea of the system being unduly complex and only there when you're in crisis is one that they've had to fight for the support for the person that they care for. However, it probably doesn't surprise you that I would say that the most pressing need at the moment in relation to the development of the national care service and indeed now is in support and unpaid carers. We know that there has been an increase of around 400,000 people taken on a caring role during the pandemic and that has had significant effects on their mental health, their physical health and their incomes. We think that there are some real opportunities within the national care service, particularly around a right to a break. However, that wider question of a social care system is a springboard rather than a support. If you provide the right support for the person who is currently being cared for, then in effect you provide the same support for carers and enable them to manage their care and role frame and their lives alongside that. We certainly think that there's a need to look at what carers need as part of the choice that they have available in becoming a carer. We rarely ask those questions if the right services were available, if the right support was available to your child, to your parent, to your spouse. Would you become a carer? Would you become a carer at the same level, but too often we take that choice away? In general, we are very positive about the opportunities that the adult social care review and that discussion now is opening up about bringing the value of social care and the support that carers provide to the four and looking for the ways in which we can make that more consistent. We can make that something that is easier to access and that prevents many of the impacts of the error in terms of their physical and mental health and losing employment and the impact on their incomes. I'll leave it at that for the moment. I'm sure that I'll have other things that I want to chip in as we go along, but I just wanted to make those points. A lot of what you've said there, particularly around unpaid carers, members want to come in and dig deeper on that particular issue. Can I come to Professor Bell? David Bell. Hi. Hello, we can hear you perfectly. Did you want me to come in? Yes, you put an R in the chat box, so imagine that you want to come in. If other members want to do so, then it would be great to hear from you all about what you think the main issues are, but I'll come to Professor Bell first. I have a quick comment on your first question. I'm not in a position to talk extensively about children's services, but I think that one of the reasons for focusing on adult social care at the moment is that we know that there are particular issues coming up, which are to do with the increase in life expectancy among older Scots. There has been a bit of a hiccup during the pandemic, but it is likely that life expectancy will continue to grow post-pandemic, whereas we know that the number of children is declining. I'm looking at projections that my colleagues at LSE made for the number of people with, for example, severe dementia in Scotland over the period 2019-2040. The number of people with severe dementia is expected to increase from 36,000 to 74,000 over that period, an increase of more than 100 per cent. If we think of the fact that we have only about 33,000 care home places in Scotland currently, that seems to me to be an issue that merits a very significant attention by the Scottish Government. Indeed, that review, to some extent, is perhaps the first part of that. I think that the most pressing issue is about people, about the staff and, as has just been mentioned, informal carers. If you look at any estimates of the costs of long-term care, adult social care, a huge proportion of those costs are associated with what we call informal or unpaid care. That is people having to give up time that they might otherwise be using for leisure or for work or whatever. Those constitute the largest of the costs, because much of the support for adult social care is non-medical support. Part of the reason why it has been so squeezed in the last decade or so has been the squeeze on local government funding. The health budgets have been less squeezed during the period of austerity, and that is what has pushed up thresholds for access to services. That is the squeeze that has been put on local authority funding. That has consequences around the kinds of contracts that are made with care homes and the kinds of terms and conditions that care homes can offer to their staff. I suspect that, post-pandemic, that will be a real issue. There are already lots of people who have been leaving the social care service because of the adverse effects of the pandemic. Conditions that were already not very good for care workers have been made more difficult, in a way, because of the experiences that they have had during the pandemic. The only question is that there is certainly a need for a review of children's social care, and I also think that the transition that we have been recently doing is some work around transition. There are lots and lots of problems with transition. I am focusing more on young people in transition, but I think that one of the big problems is that, when we look at transition, we are just looking at transition of just the immediate post-school environment. We need to be looking at transition up until young people become 30. A lot of evidence suggests that the transition can be delayed anyway because of the structures that are put on them. In the EU now, young people are looking at transition for seeing transition services going on to 29. If there is a focus on transition, we need to expand it out. I think that one of the problems that I see with the Feely review—I would be really interested to see what Mr Feely has to say about that—is that it seems to be presenting two different futures for social care. It seems to me, on the one hand, to suggest that good social care is the product of people power, co-production of services and a diversity of approaches that are adapted to meet needs of the locality and the needs of the service user. On the other, it is called into centralisation, standardisation and institutional power with the national care service. I just find that those two approaches seem to me to be in tension with each other. I really struggled when I was reading through the review to see how that can be reconciled. We have the transfer of power to those who receive care and support and those who are giving informal care and support. There is a call for blending of informal care with more formal care provision. Care becomes relational, and power is placed in the hands of a national care service with a care workforce. Care becomes much more transactional. It is difficult to see how the third sector will fit in with that role. One of the things that emerged from our research on the experiences of disabled people during Covid, both in Scotland and in England, was the role that the third sector played. The third sector, compared to the state sector, is agile, flexible and able to adopt the way that it works very quickly. It was able to meet the needs of disabled people, where the statutory services—I think that there were lessons about health and social care integration in the ministers both in England and Scotland—looked at healthcare and took their eye off social care. It is not a critique that you cannot have the bandwidth to be in charge of both health and social care with the demands that were placed on the ministers. However, what happened was that social care slipped out. I would like to see how you envisage the two tracks and how you pull them together and how you keep the third sector and the vibrant third sector within a national care service. One other point that I would like to make is in relation to self-directed support. We have been tracking self-directed support for six years now, getting freedom of information on a number of people on various options by local authority. It has virtually remained unchanged since SDS was first introduced. About 10 per cent of people are on option 1, about 80 per cent are on option 3 and about 5 per cent each are on options 2 and 4. Option 1 is very good for those people who receive it, but not everybody wants the responsibility and the control that goes through option 1. What we are currently doing is setting up a system where there is inequality in the care system, because option 1 is undoubtedly better. I think that we should be looking at option 2. Option 2 is where we bring in the third sector and we can be looking at the third sector working with it. I would like to see more review within more debate about how that will be realised. Maybe this is the way to do it. I can see why a national care service seems a good thing, but I am yet to be convinced that it is the answer in social care, given the infrastructure that we have in place at the moment and all the small care providers. I mentioned two hacks today, so I will try not to overlap too much, but I think that if I could make a point from a fair work perspective and perhaps I could return to this at some point, but we held a very detailed inquiry over a two-year period and produced a series of recommendations since 2019. The core message from that is that fair work is not being delivered consistently across the social care workforce. The main issues that we found related to how services were being commissioned, how the balance of risk was being passed from those who were assessing commissioning needs to organisations in the latter to the workforce. Many people in the workforce are very changeable work patterns and hours, ranging from some people doing 70 hours per week to people being in fewer hours and not necessarily having enough hours to live off. I could come back to that at some point today. I think that the recommendations that Derek included substantially in his review are something that we should really deliver on. In terms of the people living with dementia, the scale and the size of the issue and the challenge and the national care service, we welcome the national care service and we understand the complexities that Professor Watson just highlighted and I think that they have got to be worked through. We have had three national dementia strategies. We would say that the strategies themselves have been excellent. The content, the vision and the approach in the key areas are probably seven fundamental areas of transformation, ranging from diagnosis to post-diagnostic support, integrated care, advanced care and wrapped around that substantial work within our hospitals, both general and specialist, and an underlying aim of making Scotland a dimension friendly community. We would not really question that as a national strategy. In fact, it has received quite significant international attention. The difficulty begins when you start to try to implement the same vision in a consistent way locally. You will see small components of that being delivered, so you might have a one area that delivers a really excellent post-diagnostic support service, but you will then falter as you go through the more integrated towards advanced stages. There is not a methodology or a mechanism just now of the national strategies having any depth of accountability to those that are conceived of them. We have the strategies that are developed by Government that are owned between Government and COSLA that have ministerial drive and policy support, but in terms of implementation, it then falls through to the 32 local areas. There is no accountability structure in that, so when Derek's report highlighted the gap there and determined that what we had to do was to give that ministerial level of accountability, we welcomed that very much. What we really want to try and do now is not wait. I think that the committee has a really important role in making sure that what does not happen is that the national care service becomes the longest grasp that we have ever found ourselves in. We are talking now about a five-year period of developing it and we see, as Professor Bellish mentioned earlier, the issues, the challenges and the scale of the problem that we are facing in terms of people with dementia needs a really significant level of attention and focus. That should not all be simply at the end of that. We need to push forward and we are doing some work just now jointly with the Scottish Government to tackle things like prevention and brain health. We know that we can prevent around about perhaps 30 per cent of dementia that are thought to be preventable. That is mainly due to lifestyle factor changes and through an invention in your 40 and 50-year-olds. We have a strategy for that, but that needs universal applications across Scotland and it needs a little bit of testing. In terms of diagnosis and post-diagnosis support, the earlier that we can work with individuals and support them after diagnosis and as soon after diagnosis as possible, the more we can help them to build resilience and retain a really high quality of life. Indeed, the evidence from that is that that will take pressure off inappropriate and unnecessary admissions to residential care. Perhaps for some people our two or three years might be the time that we are talking about and that is a lot. If you consider that intervention costs £1,500 per person per year, it is a minimal intervention that might return that to everybody's work. We have never been able to manage that consistently. That target, that commitment to every person who receives a post-diagnostic link worker for a minimum of one year, we have only ever really reached it before 50 per cent of that. Again, it shows you that, despite strong evidence, strong models, strong ways of perhaps reshaping our system, you never really achieve that approach across Scotland that gives everybody the consistency and the level of support of their mentality. Subsequently, you do not get a transformational change in the system because it is too scarred and you do not get the full potential of the national strategies. Equally, I do not think that you get any return in terms of people being held to account for delivery, because there is a real breakdown there between those national strategies and local delivery. I will probably stop there, chairman. Thank you. A lot of what all of you are saying is that, as I say, members are wanting to come in. I am going to bring in Judith Proctor before I go back to Derek Filley for to round this off and then come to my colleagues, Ms Proctor. Thank you. Good morning, committee. Good morning, chair. I think that it is a really, really important debate and chief officers are really keen to be involved in the discussions about the development of the national care service. Just in relation to your question about the things that I think are most pressing around that, I think that they have been touched on already this morning and they are, for me, around the workforce, repairing the workforce and the resources that are required to achieve the sort of equity of access, equity of outcomes for people. I think that the whole issue of creating really good jobs for people and making care be seen as a career that somebody would aspire to and have opportunity and is also really, really important on that. We have got some challenges right at this moment in terms of the workforce providing care and support for people, and I think that we could be doing more in relation to terms and conditions, making these good jobs and so on. I think that I also want to point out the issue, because I think that it came up when Derek Filley was talking about that ambition that set out that I think that I would really, really support in the national care service for access to be equal for people, for it to be easy for people. We would want to point out to the committee that the way that we are set up at the moment, as you understand, is that we are not all set up in the same way and not all systems locally have the same resources to deliver those services. Resources are not necessarily allocated in the same way, and over the years we have seen those differences in the allocation of social care funding for adults in particular. Key to the development of the national care services, we go forward, has to be the fair and equal allocation of resources, whatever the structures are, that emerge from that, so that we can create that fairness, equity and access across Scotland for people. Recognising, of course, that we will seek some variation there just in terms of the different geographies in different areas as well. I would also agree with Professor Watson his point that there are many other things that will create this sort of springboard in people's lives than formal services alone, and I do think that the work that happens in the creation of the national care service has to think about the sort of community support that we would want to see. I think that the things that really support people outside formal services are thriving and vibrant communities and those community opportunities that are usually delivered very locally or local community groups, third sector, and it's really important as we develop the NCS to engage with third sector organisations to really think about that tension between a nationally delivered service and nationally delivered standards with the need for localities to reflect local areas. I would disagree a bit if I may at this point, however, with the point about it being difficult and not having a bandwidth to manage both social care and health in an integrated system. I think that we've worked hard over the years in IGBs and health and social care partnerships in order to create and develop our services as integrated as we're able to do within the current arrangements and to manage that as an integrated system. I think that what we need are the levers to go further in that rather than to repeat them as a core principle because we have made games in that and I think that it's important that we don't lose the work going forward. Thank you. I'll come back to Derek Feeley before handing over to my colleagues. Thank you, chair. It's just to come back to your point about priorities. In our report, we identified three sets of priorities. While a lot of the focus, quite understandably, has been on the creation of a national care service, that's only one part of the report. The other two sets of things that we thought were critically important was firstly a shift in our thinking about social care support, being seen as some kind of unsustainable burden on society to seeing it as a good investment, away from crisis to wars, prevention and anticipation, which we've touched on already, away from seeing social care as about managing need and towards seeing it as about ensuring that people's human rights are met. I think that without that fundamental shift in our thinking, there's a risk that it will just end up with a national system that is about burden, crisis and managing need. That seems to need to be a priority. Secondly, a number of the colleagues have already touched on that. We thought that it was important to strengthen the foundations of our social care support system, so a recognition of the work that unpaid carers do and enabling them to do better, a recognition that they too have human rights, an investment in our staff, who are fundamental to the work that we need to do, and a way to close the implementation gap. There's a gap between intent of legislation, self-corrected support, integration of health and social care, all ground-breaking pieces of legislation, but a gap between the intent of that legislation and people's lived reality. That was the second priority that we identified. I need to strengthen our foundations. The third was about redesigning the system. That's where a national care service came in, but there's also a need to reform commissioning and procurement. There's a need to elevate the voice of lived experience at all levels of the system, and that's one of the ways in which we get to Nick Watson's questions. He's probably right that there is a tension between standardisation and personalisation, but the unfortunate fact is that we need both of those. We need to enhance standardisation and personalisation if we are to have the kind of social care support system that we all want. We are going to have to manage that tension in the best way that we can. Self-directed support is a great example of that. Self-directed support is about recognising the needs of every individual, but the report that came out in the course of us doing our review from Self-directed Support Scotland and the Alliance showed that we were about 50 per cent towards where we need to be with the implementation of social care support. That's one of the reasons why we recommended in our report that one of the priorities for a national care service should be to prioritise the improved implementation of self-directed support. I think that that's more likely to be done at a national level, at large scale, through a national care service than it is by asking 32 local authorities to do it, frankly. That's all been very useful for us to dig into and focus on some of the areas that you have highlighted. Can I come to Sue Webber? Thank you, Derek Freely, for the very hard work on producing the review that has had much discussion in Parliament already. We have seen the plans for the national care service come to Parliament recently. It has obviously expanded quite rapidly since that review that you carried out. I suppose that I am looking to find out if you think that this larger remit could lead to potentially, especially what we have heard today, the requirement and the need for social care reforms in the adult sector taking longer and can we afford to wait that long? It can be extended out to other panel members as well. You have directed that to Derek Freely. Yes, sorry. Thank you. It has taken us many years to create the system of social care support that we have just now. To change it will take some time. There are also some things in the report that we could be doing right now. We could begin the process of changing that narrative, for example. That is one of the reasons why the social care covenant has been set up to start to change people's perceptions. We make some recommendations in the report about further investing in the independent living fund. We could do that now. We could begin the process of reducing the chasm that exists between purchaser and provider in the commissioning and procurement process. We could do that now. While it will take some time, no doubt, for a national care service to be established, I do not think that that necessarily needs to mean that we do not do any work to improve social care in the interim. I very much hope that we will get on and do some of the things that can be done without legislation during the course of the absolutely necessary path of any legislative legal. Any other members want to do that? No other as a panel wants to commence. I am going to move on to talking about fair work. Carol Mockin has got some questions about that. Yes, thank you very much. As Sue mentioned, there has been lots of discussion about the work of the field report. One of the key aspects has been the staff and how we support the staff. I am interested to know the panel's view on just how key it is that we get it right for the staff when we make it a fair work place. I am interested in particularly some of the aspects that the trade unions are interested in around pay, terms and conditions and also about it being seen as a profession with proper structure in the way staff are trained and then employed. I would like some feedback on what we should be looking at in that area. Do you want to direct us to anyone in particular? Henry Simmons seems to be an obvious starting point for this. Hit the start, that would be excellent. I refer the committee to the inquiry report that we produced in 2019 on behalf of the fair work convention. I was chaired by myself and Lillian Macer from the University of Unison. We took a two-year period of time. It was the first bit of work that the convention engaged after having developed the fair work framework. We did that because so many issues have been highlighted as part of the development phase of the framework about social care. There were three components to that work. The first was to set up a social care working group, which was experts from every area, from local government and local government providers. We used that group as a point of analysis to reflect, to take evidence and to take views from the sector, but mainly through the views and eyes of the worker, the lens of the worker. We commissioned, structured universities, the Scottish Center for Employment Research to do two pieces of research. One was to look at volunteer organisations that the committee supported if fair work was being delivered within the organisations. Then we looked at the issues of personal assistance. What we found was that fair work in social care is fulfilling for those who are doing it, but it is not fair. When you try to summarise and look at that, I think that there are a couple of areas that the committee would really want to know about. The first of them is probably that there are over 1,000 organisations that deliver social care through Scotland. Within the organisations, there are variable approaches to the effective voice that workers and employees have within them. Some have great approaches to that, some have trade union recognition agreements and some have none, so it is a very variable position. What effectively you have then is that you have a workforce of 200,000 workers who do not have any national effective voice or any national approach in terms of negotiation or protection of some fundamental opportunities and rights. Within that, what then happens is that you need to cross-match that to the commissioning processes that have become the norm since the purchase and provider split of the 90s. The organisations have to engage in various forms of tendering and various forms of commissioning approaches. It went from organisations having stable grants that they knew how many staff they would require and how long they would be able to employ people for to that move towards more of a early rate process, where staff perhaps were then not certain about the level of hours or levels of support, but they were then moving to prior to the pandemic to what we described in our reports as a non-committal framework approach to commissioning. We think that that probably is one of the most fundamental flaws in our system, because what that does is that it asks an organisation to commit to becoming part of a framework agreement within a local authority area. The process of that is informed by fair work principles. The detail of it is probably reasonably okay, but where the problem lies is that the organisation that commits has no idea how much work they are going to be asked to do. There is no sense of that, so they have to take a risk in committing that they will then be able to have the staff to deliver it. The local authority, or the IJV, who is commissioning that approach, would be looking to have several providers in order to meet that variable need that exists within social care. The organisation then commits and signs up and is on the framework agreement and then waits in terms of work coming in. That work can come in and a trickle basis are on a really heavy floor. They do not have a capacity in terms of workforce sitting waiting to react to that work. What the organisation then has to do is bring people on low volume hours, or, in some cases, about 11 per cent that people are in zero hour contracts. What that gives the organisation the opportunity to do is to react to the need as it comes through. The local area is benefiting by having organisations that can react to need. The organisation is benefiting because it can then secure that level of work. The worker is the person that is not benefiting, so they do not know if they are going to be asked to work if they are in a four-hour contract or a zero-hour contract. Very often what happens is that if they are on a 35-hour contract, because the body fills that gap in reaction when the tap is turned on, they end up working 70 hours per week. There is a really difficult risk shift from the commission process to the organisation to the worker, and it is the worker that bears the burden of that risk. That is fundamentally, in our view, unfair, because we do not have that in other parts of the system. There are loads of our health and social care system where we cannot predict need, but we can estimate it, we can determine it, we have access to emergency units, we have primary care environments where it is exactly the same. However, why is it that it is only the social care workforce that we do not give that security to? We advocated in our recommendations that what should happen is that we have a national body that tackles and sets up all of those terms and conditions and creates a minimum set of standards. I would pose far as saying that no one should be employed in less than a 17.5-hour job per week, and that should be determined by personal choice. We need to balance out that more detailed understanding of data, prediction of need, to then have a workforce that is securely employed to deliver that. We should remove that risk of the worker being the person that has to manage the gap between unpredictable volumes and delivery. Fundamentally, we argued in 2019, sadly before the pandemic, that there should be an immediate end-brot to non-committal framework agreements and that there should always be, in any framework, a commitment of employment requirements so that organisations could then say that we will have 10 staff that can deliver in this framework for you. That will mean that there might be some gap in that. It will mean that there might be times where there is downtime, but the philosophy that is crept into social care about there being no downtime, there being no travel time in some cases, there being no minute of public money not being used in a delivery of service, is part of the thing that has corrupted it, because that is just not real. What has happened is that the workers do not have the chance to manage their own diaries in social care. They are given timetables. They do not have the opportunity to make a decision about spending a bit more time on an individual that might need it. They are on a pass-based slotted approach because everything is so tightly driven because we are trying to make sure that every single penny has been spent to the best value. All we are doing is losing value and destroying that workforce. I would not be exaggerating to say that this is not a workforce that is probably one of the most important, the most significant but yet the most undervalued and poorly delivered on standard, high-quality terms of conditions. The Proctor would like to come in on the fair work issue, Judith. Amy Simmons has touched on, again, the principle that Derek Feeley mentioned earlier, every system is perfectly designed to deliver the outcomes that it does. I think that some of the challenges that we see at the moment are as a result of the system that we have in place, where in some areas my own, in Edinburgh, where so much of what we do has been outsourced and commissioning practice has been competitive rather than one of co-production. Lots of work happening in different places to try and address that. How do you create good co-production in a commissioning framework? Derek Feeley's report talks about ethical commissioning being one of the principles and putting that in place. Where we need to start with that is understanding what that framework is for Scotland. What are we going to use as an ethical commissioning framework? What are the principles of that? How are we going to apply that nationwide? How will that be scrutinised? How will we know that, when we put those good ethical commissioning principles in place, the impact on the workforce will be the improvement that it would want to see? I echo the comments. It is hugely important to listen to the workforce. It is a hugely motivated workforce for people who want to do an excellent job in caring and supporting people and helping them to have a good life. However, we are seeing people leaving that workforce because the difficult job sometimes makes it more difficult to find conditions and challenges that are in place. We need to listen to the workforce and what works for them and what makes for a good career and a good job. It might be a variety of different contracts for different people. One of the other things that we want to see is a more diverse and diversified workforce. We know that it is largely a female workforce, and that has certainly not helped in relation to fair terms and conditions being a relatively lower-paid job. We need to go far to make it an attractive job and attract a diverse workforce. Flexibility is key in that. We should be working with universities, colleges to support students to think about part-time work alongside their studies in care. It gives them a tremendous foundation and experience that would help them in their life. If we are going to attract that diversity, we need to be offering flexible roles and flexible time for people to work. If we treat the workforce well and create that diversity and flexibility, the people who get support are able to get far more flexible support than we are sometimes able to give them now. Focusing on fair terms and conditions, we improve not just the experience of individuals providing care but also to the people who require care. That is really important. I would add something to that, because it links to the question of localities, locality working and localism. I believe that the more we recruit very locally the services, we create the continuity that we are looking for in our communities and create better jobs for people, particularly in some of our more deprived areas across Scotland. It is important that we think about being able to recruit locally for those local services. I think that, just very briefly, the one point that I want to make about fair work is that having cautioned against a national care service, one of the advances of a national care service is the possibilities that it gives staff for career progression and for advancement. I think that one of the problems with social care is that a lot of care workers are working very contained lives where they are just working with particular groups and there is very little opportunity for employment progression. In a national care service, people can become area managers, senior managers or supervisors and there is a possibility for training, so I think that that is something that should be recognised. Given that this group of care workers, the majority of women and large numbers are from disadvantaged communities, they start to have the potential to tackle some equality issues. At this point, I am going to bring back Fiona Collie, because she wants to come in on an earlier point before I go to some questions on this from Gillian Mackay. Thank you very much. I actually wanted to come in on Sue Webber's question about this larger remit and could it lead to taking longer? I will admit to having some anxiety around that. We simply cannot afford to wait. I think that the development of a national care service is very important, but we also need to invest now. The pandemic continues to be highly damaging for carers. It stretches carers to the limit and beyond. It has exacerbated existing impacts and inequalities. We have eight in 10 providing more care. Critically, in something that the system will need to look at, three quarters of carers have said that the care needs of the person that they care for had increased. Moving forward, there may be more care required. We have discussed this with COSLA and the Government of identifying both investment, but for one of a better way to put it, quick wins will be able to get money into the system, to be able to get support into the system as quickly as possible and whether that is to support staff, carers and people who receive services. However, to get that money in the system now, because if we look over the past few weeks, we have talked a lot about ambulances and A&E. Let us talk about the challenges of social care and the challenges in providing support at the moment. The challenges in meeting the demands just now, never mind the demands as they progress. When we start coming further out of the pandemic, and hopefully we will, that respond to those people who have had more care needs now and respond to carers who, in a lot of cases, are beyond exhausted and will need additional support moving forward. We will be coming back to Covid-19 and coming out of the pandemic and other questions. Can I come to Gillian Mackay's questions on fair work? There was a lot of focus on the incredible work done by care workers at the beginning of the pandemic, but it feels that some of that focus is waned as the attention has moved to the pressure being placed on the health service. Are we doing enough to continue to value and highlight the contributions of care workers during the pandemic? That would probably be best directed at Fiona Collie. It leads on very nicely from what you said. I suppose that the answer is probably no. I think that many carers and I think that probably care workers feel very similar that they are their contribution as the demands increase. The demands are increasing and they are not decreasing for carers. Their contribution is overlooked and what they need to see on the table is some clear provisions to be able to support them coming out of the pandemic. We are in a position where, for example, as furlowe ends, carers are having to make choices right now around the current delta variant and how much more infectious that is. They are having to make decisions right now about whether they go back to work as offices reopen. Carers are having to make decisions right now about whether they are able to go back to work and what that means to the wellbeing of the individual that they care for. Although vaccination has made a big difference, there is still a gap and we need to find a way to fill that and find a way to support carers through that just now. Judith Proctor would like to come in on that. I think that that is an important point. There are real pressures right at this moment in terms of care workers. We have seen people who joined the workforce during the pandemic—perhaps who were furloughed or who were inspired to care because of the support that was there—returning to pre-pandemic jobs or moving to different sectors. A society has opened up again and demand has been huge in other sectors, although we are seeing wages in some other parts of the economy that are offering more than carers are getting. People are, as colleagues have said, tired. Carers are tired. This has been a very difficult period for them, and people are leaving making choices to go to other roles. We have to do more nationally in terms of promoting roles in care, supporting people in care, and more locally as well. We cannot go into the winter ahead of us with a depleted workforce. We really need to be focusing on what we should be doing now, as well as creating that aspiration for the future workforce in support of carers. Henry Simmons would like to come in. I support everything that has been said, but perhaps I do. One of the key challenges that has always been in the social care sector is that when you look across the health sector, you look across to the terms of conditions, the security of employment and their value. That often comes from the discourse that occurs at a national level. People talk all the time about the NHS and the examples that we saw through the pandemic when we relied heavily on the social care workforce, but the social care workforce could not access even the supermarket slots in the first few stages. There is a real need for us to see. We must start to equalise those terms and conditions. We must make a commitment to that social care workforce, because, as I said earlier, they are in crisis and there is not enough of them. We still restrict them to the minimum levels of hours and employment, and then use them in a flexible way. We do not need to do that. We do not have enough workers to support them. We need to move quickly and agree that a standard set of terms and conditions is the top priority that everyone gets. The committee should be aware of what will happen is that organisations who have the ability to offer better terms and conditions—sometimes that might be the bigger organisation or the local authority themselves—will suck the staff who are looking to get that security or organisations that can offer a 35-hour-a-week contract. The smaller organisations that are providing vital support have stood up during the pandemic and done things that you would not imagine. Organisations have become food banks and delivering medication and helping people to get money. It has been a phenomenal response from the sector, not just the social care sector but the broader civil society and the third sector. All of the organisations are now under threat of their funding. Very few of them might survive fully intact, which means that some of the workers who have been there will perhaps be in a redundancy position. You really start to see the infrastructure of our voluntary sector is intertwined with the infrastructure of our social care sector, which is intertwined with our infrastructure of the NHS. The only thing that gets the main attention and focus is the NHS. We need to look across our community structures in such a way to highlight each of the areas with the same level of focus, priority and respect, and then we might get somewhere and help them to deal with the whole system changes that are required. One of the things that we found in our work that we have done on Covid and social care has been that at the beginning of Covid, there was a big reliance on family members, and a lot of families did not want people coming in because they wanted to keep it out. We have seen a lot of people who are concerned that having taken on that care role, they have not been given the support back again as we have started to open up, and care has been reduced. People are trying to get new assessments. There are a lot of issues about getting new assessments for where conditions have got worse and support needs have increased during Covid, people cannot get assessments and so on. One of the things that we have got to look at in any of that is that Covid was already creaking, and Covid has created a big mess. The person who said earlier about saying that Covid was Judith's saying about the bandwidth, I did not mean that they should not be integrated in health and social care. What I meant was that all of the focus at the beginning of Covid went to health. Nobody talked about social care, and when they did talk about social care, they talked about social care in care homes, and nobody talked about domiciliary social care. There was a lot of argument about, can we get PPE into care homes? Nobody said, how can we get PPE to those people who are receiving care in their own homes? It took groups like third sector organisations who had to run round to find and source their own PPE because it was not being provided. I think that domiciliary social care disappeared off the map at the beginning of Covid, and it is because people do not have the capacity to look at all of these different things. I think that there is a danger, the more integrated we get that some of the things disappeared. Social care became just about care of the elderly in care homes at the beginning of the pandemic, not about those people living at home receiving social care in their own houses. I am going to come to David Bell, who wants to come in on this before I go to another committee member. David. Yes. Hi. Just to agree there, the esteem of social care is so much below that of the NHS, and anything that can be done by the national care service to increase that level of esteem is potentially very beneficial. I think that there is an elephant in the room here that nobody seems to be wanting to speak about, which is the overall level of resources that are being devoted towards social care. That comes through the look at the moment. It would be interesting to see what happens once the national care service is established, how it is going to be budgeted for, but at the moment it is coming through communities and local government. Their budget increased by 4 per cent in money terms between 2019 and 2021, whereas the health budget increased by 18 per cent. There has to be some decisions made about the strategic direction of resources in relation to health and social care overall and how those resources are allocated within that overall budget. One point aside from that, which Derek Feeley made in his report, one of the benefits of a national care service would be an improvement in the data that is available to make the kinds of decisions that need to be made. Our work on care home deaths during the pandemic really was not helped by the quality and availability of data across the social care sector. Even as Professor Watson was saying, it is even worse for doncillary care than for care homes. Kane has got a question on the specific point around pay. Paul, if you can direct it to somebody in particular, that would also be great. Thank you, convener. Professor Bell spoke about the elephant in the room, in terms of finance, and I think that pay is part of that as well. Certainly trade unions like the GMB are advocating 15 times an hour for care workers. I suppose that I am just trying to get a sense of whether that is the first step in curing better rates of pay and more sustainable rates of pay. The other aspects that we have discussed follow from that in terms of training, qualifications and a longer-term career. I do not know if Derek perhaps wants to comment on that. I am sure that I thank you for the question. It was certainly the case in many of the conversations that we had, regardless of whether it was with sub-sector organisations or people who received social care support. It was noticeable how many of them said to us that they were going to invest in one thing and investing in the workforce. Henry, Lily and the colleagues did in their review of fair work as an outstanding foundation for making that investment. In the conversations that we had with the trade unions and the discussions that they enabled us to have with their members, people have perspectives on what a fair rate for the job is. At the moment, we have focused on the real living wage, which in my view is a starting point, but not necessarily an end point. We need to get beyond that if we are going to see social care as a valued career and for the highly skilled work that it is. We recommend in the report some kind of national programme of job evaluation, like we did at the NHS, which will give us some sense about what fair pay really is. That is one of the reasons why we could not put a firm price tag on what the level of investment might be. For every pound that we go above the real living wage, we need us to invest about £100 million. I will come to Henry Simmons, who wants to come in on that before moving on to questions from Emma Harper. Thank you. I would like to say that it has been good progress in terms of living wage, but if you have a great early rate and you only have two hours' work a week or 10 hours' work a week, it does not really matter what you need to fill package. I would ask the committee to look at the fair work framework. You are looking at security, respect, film and opportunity. You need the full package to have good quality work and good quality employment, and you do not have that within the social care set. In terms of condition arrangements, you also need access to training, access to support, supervision and time to reflect. All that makes for good work, and we do not have that because the system has pushed that away. We need to agree what a good, fair, equitable early rate is and probably the best place to look across to our healthcare colleagues. If you imagine the terms and conditions that are enjoyed in the various levels of the NHS, they have been well developed, well negotiated, collaborated on and agreed. We do not have that within social care, but if you drew that as a parler, you would get somewhere close to something that I think would be reasonable. I think that we will have to move on to the whole approach. The other thing that we are seeing in the sector is that, because the level of wages is increasing, the next level of front-line supervisors or managers is not, and the gap is getting smaller and smaller. Those are environments in which really skilled managers, really skilled people that coordinate and work with individuals to understand that. If we do not value that level with the same sort of comparators as perhaps we do in the NHS, then again, we are going to see that gap decrease. We will not have enough managers to manage the complexities of the system, and indeed it would not be worth their well-doing. I think that you have got to look at it beyond just the early rate and look at the whole framework and look at the whole system from the structures within organisations to deliver a high-quality service. Thank you. Moving on to a similar theme, Emma Harper has some questions about recruitment and the retention of staff. Thanks, convener. A lot of the fair work issues and the recruitment and retention, which is what I am interested in, are lots of leaching of the issues and the ideas. My first job was in a care home before I started my nurse training a long time ago, but I am interested in looking at what we should do to help support recruitment and retention outside of just looking at wages. I am interested in the issue that a band 5 staff nurse gets about £15 an hour and a band 5 staff nurse trains for three years looking at knowledge and skills development and competency demonstration and assessment. Is that something that needs to be more structured in the education in order to encourage recruitment and retention so that it is perceived as a skilled job to work, whether it is in home care or whether to work in a residential home or a nursing home? Do you like to direct that to anyone in particular, Emma, or do you want to come in? I am not entirely sure if that was on this theme. Can I come to Judith? To come in on that and pick up a bit of the previous point as well. I think that it is really interesting how much do people who have not had any experience of providing care or with somebody who has cared for know about the job? I think that there are a lot of preconceptions about the job but not an awful lot of people out with it will know what it takes, the skills that you need, the training that is required to do that and the decision making, the autonomy that is required. I think that we could do a lot more to promote and to explain and to allow people that do care to share what it is about the job that they like and what the job is like. Also, in the way that Derek Feeley's report drew out, the difference that it makes in people's lives, the life-changing difference that it makes for people who otherwise would be isolated or unable to contribute to society. It is really, really important that we do that. I also want to point out that when we talk about social care, it is really, really important that we think about the development of the profession of social work. I do not think that, in the debate, that is having as much of a focus on it as it probably should, because, of course, good social work and well-supported social workers and well-resourced social work capacity ensures that good access to care for people and it ensures that we would be able to meet the aspiration for easier access into those services as well. I think that that is really, really important. If I could do touch as well, because I think that the terms and conditions are very important here, creating that for careers, but we have touched upon the genius of parity in esteem with the NHS and thinking about the single workforce pace lines there, too. I do wonder if we are thinking about the potential in this and of linking those terms and conditions to that sort of structure, what that might do to the diversity of the market that we have currently in care, and a broad range of different providers out there. I do not want to answer to the question, but I wonder if creating that single set of terms and conditions, that single role definition, whether we begin to see a greater amalgamation of organisations or indeed whether that leads us to that single nationalised workforce as we have in the NHS? I think that there are probably a handful of things that we can and should do. The first would be awareness, so grow some public awareness about what a good career in social care could be. The second is about recognising and celebrating the value of working in social care support. We touched on that earlier. I think that there is more that could be done there. The third is about paying conditions. If we really mean what we say about social care support being a valued contribution to civic society, then we should pay people a call in that. The fourth would be training and development. We have a lot of stories when people are about how they have to do their training and development in their own time. They have to do it in the margins of their work. If we believe that providing social care support is skilled work, which we should train and develop accordingly. The fifth would be to give some people, when Nick Watson touched on that, some kind of sense of career progression. They could see that social care is a career. I think that we did those five things, raising awareness, celebrating value, improving terms and conditions, increasing training and development, and giving people a sense that they could have a career in social care. That would help with recruitment and attention. One of the things that Judith touched on is that Ian Ferguson, who was a professor of social work, pointed out that one of the problems with co-production and using bottom-up approaches is that social workers can feel just deprofessionalised if they can take away their feeling of professors. One of the issues that we are seeing with self-directed support and with health and social care integration is that there is a lot of language of co-production and co-producing services, but it has all been about co-producing and co-working with those who receive care. That is a really important thing, but there needs to be an involvement of professionals in the redesign of the service. At the moment, people feel like they are being done to when you speak to them. One of the issues with SDS and the implementation of SDS has been that social workers do not seem to be being pushed in the way by the street level bureaucrats or the people who are pushing it out and developing it. We need to be looking at involving those people more in the design and delivery of new care services. How will social workers feel about being brought into a national care service when they have always been part of social work? I suppose that there is a need to start looking at that as well about how that will come through. We are going to move on to questions about funding of social care, and those will be led by Paul Cain. Thank you, convener. I am keen to understand that we have moved from Mr Feeley's review and the work that was done there in terms of recommendations to what the Government has consulted on. Within the review, we had the figure of £0.66 billion in terms of being an adequate investment for those proposals. However, we have an expanded remit. We also have commentary from Audit Scotland questioning the growing requirement for care, particularly in an ageing population. Really, to get a sense of the panel around how realistic that figure is and what further work needs to be done in terms of trying to understand that. If you do not have anyone in particular who wants to direct that to, I will probably come to Derek Feeley first of all, and if other people want to come in on that, they can Derek. He will give it a name, Mr Feeley. I bear a limb. Thank you. Derek first. The numbers are as realistic as we could get them in the time that we had available. All of this work, then, we spent most of our time talking to people not doing the financial analysis. As we pointed out in the report, we have done the best work that we can to give some kind of indicative numbers. Again, I would say that those are probably the floor rather than the ceiling. They exclude, for example, any investment in fair work, because we couldn't quantify that before we knew what would be the hourly rate, for example. We have done a reasonable job at looking at how we could get to unmet need in an approximate way. The cost of removing charging would be the uprating of pre-personal nursing care, which we think is necessary. Our sense is that there is a reasonable approximation, and there is a decent place to start, but there is undoubtedly more work to do. Earlier on, Professor Bell gave an indication to the number of people who were expecting to develop more progressed advanced dementia. Those figures are frightening in the future. Derek Dyddon, in terms of the recommendations about pre-personal nursing care, is a great start. The committee probably needs to consider the fact that many of the individuals who will develop advanced dementia need their healthcare needs. Just now, our system puts all that in a social care environment. The issue of who pays for care going forward is going to be absolutely crucial. We would argue that it is fundamentally unfair for someone who is in an advanced state of dementia, who cannot walk, cannot talk, and needs assistance to toilet. They need their healthcare, and we would argue that they should not be paying for their care, for that part of their care at least. The recent developments in the national insurance increases contributions and the idea of caps. They miss some of the points on how we need to articulate a fair and equal health and social care system. There is no doubt that many people, as they progress, with a really complex advanced dementia, cannot be described as requiring social care, but they do have healthcare needs and a social care environment. The paying of that, which we estimated £40 million above, which is currently in play just now, would be required to make that an equal platform. There is a real need for us to look beyond the immediate situations that we have and think through the change in nature of what our care system is working with and the needs that people have. People move from healthcare to social care, but back into healthcare needs as their needs progress, and that part of our system does not adapt and change. The estimate is around £0.66 billion for the national care service. As Derek said, there really is nothing in that around improving significantly the terms and conditions of existing care workers. Currently, we spend around £4 billion a year on adult social care, so that is an increase of more than 10 per cent that is being proposed. I have to admit that I was one of the people. Another was the current chief economist of the Scottish Government, who was involved in forecasting the increase in costs associated with the introduction of free personal care. That was way back in 1999, and I have to say that we got it pretty badly wrong. We significantly underestimated the costs at that time. Having said that, I do not think that the success of Scottish Governments would regret having taken that decision, especially given any comparison with the situation, as far as social care is concerned in England. However, as has been highlighted by the increase in national insurance and its hypothecation, and the Scottish Government's hypothecation, which is an interesting take on devolution, is clearly the question of who pays if we are going to significantly increase the resources allocated to social work. As Henry has been saying, we really must expect them to significantly increase over the next decade or two decades. We have to have this conversation in Scotland around who makes a fair contribution. We have to define what a fair contribution means, but given the way that local government budgets have moved in the last decade or so, it does not look like—well, if that were to continue, it is not obvious how additional resources would be found to meet the kinds of demands that we have all been talking about, not only the demand in volume but also the things that are needed to be put in place to improve quality. I will be very brief. It is a difficult question to ask, because when we looked at the right to respite and started to do some figures on that, it could equate to £500 million, depending on what right you introduce, and the investment and what that will cost will depend on the scale of change that you are intending to make. If you are really going to try and make a difference to the lives of unpaid carers, for example, the cost to replace what they provide is around £43 million a day, which is £10.9 billion. It really depends on the scale of change that the national care service intends to deliver. I want to very briefly say that we need to start balancing out when we are working out about investment and what the cost of investment of not investing is. For unpaid carers, that is losing employment. What does that mean to the Scottish tax system? If disabled people cannot work because they cannot get social care to support them to do that, what is the cost to the Scottish tax system and the Scottish economy? We need some more balance. It is not just about cost, but what will that investment deliver to the Scottish economy? I want to say briefly about social workers. The thing that I hear most often from carers is that their social worker has changed. Their social worker is off and they cannot get social workers at all. It is an extremely important role in supporting the assessment of individuals and investment in trying to overcome some of the problems that are at the moment that are vital. We'll supplement your questions to members on this Evelyn Tweed and then we'll come to Sue Webber. Thank you chair and good morning colleagues. Thank you for your contributions so far this morning. I suppose that I'm interested in the funding and particularly what Fiona Collie has just said about the scale of change, what we're actually trying to achieve in a new national care service and also the issues of data, etc. We were raised earlier in the redesign of the national care service and if we are to excel in preventative care of the new measures that we want to bring in to really make it a great service for people, can we also ensure when we're doing that that costs can be contained in the long term or is it your view that costs will always increase? And would you like to direct that to anyone in particular and allow people to like to go to Fiona Collie first please? Well I think that potentially that's a question for an economist but I think it's very difficult to contain the cost because we have a rising age in population, I think those questions around individuals with more advanced dementia and that increase so I think it is difficult to contain the cost and continue to do what you want to do but I think that point about data and that investment versus cost and I think we need to see it in the whole because if you invest effectively and that actually helps with your local economy for example investing in the third sector has a multiplier in the local economy so we actually need to start looking at this as more than just about this is the cost of social care but there's wider economic benefits and so we need to balance them out but I would say it is quite difficult to contain the costs in my opinion but I am not an economist on this. Economist and we'll come to David Bell and then Derek Feely. Okay just very briefly on the on the data a couple of things one one is that what we found when we were doing the free personal care assessment of its costs was was they trying to get a handle on what's called unmet need which is the amount of need there is out in the out in the community that is not really being registered with local authorities or health boards or and so on and effectively there must be unmet need out there as thresholds have increased before of which people get access to services so I think that's a critical point the other thing goes back to something that Henry mentioned which is around Alzheimer's and the possibility that a lot of costs or the late term costs associated with Alzheimer's can be prevented by making lifestyle changes we are the only part of Europe and in a very significant minority in the world as a whole in not having a study or what's called a longitudinal study of older people which follows older people as they as they age and I'm part of the European scientific board for the European study and it throws up huge amounts of research that are helpful around how older people are dealing with the challenges that they face and can I come to Derek Feeley before moving on to Swerver's question just three quick points if I may chair firstly I think anybody's asking for a handout for social care we're asking for an investment in social care and there are studies that show that it would be a good investment to make the work done by the Scottish Women's Budget Group shows that an investment in social care would get us about twice as much economic value as an investment of the same extent in construction there was a study done of the independent living fund in Northern Ireland which showed 11 pounds of social value generated for every pound spent on the independent living fund so part of this was back to my earlier point about let's try and approach these issues from a with a different story about what is social care in our minds and see social care not as some kind of unsustainable burden but as an investment in a good society second constant containment of course is going to be difficult but I would argue it would be easier if we have good data I think it's an impediment to us exercising good stewardship over our resources that we don't have really good national data about social care and I think there is something in our recommendations thirdly about accountability but to help when I was the director general for health and social care and the chief executive of the NHS I would come to your committee and I would as the accountable officer I would be properly held to account for how we spend in our health budget no one has been similarly held to account for how we spend in our social care budget and I think it's time that someone lost I'm kind of glad it's not going to be me but I think it's time that somebody lost thank you we have a short supplementary from Sue Weber I know that Nick Watson wants to come in but I'm going to bring Sue's question then maybe Nick can come in after that yes hopefully and I'm sorry it might not be that short the supplementary all right okay it's more around the commissioning and the procurement and some of the challenges that we're not on we're not on paul just then so I'll bring in Nick Watson but we're not quite a procurement yet Nick there we are I just want to make one one little point about we we're also talking about care as if it's one sector we're going to remember people working care from three different sectors we've got there's about I think enable us at about 39% work in the private sector there's about 27% working in the voluntary sector about 34% working in the public sector so the care workers are working in different sectors and I mean again this is one of the things I don't quite understand how the national care service is going to bring all of these different care workers together they all going to they're going to become are we going to nationalise those working in the private sector are we going to incorporate those working in the I mean I just not entirely sure how this is going to go through or how it feeds into the national care service but I think we need to remember that care workers work in a variety of different sectors and they've got different different stretches and different pressures on them in the way they work but just in terms of the finance I think it's also really important how many people are employed in the Scottish in the care sector in Scotland and how important it is to our economy because these are there's a think nearly 300 000 people are employed as care workers across Scotland and they make a massive contribution to the to the economy and it is something that we should see as something positive in if we turn it around in another way. Thank you that leads nicely on to questions around the scope of national care service which we have touched on a fair bit throughout the session I'm going to go over to Stephanie Callaghan. Thank you convener and great CEO here today. Now the national care service we're talking about a significant increase in scope and the I'm wondering about the new community health and social care boards that are proposed and how we actually make sure they've got the bread the capacity and the collaboration there to really join up health and social care services in a way that means that we're designing care around what individual needs individuals need and I'd like to ask that to Derrick and Judith. First of all just waiting for broadcasting thank you for to you. I think we'll go first and then Judith will be able to explain more detail no doubt. So we see integration joint boards as having a really important role and they will be the way in which a national care service gets intelligence about local needs and priorities but they'll also be the implementation arm of national strategy and direction as determined by the national care strategy. There's a crucially important role for integration joint bodies in planning of integrated services locally and engaging with local communities to determine local needs and also I think in about rethinking what are the social care solutions of the future so bringing in innovative new practice different ways to meet people's needs. So crucially important role for integration joint boards and they will be the kind of delivery arm of the national case service and that's how it's imagined in our report. And can I bring in Judith Proctor? I hope you can hear me I'm afraid my system has thrown me out so I'm phoning in but I'm pleased that I was able to rejoin. I think the scope and the thinking through the function of the new community and health and social care boards is really very important and I think it's also very important that we give due scrutiny to the proposals that emerge following the consultation on the national care service so that what comes after this is workable and that we've stress tested that. Will the proposals that emerge through the bill process actually deliver the sorts of change for people that we want to see on the ground? I very much welcome the points that Derek made about this being about delivering locally with our communities. I think one of the real benefits of the development of integration as it's undertaken now is that real focus on localities. We know that we've got a real diversity of communities across Scotland and I think it's important that any organisation is of the community it's serving so I think that's an important principle for me. I also think as a chief officer who's worked in an integrated system if we're going to make the changes that we need to we need to learn from the reports, the Audit Scotland reports that said what's held us back, why have we not achieved, even though it's been a relatively short time that we've been integrated, only about six or so years, what's stopped us going faster and I do think that we need to ensure that the new community health social care boards have all the levers that they need in order to be the delivery arm of those organisations and I would question whether that can be delivered through what looks in part in the current consultation an organisation that will be commissioning elements from one of the partners in that. So I think consideration has to be given to those boards having the operational levers to pull to deliver as well as the resources and that question being addressed through a fair and equitable allocation to the boards that recognises that we don't have a level playing field just now. Thanks. Thanks. I'm going to have to move things on. I've extended the time for this panel. I hope everyone's able to stay with us for the next 15 minutes because we still have some real key issues so I'm going to move it on to talk about unpaired carers. We said we wanted to focus on this, Stephanie. You also had questions on unpaired carers and then I'll come to Gillian Mackay after you, Stephanie. I'm wondering about how we make sure, you know, how we actually go about as well getting that parity for unpaired carers who are carrying out different jobs, who have employment, who have different things. There's going to be a lot of us over the next few years with the changing demographics who are going to be looking at taking on a caring role and I'm wondering how we actually go about shown and changing. I think Derek spoke earlier on about the kind of shifts in social care support in towards human rights and things and I'm wondering about how we shift that ethos and that culture and society to actually really be valuing the care that carers provide. Is that directed at Derek initially? Derek. I'll take my advice on this from Fiona Culley. I won't say too much and give Fiona the stage. I think there is something. In the conversations that we had with carers and carers groups, they asked us for a number of things. The first was recognition. Recognise our contribution. The more that we do that, and I think the Parliament can have a really important role there, is just recognising and celebrating the contribution that carers make. Never take that for granted. That would help. The second thing is that this is one of the areas where a bit of standardisation is required. There's a lot of variation in the extent to which carers assessments are done, so a lot of variation in the extent to which the agreements are then honoured. If we promised to do things within four carers, we should deliver. I think that would help. The third thing is, as I said earlier, recognising carers' human rights too, and helping them to do the vital important work that they do by helping them into employment. They want to help them to take a break when and if they want to ease that path. Those things would help, but Fiona is immersed in this day-to-day. We got most of our ideas in our report about carers from listening to Fiona and her members. I'll hand over to Fiona now. I think that that point of recognition is extremely important, and that the role that carers have, the contribution that they make. Alongside that, I hear quite often from carers how frustrated the hidden army, the unsung heroes, and it's the delivery of support that they need to be able to undertake their caring role safely so that it doesn't damage their health and wellbeing and enables them to carry on working if they want to do that and to go into education if they want to do that. That's just to have an ordinary life where they can go for a swim, go meet their friends and have a break from caring. We know that during the pandemic that about 75 per cent of carers hadn't had any sort of break. I'd like to say that that's unusual, but it's not. Even in normal times, carers struggle to get a break from caring. They struggle to get support or even recognition for their own health and wellbeing. We hear quite often from carers who neglect their own health and wellbeing as well, so they can't get support to even go to their own health appointments and to look after themselves. There's a multi-faceted point about adult carers' support plans and carers' assessments. We started off with a challenge with the carers act. We developed a really positive approach of every carer being able to get an assessment if they needed one. It's not limited to regular and substantial. That was very much a bit preventative about recognising when people needed support and recognising from the very beginning and actually planning because there are some conditions of a person who is receiving support that we know what the trajectory looks like. There are opportunities for support to come on rather than it being crisis. However, when you overlay that with eligibility criteria, you break that, because carers are a resource. I hate to use that term as a resource, but there is a huge resource in providing social care in Scotland. We wouldn't think of saying to a care worker that, well, you can't have any holidays, you can't have any break from this. We wouldn't think of saying to a care worker that we can't be off if you're sick. We would provide occupational health, while I would like to hope that we would provide occupational health if someone has an injury. We would provide the equipment that people need and we would provide it at the earliest point. We're not at that point yet, so what a national care service needs to deliver first and foremost is choice, letting people choose what care they want to provide, because it may be that there's some level of care that they want to provide and other things that they can't do and a support plan behind that. What is it that you need to have the life that you want and to support the person that you love? That's quite often what it is about the person that you love and how do you balance that out to ensure that your physical health and wellbeing is not damaged. Where you have health and wellbeing needs are met quickly, because too many carers are quite simply breaking down. We will have a long-term impact because carers at some point will cease to be able to care because they've been damaged by the care that they've been providing. We've got huge opportunities for the national care service. We've got huge opportunities to really change and really shift how we view carers and to really get the support behind them to say that we value you, we value you, we value care workers, but we value care, unpaid care providers equally and we'll provide the support that you need for that. Okay, we are rapidly running out of time and I know that there's some panelist that wants to come in, but if we don't have time to come to you, if you maybe want to follow up by email, that's impressive, because we have got procurement to talk about and the aftermath of Covid-19, but I'm going to bring it in, Gillian Mackay, very quickly on the unpaid carers issue. I think that this should probably be directed at Fiona. Obviously, a lot of unpaid carers have been unable to take breaks, but I think that there's been a significant impact of the pandemic, particularly on the mental health of unpaid carers. Myself, when I was caring for my grandpa, the shadow of the pandemic and the risk that my activities outside of caring for him posed for his health if I brought Covid into the house and things, what do you think we should be doing in the immediate term to make sure that unpaid carers' mental health and that risk of burnout is decreased to the greatest possible extent? Do you think that there are other things that we should be doing in terms of making sure that, as we recover from the pandemic, unpaid carers don't continue to suffer unnecessarily? Fiona. I think that the point about mental health support is very important. From the beginning, we heard the distress of carers, the distress and fear of that very point about if I do X, will that put the person that I care for at risk? If I go to the shop, will that put the person that I care for at risk? That very real fear. To be honest, that continues, but you have burnout on top of that. It was good to see that the national wellbeing hub includes unpaid carers, but we need more going forward. I think that there are some short-term things that could be done because I understand the pressures around remobilising the NHS and some of the issues around mental health services, but I actually have a plan for supporting the mental health of carers, get investment out to carer centres for emotional support to increase their capacity for them to, for example, spot purchase counselling, and some carer centres have counsellors working with them. I will use the term to get some money out the door and get a plan to get some money out the door to the centres who have been providing support the whole way through and increase their capacity to offer a longer-term plan of how the NHS provides that support. However, we need to get that balance. We also need to get some quick wins in how we support carers. There has been investment going through and I do not want to minimise that, but what do we need to do now to help carers through? Is that about increasing flexibility and self-directed support for individual budgets to meet needs when care support is not available or it is going to be delayed? There is increased funding for carer centres for emotional support and other things. It is about more money going into breaks to enable individuals, for example, to have a family holiday to come and be linked in with the tourism in Scotland. However, if you do not have funds and you are on a low income, it is all very well to have a voucher, but you need funds to help with things such as transport and things like that. Speaking to carers, what is it that you need to get money out the door as quickly as possible? We have some questions on procurement and commissioning at Sea River. I want to bring all together into one question and contextualise it with something that happened over the weekend in the press in terms of promoting that preventative support and collaboration and trying to integrate and use more innovative solutions. For example, I went to see the food train in West Lothian. That is a question that is supposed for Derek Freely and for Judith Proctor, given that Mr Freely had said that there should be things that we are doing now and Judith with her role representing all the IGBs. We have heard at the weekend that, for the first time in decades, there was a 90-year-old woman that starved to death, and that the charities, in particular Age Scotland, said that it is desperately sad that it is highlighting the scale of pension and malnutrition across Scotland. It is harrowing stories from pensioners who talk of empty cupboards, problems with grocery deliveries, particularly among those who are not online. I suppose that that is why I am trying to… What can we do now while we are waiting to repurpose these services, to stop things like that happening again? Using the legislation that is in front of us now, what can we do in terms of commissioning and procurement in that regard? I will come to Judith first. Yes. That is a very shocking story. I am afraid that I have not seen that, but it is an important point. We have touched on some of the questions about this earlier in the conversation, which is about the local approach and how we fully work in partnership with third and independent sector and community groups, faith groups and people who are present in communities to create the kind of thriving, vibrant community in which people can participate and where people are visible and seen. That is a hugely important part of the considerations about how we resource a national care service and how we resource the community that we want to see. We are doing some work, most of us, in our health and social care partnerships, pathing all of us in the conversations that we have had about the lessons learned through Covid, with our third sector organisations, third sector interfaces and food and food poverty. It is very much a feature of that. How we support people who are housebound, how we support people in their communities is very important. There are some brilliant examples, as you mentioned, of the food train and the long-standing organisation that has been doing that for a number of years in different parts of Scotland, but also in different partnership areas. Other food focus charitable organisations, third sector organisations, are doing that. The role of our day services and day centres in that is also important to come back to the role of social work and how we are able to encourage people to come forward if they have got any concerns, if they are concerned about somebody and how we are able to find post and support them to those vital services. It is really important. It is one that is impacted by resources as well, so we obviously have to consider that and our ability to fund and support those organisations that we are going to create those networks and safety nets for people, particularly older people. I agree that those kind of tragedy events that you described should never happen. I think that there are two sets of ways in which a radical reform of commissioning and procurement could help. The first is around what we commission and procure. At the moment, too often, that is a very transactional timing task. The result of the commissioning and procurement process is just a lot of 15-minute visits, and that is often not what people need. We need to turn our attention to what commissioning and procuring is. How can we make that more relational and less transactional, and how can we make it more preventative and less crisis-oriented? That would help. I think about how we commission and procure. Our report makes some recommendations about that. We would like to see a more collaborative approach. We would like to take the market out of commissioning and procurement to some extent at least, and, if the market needs to play a role, it ought to be much more actively managed. We recommend a role for the catering spectra in the market oversight, so far as the market exists. We would like to see that replaced with greater collaboration. We would like to hear the user voice much earlier in the commissioning and procurement process. The second main focus is on how we should change commissioning and procurement as we weigh around the ethics of it. There is a call in our report for ethical commissioning, so that commissioning and procurement can be used as a vehicle for fair work, which we have already talked about. We also place a new set of requirements on care providers around transparency and commitment to high-quality and participation in quality improvement activities. Those would all, in our view, be essential prerequisites of awarding public money to any care provider. I come to Sandesh Gulhane, who has a question on procurement. In your summary, point 17 states that integration joint boards should manage GP contractual arrangements, whether independent contractors are directly employed. The question is, in this model, would you want the GP workforce to be directly employed or independent contractors in your ideal vision that you have set out? We are not really envisaging that the employment status of GPs would change. GPs would continue to be large with speaking independent contractors. How would the IJB manage the contract with independent contractors and those directly employed? What are the differences in that management? We are really focusing on local enhancements to the national contracts. As I am sure you are aware, there are bits of the country variations to the national contract. We think that it makes sense for at least some consideration to be given about enabling integration joint boards to manage those alongside the other contracts in health and social care that they will hold. Do you think that there would be a difference between those who are directly employed and those who are not? Sandesh, do you think that the Proctor wanted to come in? It would be best to do this through the chair, because it is quite difficult to manage. Can I bring in the Proctor first before I come back to you, Judith? I was just going to put some of that question in context, because I think that in practice IJBs or health and social care partnerships through the teams are effectively managing much of the engagement and the relationship with the contract with GPs currently. For our primary care teams, the work that has happened around primary care improvement plans is very locally driven in health and social care partnerships. The direct management of two C practices under the contract where GPs are employed is a far smaller number of GPs practices, usually in the specific circumstances, but they are managed within the health and social care partnerships that all have through the IJBs, clinical directors and the IJPs around that. There are already some of that management happening. I think that the report, Derek's report and the NCS talks about the overall contract moving from boards to the new community health and social care boards for their oversight. I hope that that is helpful. I'll come back to you, Sandesh. This has to be your last question, because we need to move on to our final theme on Covid-19. Just to directly ask again to Derek, would there be a difference in the IJB between those who are directly employed in the two C contracts and those who are independent contractors or is it going to be in much the same way? I don't think that we did not envisage a significant change in the current arrangements, as Judith MacDonald described them. It was much more about making sure that in the spirit of integration, there was the facility and the capacity for integration joint boards to oversee GP contracts. Judith MacDonald is much better able than I to describe the detail of that and how it might work. However, we weren't envisaging a massive shift in the current arrangements. It was much more of a tidying up that we had envisaged. I don't think that the arrangements that are set out in Derek's report or the NCS consultation will make a big practical difference on the ground, because we are all largely overseeing that contractual relationship now. I come to David Torrance, who has some questions around Covid-19 and social care. Thank you, convener, and good morning to panel members. Over the past 18 months, the pandemic has caused pressures and difficulty on the social care sector. What lessons can be learned from the experiences of the social care sector during the pandemic? It is hugely important that we reflect and learn the lessons over the pandemic and the lessons that we are still learning now. As a group of chief officers, we undertook a piece of work with Scottish Government colleagues and contributed to the lessons learned through Covid-19. We have done that individually within our partnership. Of course, there was a range of other pieces of work that related to support and oversight of care homes, access to PPE and those elements. What has been really important in that is the need for clarity in our communications with the sector. That was very important in the work that we undertook with care homes, being able to have points of contact for those care homes where we could support them, and having a real clarity in how we were supporting them to access and implement the guidance. It was also really important how we communicated with our own teams and organisations that we worked with to make sure that we were being clear on what we were doing, some of the challenges that those restrictions were bringing us and the amplifying of the national messages and terms of how we were operating through those restrictions, what we were asking people to do. It was obviously very important that we were able to, for the care sector, demonstrate practical support through things such as access to PPE, but also things such as sustainability payments needed to make sure, as far as we were able, that we did not see a significant level of gap in our ability to resource the sector. I think that that has been really, really important. That will remain important as we go through Covid, because we have seen impacts in terms of the capacity within care homes, we have seen impacts in relation to people leaving the sector, the increase in costs of recruitment. I think that the lesson in terms of ensuring access to appropriate resources to maintain the current level of service delivery is vitally important. I think also that the point that not every stage of the pandemic has been the same. I think that we need to reflect on the different waves and the different parts of the pandemic. I think that it is equally important that we do not think that the pandemic is over and that we have learned the lessons from it, because we are in a unique and differently difficult point in the pandemic now, so we need to reflect on this element of what we are learning with Covid now, the impact of Covid, the tale of Covid as it goes on. It is important that we take points over time to reflect and not just think that it is over, but that we have learned, because we have still got more learning to do. One of the things that we found, which we interviewed across in Scotland 38 disabled people and 30 in England and also in Scotland 20 organisations involved in social care and the same number in England twice during the pandemic to see what is going on. I think that one of the key things that happened with social care, one of the key learnings that happened at the start, I think that, admittedly, nobody knew what was going on. It was a very crazy, very difficult time, but disabled people seemed, like I said already, to disappear off the map. People told us how they felt lost, how they felt left out. If it was not for the third sector stepping in, many people would have been in real trouble. I think that the third sector played such a key role in maintaining contact, in maintaining services, in providing support for disabled people. We were told that people working in social care who were working for the local authority who might have been working, for example, with people with a learning disability, were moved to care of the elderly. That was prioritised over community services. Lots of services for disabled people were just closed overnight, people's drama groups, people's art groups, people's cookery groups. These might not seem important to most people, but a lot of people with learning disabilities are their only social contact. They are their community, and they were just closed overnight. They were left without these communities. It took the third sector, who set up karaoke groups, Glasgow disability lines, were running around the city, dishing out iPads or other things, teaching people how to do this and so on. That worked in some areas, but we can see that there were huge differences in digital access. In Glasgow, about 80 per cent of GDA's clients were digitally excluded in Edinburgh. It was about only about 20 per cent. We had different things going on. One of the things that happened during Covid was that the need of disabled people was forgotten about. As I said, people were talking about that. Communities disappeared. One of the other things that happened is that informal carers were left to carry a lot of the support that relates back to the points that were made earlier. Understandably, people's short breaks were stopped, but nobody thought, how can we go in and provide some other sort of short break? How can we provide somebody with an afternoon off to go out for a walk or something? I spoke to a mother of a 27-year-old who lived in Scotland. She had absolutely no contact from the local authority since March. She was looking after this young man on her own. She had nobody at attempted to short breaks, and she was close to breaking point. People were left. It was all right if people made a noise, but a lot of people didn't because they were so busy and so swamped. One of the things that we really have to do is to push the notion that domiciliary social care is very important, and it is something that needs to be driven to the top of the agenda. Third sector roles were central in that. Many third sector organisations have managed with very precarious working conditions. There are third sector organisations that provide services without contracts. They are going on a month-to-month basis. The precarity of employment in the third sector is quite frankly unacceptable with the way that we are treating workers in that sector. Henry Simmons, that will have to be our last contribution before we take a break. Henry, over to you. Thank you very much, chair. What I would like to say is that at the start it was very clear that people would run out of money, run out of food, have difficulty getting medications, and I think that there was a general excellent level of collaboration to try and meet their needs. I also think that it was important that some of the established services, such as day services, some of the home care services that were already being talked about, there was a good bit of partnership working that allowed us to reshape services. So care and spending registrations, for example, were modified. Funding that was for day care and was allowed to be used for digital visits and digital technology support. All of that was a good lesson that we can learn about collaboration and reacting to crisis, and we should take some strong lessons from that. What we learned most of all was that the infrastructure around individuals that are out with the main state of NHS fell apart. What happened was that our experience was that people jumped forward almost two or three years in terms of their time living with dementia. So people who are early stage needs to rapidly change to some of the mid and later stages, that we've now got a population of people who are not yet diagnosed, who need to be diagnosed, or people who receive diagnosis, who need to progress. We've had a really significant number of people who have progressed to require advanced care support that we weren't predicting. I think that I'm installing that. We've seen things like significant excess tests that we need to try and really understand. What that is about is the importance of the non-pharmacological interventions that are around individuals and families, and if anything, it's the best example to show you that if you take away that social support, social infrastructure, all the things that make people have a quality of life and stop it instantly, the decline and the impact of that decline is so significant that it's quite frightening. The truth is that we'll probably find ourselves in the future in another situation where there will be a pandemic of some kind, and we need to prepare for that and make sure that we don't just put everything dead stop and then try and pick the pieces up, but we've got to try and taper it out, and that will mean a really resource in the setting in such a way to cope with that, and the collaborative way that we did, but perhaps in a more structured way going forward. Thank you. Thanks to everyone this morning. I've kept you an awful lot longer than we originally intended, but I think it's been hugely worth it giving you time to air quite a lot of these thoughts that will inform our work programme. We're going to take a break now, back in five minutes. Our third item today is around table with stakeholders on health and social care finance, and this is intended to inform the committee's future work programme discussions, and also to inform the committee's approach to pre-budget scrutiny. I'm going to start off with a slight apology in keeping our panellists waiting. You've been very patient. I'd like to welcome Lee Johnson, Senior Manager of Audit Scotland. Professor David Bell continues along with us from the last session, who's Professor of Economics at the University of Stirling. I'm the Chief Analyst of the Kings Fund and David Walsh, Public Health Program Manager of the Glasgow Centre for Population and Health. Thank you all again for waiting and for coming to join us this morning to help us without our work programme. I'd like to ask all of you to come in and to ask about if there's a greater scope in this landscape for prioritisation of preventative spend. Given that we're dealing with the aftermath of a pandemic, we're setting up a national care service, but time and time again it keeps on coming back that we don't prioritise preventative spend enough. We heard from the last panel that when you do preventative spend, it actually saves money for the future and has better outcomes. Given that we have got this pandemic, we're in a bit of a crisis moment, you can see how it's difficult to square the circle there when you're actually dealing with immediate concerns. Can I go round all of you and maybe start off with Lee Johnson? Good morning, convener. Thank you. I think that as we've reported before, obviously integration was intended to help shift resources away from the acute hospital system towards more preventative and community-based services, but, as we've seen, that's not been easy to achieve. We've reported that there's been a lack of agreement about whether it's achievable in practice or whether rising demand for hospital air means that more resources are needed across the system. Of course, with the huge backlog that we now see from the pandemic, it requires disinvestment and reinvestment. As I've said, that's been very difficult to achieve up to now, but I think that what the pandemic does offer is a chance to do things differently, to seize the opportunity and to think about how we can deliver things differently in a more sustainable way going forward. I just echo what Lee has said. I think that part of the difficulty of moving resources towards preventative spending, as the Christy commission advocated several years ago, is being able to demonstrate the usefulness of such preventative spend and convincing managers that there are genuine resource savings to be made about allocating more towards preventative spend. That is a difficult task. It is not easy to make that convincing demonstration to those who feel that acute services are under pressure and require immediate support. In our earlier session, Henry Simmons talked about how lifestyles changes might reduce the negative effects of Alzheimer's progression. That seems now to be an accepted result, but it is difficult to persuade. It is just a reiteration of the same. It is difficult to persuade managers that putting in place programmes that may not see a successful outcome for years to come is worth doing. Many countries have tried this, some with more success than us perhaps, but it is a huge challenge. I should say that I work for a think tank that is based in England, so I was going to say an awful lot, but almost everything I will say will be based on an English context. I would make five quick observations. The first is, I think that the logical business case for greater investment in preventative service and public health services has been made. The second thing is, as the other panellists have said, that does not seem to translate into that greater investment. I would observe that things are held to different standards, are they not? If I was to propose the building of a new hospital, that would not see a benefit for five to seven years in most cases, but I am certain that that business case will get through a lot easier than the case for a transformative impact increase in preventative spending. The third thing is, in England at least for the first time, and I think that we are following your lead in Scotland to a large extent, some of the structures are changing to support greater preventative spend, but we are forming integrated care systems where the basis of work is collaboration rather than competition for greater elective activity. I think that the contractual frameworks will change, so we will get off this hamster wheel of annual spending, and we will have a three to five-year budget. That gives you that headroom to invest in services that pay dividends further down the line. Perhaps more importantly, our expectation of what the leader is meant to do in our healthcare system is subtly changing from running a good ship, running a good hospital or an organisation to being a system leader. You are thinking about the health of your population. Having made those optimistic points, I would like to finish on two slightly more pessimistic points. In almost every conversation that I am in at the moment, the elective care backlog, the waiting list for planned hospital care, take up almost all the oxygen in the room. That is for historical reasons, because that is where most of the data and performance targets are measured, and there is simply not enough funding available to parallel run-to system, a system that is focused on tackling that backlog, a system that is focused on transformative improvements and preventative spend. I think that at the moment it is uncertain what the strategic priority of the system will be for the next five years, but as one chief exec put it to me, how I work out what my priorities are, I think about what I get sacked for, and I can tell you now that over the next five years it is more likely that I will get sacked for not tackling the elective backlog than for any other issue. I am sorry, but it makes hopefully some hope and a little bit of pessimism as well. Thank you, and can I come to David Walsh? Yeah, thanks and good morning. I should preface this answer by saying that I do research in the area of health inequalities, which is less around health service and more around the broader determinants of health. I think that if we are talking about prevention, you need to understand prevention in the really wide sense of the big social and economic drivers of poor health and health inequalities that exist. It is really important to look at the context here. We talk about Covid and the crisis on the health service, but it is important to understand that we are already in a crisis before Covid. The impact of the UK Government's austerity measures in taking out £47 billion across the UK from social security payments has had a devastating impact on health outcomes everywhere and clearly in widening inequalities. We have been talking about a stalling of improvement in life experience as one marker of population health, but we know that that actually masks increasing death rates among the most deprived populations across the UK. In terms of prevention, I think that it is really important to understand that context that, even before Covid hit, we already had the widest health inequalities in Western Europe, but on account of the last 10 years, they have become a lot wider. Covid has come and Covid will go, and we will see the impact in terms of a couple of years of markers, like life expectancy and mortality rates. However, when we go back to pre-Covid rates, we were, as I have already said, in a crisis already. I think that it is really important to understand that context. You have picked up on some of the other issues that colleagues are going to come in on, but that is what I was driving at, is the interdependence of different portfolio areas in terms of government in terms of having an impact on health outcomes that you have picked up on the idea of economic inequality having a direct impact. You could say the same for educational inequality as well. I will come back to David Ford to go to colleagues. Do you see that one of our panellists last week made the comment that every Government Minister is a health minister and that you should be viewing your outcomes for health through the lens of absolutely everything else that you do? Your thoughts on that, if we were to look at something like a universal basic income, what could be the impact on health outcomes there, for example? More generally in terms of that question about does it all matter to all these different departments and somehow relate to health? That is a fundamental understanding of public health. There are thousands of models of health determinants out there that have many, many factors in them. They include health services, but health services are not only one of many things, and it is not the most important. What is the most important thing, or the socio-economic areas that you allude to? The evidence on the relationship between income and health, between employment and health, and education, and the conditions that you have brought in, are overwhelming, and they go back not just decades but centuries. It is important to understand that all those factors ultimately impact on health. At one level, that is public health evidence. It is also common sense in terms of the ability to health behaviours there, but health behaviours do not emerge in a vacuum. They are about how you respond to the environment that you are in. Socio-economic factors are imperative. Income is imperative. Things around minimum income for health are really, really important. There is work going on in various areas around trying to understand the ways that we can protect the poor, because this is fundamentally what it is about. Again, coming back to austerity, the impact of the cuts on social security has been, as I said, absolutely calamitous in terms of taking away the safety net of the poorest and most vulnerable in society. What we have to do in the context of rather limited powers in that area is to try to do what we can to protect the income and therefore the health of the poorest and the most vulnerable using the powers that we have. Although, in terms of social security, they are obviously very, very limited. We are going to come on to more in-depth discussions around some of the themes that you have all mentioned. On the idea of the strategic context for health and social care finance, I am going to come to my colleague Evelyn Tweed. Thanks, chair. I am really interested in some of the early comments that were made by the panel there. How do we give managers the headroom to deal with future and preventative care and providing an exceptional service, rather than them only having to deal with present conditions and backlog? I guess that we should maybe just come to reverse order if we come back to David. I will go through everyone. Otherwise, if people want to come in, in any of the future questions, you just put an R in the chat box because I will not be able to go around absolutely everyone for every question, so that would be very helpful. During this and the reverse order probably is not the best for me because, as I said, my research is not really around health service spend, which I did make the point when I was invited to come along, but they were keen for me to talk about other things. There are probably others on the panel that can respond better to that. The areas that I work in are more around, as I said, the broader social determinants. Clearly, they are the factors that predict poor health in the first place, rather than just when you encounter a health service as you are already in that situation of having poor health. If that is okay, I will skip that question and leave others to respond to those particular issues. I think that the headroom is for clinicians as well as managerial staff. I think that that was in your question as well. I honestly cannot tell you the number of clinicians who say that that is the first thing that goes. We call them, in this country, SPAs or special programme activities. That is basically my headroom, where I can think about changing my service. That is the first thing that goes because I am back on the back-og. I think that the answer I am picking up on some of the things that was said before. If we have not got the right supply of staff and we certainly do not in England, that headroom is incredibly hard to create. Until you increase the size of the workforce, you will always be in a hole. The second point is that there is something about the technical information and skills and capabilities that we have. Do you have the integrated data that shows you where you should be having the greatest impact? In parts of the country, absolutely. If I go to Greater Manchester, it has all the inverted pyramids over this group of populations, relatively small but accounts for a large amount of cost. If we were going to invest in more preventative spend, that is who we should be supporting the most. Other parts of the country lag far, far behind. There is that technical data bit. As part of that, I think that giving people the capability for how you can improve services because we have lost some of that ethos of lean operational thinking. The third thing—probably for me—is that the hardest to get my head around but also the most important is culture and organisational development. What particularly sticks to my head is talking to a group of consultant ophthalmologists, where I was trying to do the self for more preventative investment and greater integrated thinking. They said that we get it, intellectually we get it, but for my entire career, I have been trained to focus on throughput, getting people in and out of hospital and my service as quickly as possible. I want to do things like tackle avoidable blindness. I want to do things like tackle unmet need. No-one has yet told me, first of all, that that is what my new job description is, so I want clarity over what behaviour should be rewarded. Secondly, how on earth I do it? What is step 1, 2 and 3? I think that the places that I have been most impressed with, places like Greater Manchester and parts of Dorset, are the ones that have really invested in organisational development to support consultants working in a different way. Thank you, and can I come to David Bell? Beatryd, what Seville has just said about metrics, if all the metrics that clinicians and other health professionals are confronted with are effectively around short-term acute issues, which can be easily highlighted by reporters in press, it will be difficult to switch the attention away from acute budgets. The issue of long-term budgets, again, we are about to have a spending review, but there has been very little consistency of budgeting, which is really a UK Government messing around with the timing of budgets and their coverage in time. I agree with a lot of what David Walsh said, but the Scottish Government's budget is increasingly dominated by health and sport. It now accounts for a more than 40 per cent of the overall budget. There used to be roughly the same level of spend on health as there was on local government. For 2021, health and sport spend is forecast to be £17 billion and for local government £12.5 billion. There has been a big change, so the opportunities to engage with the preventative activities that David talked about has been much limited. I agree with the point about data. If you do not have the right data, that was a point that I made in the previous session. If you do not have the right data, then you cannot take the right actions. I am the issue of silos in terms of different ministers or different government departments being responsible for spending their own money and not saying that some of the resources that they are using would be better allocated to one of the other departments is a big issue. I will bring in Emma Harper, who has some questions on this theme. Thank you, convener. I was just waiting on my camera and microphone being activated. We took evidence at the previous health and sport committee about shift in the balance of care, moving finances into a social prescribing model. One of the things that I was interested in was the prevention of type 2 diabetes complications, because we spend lots of money mitigating complications or treating complications. £800 million is a lot of money when these are complications that are preventable. I am interested to know about how the panellists do that, and maybe we start with David Walsh first. What is the value of social prescribing? Should that be invested in more in order to help to improve health and tackle inequalities? That is something that I am interested in just because of our previous committee work on social prescribing. David Walsh, you want to go to David Walsh first. There is some emerging evidence that is quite local about the effectiveness of social prescribing. In relation to that specific question and how you have led into the bigger question about health inequalities more generally, it is about a kind of balance. If some GPs prescribing social remedies, that might work in some cases, but where, as I have alluded to, there is a crisis in basic social security funding, it is not going to address that balance. It really depends on individual cases in that sense. Clearly, if people are having their income taken away, they are being told that a walk would be good for them. I am not trying to belittle it, but it depends on how that fits with individual circumstances. More generally, when it comes to the issue of health inequalities and what we do about them, there is a really important point to note, which is that we know what to do about them because the evidence is all out there. The Scottish Government itself commissioned an international policy review of what works to address inequalities and what does not work. That was undertaken by NHS Health Scotland, which is now Public Health Scotland. That is all published, published about four or five years ago. We know that there are different levels in which policies are effective. There are policies that address the fundamental socio-economic drivers of health inequalities. That is about the stuff that I have mentioned around redistributing income, protecting the income of the poor, and addressing poverty. There are other more environmental areas, such as housing policies, air pollution, taxing alcohol, et cetera, et cetera, and there are some issues around addressing individuals' experiences of inequalities. However, the most important thing is addressing the fundamental socio-economic factors that drive health inequalities. The issue is that we get into a discussion about what works. We need political will and political bravery. However, in the devolution context, we have to ask the question of what powers Scotland has to bring about those changes and to introduce those policies. To address those more fundamental socio-economic factors, we need to have sufficient economic levers. That is questionable. The evidence is there. It comes into political will and political powers. It was just really to follow up on David, in terms of the role of Public Health Scotland, and they were set up at the start of the pandemic. I have been at the forefront of dealing with the pandemic, but I do not think that they have had the opportunity yet to do what they were set up to do in terms of that whole system approach to Public Health. It would be good to see what they can achieve once they are able to do what they were set up to do. I also want to comment on the wider approach that Judith Proctor talked about in the previous session. As I said, integration authorities were set up to try and move the funding into the community to more preventative care, but there are a number of areas that we identified in our integration report on how that could be achieved. That is around—again, some of that has already been talked about—the need for collaborative leadership, systems leadership, rather than thinking about the aims of a single organisation and thinking more about the outcomes that you are trying to achieve for your community. I think that some of that is around the effective strategic planning as well, linking your resources to the priorities and then being able to link those to the outcomes that you are achieving. However, as has also been mentioned, data is the need to have access to good data. Again, we reported on a number of occasions that there is still a lack of data in terms of what is happening in communities, in primary care, in social care, and being able to show the outcomes of those preventative approaches is important. How best do we determine the level of funding that NHS and social care need after Covid? I know that the BMA has said that short-term boosts will not be enough to deliver the full recovery that services need and that what is needed is a full review of health and social care spending in the context of a national conversation about our expectations. Would the panel support that approach? Who would you like to go to first? Sorry, it is difficult to tell. As David said, health funding was already a huge proportion of the Scottish Government budget, and that has increased through further spending throughout Covid. We have said on a number of occasions that the NHS was not sustainable before the pandemic, and costs have continued to increase throughout the pandemic. However, there is continued uncertainty about how it will be funded going forward. Obviously, the Scottish Government has made a number of spending commitments in the recovery plan and in the programme for government. It talks about a 20 per cent increase over the Parliament, but what we need to see is a refreshed medium-term financial framework for health and social care. It is also important that we bring the public along with them, because in terms of recovery and sustainability, things will have to be delivered differently. Of course, that needs a culture change among the public, so it is important that we engage with the public and bring the public and staff along with us in delivering services differently going forward to ensure the sustainability of the NHS going forward. Siva wants to come in. Thank you, convener. There needs to be a refresh of the UK's medium-term forecast for health and care spending. I completely understand the criticism that people have made about tactical short-term booster funding. One finance director said, because of this, that my financial plan moves from a cliff edge to a cliff face, because money comes at short notice that I suddenly have to spend in a value-for-money way. I can emphasise enough how hard it is to develop a medium-term financial forecast that you can plan a lot with this level of uncertainty over demand, not just because we still do not know what the path of the disease will be, but also because we do not know when demand for routine services will come back, and what complexity that demand will present and how it will spread over time. There is a question over when is the best moment to have that medium-term plan, and I would suggest that you are looking at the start of the next financial year at the absolute earliest. The second bit beyond timing is what you want to plan for. For me, increasingly, I am starting to segment it into—there are still direct costs of dealing with the pandemic—things such as test-and-trace systems, PPEs, and that is the first bit. The second bit is tackling the backlogs, and I mean that broader than just standard active care—things such as mental health services, child and adolescent mental health community care, you name it. The fourth thing is resilience. What would a resilient health service or a health and care service have like? Not just resilience to a pandemic, but resilience to other threats such as cybersecurity. That is a pet concern of mine, that, as you see the shift to more digital and virtual consultation as the default mode, what redundancy are you building in and what does that cost? The fourth and final one is the business-as-usual growth and healthcare spending, which tends to go up by 3 to 4 per cent due to a combination of factors and so you almost have to bake that in before you air in these other cost pressures. Thank you. Thank you. Can I come to David Bell? I'm going to agree with Lee and Siva. You've got this 3 to 4 per cent growth annually. In our earlier session, I alluded to what the part of the problem there is, the ageing of the population and the concomitant largely chronic diseases associated with that. We really don't know at what rate the unmet need, which was clearly there during the pandemic for non-pandemic-related healthcare, is going to be unwound and that will have an important effect on funding requirements. Currently, the budget for 2021-22 is for £17 billion to be spent on health and sport and our income tax receipts, which are our largest tax, are for £12 and a quarter billion. The funding is an important issue for the Scottish Government to address the danger that—well, how to engage with the public and staff around this inevitable growth in demand against the needs of other parts of the Scottish Government, such as education and local government and so on. I'm going to bring in Emma Harper for a very quick supplementary before I move on. Thanks, Gillian. I don't have a stop. That was just a correction of a spelling mistake in the chat function. I'll bring in Paul O'Kane. That discussion really begins to help us to think about the context of coming out of the pandemic and what's going to happen moving forward. I'm quite interested in the service redesign. We touched on that in the previous answers, but I think it's about what can we learn from the pandemic, but doing things differently will have a saving attached to it, particularly around digital. In the context of social care as well, technology-enabled care is quite interesting as well. I really just get a sense of where we think the opportunities are for some of that. I think that there are opportunities. Obviously, there has been some advances during the pandemic, as you said, in terms of digital, in terms of redesign of how people access urgent care, such as the A&E system. We have to balance that. There are opportunities there, but there are also huge increases in costs. It's just how many of those costs will become recurring, as some of the panellists have already talked about—the vaccination programme, test and protect, the increased infection prevention and control measures, PPE cleaning, social distancing have hugely increased costs that will be offset of any potential savings that are to be made. We have also talked about the huge backlog of patients that still need to be seen. The investment that is required to progress digital technology will lead to increased costs and investment. It is important that we properly evaluate some of the innovations that have happened during the pandemic to make sure—obviously, it wants everyone to make sure that they are meeting the needs of the population, but that they are sustainable in the longer term as well. I think that an overarching point that has indicated that this is largely an evidence-free zone. There are a few real-time studies that are collecting real-world evidence, but I would rely on nothing to be honest on before planning massive service changes. There are three buckets in England that people are looking at for productivity improvements that were spurred by the pandemic. The first is, as Paul mentioned, digital and particularly virtual appointments for primary care and outpatient care. It is certainly not finished, but the early evidence that I've seen suggests that there is clearly a wider societal benefit to reduced travel time, reduced emissions, needing to take less time off work. The impact on NHS productivity is much more equivocal, including whether you can reduce the number of dropped appointments or appointments where the patient did not attend. I think that it is—and clinical productivity as well. I think that the real questions around that need to be answered. The second area is about more operational changes. In this country, we have seen a lot more of things like sharing a single clinical rotor or sharing equipment, particularly larger equipment like CTI MRI scanners across a wider pool of organisations. It is not much talked about, but it has seen a reduced downtime for those assets, which has led to some productivity improvements. The third area is service reconfiguration on a broader sense of what services are delivered where. Because of the pandemic, many countries separated out band routine services, particularly in hospital, from what we call hot services, where it is an emergency harder to predict their patient coming in for trauma through an A&E department. There are productivity benefits to separating those out. The pandemic has made that possible, but I think that those are the three train tracks that we are trying to build more evidence around. Finally, Lee's point about infection control is the rate-limiting factor. Infection control guidance, at least for the next six months, will be the rate-limiting factor on how much productivity a health system can deliver. Just checking with Paul, because he is remote. Paul, do you want to come back on any of that? No, I think that's helpful. I've got some questions on just sustainability, but we can move on to that. That's fine. We're going to talk about the financial sustainability aspect of all of this. And we've got, kicking that off, Sue Webber. Yes, thank you very much. It's just to ask the panel for their thoughts on causeless comments that the consultation cuts through the heart of governance in Scotland and will have serious implications for local government. I know that maybe the first person can be Lee from Audit Scotland because they've been quite… Talking about the consultation, are you talking about the social care? I'm just aware of time that I was just talking about the finance in general. In terms of their thoughts on the consultation. Which consultation? For the national care service? Right, okay. If you don't want to ask, I can… No, that's fine. It's just that I thought it was more general points, but if anybody wants to come in on that, please let me know. I did ask Lee, but I don't know if she wants to… Lee, did you want to come in on that? I know that it's not really the theme that we were on, because that was the last panel, but if Lee wants to come in on that, that's fine. Yes, I think I've been unmuted. Just to say, obviously, I have to be cautious about what I comment on at this stage. We are in the process of drafting a response to the NCS consultation. You know that we've said that changes in how social care are provided in Scotland are needed, but the solutions are far from simple. But I think that the other thing is that the new models of care that are required will cost more money, and it's not clear how they'll be funded, but around the governance arrangements, I'll not comment at this stage. David Bell wants to come in. Just to say, I suppose that I'm less constrained than Lee. I listened to Derek Feeley in the earlier session making a very good case for the national care service, but I do worry a little bit about what that leads for local government, because their functions will be further depleted as a result of the establishment of the national care service. Having already lost police and fire services, it seems to me that there is an issue around attracting people into local government, both in terms of professionals and elected members. As functions are drawn away, the attractiveness of that route seems to me to be potentially declining and we would need some further investigation, because we are a relatively centralised country. Further centralisation always seems to be an issue that ought to be considered very carefully on democratic grounds. Bring it back to the financial sustainability of NHS boards. You want to come back on that? If we could focus on that, that would be helpful for this session. Thank you very much. We spoke about centralisation in Scotland, but it is also very diverse. In terms of trying to identify how we might want to change how NHS boards are allocated their money, because that is one of the issues with integration right now, that the money goes from the acute service to the primary care and social. What other models are you looking at in terms of what might be considered as best practice across other areas? Why do not we ask the King's Fund? Sorry, my lenses have gone, and I cannot see any of the faces at the moment. Thank you, convener. I am really sorry, but I have asked half of the question. I have got as far as allocation to acute services that then get devolved to primary care. What other models of funding might be appropriate for us to look at this national care service? Great. Thanks for that. I have never seen a model that is demonstrably better than the other. I think that other models include that. In this country, we are broadly looking at three different models. One is a contractual model that binds together health and care organisations broadly for the totality of their services. Take a patch like Greater Manchester, let a contract that basically says that all of you organisations have to work together to improve the health and wellbeing of the population of Manchester, and you get a single lump sum allocation that you decide, as a local system, how you want to divvy up to best meet that goal of improving the health and wellbeing of the population. The second model that we are looking at is more structural, so merging organisations together so that a single budget is used, but it is not a contract binding different parts of the system together. The different parts of the system are now one organisation. If you look at parts of Birmingham, you have primary care services working as part of the acute hostel together with community services, which is basically an integrated provider. The third model is much more disease specific or patient cohort specific, which is, for example, there was a contract in Staffordshire for cancer services, where, again, rather than binding everything together, it was come together to plan how you would improve the health and wellbeing and essentially mortality and morbidity of patients with cancer. If I am being honest of all of those, I have not seen any evidence that one is better than the other, partly because I say two reasons. First of all, you can do whatever you want, but if you have not got the wider conditions for success, which are enough staff, long-term planning and clarity of the strategic direction of travel, then the contract cannot overcome all of those. The second element is much less technical, purely down to leadership. If I look at parts of Tameside and Gossip and I see how they have come together across the council and the NHS to tackle rough sleeping, the contract and the structure came years after leaders coming together to say that our current model was broken because people who were sleeping rough are ending up in hospital because we are cutting services like bed and breakfast provision. What if we were to say that there is one Manchester pound and the best way to invest that is to have those preventative services and they sorted out the contract afterwards, so it was culture before form? I think that it is worth looking at a menu of options, but, with the recognition, it can get you so far. Can I pick this up? Obviously, the system that is used at the moment in Scotland is the NRAC formula. I wonder if any of our panellists would like to highlight some of the issues that there are with that, because that is the crux of the matter. That is the formula that has been used right now, but what else is out there that might address some of the concerns that has been around that formula? I am looking for anybody who wants to come in first on that. Can I come to David Bell? This is the allocation to health boards, which is basically driven by the kind of formula that also drives allocations to local government, which is essentially around estimates of need, principally driven by population, but then by demographic structure, levels of deprivation and so on. I have had a lot of experience with those kinds of formulae, whether you can fine-tune them to improve their performance. Clearly, there are areas that feel they are hard done to in relation to that. There was a long period, I think, where Grampian felt that it was getting insufficient money, given the issues that it faced. Part of the problem is that a lot of this is hidden. People do not understand how those determinations are made. Bringing that out into the general public discourse so that there was some understanding would be useful, but I would hesitate to say, oh yes, I have a better formula that will result in reduction in Scotland's health inequalities in the near future. It is, I think, a wider problem than that. It goes back to our earlier discussion about social and economic circumstances, which will not be resolved simply by allocations to health boards. Just to agree with Professor Bell and to try and provide a shorter but better answer to the question than I did before, which is that we use a very similar resource allocation formulae in England, which is broadly weighted capitation. You can tweak the parameters and inputs how much weighting is given to deprivation. I have not seen a fundamentally better way of allocating healthcare resources than by weighting capitation with the usual components of deprivation in age. If you want to fundamentally change things, there is as much to be done in how that money is used once it has been allocated to a health board, then changing how the money is centrifugally flung across the country. Thank you. David Walsh wants to come in. I was just a very brief follow-on from what David Bell said. I agree with what he said in terms of the complexity of how things are measured, but one of the things that he does is try to take into account deprivation. I would add on to that that deprivation is not measured terribly well in some respects. I think that what has happened in the last 10 years, in terms of, as I mentioned before, the impact of austerity, is that we are not capturing some of those additional levels of poverty, which also interact with some really pertinent issues at the moment in terms of the really high rates of drug deaths, for example, that we are seeing in particular areas such as Dundee, which have measures of deprivation that are similar to other places that do not have those issues. I am not suggesting a better formula, as it has been hinted. It is very complicated, but I think that there are some potential tweaks around understanding aspects of deprivation that the current formula maybe is not quite picking up. Thank you, and I certainly hear that around rural poverty as well in my area. I am going to come to Sandesh Gohani, who has got some questions about financial sustainability. I wanted to just ask about the way that the money will be used and is used. So my understanding is that a board gets its money through its funding. This is then divided up into its allocations, into its divisions and allocated. With the person, with the money, the thing that I always hear is clinicians saying that they are not able to use that money. So my question really is about who is the determinant of how that money is spent, is it clinicians or is it managers and who do you feel it should be? Who would you like to direct that to, first of all, Sandesh? Can I start with David, please? David Bell or Walsh? Sorry, David Walsh. I think that the correct answer was Bell, because I do not do any research into aspects of health funding within the NHS board, so the other David may be a better bet for us. It may not be my first choice subject, but clearly there has to be clinical input around the decisions that are made by health boards, but there also has to be an overall strategic view and it has to reflect the challenges within the area that are faced. I would suggest that it is not always the case that clinicians have the strategic picture of what is happening so that there has to be somewhere where those views are all brought together and decisions are made. Obviously, I think that clinicians have to be involved, but it is not entirely clear to me that it should be clinician driven. We are going to go on to our final questions. Stephanie Callann has some more questions on the integration of health and social care. I will direct that to Lee and Siva. I think that they are probably trying to get me to come in and suggest something else. I will also mention that I am an elected councillor at South Lanarkshire as well. Earlier on, we had Lee speaking about the systems management approach. Currently, certainly we have IJBEs and we have health and social care partnership directors who have got quite a difficult role there as well working between chief executives in health and also in local councils too there. Certainly, pre-COVID, there has been some success in freeing up hospital beds through preventative care in upskilling staff, preventing admissions, quicker hospital discharges and shifting funding into care and treatments that are delivered in patients' homes. I wonder how, moving forward with the NCS and the much bigger scope that we are looking at there, how do we achieve that much bigger shift from hospital to community care and how is it that we make that funding work and get the right culture and the thoughts in place for that to happen? I recognise what you are talking about, as you know, South Lanarkshire was one of our case studies in our integration report and the moving of money and reducing hospital beds. As I said again, I can only refer to our previous report on integration. I think that it is important that we learn the lessons from what has been difficult through health and social care integration. The collaboration and agreement that is needed for the reforms going forward has been difficult to achieve elsewhere. I think that the six key areas—again, I am going back to those that we identified—still have much relevance for the proposed reforms. As I was saying, the collaborative leadership is trying to encourage people to think about the outcomes of their community rather than what they are trying to achieve for a single organisation around good financial planning—longer-term financial planning—so that you can, as we have already talked about, plan some of that disinvestment and reinvestment that is required to shift resources from the acute hospital into community, effective strategic planning, making sure that your priorities are linked to your resources and that you are clear about the outcomes that you are trying to achieve, and the other area that we identified was around the grade governance and accountability, particularly around clinical governance, for example, being clear about where the decisions lie and when someone is no longer responsible for something. The issues around data are still key. How can we appropriately share data across the system so that people do not have to repeat their story? Of course, the other issue is that a lack of data to understand what is going on in community care, social care and primary care makes it difficult to understand activity and plan for what needs to change and the outcomes that you are trying to achieve. The other thing that we have already talked about is the on-going, meaningful and sustained engagement with the community, with the public and with the service users. As I have said, we need to take them along with us in terms of the way that we reshape services because it needs a culture change in the public as well as staff. Stephanie, you wanted to address Siva as well. Thank you. I will say four things very quickly. One, as you said, is to be absolutely crystal clear on accountability. Are you now, as a board, jointly accountable for the entire pathway because the default otherwise will be once the patient has been medically fit for discharge and has left the organisation, my accountability as a condition ends? The second thing would be that there is a strong argument for building outwards globally from particular services or opportunities where there is better evidence that joint working works. Safe discharge into a new setting is one, a second would be around end-of-life care and a third would be around rough sleeping. I say that just because I have seen too many instances where the health and care organisations come together to try and either boil the ocean or focus on things that are really an NHS-specific issue. I vividly remember a councillor saying, why am I sitting in meetings for three hours talking about a joint venture on pathology? This has got nothing to do with me. End-of-life care, I can absolutely see why we need to all be in this room. The third one, speaking to the point that I have been doing, has been any big strategic change programme. It includes just making sure that you spend time together. There is one group of chief execs in the south-west of England that every Friday afternoon they carve out and spend time together to understand each other's needs. All we need is to trust each other. We do not have to get along or even like each other, but we do need to trust and understand each other. There have been quite tactical tasks that have been set for organisations such as going away. Everyone in this health board, health and care board, go away and make one decision by the next meeting that is to the detriment of your organisation but the benefit of the system. The third thing tactically is that I have seen time and time again that people who train together and learn together in some way work better together, so opportunities for joint training and working. The fourth and final thing is about almost a reality check. Almost every piece of evidence that I have seen is quite clear that integrated care can deliver better value and a better value outcome for the inputs that we give a health and care system. It is very ropey evidence that it saves money. If the task for setting people is to improve value, great. If it is to take loads of cash out of a system, I think that that is going to create the wrong dynamic and the wrong tension setting them up to fail. Thank you. We have come to the end of our time today. I want to thank all of our panellists from this panel and the one before for the time that they have spent with us. It has been very valuable as we think about our work programme and our financial scrutiny of the upcoming budgets. So our next meeting on 5 October, the committee will consider a legislative consent memorandum, and we will discuss that future work programme. That concludes the public part of our meeting today. Thank you all.