 Welcome to the 14th meeting of the Health and Sport Committee in 2019. We have received apologies this morning from Sandra White and from David Stewart, and a sour is attending as a substitute member today. Welcome. Can I ask everyone in the room to please ensure that mobile phones are off or on silent? The first item on the agenda today is subordinate legislation and consideration of a negative instrument. The national health service free prescriptions and charges for drugs and appliance of Scotland amendment regulations 2019. The Delegated Powers and Law Reform Committee considered the instrument of its meeting on the 7th of May and determined that it did not need to draw attention of the Parliament to this instrument on any grounds within its remit. Can I ask if any members have any comments they wish to make on this instrument? If not, does the committee agree to make no recommendations? Thank you very much. I move on to agenda item 2, which is pre-budget scrutiny for 2020-2021, which is an evidence session with chief officers and chief finance officers from three integrated joint boards. The committee agreed to undertake pre-budget scrutiny for 2020-2021, building on the approach that was taken in previous years with scrutiny of the integration process, and that will be the focus of today's meeting. Can I welcome to the committee, and in some cases welcome again to the committee, Judith Proctor, chief officer and Moira Pringle, chief finance officer from Edinburgh, IJB, Avalda Sousa, chief officer and Mary Moy, chief finance officer from South Lanarkshire, and Eddie Fraser and Craig MacArthur, chief officer and chief finance officer from East Ayrshire, IJB. Welcome this morning, and thank you very much for your attendance. Can I start off with a general question on the budget process? One of the things that the committee has had a focus on is trying to understand the budget-setting processes in IJBs and how far they are achieving the same level and standards, and indeed the same timetable. First of all, for each of the IJBs, whether you did agree your budget by the beginning of the current financial year for this financial year. Who would like to start? Also, any issues that might have arisen, Eddie Fraser? I'm pleased to say that we were able to set our budget on 28 March this year, and that followed the council setting their budget in February, and the health board being able to set their budget on 27 March. This year, which has been different from previous years, we were able to do that. Because it was set at the very end of the financial year, there were still some of our balances in terms of how we were going to bring the budget into balance in terms of some of our efficiencies that we still had to work through and then take back to our future committee of the integration and joint board, but we were able to set the budget this year. Likewise, I'm delighted to say that we were able to set the budget this year. Again, that was with quite a bit of support from our partners on both the NHS and the local authority side. We agreed the settlement to the IJB from both partners, and we have worked through a process within the IJB of agreeing the budget savings and efficiencies and transformation that we need within the partnership as yet. We haven't identified a balanced budget, but we're working very positively with our partners and anticipate being able to do so within this financial year. Is it your expectation then, looking forward, that Edinburgh and future will seek to be in the same position as the other IJBs? Most definitely. We want to be in a position where, going into each financial year, we're able to set a clear budget for the partnership. Thank you very much. Eddie Frazer mentioned that this was a change from previous years and clearly it's work in progress across the country. He also mentioned that the health board for Ayrshire and Arran met to set its budget the day before you did the same in East Ayrshire. In the past, we've found that the different timeframes of local authority budget setting, health board budget setting, have had an impact on the ability of IJBs to plan ahead. Is that still the case or is that something that is changing? Judith Brokley? If I could address that one. We've tried in Edinburgh and I think all partners recognise some of the challenges and those parallel different budget setting processes. I think there's certainly been very good attempts to try and align that as far as possible and to do that in a way that gives sufficient time for scrutiny and decisions and transparency around the budget. While it's difficult, there's certainly been in my experience in Edinburgh with our partners a willingness to recognise the different processes and timelines and to try as far as possible to align them. Thank you very much. Eddie Frazer. I suppose that it's also to remember that at that time we're setting the budget at IJB, the role of the chief officer and the chief finance officer. It's for us to give advice to the integration joint board that the finances are sufficient to deliver against the strategic plan. That's part of the legislation and what we're saying there. If you don't have assurity around the finances, you can't say that statement against the strategic plan. Sometimes the question might be whether you need to go and amend your strategic plan to bring it in line with the finances available. That's why the balance of the two things being brought together at the same time is just so essential for us. Okay. Thank you very much. I'll call Hamilton. Good morning to the panel. Naturally, as an MSP for Edinburgh, I'd like to start by directing questions to Judith Proctor and Maura Pringle. Welcome to the committee. It's good to see you again. Just firstly, on the projected overspend of 2 per cent, you said in your opening remarks that you've yet to find the savings necessary to balance the budget. I mean, this has been coming for a while, and I'm just a bit concerned that, although I absolutely believe your intent to get to a balanced budget, if you've not found the savings now, how do you expect to find them in the future? We've identified a very solid savings programme within the partnership, and we're talking about our savings in the same way as we're talking about the wider transformation that we need to put in place in Edinburgh, and it's over three horizons. I think that we need to recognise a slightly longer timeframe in terms of how we get to being a truly sustainable partnership. We're really delivering better outcomes for people in the city, and we talk a lot about the grip and control that we want to achieve, and we've set that out in our submission, the service redesign that we require, but also that longer-term transformation that the board is keen to invest in. The savings that we've identified, we believe that we can deliver in-year, and again, we've been really quite clear and focused as a partnership, as advisers to the board and the board itself, that we want to achieve that without any diminution in the outcome improvements that we're beginning to see in Edinburgh. We really want to continue to focus on that improvement. We want to ensure that people have a good experience of our services, but we also want to get to balance. The approach that we're taking is very much one of partnership with NHS Lothian, with City of Edinburgh Council. How do we work together as three partners? Again, that's a set-out in the legislation to identify things that we can do collectively and proactively to achieve balance in the year, and that may well include discussions that we have around the set-out side, how we handle that across the year and what our partners might do with us to help us to achieve a balanced position in the year. Again, we're very keen that we do that in a proactive way. We don't want to get to the end of the year and find that we've not done that, so we're already in the year working with our partners on those approaches and discussions. The partnership approach is certainly gratifying to hear, and I wish you well with it. It strikes me, though, that you've got two mutually exclusive goals in this. On the one hand, as we all know, Miles and I both represent Edinburgh constituencies, that Edinburgh really faces a real problem, particularly around delayed discharge. The social care environment is not geared up for the massive pressures that it's experiencing, both from hospital exit and the ageing population. We're asking you to do far more, but you're talking about reducing your spend. I don't understand how we square that circle. If we're going to properly tackle delayed discharge in particular, we absolutely need to bolster the social care provision in the city. It strikes me that trying to reduce your spend is not compatible with that aim. I think it's about how we work and how we operate as a partnership. Of course, another key element of health and social care integration is about that wider transformation, working differently and working differently in and with communities, supporting people towards independence and rehabilitation. It's important, also in the context of Edinburgh in particular, to recognise that we have achieved some re-improvements and the decisions that the board has made to invest further in social care. We have taken budget and invested more in social care. Through that, we have seen a 48 per cent reduction in delayed discharges in Edinburgh over the past year and a 66 per cent reduction in bed days lost in NHS Lothian. As a result of the work that we have done, we have seen improvements in the number of people waiting for an assessment and improvements in the time that people are waiting for care from us. I think that there has been quite a good trajectory between board decisions about how it uses its budget and where the priorities are, such as in social care, directing budget there and actually seeing improvement. That is the kind of discussion that we are having about the whole system and how we work as a whole system to focus both on the transformation and the outcome improvement that we want to continue to drive forward in Edinburgh. Final question to our Edinburgh colleagues, if I may, convener. You talked about three horizons of change. Can you give us a broad timescale for those three horizons, at which point, for example, if we have you in next year, will we be in a balanced budget position? I think that we talk about a three to five year longer term horizon, with the medium term being two to three years within that. We are working very positively in the conversations that we are having with City of Edinburgh Council and with Lothian Health Board, or that, next year, we want to be going into the next financial year, having identified as a partnership a balanced budget and being able to do that each year after. Any of those questions or comments up to the rest of the panel, if there is anything that you would like to come in from your own position? I suppose that it is the start of the discussion about being able to have positive impact whilst improving the service to our populations. We are lucky enough to be in a position where our people are on very well in relation to hospital discharge and transferring people to care in the community. The result of that can be savings in the social care budget. People staying too long in hospital are very debilitating. Therefore, when they come out of hospital, they need higher-cost social care packages, often care homes. By us working really hard and people coming out of hospital, we have reduced the number of people in care homes by 10 per cent over the past 18 months. We are able to redirect some of that money back towards care at home. The positive performance of people transferring out of hospital and the positive impact for older people in particular costs us less money. Some of that is the positive cycle that we are trying to work our way into. We need to be able to release the money out of some services—in this instance, care home services—to be able to invest in other services. That is a really positive position that we have reached. Balda Syrran. Thank you, convener. Just to build and to add on what my colleagues are saying, the challenge that we have is working in an environment in which we have an increase in demand. It is the increase in complexity as well as people live longer with more conditions. That challenge is a little bit more than we speak about from time to time. That is costly, but it is complex in terms of design and how we deliver those services. Like my two colleagues, I think that the challenge for us is around transformation, not just review and redesign. It has to be bigger. I think that we are up to that challenge. I think that some of the time, what we need is some maybe bigger messages nationally to try to bring the public along with us in terms of what is required to take next steps and just the very difficult topic of change. People do not like change generally, so how do we as chief officers and how do we as partnerships manage to demonstrate that change is good in the way that Eddie Demonstrates and the movement from residential care releasing some resource and then being able to reinvest? I want to pick up on your observation about the level of savings that are being requested across the partnership and the circumstances and conditions that we find ourselves in. Particularly with demographic growth, the increasing number of attendances at A&E and other significant financial pressures and operational demands that are being faced by the partners and the IGIB. If there was an opportunity in the budget for 2021, then additional financial investment would be welcomed because it would allow us to invest in the services. Further to the already investments that we have across primary care and mental health, but particularly across social care services where demographic growth is increasing, we within South Lanarkshire have been relying on our council colleagues and our NHS colleagues to give us a financial envelope to allow the integration agenda to develop and to grow and to give us a chance to implement transformational change, but it is taking time. A critical area is early intervention and prevention, and it is very difficult to, on top of the savings, deal with demographic growth to also find recurring funding solutions to invest in reliable services that people can place confidence on in. I have heard the word transformational from everybody this morning. We all support that direction of travel, but I look back to the movement towards care in the community in the 90s, which is very much a front-loading of funding and almost two systems running side by side to achieve that. In your opinion, do you think that we have not done that in the sense of the IJBs that we have just expected to transform services but with the same money? That is a hard question. We have identified as an IJB precisely that challenge, the balancing of managing business as usual, managing some of the performance issues, managing to try and get to sustainable budget position with the need to invest in change. We need to free up staff, we need to work differently with communities, sometimes we need to invest in those communities third sector organisations and build in time so that the transition from traditional and institutional models that Eddie described can come work through. Our board has agreed that a transformational fund from within its budgets to do that and to help us to achieve that over the three horizons. It really is necessary to identify that funding there are times when there will be double running costs and just to say that that time and space to carve out different ways of working with our partners to achieve the transformation that we need to see. It is a really important area because I think that this is about how we transfer care. I think that our clinicians are only willing to do that if they see safe alternative models of care. If a GP is not going to refer someone to the hospital, there has to be an alternative to that that they feel is safe, so we need to build the safe alternative models of care first to be able to change what we are doing. Like Judith, we have a local transformation fund that has been funded by the council, so the council gave us money to do that, and clearly we have also got significant funds coming to us over the next three years in terms of primary care. Although that primarily is about the sustainability of primary care, it will also have a massive impact on the wider services that we deliver. Similarly, the investment from mental health is welcome, but the fact that we need to build the alternatives first to give people the confidence, first of all, not to admit people to hospital, and secondly, for our hospital clinicians to transfer care back out is absolutely self-evident. That is what we are having to do and trying to put together different resources to do that. Is that transformation fund that you identified as funded by the council, is that part of the council's standard allocation or is it additional to that? It was an additional £1 million allocation that gave us for that. In terms of service redesign and where you are looking to redirect money into services, what sort of assessment do you do of impact around that? I know that here in Edinburgh, as Alex has mentioned, we have seen debates around cuts to community services, for example, such as the Pilton community health project. In terms of the direction that the IAs take from Scottish Government ministers on that, is that patchy or is that something that you have true autonomy over? I know members of IJBs who tell me that often things are put to them, that it is not autonomous in terms of what they want to achieve. The discussions that you have with Scottish Government, for example, there was a piece of advice that £2.3 million could be taken out of drug and alcohol services here in Edinburgh to try to narrow that gap in finance. Where do you really act upon that when you are making those decisions around where the transformation or redesign or cuts will come from? Judith Proctor. Not entirely sure I follow the question. I wonder if you could reframe that one for me. When you are looking at a service redesign, which often will feel like you are robbing Peter to pay Paul just to get the money to do that, where is that advice really checked to benchmark it and look towards an impact assessment that we are not going to just displace people and there are not going to be unintended consequences in other parts of our health service? Ultimately, the decisions on the allocation of the budget to deliver the strategic plan sits between all partners with the IJB setting that direction. You are referring to particular funding streams that come into the health board and to the council from Scottish Government for specific outcomes to be delivered. We would try—I am sure that all partnerships would be in the same position—to be doing that in partnership and to really understand the system-wide delivery that the board has to agree. We would look at individual outcomes that we are seeking to achieve through separate funding streams. That is really important. When you look at the breadth of what an integration joint board is responsible for, we have to look at delivery right the way across that. It is really important in doing that that we look at the overall outcomes that we are trying to achieve, the national outcome measures, the MSG6, and to try and balance the delivery of particular specific outcomes in one part of the system and understand any opportunity costs or negative impacts on the other through doing that. That becomes part of the conversation that we have within the IJB, part of the conversation that we have with all our partners and part of the conversation that we have with colleagues in the Scottish Government. To add, we would be and do impact assessments on the decisions to help guide the board and its decision making. Speaking about our own board, we are very well aware of the complexities of that decision making right the way across what is a very large budget and a very broad and complex range of services and accountabilities and responsibilities that they have. I want to respond to the question in terms of impact and evaluation. With any service change, my approach and my colleagues will be the same. It will be about looking at data, policy and engaging with stakeholders. Those three elements have to be very powerful for you in order to go take forward redesign or it could be something that would be transformational but redesign. I will give you an example in relation to care facilities or the care homes modernisation in South Lanarkshire. We based our thoughts and our proposal around this, around a pilot that we did or a test of change around intermediate care. Basically, we tried for almost a year to see what an intermediate care model would look like, so basically whether it was step up, avoiding people going into hospital or step down, avoiding people or helping people to come out, so getting people back on their feet and home. That pilot showed that we had 56 per cent of the individuals going through that programme and could get back on their feet and home. We then designed a programme of modernising fair care facilities around that kind of data. When we get to implement that fully, we will be mindful of the data, the engagement and the policy the whole way through that process and we will be evaluating it as we go. In that case, I welcome it, but I think that one of the areas that we have seen across Scotland is actually with drug and alcohol partnerships. In terms of their services, there is a pattern of their budgets being raided. Have any of your IJBs taken drug and alcohol partnership funding away then in the last year? No, we have not taken the money out of the drug and alcohol partnership. As you know a number of years ago, how the money was allocated through health boards to alcohol and drug partnerships was partly from justice and partly from health. That was aligned so that it all came through health. At that time, if you looked at that, there was a reduction in the totality coming for that, but then that became part of the overall sum that went from health to the IJB for the IJB to decide how money was spent. We did not reduce our funding to the alcohol and drug partnership and that was based on what Val and Judith have been saying. It is a strategic priority for us. The level of alcohol and drug misuse in East Ayrshire and across Ayrshire is high, so we would not reduce that. That proved sound when we did that a couple of years ago because in the following budget we got a significant increase in terms of the allocation and therefore we were able to make that sure. That was a sustainable delivery to what we were doing there. However, the general picture is that we need to interpret at an IJB level the totality of the funding that we have in order to make sure that it fits with the priorities of our strategic plan. The package of funding will come with a number of priorities to it and we clearly will take into account the national priorities, health board priorities, council priorities and mix all that together in the integration joint board to what we commission as a services to meet our local communities. There is clearly a different picture in different health boards across the country. You have varying levels of challenges around the proportion of money that comes from the national health service, the proportion of money that comes from local authorities, the amount that you might have as a projected overspend, the amount that you might have in reserves or the projected savings that you will be needing to make in each of the next three years. Can you just set out what that means in terms of money that you need to find in each of the next three years? When I say find, I mean either in terms of a saving or in terms of pleading for more money, whether that be for the national health service or indeed from a local authority, what level of money are you looking for? Who would like to start with that one? Yes, Moira Pringle. We are in the process of developing a medium-term financial plan, but in this year we are in just now for Edinburgh. I was starting gap in terms of our savings requirement was £24 million. Given all the demographic pressures that people have already talked about that are in the system and the on-going pressures on public funding, I would imagine a similar, if not greater, size gap in each of the following few years, which I guess is why we have to look at doing things very differently. In respect of 1920, our cost pressures came to about £18 million, and we did get additional funding through the Scottish Government for about £15 million, so left a £3 million gap. The majority of which has been addressed on a recurring basis from savings, but there is reliance on non-recurring solutions at this stage, which we need to be alert to. In terms of moving forward over the medium to long-term plan, I would estimate from the work that we have done with both partners that our gap in terms of cost pressures could continue to be of the order of £3 million to £5 million. That is assuming the level of Scottish Government funding that has been available until now continues in future years. It still does not create enough financial capacity to address the increases in demographic growth that we have spoken about, and the aspirations to further develop the services, particularly the third sector, early intervention and prevention services. Greg MacArthur We have a similar budget gap, which is the Marri outline. For the 2019-20 financial year, we are looking at around about a £5 million budget gap, and we would anticipate that being a similar level of challenge over the medium-term year-on-year. That is a significant element of that in relation to additional demand and demographic changes, which we recognise. That is very much about transformation and delivering services in a different way, which is how we would certainly hope to manage that demand differently. The balance of that is very much about cost increases, pay inflation, normal inflation and so on. However, managing demand is a big part of how we would want to deal with that into the future. 31 integrate authorities in front of us, one saying a gap of £24 million in each of possibly the next three years, another saying £3 million to £5 million in each of the next three years, another saying £5 million in each of the next three years, times that by 10 broadly in terms of what we are talking about, in terms of local or integrated authorities across the country. We are talking about almost £300 million a year as a gap of what is needed in either savings or further investment. That is a massive amount of money, and that is not just in terms of transformation. That cannot just be about recurring, non-recurring. Some of that is going to be cuts to the bone in terms of services and impact on service users. What is that projection in terms of what that means for your service users and for services that you provide? Judith Proctor I think that it is going to mean some. We have all talked about transformation, and it is probably important to think about what we mean when we say that. It will be lots of different things. It is about how we use our traditional services quite differently. It will be about how we utilise money that may already be in the system to do things differently in the community. It will most definitely be about how we use technology to support people at home and in a community setting. It will get us into discussion about the set-aside, the acute funding, and how we potentially use that. If you look at the conversation that we have had briefly about the number of delayed discharges in Edinburgh, not only is somebody being delayed in hospital when they are ready to go home not good for that individual that someone is being cared for in an inappropriate place, it is not using public funding properly and appropriately. If we are really able to tackle that and do it in a way that, as Eddie says, is safe, effective, useful and appropriate alternative deliveries of care, that should, when we go back to the intent of integration and the legislation, that should enable us to deliver services within a sustainable financial envelope. It gets into, and those are some of the conversations that are picking up Val's point about the national conversation that we need to get into that. Our services will have to look very different indeed, because we can do things differently over coming years. We have to be really quite open and transparent about what that difference will look like. I imagine that the other two local authorities would accept that as well. Interestingly, what Eddie Fraser said earlier on was about invest. A lot of it is about investing in order to be able to save, but if you have to make a £300 million saving across all integrated authorities this year and every year for the next three years, there does not seem to be much room for investment to save. It just seems about save and we will use the clunky word. We will use a nice term of transformation as we save. There is going to be a cost to this, a human cost to this, is it not, in terms of services and service users? Should we not be, as part of that, honesty with the public about that transformation that needs to take place? Honesty with the public in terms of what is going to mean for services and for service users? The last part of that should be the audience, the public and local communities, absolutely, because we have no credibility if we are not. You can invest in ways that are still delivered even within the calendar year in terms of saving. We had projected an increase of 3 per cent in our care-at-home social care costs. To mitigate that, we employed more occupational therapists, more intensive social care workers. When people first contact us asking us for these services, we work with people to make sure that they are as independent as they can be. Therefore, the size of the social care package is less, but it is not only about being independent. One of the big issues for us now is to make sure that people are included in local communities. Some of our work in East Ayrshire has been that work that is not directly delivered by the health and social care partnership. It is our work around—I am not being flippant—tea dances and different things that our people are included in local communities. Our public health colleagues would tell us that the impact of being excluded and the impact of social isolation is equivalent of smoking 15 cigarettes a day. The impact on health of working properly in local communities and including people in local communities is massive. That is some of our focus. That is the part that Craig spoke about—how do we reduce demand? That is what we need to do. When people need their social care services, they have to be there and have to be of the highest quality so that they are responsive to people's needs. It is trying to reduce demand by doing things differently, and we have achieved that up till now. We are right to say as we go forward how we do that. When we talk about how integration joint boards work, they do not work in isolation. Some of our biggest successes in the areas are when we work very closely with housing, and we look at different housing models to make sure that that works. At one time, our high-need supported accommodation, particularly in rural areas, had vacancies in it. People did not want to move there. Now, what we see is a lot more activity going on there, so our vibrant communities teams go in there and have lots of activities that serve not only people who live in the supported accommodation that are now full, but also the local community. We are driving less demand for paid social care through the types of routes. That is what we mean by transformation. It is changing people's experience. I completely agree on what integrated authorities are trying to do in very difficult circumstances. You have absolutely the right intentions on what you are doing in communities. It is transformative, but does not it come back to the point that around £300 million broadly across 31 local integrated authorities of savings that we have made in a year means that there are going to be budgetary pressures? Can you just say this final question for me? We hear a lot about record investment in our national health service, and at the same time we have local authorities screaming about budgetary pressures that they face, saying a bit about how the budgetary pressures that are faced on local authorities, what that means for how much they can then invest from their budgets into integrated authorities, and how that can perhaps help to bridge some of that £300 million gap. I think that we all need to speak from our own perspective on this. When you mentioned £300 million, I guess that is not my challenge personally. That is our challenge nationally. Again, I want to build on what my colleagues have said to say that there is an honest conversation, but the honest conversation for me at this point is not about closures and shots, it is about replacement redesign, it is about an honest conversation about change happens and sometimes change is good, and building that confidence about putting something in place before you take something away sometimes as often as we can. I think that locally, I see my colleagues and from myself locally, we are having that conversation, but I think that we need a bit of a scattergun approach to the communications around change, the need for change, and actually it is a bad thing to be in hospital. I think that the general public still believes that a hospital is a good and a safe place to be in. That is no disrespect to my acute colleagues, but it is not a place to languish, it is not a place to stay. We need to have people in hospital for the reason that they need to be in, and they need to get that flow and get people back on their feet and back home as quickly as possible. I think that we are having those conversations, but sometimes it is hard to shift the global thinking, the national thinking around this. I think that change can be good, change is necessary, and I suppose that we need some support in the integration authorities to try to get that message across. I think that from a South Lanarkshire point of view, the NHS has not been funded the full NRAC allocation, so that means that there is a 0.2 per cent less allocation, which accounts for about £9 million. From a South Lanarkshire point of view, status quo, we have worked really hard to balance the budget and we have done it, but that is, as Marie was saying, going to be more and more challenging, particularly in 2021-21-22, in terms of not being able to find recurring funding. We are all getting into this place of redesign and transformation. From the local authority side, the sympathy that I have with my local authority colleagues, because they are very supportive to the IJB, is that I see my corporate management team colleagues from housing not so much education because education is a little bit more protected, but from housing roads, the different functions within the local authority around community and the kind of interconnectedness that we need to have in the way that Eddie describes. If you protect education, social care and social work, then our other colleagues around that team are having to take a bigger slice of their budgets, so that is attention in itself, but one that we need to keep getting around and keep having a conversation and a vision for what is the best for our communities in the whole, not just about the different types of budgets, but there are real tensions around that. One of the things that I would like to ask about the integrated joint borders, you have to look at different ways to work. You have to look at the whole idea of the integrated joint borders, to look at different ways to do things and deliver services. Now, as we have heard today, people hate change and it is always going to be difficult. My question is, how do we take that next transformational step, that change to services, because you are bridging, you are at the coalface, you are bridging between the health board and the council itself, which is a great place to be. It is challenging, but it is a great place to be, in my opinion, having worked as a councillor previously. Most importantly, how do we make that transformational change and how do we really importantly make sure that we take the public and everyone with us as well in order that we see benefit in what we are trying to provide to you? I suppose that, again, it comes back to how we work with local communities. As well as clearly being the chief officer of East Ayrshire IJB, I am a director of NHS Ayrshire Narnham and a director of East Ayrshire Council. When I go out and I talk to local communities, none of them care about any of that. They are there about what we are there to talk about how services can be delivered to local communities and what are the priorities of local communities. For us, we have worked with community-led action plans. Our 31 local communities look at what their priorities are and what their action plans are. We then look to see how we can serve them as local communities. The roles that we have done around participatory budgeting and the IJB alongside the council in particular have taken that really seriously. We have seen local communities prioritise how money should be spent, and we have seen big changes particularly to the preventative agenda that people have been speaking about. For us, that is not about simply sustainability of the integration joint board. It is not about sustainability of the councillor of the health board. It is about how we talk about that altogether. I suppose that that is the privilege position that we get to sit in and about how we bridge across that. It is about not doing it. That might sound flippant, but it is not doing it to communities. It is talking with communities about what the right things to do in their local areas. We are talking to local communities and local people, including GPs who work in their communities. We are talking to local schools about what the priorities are. That is our way forward. Our way forward in East Ayrshire is to have our 31 local community-led action plans to work with our local communities about how we take things forward in meeting local need. People are very honest, so we do the village hall, town hall meetings and talk to people. To be honest, we are people about what our pressures are and then listen to people about how they might be resolved. An example that I could give to you is just now that we are looking at how we call the developed place. That is not primarily being done by the health and social care partnership. It has been done by our department under the safer communities, but that is how local people who work in a local area can do a range of different jobs. Just now, if in Dom Ellington somebody pulled their community alarms, I would likely need to send one of my social care vans across from Cymruc across to Dom Ellington to see if the person is okay. However, there are guys working around there who are cutting the grass. How can they not go and chat the door and make sure that they are okay? They are the types of things about making sure that we get the best resources to serve local communities. The other example that is about place and about the totality of funding is that there is no point in saying that you just cut the grass once a month, no matter what the weather is like. It is about giving people devolving power to the local communities to do whatever is important to the local communities. That is the type of thing that we need to do to make ourselves more sustainable. Again, it is why it is important for me always to say that IGIBs do not work in isolation. They work alongside the council and the health board, but they are also the wider community planning partners. Our relationship with Ayrshire College, our relationship with Police Scotland and our relationship with Scottish Fire and Rescue are all really important to us in that wider community planning arena. We see Police Scotland doing work around trauma. We see Scottish Fire and Rescue getting in and doing some of those safety visits. We see a whole range of different engagement going across. I think that that is a future public service that we deliver that we are part of. I would agree with what Eddie is saying. We are not quite established as Eddie is, but we are certainly moving in that direction. I think that we use the word transformation a lot, and sometimes we try not to. One of the things about transformation is that when you start the journey, you do not know where you are going to end up. That is really one of the challenges for us, because if you make a change and you can say, this is what it is going to look like, this is what we put in place, then it is so much easier to bring people along with you. However, when you are saying that this is going to take about three to five years, what we are hoping to do is we are going to look at the data as it emerges, we are going to do the best thing for you, it is very nebulous and it is far more difficult for people to really hook on to what you are going to do and have confidence. Sometimes there is a leap of faith required in transformation. I think that our approach to that is around engagement again and it is around full engagement with our communities. Recently, we launched our next three-year strategic commissioning plan from 19 to 22. We invested a huge amount of energy and time going out to our communities, asking them what they wanted and what their priorities were. We did it in two phases. We went out first and said, what do you want? We collated all the information, then we brought it back and said, this is what you said, do you agree? So to try and prioritise and then to try and say, well actually in terms of your priority, what is number one and what is number ten? Early intervention and prevention was the first one. In that kind of engagement, the answers you tend to get surprise yourself and let myself in the past when in the council we did engagement like that, the answers you got back were rather surprising. How do you then take that on to the next stage in your case to actually put that forward to the public? Well, I go back to the question that I answered earlier and if we are very, very, very surprised, if we're surprised we need to listen. That's what we're there to do, so we're there to listen, we're there to make sense of where they're to understand and we're there to work in a very big partnership about place, so it's not about any one thing, it's about place and it's around people and their place, so we need to understand that but we need to check that against the data, we need to check that against the policy direction, so we need to make some sensible decisions about how we start to take forward some of those priorities with our communities. One of the little examples that I have and it's a very small example and I hope the people of Tarbracks don't mind me mentioning this, we're not sure where we're going to go with this, but it is a listening one if you like. We have a programme called building and celebrating communities which is around trying to address some of the issues around that 300 million that we're talking about earlier, so it's trying to do things really different but it's very much building the strengths in your community. We're having quite a lot of discussion with our communities now in Tarbracks that there was a meeting about two or three weeks ago where quite a lot of active local people are saying, you know, we've only got 400 people in our village and we've got, you know, some of them are aging, some of the kind of themes that Eddie talked about earlier about trying to keep people well, social isolation, people keep it involved, include. So some of these folk are coming back to us to say, you know, how would it be if you paid us to undertake to pay us for the care as families with our local communities, but what we would do is we would care for folk, but we would do the other stuff that they need which might be, you know, taking them for prescriptions, it might be taking them for a walk, it might be walking their dog, it might be cutting their grass or whatever. So it's really joined up thinking from our communities. Sometimes I think when we go into the consultation engagement piece, we've traditionally been a bit frightened about what we've been, we'll be asked and like Eddie, I think our communities are very realistic and I think they don't over demand largely. So I think we need to be braver about having these honest conversations in our communities. I won't surprise you to know that I agree with most of what my colleagues have said about these approaches. I think obviously there's a variation to this in Edinburgh, a very large, very diverse city, but the approach about working in and with communities where they are is an absolute principle of health and social care integration. Of course another constituent in all of this is how we support our staff to change. I think a key one for us in Edinburgh is about how we work at locality level. So we've got four localities in the city and each of those is actually very large. So how we empower and support our front-line managers and staff and teams to work in that very co-operative, co-productive way with people and I know that they sound like jargony words, but actually they get to the heart of what we're trying to do. That's really, really important. So we're doing a number of things in this area. We are developing a three-conversation approach, so we're trying to embed in the way that we all work from practitioners right the way through, embedding that in three conversations to really humanise the care that we provide and that is centred around the individual, the support that they need to live a good life in the community, connected to the sorts of things that in the community that Val and Eddie have described, and in parallel to that how we then invest in communities, community provision, third sector organisations, communities and neighbourhoods themselves to create the vibrant and resilient supports that people need. So there's a big element of our strategic planning around that and a big element of the hearts and minds with our staff and our teams around that as well, how they can be working in that way. And we've got some really good examples of our locality managers leading that engagement with partners, with the police, with GPs locally, with third sector organisations in the community themselves around what will make a difference here, what are some of the things that we can do. And they may be surprising things, but they are really, really important things. And it is about community cohesion, community growing schemes, allotments, things like that make a tremendous difference in communities. More broadly than that, as a public sector partnership across Edinburgh, we're having a lot of discussions around that place-based approach. And when opportunities arise to develop new capital builds, how do we get around that as joint partners to think what could we do here? It might go beyond we need to build a new school as a local authority to, okay, we need to do that. But what are the other opportunities that sit around this investment in this community whereby we can deliver services very differently and a far more joined up way? So there's a lot of strategic thinking happening about that as an approach. We do a lot of work with our partners in the council and the NHS around opportunities for development and how we might invest from traditional institution based care into housing models that can support more people differently and in a more sustainable way in the community. So there's lots of discussion around that and I think it is really, really gratifying that increasingly we're seeing that come through the community planning approach with our broad partners. We're all trying to do the same thing and I think we'll do it far better if we do it collectively. I just wanted to come in on that because I think for Alex and I as Edinburgh representatives, we have people come to see us who say the polar opposite of what you just said in terms of how they feel they're included and just looking at the Pilton, you know, Scotland's oldest community health project, the Pilton Health Centre, you know, they were told about their imminent funding hours before and just looking at all their comments online from that time, they don't feel they were ever included in any future proofing or discussions around service redesign. So what you've just said, what would you say to people from Pilton? Because they don't feel any of that's taken place. So those are different processes. That was a grants process that was overseen by the integration joint board and grants processes by their very nature are quite challenging. You may or may not be aware that the grant that we had to distribute under the health and social care partnership was made up of different elements from both previous NHS funding and council grant and against the £14 million that was available we had £35 million worth of bids against that. We undertook a very thorough process within the IJB to consider and we did this with our partners, we did this with our partners in the third sector and we were already very supported by the third sector interface around that to develop an approach that as far as was possible in those circumstances was felt to be by the IJB fair and proportionate. I think for some organisations we're very, very well aware and some we're not successful in drawing down the funding but through that we did actually see the development of new health and care organisations in the community. So there's something really, really positive about that because this has to be both about growth of new responses that can be adaptive to the current needs within communities as well as sustaining some organisations that we're able to develop new approaches as well. We also worked, we believe, very closely with organisations in the community and with EVOC, our third sector interface partners on some of the transitions that might be needed. We worked very closely with the organisation that you mentioned after the decision was made and colleagues met with them several occasions to look at how they might rationalise what they do now or secure other funding sources or work differently. So we believe we've undertaken as thoroughly a process as possible and our board is holding us to account in terms of impact assessments. Have we undertaken quite in-depth work with them over that? It remains something that is quite difficult for organisations and we recognise that and the board is very interested with our partners in looking at the impact that those things have. Can I ask for each of you a couple of points? First of all for relation to this current budget, this year's budget, whether social care contributions, additional and social care money provide to health boards, has that all been passed on to yourselves? Secondly, have your local authorities taken the opportunity to reduce the contribution that they're making to social care budgets in your area? Craig MacArthur? I've just confirmed that, yes, in terms of our budget setting process, all the additional contributions from both health and local authority partners were passed on and the local authority elected not to take a further reduction at Easter. All Scottish Government funding has been passed on to the IJB. We did agree a small amount of savings from a transformational point of view with the local authority partner that we felt could be implemented in the year, but over the past three years, particularly the local authority partner, has minimised the level of savings that it has asked of the IJB partner, being supportive of the agenda. Similarly, on the NHS Lanarkshire side, they have passed overall the funding and they have also continued to manage the risk associated with budget pressures on the set-aside services. Again, it's a good work in relationship and a supportive one. Very similar position in Edinburgh. We in Edinburgh have a budget setting protocol, which we have agreed with our partners and, as Judith mentioned, we meet them regularly and on a tripartite basis. The strength and benefit of those discussions is one of the things that will help us to move the IJBs forward. We are only going to really progress, as I think was pointed out in the recent MSG report, if we all understand each other's position and have a shared view of the financial position of the IJB. To specifically answer your question, yes, NHS Lothian passed on in full its 2.6% uplift and a share of its other funding, because, like Lanarkshire, Lothian is below in that parity and the council also passed on its share of the local government settlement in full. Potentially, subject to performance, it has set-aside some additional funding for the IJB. Thank you very much. On the issues of funding gaps that you all addressed in answer to Anna Sauer, part of that is going to be around efficiency savings. Is there scope for on-going efficiency savings, or is this all about fundamental change? In Edinburgh, we set out a three horizon approach to financial sustainability, which Judith referred to earlier. Part of our programme is about gripping control and being more efficient with what we have. Part of our programme is about redesigning existing services. Another part, which is the three to five year part, is about transforming services and doing things very differently in changing the conversation that we have with the people of Edinburgh. It is not just all about cuts to services. There are some parts of what we do that are very difficult to see how we deliver in terms of efficiencies. Much of the services that we deliver, particularly through the NHS, are staffing. For instance, we have 42 health visitors. If the health visitors are part of the totality, the number, in terms of the additional 500. If they all go from band 60 to band seven, that is a cost to me. I understand the benefit that we get out of that, but it is also a specific cost to me. I do not see a saving there. If we are going to continue to shift and support people in the communities, I do not see how that would be effective to cut my number of community nurses with our priorities around mental health. Again, looking at my community mental health teams, I am not clear that I would want to reduce that. Therefore, if a budget is asked to look at cash release efficiency savings, it is very difficult to square things in what we are doing. The answer to that has to be, at the end of the day, quite frankly, no. At some point, we have to look at making sure that we have the full funding to deliver in terms of what we are doing. That is where either transformation or additional funding comes in. Overall, transformation will only happen if there is money to move from one side of the business to another. The scale of what is needed to deliver for our local communities is not clear if that scale of funding is available within the acute service to transfer back out. That has not been evidenced by the scale and number of beds that we need to close on the acute estate to deliver an effective community estate. We can be efficient, we can look at skill-backs, but we also need to listen about how we deliver in the service and everything can't be a bit efficiency. Some of it will be transformation and some of it will need to be additionality. I totally agree with everything that Eddie has just said. The scale of the challenge is such that, yes, we need to embark on transformational change, but we absolutely need to identify additional funding that will allow us to progress on that agenda. In terms of looking for more efficiency savings, that exercise that aspiration will never stop. We will always continue to look for improvements in service delivery, but over the past 10 years, in particular, local authorities have been managing tighter financial constraints. As Val has highlighted, in NHS Lanarkshire, there is good effective financial management, but it is within a reduced financial pot. In terms of being realistic about what can be achieved moving forward, we have to be careful that we build on sound financial plans. A lot of the transformational change agenda and the outcomes from that, both in terms of financial savings and performance, is still to be tested. A whole-system approach definitely needs to be adopted, but it is how realistic it is that both partners can continue to help us to find savings and how realistic it is that we can find savings from, essentially, what are front-line services that have been delegated to the HIB? The number of changes that the Scottish Government has made or is making one is the medium-term financial framework, with planning its own funding five years forward for the NHS, another is the financial requirements that are placed on health boards. Changes have been made there, and the requirements have been increased. Of course, the Government is sometimes criticised for it, but it will provide one-off in-year additional funds for, for example, delayed discharge or waiting times initiatives, whatever it may be. How far do those changes offer opportunities to strengthen your own financial planning and how far can you take into account in your payments when you are addressing the kind of challenges that you are describing in balancing budgets on an annual basis? I think that if we can get clarity about three-year settlements, for instance, in terms of our funding, it gives you longer, and just as importantly, it gives some of the people that we commission services from, particularly around the third sector, the independent sector, it gives them a bit longer. We can give them more surety if we know what we are doing in terms of our funding. In small amounts, we, on an annual basis, can likely predict within one or two per cent what our budget would be, but if you have a £250 million budget, two per cent is £5 million, and that is a lot of services that you are having to adjust at the end of the year. The longer-term budgets and budget setting that we have helps to align that better with our strategic plan, helps to see where we would shift services from, and therefore resources from around. That is very helpful for us. In terms of in-year settlements, we are always keen to work at change. Quite often, in-year settlements also come with a level of particular support in terms of how you test change, how that is learning, how we can take something in bed wider. That is helpful in terms of where we are as long as it is on that basis. If it is a reactive thing that has come in, that is more difficult. Sometimes, if it is reactive, it is difficult for us to go out and just suddenly recruit staff from somewhere to deliver against that reaction. However, if it is about a progressive investment that we get, so recently, we have confirmed further investment in technology-enabled care around one of our particular localities over a couple of years. We can think, then, how are we going to put in funding around clinical leadership? How are we going to put the social care support around that? How are we going to communicate with the public what we are trying to achieve? That type of in-year investment is helpful, but if it is very reactive, saying that cross-house hospitals are full, how can we take people out of there—not that we have the lead discharge, but that is an all-story—you cannot just magic up the social care service, but you cannot just go out and suddenly recruit social care workers to deliver on that. It is important that we are in-year moneys come in. They do not often come direct to the IJB through the process that we have been in, but what is really, really important is that we are in discussion with our partners about how some of that money could be used differently. We need to talk about funding coming in to health boards to help them to address some of the pressures that they have. Often, the solution to those pressures—or sometimes, the solution to those pressures—might be about investing more in a community setting to achieve a longer-lasting change. That is really, really important. I recognise and think that we said in our submission from Edinburgh that the challenge that we are in with one-year settlement in partnerships means that this is a continual process of discussion around the budget. In some ways, that is useful, because it helps us to understand each other's position. It helps us to have those live conversations about how we, as a whole system and people involved in that whole system, will operate. It can mean that we are spending an awful lot of time on that when we will want to be focusing on the change and the transformation that we are in. I think that any opportunities that the committee has to consider the levers that might already be there for the Government and for partnerships and for the broader partnership to use that can help that would be, I think, very, very welcome from our position, such as the thinking over the course of the three years rather than always in the year. I think that the levers are there for Government to do that without any significant or specific change to the legislation that already exists. Okay, thank you very much. Mary May, do you want to come back? No. Okay, thank you very much. David Torrance. Thank you, convener. Good morning, panel. What progress has been made in linking budgets to outcomes and to comply with legislative requirements in this area? Outcome budgeting. I'm going to challenge it. Eddie Frazier. You know, we are, as part of the integration scheme, required to report twice a year to both the council and to the health board. We report once a year in relation to our strategic plan and we report once a year in terms of our performance report. Our performance report is totally built around the national outcomes. For us, there are 12 national outcomes, and that's 20 national outcomes. That's because we also have children and we have justice as well as adult services within that. Our whole reports in terms of how we report are based around the outcomes. They're based around getting it right for every child for our children, they're based around the community justice agenda in terms of criminal justice services, and they're based around our wealth and wellbeing outcomes in terms of how we deliver. So how we do that is very much engaged within that. It's not just about how efficient our services are. It's about how we're changing. How do we change to invest also in the preventative stuff? How do we invest in wellbeing as well as in health and social care? You'll see in our reports that that is how we do it. How do we work in partnership with housing colleagues? How do we work in partnership with our education colleagues in terms of some of the inequalities that we see there? For us, we align our whole reporting structures around the national outcomes. We do likewise to build on the conversation. It's in our return. One of the things that we have adopted in Lanarkshire and South Lanarkshire is a tool called contribution analysis, which is around identifying how confident you are that not just the finances but any of your inputs, any of your resource, so it could be time, it could be money, it could be people. But how confident are you that that's leading you to a positive outcome for you, the nine national outcomes? It's been a number of years in the making and it's proving now to show some evidence that we can connect what we are putting into the system to supporting the nine national outcomes. For example, the methodology is around identifying what are the resources that you put in. It's then about trying to set out a plan, sort of like a logic modelling, about what would you expect the outcomes to be in a short, medium and long term. It's then about interrogating all the different kind of resources that might claim success in leading to that outcome and basically saying and really sort of narrowing down which of the areas of investment have actually given us the greatest effect in terms of efficiency and effect this outcome and disregarding the ones that may not have contributed as much. So it's a constant sort of review and cycle of looking at what we're doing, how all of the kind of things that we're putting together in terms of investment are contributing, disregarding those that aren't and trying to get to some kind of a science around the link between finance and outcomes. I think the starting position is that it's a vexing question and it's a complex area, so it's not about an input and an output. Having a tool like this has been very helpful to us in South Lanarkshire. I have an example that I can give you in terms of best value if you would like it, but I'll need to read it. It's around technology because our last outcome is around best value. In terms of our tech programme, we have looked at how the investment has impacted on that national outcome nine, which is resources used effectively and efficiently, and this is about our home monitoring programme. So an average of 4.3 blood pressure appointments are avoided by remote monitoring, and if you take 4.3 by 3,545 patients that are already registered in South Lanarkshire, by £5.41, by 10 minutes, and for a practice nurse appointment, you have a saving of just over £82,000. You can see why I read it. Basically what we're looking at is the contribution that the technology enabled care, the home mobile monitoring, the impact that it's having on that ninth outcome. We say that there's over £80,000 of a saving in there in terms of the way we're remodeling that. It's not always cash releasing, so I probably need to make that point, but probably what it will be doing is responding to some of the questions earlier around managing demand and the demographic demand and the type of demand that's coming towards us. Myla, do you want to add? I think that it's probably fair to say in Edinburgh that linking finance to outcomes is not something that we've made very much progress with. However, we are looking at how we make an investment in evaluation generally. I think that the whole idea of linking money to outcomes as well as indicated is not a straightforward thing to do. There's not a one-to-one relationship with investing some money in any service and what that outcome is, because outcomes are delivered through a variety of services. It's quite a complex thing to get into, but I think that we will be visiting Larrattshire to find out more about that approach. National health and wellbeing outcomes, what support has been provided by the Scottish Government to help to develop, integrate and develop reporting in this area? We have support locally. We work with both our partners in NHS Lothian and in the council on some of that evaluation and the intelligence-led data-gathering and reporting, but also the list analysts who are provided to each partnership through the ISD information statistics division. Within the Scottish Government, we've found that an invaluable resource and support. As Moira has indicated, there's no one-size-fits-all, and often the conversations that we're having with those colleagues is that this is the sort of thing that we want to try and find out. We want to understand that, and our colleagues, our experts in this field, will usually help us to apply. This is the information that we could help you to gather that would help us to interpret the outcome there. I hope that we're working quite well with our support from ISD. They're embedded locally with our own data colleagues, which I think is a very important thing. It's not something that is done and lands on Edinburgh and then goes away again. It becomes embedded in our system, so it understands the way that we work. That is very helpful, but, as my colleague Moira has said, we're also looking at how we strengthen that further, particularly around transformation. When we're talking about this as the change that we want to make and we believe that that will have a better outcome, and we believe that that may help us to manage within our resources, we want really good evaluation right the way across to tell us, are we going in the right direction? Do we need to trim our sails? Or do we need to change what we're doing completely? It's a very important underpinning. Any further on the invalidation? I'll just say that there are a couple of examples that we've been doing recently with different parts of government. Alongside the integration team, the chief officers have been trying to look at best practice in terms of discharge from hospital, trying to look at variation and then share that across to see what areas are doing well, what areas are not doing well, and actually use the self-evaluations to enter into conversations with each other, and also enter into different benchmarking that's not just about looking at numbers, it's going to cross and visit each other and actually the teams visit each other in doing that. So that's one area where we work with integration team. One of the other things, and although some of this data is still quite acute focused, it actually drives interest for us in the IGIBs, as the new tool that they call the Atlas of Variation. It looks at the variation in different health procedures across Scotland, so for instance there are much more proportionally hip operations in Ayrsynlar and there are other areas that are done very simply in terms of maps showing shades in that, and then it starts to get you to ask the question why. Is that a bit clinical variation? Is that about the health in the communities? Is that because of obesity in our local communities? So we're starting to get quite a lot of rich data, I think, from Government. That actually helps us to ask the questions, how can we change the health of our local communities, what's the big priorities around that, and it's not simply that the consultants in Ayrsynlar must be deciding to do too many hips. It's actually if you go a step back and actually look at the health of our population, they're required, and why they're required isn't about obesity, it's about community health services, so we get quite a lot of data and our job is obviously to make sure that we translate that data into meaningful information and then take actions to deliver against that. The only thing that I would add really is that we've got very good support from the Scottish Government to think that that was your question around ISD and around what we call the big six, the unscheduled care, the delayed discharges, accident emergency emissions, etc. So very good help around that and support around that, and nationally we are growing that support. The point that I would make in this discussion is around the quality of data, so I think what we're trying to do more is listen to patient and client, our resident stories, what are their stories, so what feedback are we getting from people about their experience, what's their experience of services, and that's the bit that I suppose is more on the not the input output bit, it's the more of the sort of what are we contributing and what outcomes are people living better lives, are they keeping themselves healthier, are they able to look after themselves more, do they have the information when they need, do they have the right interventions when they need, so what are people telling us about that and I think that's an area that we collectively recognise that we would want to go stronger and I think we're working on that. One of the things that we've done in South Lanarkshire is I've appointed a communications manager and the point of this is around it as you can probably gather the engagement and communication pieces really really big for us in terms of what we do locally but again going back to that conversation about what we need to do maybe nationally and to grow that, but the idea of bringing communications manager in was to link not just to respond to and react to the requests that we get in the system every single day, whether it's from the media, from a whole lot of different sources, but actually to link the communications from the partnership to the nine national outcomes so to proactively communicate what we're doing and how we're doing that and how we can link the different parts of our work together, so that will help us with our outcomes as well in our patient stories. To come back to a point which Eddie Fraser made with regards to outcomes and the third sector, obviously in the legislation which established IJBs they weren't part of the table discussion at the early start of integration, do you think that was a mistake and how are you trying to build the third sector involvement going forward? I know here in Edinburgh the hospice movement works incredibly well as a charitable third sector organisation, but how do we get them into discussions early on? Often they deliver services and transformation far better than NHS or local authority in moving things forward. Absolutely, I agree that they are fundamental partners to how we do this work. Third sector interfaces across Scotland do sit on IJBs as advisory members and on voting members of that. That's a really important signal, but of course it's the people that sit behind the interface and all those organisations, some of whom are working very locally in communities and in neighbourhoods that we want to tap into. I'm sure that, like others, over the years, when I was highlighted in the Audit Scotland report, a huge amount of work had gone on and continues to go on in Edinburgh about how we engage with those partners in the work that we are doing. We are in discussions now about our new strategic plan, many of those hosted by and led by third sector organisations, them contributing to that, us understanding their contribution to doing some of the things that maybe have been traditionally done by the statutory sector and them as an absolute link to communities and neighbourhoods and people in Edinburgh who we want to work with and discuss change with. It's a very broad constituent. Sometimes the danger is that we talk about the third sector as one thing, but of course it will span from those large national, sometimes internationally, present organisations all the way to the hyper-local. That can be quite difficult to span on that, but I hope that we stick to the principle that they are absolute partners in the work that we're trying to do. Good morning to the panel. What I wanted to look at is the impact of the shift of care, the reality of the shift of care from acute to community. I know that there's an example that we've been given here in South Lanarkshire about changing that direction of travel or redirecting towards community-based services, and the impact of that was with the closure of a 30-bed elderly care ward in the hospital. That's the brutal reality of what we're talking about here. That's the impact on the ground for our communities. I wondered what challenges you faced in making that kind of decision, and was there a push back against that? We talked about that last week, and we were mostly invested in bricks and mortar in terms of care. How difficult was that to get to that decision? I'll decide that. It was tough, but I think that sometimes we get caught up in the before and the after and don't spend enough time talking about the relationships and how we build relationships when we're going from A to B. I would say that the relationships with the South Lanarkshire partnership became very much stronger through this process, so it took about a year. It took quite a long time, but we started pretty much from scratch because when you're talking about closing a ward like this, you under the territory that we're in with the integration authorities and health and social care partnership, there isn't a route map, there isn't a pathway. My colleagues may have one, but we didn't have one, so we had to start from scratch and think, how are we going to do this? We started with a position where it was a care of the elderly ward. It was 30 individuals, and it was Douglas Ward. It was managed by the acute sector, so the acute sector is forgiven for thinking that the release of that money might have been theirs. However, it was in the set-asite budget, so we were very early in our agenda and trying to understand this. A lot of the challenge was around who do we engage with, who makes the decision, who's money is it, so there were the three big ones. The engagement is an interesting piece, and it would take us quite a long time because in terms of the integration joint boards, we don't have to comply with cell 4, which would be the major change guidance that the NHS usually has to adopt. We didn't have any guidance in such in terms of engagement. Engagement was tricky, and the best I could do was to listen to my partners very actively. I had to act counter-intuitively because I come from a local authority background, and I was actually taking some intervention from an NHS point of view. Sometimes you have to do that because you have to listen, you have to say, actually, this is the way this part of the system works. So there was a bit of that for me. What we did over a period of time was we didn't want to just say this ward, which is worth or costs just over a million, it's £1.072 million. We didn't want to just say, well, how much of that should the community have? How much should the acute keep? We benchmarked around the country and we didn't find a science that we could apply, so what we did is we got a steering group together and we plotted for each of the 30 individuals and those that would have gone before and came behind. What would their care look like in the community? What would it cost? What would it have cost if it was still in the acute sector? What would we need to put in place? The length of stay is quite important there. We applied a bit of science to this. It took us quite a long time. That was about building up trust as well. I go back to the relationship thing. It was about building up trust. It was building up the shift to actually, you know, I think there's a lot of this money will be moving from the set aside to the community and we will bolster the community in order to get that whole system working, but we'll need the release of that cash. Some of it was about trying to give reassurance around risk and some of it is around the engagement with staff, with relatives, with patients themselves. The starting position was £1.072 million, as I say. The end position was that we agreed to £700,000 coming into the community. We agreed two pots of money that would stay with the acute. There was about £760,000 that was in recognition of. I guess the point was that acute sector were saying that, you know, the people that we will have remaining under our watch will be a little bit more complex. So can we have a bit of recognition for that? So it was negotiations, so we suggest that's fine. The other thing was, and Marie mentioned this earlier, the NHS have been very supportive of the IJB and they have not passed on the on-costs and the uplifts of the set aside budget to the IJB, so we negotiated another £760,000 in recognition of that. But the bigger point, I guess, is that three quarters of that money with this kind of scientific methodology, and I'm not sure it's perfect, but it was kind of as good as we were going to get. Three quarters of that money was actually transferred to the partnership and, as a result of that, we have been able to invest, we've added to it, we've put an investment of £760,000 into our four localities and that's around getting rapid access to get folk out of hospital a little quicker and to work in our locality teams around community pharmacy, district nursing, home care and really building on our integrated teams around localities. So it took a long time, people might think it's a very easy thing to do, but I couldn't emphasise how important the relationship building and the trying to understand each other's agenda and the shift in policy and how all that nets together and very respectful relationships grew out of that, but it was one of our successes last year, so thank you for the question. I think that we're moving on from that, and again we had this discussion last week. If we extrapolate that, what we're probably talking about here is, in that shift to community care away from acute, it's losing a thousand beds in hospitals. Are we ready for that discussion? Are we ready as a country to have that kind of discussion? I think that that's where we get back to communication and trust. We regularly, between the partnerships and acute colleagues, do what we call day of care audits, where we actually look at all the different patients who are in a hospital and at any one time between a quarter and a third of the patients within a hospital actually don't need acute hospital care. They're there because they're waiting for something else, and actually we're back to saying if we can provide that something else, then the trust bit comes in that the acute hospital's reduced by that capacity and that we then don't fill it up again, because actually if you close the ward, if you move on, there is no nurses there, there is no space there to do it, so it has to be about, we spoke a few times about using data, but it's more than data. First of all, you need to start with the data. I think that you need to start with the day of care audits that really evidence there are a lot of people who are sat within our hospitals every day who actually don't need to be there, then you need to build an alternative to that. We need to build trust in the different services, both care at home and care homes. We've not mentioned care homes, so one of the fantastic relationships we have is through Scottish care with care homes, and actually some of the work that we do about care, about physical activity and the my home life management programmes in care homes is these are good places to live in our local communities for people who need that level of care in much more homely environment than living in a hospital, but they are the types of conversations that we need to have. Anyone who, I think, without giving a really sound alternative to hospital care that tries to make that argument, it's not a sound foundation to make it, so I think that if anyone said, should we shut 1,000 acute hospital beds and we'll do something differently, I don't think that that would be very well received. I think that you actually need to evidence that there is a different way of doing things and it's also a better way of doing things for the quarter to third of patients who are sitting in hospitals who don't need to be there. I agree with Eddie very much wholeheartedly on that one, and I think that we are getting to a place where we're more likely to be able to have the conversation, but it is about that balance of what we might change and not do, but really celebrating the alternatives that we now know we can do safely and well in communities. It's a fact, isn't it? A hospital, a bricks and mortar thing is far more recognisable in a community than some of the things that we do in supporting people in their own homes. That's largely invisible or in care homes. We don't see a lot of what happens, we don't celebrate a lot of what happens, and unfortunately some of the things that we see and read about care in the community and care in care homes is that the other end when things don't go well, which is by far the minority of cases. I think that nationally we would benefit from a conversation about how is our care and support, how is our system changing and how is that improving people's lives and how is that better for people and that whole system thing. If we're able to deliver those safe and valuable alternatives in the community, it means that our cute hospitals, which are valuable resources, can be working at their optimum for people that need them, when they need them and for no longer than they need them for. So I think that we need to think about that right the way across the change, but what we're actually putting in place and the benefits that that can have for people. In order to be ready to close a thousand beds, we do need to create the conditions that would support that. As Eddie and Judith have both highlighted, we do need safe, reliable, alternative, community-based services. Within South Lanarkshire, we have tested change in pilots that are being taken forward. We've spoken about telehealth and telecare and given people the opportunity to manage their own care. Through contribution analysis, we're seeing that that is resulting in a drop in the attendances with doctors and GPs because people are able to communicate their results electronically and get feedback. Those are positive steps and positive developments. In addition to that, we've also had IV therapies as a test of change in a pilot, where people have received IV therapy treatment in the community and they've not needed to be admitted to hospital for that. However, those are tests of change that predominantly are being funded from non-recurring funding solutions. The challenge now is how do we scale up to an extent where we can move the resources, move care to a more appropriate place that is better for the individual, better from an efficiency point of view across the whole system, and then, after that, release the resources, which is difficult to predict where those resources would be released from in the system and at what time. The complicating factor is the budget pressures and other challenges that both partners are wrestling with. That feature is part of our conversation. As Val highlighted with the example in Udston, we recognise that our partners have problems. Therefore, we could not insist on securing the million-pound investment into the community. We felt that it was a fair and appropriate response that part of that remained with our acute service colleagues because of the services that are critical and that they are also delivering. Fundamentally, the point that I am probably getting to is that there needs to be investment and it needs to be upfront investment if we are to develop those safe, reliable services that we can all place confidence and rely on. Once we have that conversation about closing the beds, it would be an easier one to have with the public. I want to move on. If I could take that conversation a little bit further, there are two areas that interests me greatly. It is the impact of the third sector on healthcare, both in prevention and rehabilitation. It is also the implementation of technology. I think that it is of absolute paramount importance if we are going to create that shift into the community. In Eddie May's point, he said that I am not being flippant about T-dances. That is massively important. It is hugely important. The impact of the third sector on your budget, so there are two things here. How is that accounted for in terms of how can you account for the third sector involvement in your budget? We all know that the third sector budget has been hugely squeezed at the moment. It seems to be an easy target. Is that being factored in in terms of your ability to manage your budget? One of the first things that we did to put that flag of how important that was is in our strategic plan, when we look at what our priority is. That prevention and early intervention sits right there at the top of where we want to be in terms of our strategic plan. How we work with our third sector partners is very much about funding them, working with them as partners. Many of our third sector partners in East Asia are specifically that, but they are not commission services. When we work with the CVO, the CAB, the East Asia Carers and the East Asia Advocacy services, they are partnerships that we are in. They are not commission services, so people are able to work with us in a different way because they have more sustainability around their funding. In terms of the ways that we have been able to work with the wider, the smaller local partners, it is working with the third sector interface and funding the third sector interface for outcomes. It is then being that conduit to fund a lot of the smaller partners in terms of doing that. It takes away the criticism that many of the smaller partners have about the level of red tape that they have to jump through when they are working with statutory bodies. Working with the sector is one of the things that we do. Our third sector member on the IGIB is our rep on community planning. It is not one of the officers, it is not one of the health board members, it is not one of the councillors, it is the third sector rep that represents us on the community planning partnership. Clearly, it is much wider than just our work around what we traditionally think of some of this work in terms of health and care. Our violence against women partnerships are heavily supported in terms of the third sector, in fact, led in terms of the third sector, some of the work that we do around community justice in terms of rehabilitation and command up prison. Again, centre stage and other organisations in the third sector are very much up the middle of that. I do not think that the third sector is a parallel service to us, as it is integral to the delivery of what we do. We talk about the third sector, I mentioned before, about the independent sector, particularly in terms of care homes, and we also want to talk about the faith sector. Again, some of the work that we get in terms of homelessness, some of the work that we do in terms of work around learning disabilities, the support that we get for the faith sector is fantastic. That whole community out there, that wider Scottish society that can support us, is really important to us. I think that we need to make sure that we commission with all those partners appropriately that give them sustainability. That is one of the big dangers of IGIBs. Do not ever really notice what they are doing in terms of their funds. How do you work with third sector partners or other commissioned partners? For instance, partners will come to you and say that they are going to be funded in the next financial year, because some of them will say, if not, that they are going to have to serve their staff notice at the end of December. In February, they say that funding is okay, so they need to withdraw the notice. It is no way to continually deliver high-quality services. That is an important area for us that we spoke about before. If we have longer-term funding, that is what I meant by how to do relationships with the third sector that we can do better. We are a little tied for time, so if I can encourage Judith and Mary to respond briefly to this question then we can move on to address set-aside, which we need to cover as well. Very briefly, again, I agree with Eddie. I think that those points towards the end, you know, the procurement of third sector organisations versus our ability to really invest longer term in them. Again, I was going to make the point that we can't also in valuing our third sector and not forget the role of faith groups in this. It is very, very important in communities and in what they are able to do. Our need to invest there and the independent private sector is important partners, too. We have to think of them as part of the overall continuum of what we are doing in Edinburgh. We are all in this together. In terms of the funding that is available for the third sector, we have allocated funding to take forward those initiatives. We have tried to protect the third sector organisations from applying savings, but what we have not been able to do is further add to the investment that we have already committed. That is a challenge for them, managing any cost pressures that they have within the financial envelope, but it would be an aspiration that we could contribute more to them as we go forward. In terms of the third sector, there is also the role of the volunteers. We have got two areas of work, the distress brief intervention, where volunteers who have a lived experience are contributing significantly to the outcomes in terms of that particular project and through the alcohol and drug partnership in terms of the recovery hubs that are being set up. Again, it is people with lived experience that are better placed to assist people at a time of crisis in their life and when they are suffering from difficulties and challenges. It is a complex landscape, but it is definitely one that the statutory partners alone cannot deliver on, and that partnership working with the third sector and the wider community is key. Brian Whittle is a supplementary, inviting, very, very fanciful, I think in the last case. I want to tackle the issue of implementation of technology very quickly. There is fantastic healthcare technology out there that is not currently being deployed within the healthcare sector. It is not just about the parts of the technology, it is about deploying that and the CPD to those in the front line that are going to use it. Within your budgetary restraints, is that an issue? We very much want to utilise technology as far as possible, and it is not always the cutting edge stuff. There are some basic things that we have not nationally really embedded to really support people at home. I was thinking about your earlier comment about 1,000 beds across Scotland. Moira Nai, our colleagues in our technology-enabled care service, ATEC 24 just last week in Edinburgh, which was great just to see the technology that they have, the way that we distribute it across the city. One of the things that we saw when we were there was the sheer number of hospital beds, so those adjustable beds that we have. We have hundreds of those now right the way across the community, in people's homes, delivering sometimes palliative care, sometimes really complex care there. We are seeing that transfer through the use of equipment as well as technology and doing things very differently. I think that there is more that we can be doing, which highlights the way that the technology and adaptations and aids and so on can support people. I think that we need to highlight that more. I think that as we begin to work with our training establishments and higher education, we need to prepare those students and those new workers coming into our systems to work using the technology more, because that generation of people that are coming in as nurses, doctors, OTs, social workers are far more familiar with technology and far more used to using that. I think that we have to really think about that next generation coming through, the next generation of people that we will be looking after, and really being open to testing new ways of working. Again, some of that comes down to our willingness to invest in that. Again, it is also about the underpinning evaluation. Does it work? Is it as safe? Is it as effective? On Val's point earlier, the individual's experience of that is often far better, and we need to be better at communicating that, sharing those good news stories and being willing to do things differently. I think that, likewise, I am going to build on what my colleagues have said. The technology, we are very fortunate in South Allynshire to be really developing a very strong team around our technology, the technology enable care, and some of that is around the attend anywhere, which is being able to do home visits and for occupational therapists to be in the room and for physiotherapists to be somewhere else. When we are covering a bit of a rural area where transport can be an issue, that is really useful, so that is maybe one of them. We do a lot of VC video conferencing around our care homes, independent sector and our own care homes. That can be about connections, but it can be about some surgeries. The other one is the mobile monitoring, which I mentioned earlier. I think that we are well supported and we have very good connections with the Scottish Government in relation to technology enable care, so we are hoping that we are going to be able to scale this up even more in the future. However, some of the basic things that Judith has covered, I think that we need to make sure that we do not forget them because some of the fundamentals need to be in place. One of the examples that I would give would be around home care scheduling, because that is becoming really complex, but very important in terms of efficiency effect and just getting the right person in the right place at the right time. I will stop there because of time that you could go on. Thank you very much. I suppose that I take it away from technology enable care and look at the support of our staff. First of all, you can only use tablets and access records, if the record is digitised. One of the things that we have had to do over the last year is actually spend significant amounts of money to get all the social work records first of all digitised, so that you can access them. We have still got a lot of work to do around that in terms of some of the community health records. Secondly, I think that in future, when we talk about employing staff, there should be an element of that that is included to make sure that they have the money there recurrently to further tablets, so that it is renewed every three or five years or whatever we need to do that to make sure that there is support on hand, that if the tablet does not work today, nobody tells you you need to wait a fortnight before you get it fixed, because you need it fixed today. Actually, we need to build the actual basic infrastructure to make sure that people can access that range of things there. I think that many of us have parts of it. I think that if you look across, do we have recurring budgets in, that would actually mean that everyone in my 2,000 staff, if they all needed a tablet or a mobile device, would they all have a budget sitting there that would renew them every three or five years? I do not know about other colleagues. The answer to me is no. It is almost opportunistic that we actually do some of that type of work, and secondly, we need to invest in the support teams that make sure that people are supported. I would say that, as well as doing the kind of advanced stuff in terms of what we can do and what we can imagine for the future, we need to build the foundations around that as well, and I think that the foundations have got a bit of work to be done. I am interested in picking up about the set-aside budget. I know that Val has talked about that, a good example of how set-aside was used in South Lanarkshire for the ward that was closed and then care delivered in the community. We have discussed set-aside a lot in the committee previously and how it is operating well in some areas and maybe not so well in others. As a consequence, my issues are set-aside if it is not managed well in paid integration. I am aware that NHS and Freeson Galloway do not even use the language of set-aside. They call it something different. I have a couple of questions. One of them would be, could you, the panel, say that the set-aside budget is operating as intended in your areas, and if not, what is preventing this and what needs to be changed? The situation in Edinburgh is that we have very good discussions about the set-aside, and we identified through the self-assessment that we have submitted for the MSG review piece of work. We are certainly partly established and moving towards it. We are established in understanding the position where the set-aside is. We get good information and data from NHS Lothian in terms of our share and we understand what that means. However, the challenge around the use of the set-aside is that it is absolutely embedded in the delivery of current services. When we think about the set-aside and conversations that we are having now, we are thinking about services that are currently being delivered with the use of those resources. We also sometimes fall into the trap of thinking about the set-aside as just a budget as money, but it is about all the resources that that funding provides. It is staff, resources, expertise, infrastructure, costs and so on. The transfer of that towards a community setting can then be quite difficult. The conversation about the set-aside is complex just by its very nature and by the fact that this is the wider transformation and move from what we do now to how we might deliver in the future. The starting point has to be the transparency of the conversation and the clarity about where responsibility for that sits. In Edinburgh, we are making certainly good progress in understanding the resources where they sit, our responsibilities. I do not think that we are there yet and how we as an IJB would commission the use of those resources differently. However, we had opportunities arise when we were talking about the potential to change services. We are having that discussion about what does that mean for the potential release of some of that funding or the transfer of the funding and resources towards a different model. We are there in the discussions but it is quite complex. We have some examples of where we have managed to use that around mental health and learning disabilities where we have transferred the resource in supporting individuals who have lived in institutional care and supported them in the community with the resources following them. It gives us a good blueprint to work on around that. Positive discussions, but I do not think that we could say that we are there yet in terms of our ambitions of where we want to go. I suppose that setting aside is just almost code for the number of unscheduled care bed nights and IJB wants to commission off the acute sector. When you talk about setting aside, that then gets down to 10 specialities in particular. That has felt that the IJB's kind of a real influence over. In terms of using setting aside properly, that is about what do we want to commission from the acute sector this year and what do we think over the next couple of years will be the direction of travel around that. That is where that opportunity within, given directions from an IJB to a health board, that legal term directions to a health board into the council over the next couple of years. I want to commission 100,000 beds this year, next year I think it will be 98,000 beds and next year it will be 96,000 beds. It is then about saying how do we do that and using directions to be able to do that. When we look at the MSG indicators in terms of unscheduled care bed nights, many partnerships across Scotland—in fact, I think that the majority of partnerships across Scotland—have seen a reduction in the number of unscheduled care bed nights that they commission from the acute sector. However, sometimes acute hospitals are just as busy. If you operate in a board area like Ayrshire and Arran where more than one IJB utilises a hospital, then it has to be that all the partners reduce the pressure on the hospital before there is any actual release. There are two different things. There is the equity of the use of the resource from each of the IJBs. Secondly, there is the totality of the resource that goes up and down. If all you do is shift it, like we put some down in north or south, but more up, then there is no release from acute. They are still delivering the same level of service. Similarly, we need to work together around how we bring that down. We are still at quite early stages in terms of the set aside. I agree, Judith, about the understanding of where we are. We are at work with the Scottish Government in terms of saying what would directions look like to be more strategic over the next year, so we are working with integration to the Scottish Government to look at that. However, I think that it is equally important to understand the relationships between IJBs as well as the relationship between IJBs and the acute sector. I have an example of what set aside would mean. For instance, anti-coagulant therapy monitoring can be done at home, so why are patients going to get their blood drawn once a week and all of the associated costs of that when a coagulant device can be installed at home that will talk to the GP remotely and tell patients how to fluctuate their warfarin tablets? All that can be done remotely, so if funding can be found to support patients using coagulant at home, is that a function of set aside? Is that where that money would come from, NHS, and then move towards community care? I will do so. Sorry. Eddie might give a better answer to this one, but yes, it is probably one of the direct answers, but it is tricky, it is complex. We were fortunate with the Odston example, one of the other things that we were doing, and I referred to, there was not any pathway for this when we started to work on this, there is no guidance and no pathway. One of the other things that we did with NHS Lanarkshire in South Partnership is that we called it a 5 per cent project, so we basically said, we bet like your example, what is going on in the acute sector in that ward that we could actually try 5 per cent of that in the community, it is like a test of change, and we did that with IV therapies. We put the staff around, we got a responsible medical officer to overview it, so we put all the clinical safeness and effectiveness in place for that. It is successful, so we have taken out something like, I think there are approximately 14 people at any one time in any hospital and IV therapies that could probably be in the community. We had a threshold of two at a time in terms of the scale. If we were to transfer that resource, so it is successful, we need to know how to scale it up, that is our next challenge, how will we do that, what will we put around, how can we build that in the community, but we are starting on a really sound basis there. We have also done it for COPD actually in Clydesdale, which is a really interesting model. What you are looking at is, you are looking at trying to, how can you get the cash released from that, and when you have a ward that has staff, has IT, has a whole lot of other bits of infrastructure that are all really embedded in delivering that ward, and that is only one of the functions on them. It is very difficult to release that cash. In Utston, it was one care of the elderly ward, so it was 30 individuals. There was sort of like a boundary around it, so it was a unit, so we could put a cost on it. But when you are talking about the very core functions of the acute sector, the delivery is so much wider, so much more complex, it is the infrastructure that it needs in terms of staff and the general infrastructure, it is very difficult to release resource unless you are doing it on a big scale. The way that a cyticide is normally held within the NHS, does that mean that the NHS owns it or makes it difficult for it to be released? Do they consider it that it is their budget that is being handed out? In terms of the approach across Lanarkshire, there has been a very open and transparent approach to the cyticide services. There is a non-scheduled care group that is meeting all key stakeholders. From a day-to-day basis, it is the director of acute services that manages the services on behalf of the IGIB, but Val and our other colleague, the chief officer of North Lanarkshire Council, are very much key partners in taking the cyticide concept forward and transferring and shifting the balance of care. I would like to pick up on your earlier observation about what could be impeding the implementation of the cyticide, as well as the role that NHS Lanarkshire has in terms of their transparent approach. In terms of what is impeding it, although we are trying to move resources and we are trying to shift the balance of care, we need to revisit the fundamental underlying assumptions upon which the cyticide budget has been based. From a Lanarkshire context, we know that over the next eight years, up to 2027, there will be a almost 30 per cent increase in the older population. We would need to make more beds available to accommodate that increase. We would need to make more social care services available, but what we strive to do is, through shifting the balance of care, manage the demographic growth increase within the financial envelope. The underlying assumption that we can release the resources from the acute services to fund that is, in my view, unrealistic and flawed. I believe that in terms of the totality of the whole system and the totality of all the cost pressures, including the new medicines and the drugs, and recognising the acute services, the areas of services that are not within the cyticide budget are also critically important to the people of Scotland, the cancer research and outpatient clinics. There is a whole range of services and it is a whole service system approach that we need to adopt towards that. It would probably be helpful to revisit the underlying assumptions that we are assuming that money can transfer out of acute services to fund the community services. It is probably an opportune time to revisit that. Interesting point of view. Are there any other contributions on that theme? Eddie Frazer? I know that it is almost along that line. Everything around cyticide, we tend to talk about in a quake back to occupied bed nights. Changing what we are doing around those specialities impacts not only on bed nights, but on outpatients and prescribing. It impacts on some of our primary care services as well. By doing positive things in relation to some of the specialities, we can see a much wider impact and the focus all the time only on occupied bed nights. Going forward, that might not be the most helpful focus to have. I will move on to leadership aspects, because that has come up previously as well. I am interested in whether the panel members would agree that leadership challenges exist or have they hampered any progress. Are there any thoughts on how we support and develop people to become leaders? Judith Brown talked about supporting staff for change, so it takes good leadership to support staff. A lot of people do not like change, so what is happening in that area? I think that this is a real leadership challenge right the way across. It is not just for chief officers individually or us as a group, but for all public sector leaders that are involved in this now, because integration to work well involves us all working together on things that we maybe need to give up and things that we need to recognise where the responsibility maybe sits elsewhere. It is quite a sophisticated level of conversation that we need to have right the way across our partner organisations, where the accountability sits, where the leadership sits. I think that a big part of this is leading the cultural change that we want to see in our health and social care partnerships. Our staff mostly, obviously Highland, is a different partnership set up differently, but for the majority of the 30 other partnerships in Scotland, our staff still work to their parent organisation, to the NHS terms and conditions of the council terms and conditions. However, within that, I think that the leadership for us as chief officers and our IJBs is about creating that IJB in health and social care partnership identity. What it is that we are trying to do is distinct organisations and leading our staff towards the outcomes of that organisation. I think that that is really, really important and you are right. It sits beyond us as chief officers, as our senior teams, and it is about our front line managers, our leaders, right the way through our organisations, how they are leading that change, supporting change to come forward. A big part of that, of course, is about creating the conditions in which ideas and different ways of working come from there. It is not about leadership, which is all about setting direction, and this is what we are doing. It is about how we work together to build a movement for change in our organisations and beyond. I think that leadership is key in delivering change and leadership at a number of levels. I think that leadership in terms of understanding our local communities, local political leadership, how that is then supported by the wider partner organisations, including the health board, local colleges, etc. That leadership is about community planning, real belief and wellbeing for our communities. I think that the relationship between the chief officer and the two chief executives is key. The trust and relationship are an open relationship across all three. That is a huge support to take forward. Not integration in itself, but the outcomes that we try to achieve from integration. If there is a high level of trust there in terms of what we are doing, if there is a high level of openness, that is transmitted in terms of what we are doing when we go back into everyday discussions, not just in the IGIB, but in council and at the health board. I think that continually making sure that the relationships are strong, that there is an openness there, is one of the things that we need to make sure that we continue to develop from. I will just build on what my colleagues have said. The leadership is key. Trust, respect and absolutely key across all the partners. I think that there are two parts to this. It is about leadership with people and leadership with a focus on place. We have more or less covered that, so it is about understanding what you are leading, where you are leading and being for your place and for your people is really important. People are part of your workforce. Sometimes, when we are introducing a bit of change, we will test it out with our 5,000 staff because they live in the area. They work in the area, they live in the area, so there is a bit about fundamental leadership at all levels, so it is really important. I know that the convener has said that time is tight. I did have a couple of questions around housing, because that is really important. It might be that we follow up with questions around housing, because Eddie talked about vibrant community teams supported accommodation, how integrated housing is with the IJBs, but I am happy to follow that up at a later point. If witnesses are happy to deal with that, and we may have one or two other things too, then I will thank you all for your contributions. It has been very informative and we will suspend briefly and resume in private. Thank you very much.