 Good morning, colleagues. Welcome to the 16th meeting of the Health and Sport Committee in 2019. We have received apologies from Emma Harper, David Stewart and Brian Whittle. They are at Westminster today participating in the Scottish Affairs Committee on behalf of this committee. Anna Sarwar and Bob Doris are here as substitute members today. I would ask everyone in the room to please ensure that mobile phones are offered on silent. I welcome to the committee Stephen Fitzpatrick, assistant chief officer and Alan Gilmore, planning manager of Older People Services and South Operations, Glasgow City, IJB, Sandra Ross, chief officer and Kenny O'Brien, service manager with Aberdeen City, IJB and Jim Forrest, chief officer and Yvonne Lotton, head of strategic planning with West Lothian IJB. Our witnesses are here today to assist our inquiry, our pre-budget scrutiny, in which we are following on from the sessions that we have had two weeks ago in public session and also some other work that we have undertaken. This is all directed towards the budget for 2020-21, building on the approach that we have taken in previous years to highlight issues around integration and integration authorities. I am very glad to have you here and welcome to the committee. One of the items that this committee has pursued vigorously over the last couple of years is the question of access to financial information or the publication of financial information around integration and joint boards. We have certainly seen progress in that, but nonetheless it is still the case that the financial information that we receive regarding the budgets of IJBs is quarterly in our years. For example, while we know that you will all have set your budgets for the current year, at least we so assume, that financial information is not made available to us for a further three months beyond the decision being taken. I wonder whether I could start by asking witnesses if there is any reason why you would not be able to provide financial information directly to Parliament in that timely way. I wonder if anyone would like to start with that question. Basically, looking for the most timely information that we can obtain, but also recognising the changes that there are to budgets of your partner organisations as well. Who would like to kick off? I am happy to start just to say that it is not my irresponsibility, but I know certainly that our IJB meets every six weeks or so and has monthly financial reports there. We have set our budget at our March meeting just over two months ago. That information is in the public domain, so it would be straightforward to find a mechanism to share that information, which is routinely available publicly anyway through the Parliament. I am sure that that would not be problematic. I will commit my finance colleagues in Glasgow to that. I am sure that they will be grateful, but can I ask if similar situations are applied to Sandra Ross? Our budget has been approved with our partners as well, so I am sure that we can share that as well. The same position in West Lothian. We agreed our budget in March as well. We meet every six weeks as an IJB, and the updated financial information goes through the IJB and is a public document. If that is the detail chair that the committee requires, we will happily come up with a mechanism to provide it. That is very helpful. From the way that you have described it, the mechanisms that you have described would appear to be likely to be the same in each and every one of the IJBs. I see a lot of nodding to that suggestion, so that is perhaps something certainly very grateful for your offers, which we will look to hear from you, but it is something that we can raise more generally in terms of ensuring that such information from all IJBs or all integration authorities is available to Parliament and to me as well. On the matter of finance, can I ask more generally whether they move to three-year financial settlements in the NHS and, potentially, in local government as well, whether that will assist in long-term budgeting and planning for your authority? I think that it will assist us in financial planning. Clearly, the challenge for us is to try and get to a stage in which we can have medium-term and longer-term financial planning. If we get that in place, the strategic planning and the commission-type decisions that we need to make become clearer. We would welcome that. I think that that would be the same. I think that it comes to our evidence submission that one of the challenges is the short-termism and the uncertainty around the financial settlement. Even if the financial settlement is difficult, there is a value in the degree of certainty around what we are facing to allow us to make some longer-term financial decisions. Are there barriers in the way of longer-term planning on broad and negative budgets? In other words, are there things that you are currently not able to plan because you cannot have certainty about the last one or two per cent of your budget lines? Is that something that affects students' perspective? Yes, to an extent, but, as you say, it is proportionate to the level of certainty that we have. We have a lot of experience and indications of what we will be facing financially, but, nonetheless, it can be quite significant. If, for example, the savings targets that emerge from the partner organisations are higher than expected or the settlement figures are lower than expected, it can have a significant bearing on our detailed planning and so on. Being proportionate about it, it can be at the margins but, at the same time, we would want it to be as certain as it can be to allow us. We have a difficult task planning ahead, as I am sure that we will go through over the course of this morning, so, as much as I am, it is possible that we will be our play. Sandra Ross I would echo that. I would say that three-year planning would allow us to move more into the more roundabout prevention agenda, which will impact, especially with the demographics and things shifting as they are. A more committed and more understood direction of spend will allow that balance to be moved. Thank you very much. Jim Forreston In addition to what my colleagues have said and parted to the committee, clearly there are a number of things that we have to be mindful of in terms of financial plans. At the moment, we have to do a degree of forecasting based on some of the settlements that are coming out. Clearly, as we move to particularly the health services, national wage settlements and negotiations with staff-side organisations, that takes a while for that to be negotiated. Then there has to be a decision of whether the budgets will be increased to pay for those increased salaries or whether it is partly going to be paid for centrally and some additional efficiencies. There are some things that you have to try and set a balance out of where you think it is going to be, what you think the pay settlements are going to come out of. Sometimes we get that right, sometimes we are a bit adrift of that. Clearly, that has an impact, because salaries are probably our most significant cost. The other area that I would like to ask about in terms of setting the scene more generally is benchmarking. We heard at the last evidence session with Eddie Fraser and other witnesses about work that is done to learn from each other's experience and to set benchmarking. I wonder whether you can tell us what access you have to benchmarking data from other integration authorities and what use you are able to make of that. Are there other good examples that we should be aware of? Jim Forrest. Luckily, in West Lothian, the local authority has a benchmarking family of other local authorities, which we have used as a basis to start looking at how we perform, particularly in social care, across that. We are in the process of looking at how we would incorporate the health information to do the same thing, to give us that co-terminosity and consistency. Benchmark across a whole range of activity, if you are speaking for Anseld, is probably not so much my area, but we tend, similar to Lothian, to look within our own health board area. There are a lot of comparisons across our constituent HSEPs, but in Glasgow we also try to look further afield, given the nature of our authority to comparable health authorities in not strict ourselves always to Scotland. We will look to Edinburgh and Aberdeen and other cities, but often to England as well. When we are looking at some of the challenges that we face, we will often look to Leeds and Birmingham in Liverpool. We have a good relationship with Manchester as well, and we have spent a lot of time with our peers there, looking at some of the same issues in a big complex post-industrial urban authority. We are probably more locally based with using our other health and social care partnerships around our benchmarking, so taking on board what my other colleagues have said, but we tend to be more local for ourselves. One of the things that has been striking in looking at the data is that sometimes there is quite a lot of variety even between close neighbours authorities. Is that something that you analyse or study in order to learn lessons about what more can be done? Alan Gilmour? We use a lot of the list resource that is available to us, so that is really helpful. Obviously, the ISD data, our forming partnerships through Health Improvement Scotland, and a lot of that is about bringing benchmarking data in for us to use. We have developed local dashboards, as Stephen was saying, in relation to comparing across our six partnerships that form NHS Greater Glasgow and Clyde. The important issue is about comparisons so that you are looking at like for like. Some of the variation can be explained in different ways, in different systems, so it is having that sort of intelligence that sits behind the data to make sure that you are looking at the right things. I suppose that what we have tried to do is look at the benchmarking data that is available, but also visiting other authorities has proven to be very useful because you get behind some of that data to understand the circumstances that you are comparing. Not only is it about access to data, but it is about the opportunity to share good practice and understand the challenges based on other areas. Can you hear Brian? Yes, I would echo what my colleagues say. I think that my particular area of focus more than anything else is delayed discharge performance, and so one of the things there is that yes, the top line of comparison is important, but then you have to really dig deep underneath for that. For example, some people may have very differing delayed discharge performances, but they may have very different labour markets in regards to social care. They may have a different volume of care home beds available in their partnership area, so it is then being able to take what the lessons are, and again I would reiterate that going and visiting those places and then pulling out the relevant stuff is probably the best thing that we can do from benchmarking. It sounds as if that is now quite common practice, would that be fair to say? That is something that all authorities engage in. One of the other questions that we have addressed in previous years is the outcome-based budgeting, and I wonder if any of you would like to comment on what support the Scottish Government provides for developing a budgeting that relates to outcomes. Is that something that you are engaged with or familiar with? Perhaps the fact that— I suspect that he speaks volumes that we are working across to see— You took the words out of my mouth. Scottish Government support for outcome-based budgeting is a question yet to be answered, is that fair? Thank you very much. Can we now move on to consider the delayed discharge and start with George Adam? Thank you, convener. Good morning. I would like to ask everyone—I know that everyone is committed to reducing the number of people who are waiting in the ward to get out to a more suitable—I know that everyone is working towards that, and I know that Scotland has already said in the past couple of years that there have been improvements. However, we have a table that Spicer provides in front of us that has a percentage of delayed discharge bed days as a percentage of the population, and it is quite varied throughout the whole country. When you look at it, for example, you have got Inverclyde at 2.5 per cent, Malone area at 3.3 per cent, Glasgow city at 5.9 per cent, and East Ayrshire at 4.8 per cent. However, on the other hand, you have got Aberdeen city at 10.1 per cent, Highland at 19.1 per cent, and North Ayrshire at 15.3 per cent, and West Lothian at 13.6 per cent. There is quite a varied difference there. My question would be, what is everybody doing differently in those areas? Is it demography, geography, or both? Is it in certain areas there are new ways of working that are working extremely well, or is it simply all of the above? I think that you have probably covered it with the last statement, all of the above. I have not seen the particular table that you have referenced, but I would say that one of the good things, particularly about delayed discharge data reporting, is that it is quite granular. It is not just a headline of, here are your bed days lost or here are the number of people who have delayed, you then get quite deep into the reasons why somebody is delayed. If you go on to the ISD website, you will see when you get into their Excel spreadsheet, which I want to do, but many people are not. I would say that there is very good detail for each of the areas in regards to where there are still delays. For example, you will find that, in Aberdeen, my area, one of our biggest areas of delays still relates to care home placement, and that is partly due to the fact that we have a small number of care homes in other areas that are available and accessible to us. That does not in any way mitigate that there has been improvements and there are other things that you can do to improve flow out of the hospital. In other areas, it will be more about demographics, and in other areas it will be about the labour market for social care in regards to recruiting home carers to allow people to flow home instead. One of the areas that Aberdeen has done better than in other areas is in regards to housing and adaptation-related delayed discharges, because we have been able to access more of the bricks and mortar to allow people to flow out with disabled access housing. The answer is probably that there are a lot of things that are in play in regards to varying performance, but certainly there are things to learn from those areas that are doing exceptionally well in regards to the reporting. I asked about benchmarking, and I suppose that my sense of it across Scotland as a whole compares very well to England and to the rest of the UK on this, and I think that there has been a real focus on it. Again, Alan and I tend to be... I've always been patriotic around delayed discharges. Everyone else around the table is very wrapped up in the whole delayed discharges, and it's very much a priority shared across Scotland. You tend to look at your own local area, so we're very involved in whatever's happening locally. Again, my sense is that I'd be corrected by the data across Scotland as there's been an improvement trend over the last number of years as well as that comparative point to the rest of the UK, but I do think that there are significant contextual differences, so certainly in Glasgow one of our great assets is that we have a very responsive home care service, so something like 65 per cent of our referrals for home care are discharged from Wards within 24 hours notice of the referral, so hugely beneficial impact to managing our delays performance, whereas I know that in Edinburgh and other places there's real challenges in kind of mentioning this about the workforce and the economic context can be different and very often maybe cares a more attractive employment option in a city like Glasgow and maybe in a city like Aberdeen or Edinburgh, so all of these things I think have a bearing. We know that practically in terms of our performance and some of the performance differences, but it's quite a complex picture, I think, to explain the differences between different areas, but generally I think quite a positive picture over time in Scotland. I think that in terms of what was mentioned, I mean clearly that the factors that were mentioned around demographics etc are very important. From a West Lodian point of view, our performance and delayed discharges probably deteriorated about 18 months to two years ago quite significantly and we took a number of decisions that we're going to try and remodel the whole service that we're working through at this particular moment in time. In relation to seeking information from elsewhere, so we sought information from Aberdeen City in terms of the plan that they had at the time and what actions that they had put in place. We've been in contact with colleagues in Glasgow and various other places, so we've made significant improvements in the last probably more so in the last six months as a number of these actions have come into play and we've seen significant reductions both in delayed discharges and occupied bed days and various other things. There is still work to do, so we've learned from the previous framework agreement that we had for care at home and we're about to go out to procurement for a new framework agreement, which will be radically different from the previous framework agreement. We've also had a number of operational challenges in that time that are out with our control, so the care home market, if we take the care home market in West Lodian, all our care home beds were full. We had no care home beds at all and clearly we were waiting for vacancies to arise, so we've worked very closely with the care home providers to try and negotiate some additional beds from them, so as well as West Lodian procuring and commissioning a number of the care home sector, there was about 25 per cent of it that was either people who were self-hunders or that beds were being purchased from other local authorities, so we've tried to get some additional beds and give us a higher proportion of the care home beds, which we're now starting to get and we've worked very closely with the care home providers in that. Some of the other operational challenges, if we stick with care homes, were we've had a number of care homes who have been under investigation because of their grades dropping and they don't take any new admissions quite rightly at that point in time. That doesn't sound a lot, but if you've got 120 beds that are under investigation and not access for admission, that can take you six months to work your way through that, get the assurance that you need and have these care homes open for admissions again. We've had two or three of them over the past two years. We've also had major challenges in the care at home sector as well, where we've had providers who have been under investigation, unfortunately our largest provider in West Lodian, and we've had to work very closely with them on an improvement plan before they could accept new cases into their caseload. Now, all of that added to the change in demographics, the increase in demand had a fairly fundamental negative effect on our performance. We've been working quite closely with the care home providers, the care at home providers and we've been remodeling our in-house service as well to change that in a way. We've invested in our in-house service so that a number of the things such as new cases for assessment and reablement come through our in-house service before we ask a care at home provider or a care home provider to take them on. That's work in progress at this moment in time. There's a number of fairly significant operational challenges that we've faced, and we'll deal with those and there'll be a number of others, but it's about being flexible and dynamic to respond to the challenges that come forward. George Adam? Just when you mentioned your mentioned care home provision has been one of the challenges that you have in some of the areas. From the figures that I've got here, Fife is at the higher end, it's at 9.7 per cent, yet I'm led to believe that it has capacity. For my own understanding of the situation, why is that situation? I'm not trying to tell tales at school, I just want to know why would Fife, who has the capacity, still be at the higher end of the scale regarding care provision? I'm not sure that I can answer in terms of Fife's performance. The only thing that I would say is that where there's been vacancies for care home provision, whether it be in Fife, whether it be in Glasgow or other parts of Lothian, my particular authority has made it clear to individuals and their families if they're waiting for a care home place, would they be interested in a care home in another part of the country? They would welcome to go and see it and we would provide the same level of funding that we would provide whether it would be within West Lothian. We've made these offers, one or two people have sought them out, but we have not had many takers for that, mainly for if they don't have a family connection in that particular area and it's more difficult for family to visit. Where there's been a family connection, we've actively tried to explore it. We've got co-operation from our other partnerships, but that hasn't been an option that's been attractive to families. The other thing that I was going to say again, I can't speak for Fife's data, but what I would say... I'm not saying any of this to be, I'm just trying to understand more on if there is capacity. Of course, the point is that care homes are only one part of the puzzle in regards to delayed discharges, so they may have vacancies and voids within their care home sector, but there is the potential anywhere for you to have vacancies and space within your care home sector and still have significant delayed discharges if you have an issue more, for example, with the care home market, or you have an issue more with housing and adaptations, or with social work assessment and provision, or legal guardianship and proceedings through the courts to facilitate discharge. You may well have 20 per cent of your care home capacity-free and available, but if the people who are in hospital don't need a care home, if they actually need support to get home, but you've got blocks and barriers and other bits, you could still have capacity but still have a significant issue with your delayed discharge performance overall. Basically, Glasgow IGB's paper says that there's too much focus on delayed discharges, and that distracts from investment and preventative interventions. Can we explore that a wee bit further more? What do you actually mean by that? Recently, I was saying before we came in, we've been around various locations in our system in the last couple of months presenting some of this argument, saying that over the last number of years, Glasgow has made progress in terms of its delays. Our position back in 2011-12 was probably the worst in Scotland. I think that it was the worst in Scotland, so we have progressively driven down our delays, although it's been challenging in the last couple of years. We still are at a relatively low level. The argument is that we've already realised most of the opportunity to improve the overall impact of delays on the system. Yes, we will continue to focus on getting to the lowest possible number of delays, but by definition, we've already generated most of the benefit over the last number of years, and the system still remains under huge pressure. I think that this week, our hospitals were sitting at 97 per cent occupancy, even though our delayed discharge numbers weren't helping, but they weren't the main cause of the pressure. If you really want to address that, your strategic focus needs to move from the back door now, where it's been the last number of years, to the front door, because we think that the main efficiencies now are in people who are presenting at the front door and creating demand who could have their needs met somewhere else within the system. That really is the argument that we've been making within our own system. If you're too distracted by the back door, you're missing where the real opportunity is going forward, which are at the front door. That's where our strategic focus needs to be now. Very much. Anna Sarwar. Just on that final point, sorry, good morning. I completely agree that the focus needs to be on the front door in terms of reducing the number of people that go into hospital and then need to stay in a hospital in terms of the long-term strategic outcomes. We're going back to delayed discharges for a moment. One of the things that Glasgow has successfully done in terms of reducing the delayed discharge numbers is—forgive me, I don't know the name, but you'll know in terms of an interim process where they're out of the hospital but not yet either in a care home or in a home setting. What's that? Intermediate care. Whilst that's welcome in terms of intermediate care because it opens up a bed and it reduces a cost for the acute service, it still puts a pressure on the council and the IJB and it's still not a definitive care plan for the individual involved. How much of that reduction and delayed discharge figures in terms of that acute setting statistic is people going into these intermediate care and actually not getting into final care packages? Alan might be able to help with the specific figures, I think. I always think of the population leaving hospital in different cohorts, so the main cohort ideally are people who go on without any need for continuing social care or healthcare involvement, so we don't know what the numbers are. We would not necessarily know that. Then home care is the next level up and that's by far the highest volume of people who came out with a care package from Glasgow. The people entering intermediate care tend to be the most complex people who require a social care assessment, so the logic in introducing that model in Glasgow and elsewhere is that assessing someone in hospital is your worst option, if you like. You tried to create an environment that is as close to home as possible, so it's by definition quite a small minority of the population who discharged from hospital the most complex, and the intention was in Glasgow always that you maximise the opportunity for people to then return home because it's closer to the home environment. It's not exactly the home environment, but it's got a very reablement and rehabilitation focus in a way that traditionally an assessment for social care and complex circumstances on the words wasn't. In all of the evidence points to that being very detrimental to the long-term outcomes for people, if you are assessing them in the least amenable environment effectively. The numbers are small and it's always about maximising the prospects of people going home, as well as relieving pressure on the acute system. You say that the numbers are small, that's in terms of all discharges? All discharges, that's a foreclosure. Obviously the numbers are going to be small in terms of all discharges, but if you look solely at those discharges that require a care package of some sort, how significant is a number of those that are going into intermediate care? I might be able to tell me in terms of turnover. We have 90 intermediate care beds across the city and we run close to 90 per cent plus occupancy at all times. At any given time we would expect to have upwards of 80 people within our intermediate care system, but there's obviously a turnover within that, so we operate to a four-week target. We don't always meet it, but our intention is to maintain throughput, because we recognise that we can't swap a hospital bed for an intermediate care bed, so throughput is a key performance measure around intermediate care too. Across our performance measures that we attached to that model that we first brought in, we have been successful in our throughput and returning people to the home environment in the past. These are people who we don't get into long-term care home, but we're getting quite a high proportion home from that. In terms of the controversy that surrounds the latest charge over a long time, it's around one not having a bed available in the acute care setting. Second, it's about the huge cost for acute care, because it's more expensive keeping someone in hospital than in another setting, but it's also been about a failure to deliver a social care package quickly for someone who is clear to leave hospital but is stuck in hospital because they can't get a social care package. For those individuals, you're talking about sometimes days, weeks, even months, where they aren't getting a social care package while they're stuck in hospital. Yes, we might reduce the delayed discharge if I put them into an intermediate care setting, but it isn't the truth that for some people they might get out of the acute setting, but then they go into an intermediate care setting where they are stuck for days, weeks and months not getting a social care package. It doesn't appear on the national statistic if you look solely at the delayed discharge figures, but it's taken off that figure, but they're then sat in an intermediate care setting where they're waiting weeks, if not months, for a social care package. We have a balance scorecard, we have a lot of data that comes through and we keep an eagle eye on our throughput, as I say, so where people are beyond their 28-day target, we have a particular focus on intermediate care, so it's the same performance focus on intermediate care. We cannot afford if our system couldn't achieve the performance that it does in delays. For someone who's cleared to leave hospital and go home or go to a social care setting, four weeks is still quite a long time to be in an intermediate care setting. Those are people who are going to be being assessed with an hospital at least for four weeks and longer, so I don't think there's any—we have no sense or evidence that indicates that it's taking longer to assess people in that intermediate care setting that we would have done in a hospital, but an intermediate care setting is more appropriate for their needs, and we are seeing outcomes where those people are being supported home in greater numbers. Also, we have seen a change in terms of their final destinations, so the majority of people still get into long-term care, but we have seen a real shift from nursing care and higher levels of long-term care to residential care, so the outcomes are not just beneficial in terms of the increased number of people who are returning to their own homes, but also lower levels of long-term care as well, so there's been a number of benefits from having those assessments. I'm not disputing that, but it is fair to say that looking crudly at Glasgow's delayed discharge figures being reduced, you cannot directly say that that's a great reduction in delayed discharge, meaning that people are getting their social care packages quicker and getting into that setting. That's a very crude way of looking at it. You can't do that alone just from looking at the delayed discharge figures. If you were to assume that intermediate care is equivalent to staying in a hospital bed, that would be right, but that wouldn't be my assumption, because intermediate care is a social care service, and it's not an NHS service, so it's a social care. It's also not a final destination in terms of either a care package home or a social care set. One final question, which is that Kenny O'Brien completely agreed with your point around the difficulty around capacity and still having high delayed discharge figures, but one of the things perhaps that's also missing is money. You might have the capacity to fill a social care place, but if you don't have the money to put someone into that social care place, that place may remain vacant. How much of it is around not having adequate budgets around local government, around IGBs, to be able to use the capacity that you have to deliver those social care packages? I can only speak locally to my context in Aberdeen, but certainly that's not the case in Aberdeen. I have never had a scenario where I'm operationally in charge of hospital social work, so I handle the placements in the professional decision making as a social worker in relation to people going into care home settings or going back to their home setting or to sheltered housing or any other setting. I've never yet, in my period of time working there over the past four years, had a situation in which I've had spare bed capacity or spare care home capacity, and it's been restricted to me on the grounds of budget. Can Glasgow say the same? We obviously, everyone else, face significant pressures on our budgets and that's our biggest budget, our purchase care home budget, but for a number of years we haven't had any delays for financial reasons, so no one delayed it because the budget isn't available, but what I would say is that our care home budget last year was the most difficult to manage for a significant period of time, and we did overspend against that budget, and already this year we're seeing significant pressure on that budget two months into the financial year, so we are experiencing significant pressure on that budget. Thank you very much. Good morning to the panel. I'd like to ask about delayed discharge as well, not least because, although I recognise that there's nobody from Edinburgh here, Miles and I, as Edinburgh MSPs, are very dismayed to see an increase of 6 per cent in delayed discharge in the capital last year. I wanted to ask, following on from Anas Sarawak's question, Stephen Fitzpatrick, you referenced the different cohorts of people that might fall into the bracket of delayed discharge or the cohort that's leaving hospital. I wanted to ask about fourth cohort that I think exists, and that is we often assume that delayed discharges for people who have been declared fit to go home and are well enough to either go home or to care setting. There's another class of people who are at the end of life and really hospital has done all they can for that person, and it may be in the interests of the individual or their family, or both of them and their families, for them to spend their remaining days at home. I would put it to you that they are another category of delayed discharge, that if there is insufficient hospice care to receive them, or that clinicians are not supported to have those conversations to support families to go home, that we are creating another cohort of people who are otherwise taking up hospital beds. How would you respond to that? Can I start with you, Stephen? Well, I think that if you look at our data again, commenting on our local data, that's certainly a performance target for us is to support higher proportion of people to die at home rather than hospital, and again Alan will correct me if I'm wrong on this, but it's been creeping up in the right way over a period of years around that, so we are making some progress. It comes back to the front door as well, and it's a priority in our unscheduled care programme to try to avoidable admissions for people with pallent of an end-of-life diagnosis, because there is a danger when people are as gravely ill that the system responds by drawing them into hospital when a more effective intervention might be to support them in a different way. We are looking at that for different populations, including people who are very close to end-of-life and other people who have a terminal diagnosis but who are not close to end-of-life. Their conditions may be dynamic and so on, so what can we do differently to support them being admitted? I think that that's where we will get most progress, because we always know when people are admitted to hospital that that's probably the worst factor in terms of determining their long-term outcomes. Yes, we will try to affect as early and positive a discharge for that population too once they are admitted, but I think that it's a twin-track approach. We try to stop people going in and we have a focus on that at this point in time. One of the positives in Glasgow in the past couple of years is that we have taken on from the acute system the management of the two hospice contracts in the city and we are working very well with Maricure and PPW to try to expand that model away from just a beds-based model, so can we use their expertise and their value-based and so on the way that helps us to create more pathways out of hospital for the population and to support the population living within the community? We are very active in looking at that, but I think that it's a point well-made that there's a danger that the system fails at that population and they remain in hospital to the end of their lives when we could possibly do something else for them. You make a very good point that I think that culturally primary care clinicians have sought to draw people into hospitals when their situation is very grave or life-threatening or life-ending. Catherine Caldwood of CMO set out a very interesting prospectus in realistic medicine, but how are each of your authorities or your health boards or your IJBs supporting clinicians to change that culture within the hospital and to say, actually, that we could intervene but it's probably better for everyone if we don't and we just support that person to go home and be comfortable? Certainly I would agree with my colleague that it has to be at both ends of the spectrum. There is the element of realism at the point of primary care and also social care, because it's not just about the GP in the room, it's about a GP can make decisions in relation to realistic medicine, in relation to what are the thresholds of intervention for an individual who has a life-limiting illness and has an end of life, but if you don't have the social care resource and the family support to wrap around that clinical decision, it means nothing in the first place. So yes, certainly there is work already being done there. I'm participating along with some of my colleagues from both acute primary care and within the third sector. Right now in relation to some workshops and some strategic work we're doing about the palliative pathway across Grampian, Grampian wide rather than just in Aberdeen City, but also it's very much the case that for clinicians in hospital we're trying very much to work with them in relation to early case conferencing, doing a lot of work in regards to anticipatory care planning for when someone goes out. Just yesterday I chaired a case conference for an individual with a life-limiting illness where the agreement was that the person had, to be fair, not inappropriately but had bounced in and out a little bit in regards to admissions in, admissions out, admissions in, admissions out and we were taking stock and actually saying that well you know what, all including the family are in agreement that this is now a situation where we have to make a call. Is this now a situation where we will tolerate higher levels of dependency and medical instability within the community because it's part of this person's journey and their wish to remain at home rather than bouncing in and out of hospital and so we as a partnership are trying to facilitate that more with anticipatory care planning and with that anticipatory care planning moving a lot more seamlessly for example between the case yesterday, the consultant geriatrician on the ward, the community nursing staff and the GPs and even trying to do some cleverer stuff with loading all that anticipatory care planning into the computer system so that the ambulance service can see it as well so we are trying to really move upstream so rather than a crisis point where you're talking about the point of hospital admission and only then in a bit of a pressurised situation going are we going to do it or are we not we're trying to pull that kind of point of decision back a little bit so it's a bit more of a rational and reasoned decision when there's not pressure. Just in terms of adding to what Stephen has said there, as well as the relationship with the hospices, we also have a palliative care pathway that we work very closely with Macmillan so that's very much a community home-based package. I'd reiterate the big win here is around anticipatory care so and that's about having all stakeholders signed up to that understanding, aware of that process so that everybody is clear what to do in the event of somebody deteriorating and we've had lots of examples in the way that Macmillan responds and supports and our own community supports is available that actually stops people from going into hospital unnecessarily and it's quite a obviously it can be quite a distressing experience and you know I think probably ourselves and most of the partnerships do recognise that cohort of people in terms of whether you class it as end-of-life or palliative so that we do target that group and try and support where we can do. I want to follow up on Anas Sarwar's comments but I think that she's putting the record following the line of questioning with Alex Cole-Hamilton, a children's cross-party group in palliative care in the Scottish Parliament and I've met with palliative consultants who are hospital based in the acute sector and I think they would want me to say that for a small amount of vulnerable patients that they finish off the last few days or weeks of their lives in an acute setting and they put out an appeal to say that an acute setting should also be a high quality appropriate sensitive place for someone to have the last few days or weeks of their lives and that's sometimes patient family choice as well and they've had a concern over the years that quite rightly because of wanting to the majority of people wanting to finish their lives in a at home or homely setting as much as possible that we shouldn't forget about the quality of care required for a cohort at hospital so I hope you don't mind me using that opportunity I think that they've been a mess of me not not not to do that but Anas Sarwar made some really interesting points about the success Glasgow has clearly had I want to look at the sustainability of that success but I think we should flush it a little bit more of the the role of intermediate beds and I always used intermediate beds I used especially step down beds as opposed to intermediate and what I had in my head and I would like some of the assurances over this or else I might tend to agree with Anas that the step down beds you're doing something a bit different from the acute sector so I'd be looking to see my constituents and I've experienced those constituents in case we're having better access to physiotherapists better access to OTs better stimulation because quite often my constituents have had the case load it's not clear whether someone is fit to go home and sometimes there's a wrestling between an individual in Glasgow not wanting to go home because they don't actually think they can be sustained at home but they need a care solution and Glasgow is saying no we think we can support you at home or the contrary actually so it's not always clear cut about when someone is ready willing or wants to go home so back to those 90 beds intermediate or step down in Glasgow what reassurance can Glasgow give that those beds are doing something different other than just taking 90 people out of an acute hospital bed and put them into a step down bed so that it changes the figures a bit so what is there that's different that happens in that intermediate or step down setting? So of our 90 beds it's very much a community rehabilitation model so the locations of those are within care homes they're in specific wings of the care home so that's quite important because it's not part of the broader general population so there's very much a focus on this group of 15 individuals within each of the locations wrapped around that is a whole multidisciplinary team that includes our community rehab colleagues with physiotherapy OT nursing staff we also have social care staff who are involved in that and very much the focus of that is about assessing the individual within that environment but also providing that rehabilitation opportunities and we've actually been pleasantly surprised by the number of people who whilst in the hospital setting the view may have been that they would either go to a long-term nursing home placement we've managed to maybe rehabilitate them to a stage where they've gone to a residential placement or alternatively they've actually gone home so it does lend itself to those opportunities and I think the important thing is about understanding the cohort understanding the individuals so these are actually some of the most complex frail individuals where you're actually taking them from an acute setting bringing them into a care home allowing them to have some time to be assessed to look at various options to engage with the family to provide a whole range of physical and other supports to progress the individuals and actually our drive really is we would like our default position to be home as an outcome of intermediate care but what it does do is it allows us to have a more effective assessment of the individual and look for any opportunities to improve their independence reduce the frailty within the system the other thing I would say from Aberdeen's perspective is that we also have intermediate care but we've divided it as well it's not just care homes for us we have 20 beds within a care home that deliver intermediate care with wraparound physiotherapy and occupational therapy but also we have 19 flats that are specifically designed to mimic a person's own front door and their own home with the idea being that there's occupational therapy and physiotherapy there as well and we find that is exceptionally useful particularly in the borderline cases where you can't really tell from when someone's sitting in an acute hospital bed whether it's going to be safe or not and exactly the volume of care or support they're going to require what we do also find is that when people are out of a hospital bed or having to you know to be honest get up and get to the bathroom get up to the kitchen themselves even if we're giving them support because they're doing that having actual significant activity what we do find is our baseline of what we thought they might require before they go into intermediate care and then the amount of care and support and social care they require when they leave intermediate care it tends to come down the way and that's a win for everybody because social care is a scarce resource so if we can actually use intermediate care to size appropriately and reduce to the the minimum that's safe and necessary for somebody to go home the level of care they require we find that to be quite a win we had one individual also who we didn't think would ever get home he was a complex brain injury and we've managed to step him down into his own front door and he's surprised us all and that that's the good news story of intermediate it's not just about cohorting people who would otherwise have been in a hospital bed it's also about giving people that opportunity to show they can do something as well when perhaps they're not able to demonstrate that when they're stuck in a bay of six people in a hospital bed I don't want to miss this point when we designed intermediate care model step down model which you're right to describe as principally we were always very conscious this wasn't just about relieving pressure on delayed discharge as an improving the performance of the acute system there was an equally important target around supporting people to get home who in the past would always have gone into long term care this population as Alan describes it are very complex and in the past in Glasgow would invariably have gone into long-term care so the whole ethos of the system is driven by that dual target and it was part of the discussion with the acute system colleagues around it's not just about relieving pressure on the acute system we also place a value on supporting people to get home so that it is something different. This question might just be left hanging there for giving information back to the committee but I get a reassurance that the theory behind stepping into the bed is very different from the acute sector so that gives me those reassurances however that's an assertion I suppose that we're hearing today. I'm merely passing through this committee as a substitute member but I'd be very interested to know the cost per patient per day in a step down facility vis-à-vis the acute sector it may very well be more intensive and therefore more costly but as Mr O'Brien is saying that might be that short term intensive support to quicker enablement they can use it or lose it theory behind enablement that I have seen with my constituents might be very beneficial. I'd be interested to know the average duration for each patient in a step down facility before they go to their eventual destination be that long-term care residential care or enablement at home and how you monitor the outcomes out of that so is the situation breaking down two or three weeks later and there's a follow-up acute admission or acute admissions reducing in those circumstances I don't expect you to answer any of those questions just now but it's an assertion that step down care is very different from acute care that's my experience with my constituency caseload but unless we get some data around it we can't flesh any of that out convener. Very briefly does anyone want to offer numbers today, Kenny O'Brien? I can give you one bit of the numbers just now so in regards to our intermediate beds within the social care sector that would be priced at approximately 900 pounds per week now in regards to one thing that appears is very difficult to put a price on is the cost per bed per day in a hospital because depending on the speciality depending on the war depending on the other things that are in there NHS Grampian which is the board that I contribute to as part of the health and social care partnership for Aberene city put a minimum bed day cost I think it was in the 270 pounds per day realm and that's minimum there will be other beds and depending on where you pull from the cost will be higher because it's neurology or it's got more specific diagnostics or other things in there so if you compare that if it's 270 pounds per day versus a 900 pound a week we find it's the cost benefit analysis works well in regards to that. At least a 50 percent reduction in cost. Just in terms of the contacts I think you have to understand that there's also a cost to make the wrong decision and so if you rush into a decision you're actually potentially pushing somebody into placement that maybe isn't what they want and you know so there is a there is a cost in that for the Glasgow model we're very closely on top of all aspects of the throughput in terms of intermediate care so we look at the outcomes data that includes people going to nursing home residential readmissions and we also look at included within that is the development of clustered supported living so that's become a major benefit for the population of Glasgow in terms of an outcome in terms of making sure that we work very closely with housing to develop that in terms of our readmission rate again you have to understand the context of the of the client group there are some of the most complex most frail individuals so actually you know the placement is at risk of readmission so our readmission rate is around about 10 percent and actually in discussion with our acute colleagues they they actually assess that as being well within a threshold they would accept that as being acceptable we do look in detail at the reasons for readmission so again that's there is a there is an audit process that sits underneath that so again that's about learning from that and saying are there any themes that we can we can address in terms of trying to prevent that but generally speaking it's because this is the most complex and frail client group that we have excellent that's very helpful and if you were able to provide more of the numbers in due course that would be that would add to our knowledge in this area thank you convener and good morning to the panel I wanted to follow on from what Alan Gilmour has just said there because I was wanting to pursue a bit more attitudes around hospital admissions and how we changed that and almost a presumption against admission so I wanted to see in terms of innovation I know around the country there's different things IJBs are looking to to take forward and one area which is of interest to me is around the number of people living with dementia and actually how often they're the ones who are being readmitted and I know Aberdeensia have looked towards a dementia village to sort of address that patient need and I wondered if you had examples of other ways we're stopping hospital being the end point for people in that care package who would like to start pre how to defer or avoid hospital admissions Sandra Ross so I could give you some examples around about Aberdeen city less about Pacific population and more about looking at the whole prevention of admission agenda so we've tested out an art have implemented acute care at home which was initially started off as to be geriatrician lead was where people had been either coming out of hospital or turn right at the front door or not having a coming in that to start with due to issues with recruitment consultants and things like that we've morphed that model slightly and we've looking at A and P lead making sure it's much more multidisciplinary team lead we've mixed we're now aligning it with our west visiting service which is the service that's there we're also aligning our out of our district nursing and aligning our 24 hour social care call out as well so by starting to look and joining up all those that all those areas across the system which up until now had been working very independently what we're starting to see is that we have a real the gps are much more confident now in saying they will maintain that clinical oversight of people where we're able to prevent the admissions and it's we're working closely with care homes or working closely with all the areas across the system and starting to see real benefits as we can stop admissions coming in Stephen Fitzpatrick I think there's a number of approaches in Glasgow we're looking at in relation to this so we've had our dementia strategy for the last number of years and we've been looking at again that prevention of admission and supporting people to live with dementia for longer in the community so I focus on the five pillars approach at the early stages of the illness and the eight pillars approach Glasgow has helped pilot as well for more advanced stages big focus on family and care support sustaining that the application of technology enabled care so gps and so on all of these things to to try to mitigate risk of admission is a big part of it going forward we have a review of all of our older people mental health services because very often dementia is associated with older people mental health in patient beds rather than the mainstream acute system and so much of our focus now is on how might we continue to shift the balance of care there I think we've shifted the balance of care from opmh in patient beds with about 15 percent over the last six or seven years we think there's some scope to go further there but we're in conversation with our psychogery trishins and other lead consultants around what might the model look like differently now going forward which might allow some of these patients to be supported somewhere else and it might be in their own homes it might be in some interim setting like a care home but it might then have an impact on how their skills and resources are being deployed so rather than the patient coming to them and in patient setting might they be outward facing and provide more of an outreach to have some what might that look like and we're in discussion at the moment we're in the early stages of that we've been doing some work we had a session with them at the end of February on this stop pill hospital and some ideas emerged from that about how you might make that a practical reality so it's something that we're looking at where we think it might be avoidable for people to be impatient that we can support them safely but it's a range of approaches I think to that population. John Forrest or Eran Lutton? Thank you chair. In addition in West Lothian particularly for people with dementia and older people in general we seconded the GP to work with a nurse practitioner and go round all of our care homes in West Lothian and look at how we would set in place anticipatory care planning for those who are in care homes that included those with dementia and the results of that have been that for those care homes and those GP practices that engaged which was about 90 per cent of our GP's. We've reduced admissions to hospital fairly significantly from care homes. In addition we've put a mental health team in led by psychology as positive behavioural support for those residents in care homes and to work with the care home staff to manage behaviours that people may have due to their illness and how they should manage that and we've been working quite successfully across care homes from that perspective which has seen a significant reduction in admissions as well and it's actually meant that care home providers staff feel equipped to deal with people as they have an exacerbation of their condition because what happens from time to time and it gives that sort of professional confidence that they're able to do that. We've also got a system in West Lothian where there's a GP practice attached to a care home and the district nursing team from that GP practice both with the GP's and the district nurses visit these particular care homes and do the equivalent of around in terms of how we update things and the care homes have direct contact with that provision. We've looked at increasing our post diagnostic support for those newly diagnosed with dementia and increased the resource there and working on that and we've reconstituted community mental health teams specifically focused on the over 65s. Work in progress and has shown positive results. One of the areas that we all need to get into is for those who are in a much younger age group diagnosed with whatever form of dementia and how we support families to work with those young individuals. It's quite frightening for somebody who's young who still retains a degree of understanding that their memory and other capacities are beginning to fail. There's a whole challenge in how you manage that and how we do that and that's probably better managed in a home setting with the same routine that is consistent and that the individual understands what's going on, which we're working on at the moment. Unfortunately, we're seeing a number of cases coming up where people who are fairly young are diagnosed with a condition and that's a challenge moving forward as to how we deal with that. In terms of acute care at home, we have what we call a react team which manages to, so the idea basically is that we will provide acute care at home and if we can deal with the exacerbation of the condition, then the person remains at home. If we've put in acute care at home and their condition is still deteriorating, they've got contact with the hospital services, we then admit the person. The change in the dynamic is that from what used to happen before we had those services, people would be sent up to hospital for an assessment and a decision as to why what we should do. That decision is made at home now that either you're staying at home and will manage that or you need to be admitted because of this condition and here's what needs to happen. One of the key challenges that has been highlighted to us by other organisations is the sustainability of the care home sector. Scottish Care, obviously, has highlighted what they are calling a crisis in provision. We know certainly here in the capital private homes closing or going into administration. What's your reading of the situation now? From what Scottish Care, I think I'm right saying, they predicted a need for another 2,000 beds across the country and we're actually losing beds. In terms of your own areas, I know they're very different in terms of the care sector market. Glasgow, obviously, is having a larger supply of council-owned and operated, but where's your reading currently of where we're going and the sustainability of the care sector? Jim Forrest. I think that the care sector we have got is a fairly fragile, difficult area. I think that we have to be realistic and if you're going to have beds of any description, that's a very high-cost decision that you have to make. I think that you have to make best use of the assets that you have at that particular time. If you're to speak to people invariably, most people would say that they want to remain at home with the services coming to them with the least disruption for as long as they possibly can. Some of the sustainability has to be on how we further develop our care at home models, how we learn from the experience and the differences of the various populations and how we do that. It's not a blueprint that you can pick off the shelf. There are some pointers there, but you have to modify them to your own population. The public opinion would be that they want to remain in their own home for as long as possible. I think that we have to develop a service model that allows that to happen, but delivers good-quality outcomes for the individuals as well and frees up some of the capacity that's already there, so that if somebody really needs to be in a care home because that's the most appropriate way to meet their needs, then they're able to get access to that, not waiting five, six, seven or eight weeks, to get access to it at the time that they need it. I think that the key to all of this is whether it's care at home or care home or hospital, that you deliver the interventions at the time the person needs it for the period of time that they need it and then you move and change it from there. That's easy to describe, but it's quite a dynamic process that will require constant maintenance and constant development. I would like to say that I think that sustainability within the care home sector, both care homes and care at home, requires some, personally, some honest conversations. We're embarking on an approach within city, looking at commissioning in its realist sense, looking at a co-produced approach. We're meeting with our procurement teams, with our care managers, with all our providers and putting some basic having, really honest conversations where we put cars on the table and say, this is what's facing us in the terms of demographics, this is what's facing us in the terms of finances, this is what's facing us in terms of workforce. How are we going to collectively as a whole system start to look at that? I think until we start to work together and start working as a whole system across that bit and working genuinely in partnership as partners, that we will continue to have this conflict and this competition, which is in the care home sector. At the moment, I feel that what we have done through procurement and through different modelling is that we've ingrained an environment of competition within our providers. We've said how can we get the cheapest, how can we get the most, how can we get this? We haven't focused on outcomes, we haven't looked at that and we certainly haven't looked at sustainability. If we want to start looking at collaboration, if we want to start whole system approaches, we have to start from a co-produced approach. I totally respect the opinion of my colleague. I think that from our perspective, we're embarking on that co-produced. What that will mean is that we will have to take longer and there will be some very difficult conversations, but it's the honesty and the joint approach on that. I think that that's what we'll bring about some real sustainability. I think that Glasgow is in a different position to what John was describing for West Lothian. We've never had a problem with under-provision, historically in Glasgow of care home places, but we have had a problem historically of over-provision. That was associated very much with a lot of speculative development about 10, 15 years ago, 20 years ago, sometimes associated with lower land values in East End of Glasgow. We tend to have a real concentration of provision that we hadn't commissioned by design but was there, and our system responded to that by placing people because the capacity existed and that was something that we consciously, at strategic level, wanted to change because we thought, and there's quite a lot of evidence for this, that we were accelerating people's journey into care before they had to be there and against probably their wishes sometimes. We have consciously, over the last number of years, sought to impose greater tests around admission to care, and we have seen a shift in their balance of care home placements, reducing by about 20 per cent over the past six or seven years. Some care homes in Glasgow have closed probably because we are the biggest customer there, but we think that we're probably closer to the right balance now, and I think that we might be reaching the end of that journey. We're now starting to see that demand picking up again. It's a reference to the pressure on that budget that I mentioned earlier, so I think that we're probably closer to the balance but we don't have an issue within Glasgow around sustainability but we recognise that it's different to other parts of Scotland. David Torrance Thank you, convener, and a good morning panel. We've talked a lot about shift in the balance of care and given various examples of how we've managed to achieve that from hospital community care. It's enough been done to share these good practices across everybody, all the different worlds, because it's all various different ones you've given here in front of a bit and all the different examples. It's enough been done to share that good practice amongst yourselves. Kenny O'Brien What I would say is that I don't think that it's 100% consistent across all the different areas that we're doing things. I mean, in my area of expertise, which is delayed discharge, there is quite a lot of that. There are conferences where we all meet. There are visits sponsored by, for example, the Government to actually see high-performing areas, probably because of its very visibility. There's a lot more being pushed there in regards to the sharing of what's being done in other areas, sharing of action plans, sharing of models of care. I'm not 100% convinced that across all the different elements of what we're doing that we're there yet, if I'm being honest. And perhaps particularly around the shift from hospitals to community care, would that be one? I would say yes, but I would say probably because of the myriad different ways that you can shift that balance. In essence, a lot of it is almost everything we do now in regards to partnerships. So if you want to deal with that issue of shifting that balance of care from hospitals to community, you're really at everything that partnerships have got their fingers in the pie in. I think that we talk about shifting the balance of care and moving it from hospital to community. In lots of ways, I feel that we should be looking at it from the other angle that, if we presume that home is the first place that we want to be, how can we design our systems around maintaining someone at home for as long as possible? Whilst we're dealing with short-term challenges or challenges that we're being faced with now, thinking about longer-term planning perhaps needs to have a different focus and be focused on that home first approach and building systems around individuals and community settings and designing those systems from that perspective rather than from a shifting the balance of care perspective. I think that more can always be done. A lot is happening as Kenny has described but there's always room for improvement around us because it's a complex world and so much is happening. You see a lot of innovation out there and sometimes you happen upon it by accident. I also think that there's an onus on all agencies, including the HSCPs, to be looking at this proactively. It comes back to the benchmarking point. If you see another authority performing very well, it will generally be of interest. Rarely a day or a week will go past. We don't see why a member of the committee is achieving that or such-and-such. Let's go and find out more about that because you need to dig under the numbers. As I said earlier, we're always looking as we'll try to look externally and avoid the temptation to just be too insular. Next week, for example, we've got a delegation of senior managers going down to Coventry because they have managed to achieve budget sustainability around social care in very straightened circumstances in England while performing very well on their acute performance in terms of delays and so on, so in their balance of care. We're always looking to see if there are other models there and we can learn from other approaches that fit with their own strategic priorities. We're trying to look outward as well as just to look at what's happening in their own authority area. David Torrance. Is it realistic to achieve a reduction in resources allocated to hospital care in the context of our rising demand and demographic pressures on prescribing costs? There's a big question. Who would like to have a go at that? Alan Gilmour. There's a balance here in terms of improving and using what you've got to the best ability where eventually you'll get to a point where your capacity is being outstripped by the demand and you cannot deny the changes in the population. There are a lot of things I think that we can do that are anticipatory in nature, so if we can really reinforce the health improvement agenda, we can really try and get a better, healthier population, but also to have things in place that support decision making later. For example, the power of attorney and guardianship is a big win for Scotland. We ran a couple of campaigns in relation to power of attorney. We've got another one under way. We're looking at that with our acute colleagues. We're supporting that through our carers agenda. Again, any opportunities to be anticipatory in nature will, I hope, ameliorate some of that. Sandra Ross. I would say that the question that you pose is quite difficult to answer, but I'm picking up from a colleague and also from Yvonne. I think that it is really about how we're designing our systems and starting to look at the whole system and starting to look at how do we prevent and how do we shape that prevention agenda? How do we start to say how do we have fitter focus on our children, have fitter adults and therefore less ill population? That will start to help to shift some of that balance, because otherwise, if we continue as we are doing at the moment, as you say, it will be extremely difficult, given the demographics, to maintain that. Thank you very much, chair, and good morning. Thank you for your written submissions, which I found really interesting and your evidence as well. It's been very honest, as Sandra Ross had said. I want to concentrate on the set-aside budgets. We're talking about, obviously, budgets and lack of funding, etc. When you look at set-aside budgets, it gets a bit problematic, if you might say. I feel as though they're not operating as they're intended to do, but I'd like to ask the panel members. Basically, if the set-aside budgets and your minds are operating for what they're intended to do in your areas, if it's not, what's stopping it from working that way? I'm fairly new at posting in September, so one of the areas that we have strategic responsibility and strategic planning for the services with the set-aside budget. We've been working quite closely with the three IJBs, Aberdeen Shire, Murray and Aberdeen City, along with NHS Grampian for the whole area. What we've agreed as a system is to start to look at it whole system, to take the money that was within the system. For example, we've started with mental health and care of the elderly, pallet of care—those are all at different phases. We've agreed that whatever moneys is there, that will sit there, and then we will look at it as a whole range of workshops and professionals, so that's across the third sector. People who use the service, professionals within acute, community and all that, and looking and saying what is our strategic direction, what is our aim. When we're almost at the end of our mental health one, coming up with our strategy, we've got to start to pull together for June. That will start to dictate what the direction of travel is, and therefore the money and the flow should start to follow that. Ultimately, otherwise, it's a case of working in siloed services and protecting those bits, whereas the set of side is about saying what does the whole system look like and how can we shift that whole system to move the service and therefore the finance to match that. In response, it is a complex issue, it's a bit of a wicked system issue, but we're working collaboratively to say how do we do that and how can we shift that. Stephen Fusbattrick I mean, it really is a complex issue. It goes to the heart of integration, I think, in our view in Glasgow, and you'll see from our evidence submission that our view is that it's not yet real. It's talked about in abstract terms, but I think that our capacity for it to not be real will run out of road at some point in the not too distant future given the pressure across the whole system. I'm coming back to David Torrance's question, I think. For us, we are looking at the potential around people who are currently in hospital who don't have to be there, so there's been a serious day of care audits across Glasgow and Scotland over the last number of years, and what we're seeing consistently is around 15 per cent of people at any given point in time in our hospitals who potentially could be someone else, and the other 85 per cent need to be in hospital. Your opportunity is around that 15 per cent. You're never going to get to zero, but somewhere between zero and 15 per cent is where the opportunity for the whole system lies and where the potential to potentially free up some of that set-aside budget will lie. That's, I suppose, the guiding point for me. We also have experience in Glasgow of the changes to continuing care, so a whole system approach over the last number of years around those continuing care off-site beds, which have transferred from acute management into the HSCP's management, and very similar challenge around that. How do you move from a sensual and impatient model to a community-based model, and how do you do it across a whole system with six HSCP's and acute system that bears the risk that, if it doesn't work, they are the provider of last resort, and that's always the driving concern for them? So, yes, we might pass resource to the HSCP and you will promise us the earth, but if it doesn't happen, we have to find a way to meet the needs of that population. We've managed to do that, and it's in our evidence as well that we have managed to shift that balance, and I think that it's in miniature of the challenge around the whole set-aside and shifting the balance gear. So, we've got some direct lessons that we can learn from there. What we're doing across Great Glasgow and Clyde is we're embarking on a commissioning planning process to try to move it from the abstract into the specific in the same way that we did with continuing care. So, can we look at particular points in our system? Now, it's winter beds or other aspects where you can start to point to something tangible and say, well, if we could reduce those number of beds by 30, 60, 90 from the acute system and put in place something that would give us confidence that we could head off that demand, can we get an agreement to that? But it's really important that we have a whole system by and to it. We need to have the conversation with clinicians and acute managers, and they need to be shaping that, rather than it being something that comes from the HSCP. So, it needs to be a whole system approach, but we do have that experience from continuing care, which isn't straightforward but has delivered some results for us. I think that agreement with my colleagues is a complex issue. In terms of the experience that we have in West Lodian and the Lodian experience, I currently have the mental health budgets devolved to me and devolved to the partnership, which works well. We have now the learning disabilities budget devolved from health and social care devolved as well, and the substance misuse budget. So, there's quite a number of things that have been devolved to us. Where the major challenge comes in unscheduled care, and particularly those going through the front door. So, in keeping with my Glasgow College, clearly there are four partnerships in Lodian and there are three acute hospital sites. So, there's a complex issue as to how you actually set real budgets in relation to activity and how does that impact on what we're doing. My finance officer for the IGB is heavily involved with the finance team at NHS Lodian, who is looking at working on how we develop this and how we maybe run how the budgets are set this year and how, if we'd used the different funding model, how would that look running in tandem with what's actually happened, to give us some evidence and science behind how we would make future changes to the unscheduled care budgets, which we are very closely involved in. We've been very closely involved with both parties in terms of the financial resource that we have. We have worked in an integral part to each of the management teams in both parties to look at the efficiencies that are required. We have been embarking on that for the last few years and we have a very close work in relationship, particularly with the finance team at NHS Lodian, to design those budgets. From a West Lodian perspective, we have St John's hospital where probably around 75 per cent of the unscheduled care activity will go through St John's, so it gives us a better handle on what's actually required. We have got the complicating factor that some of that doesn't go to St John's. It either goes to the Royal Infirmary or goes to the Western, and it's how you find a balance that gives stability to the whole system and agreement to some of the changes and adjustments that need to be made. I think that that's basically work in progress for us at this particular stage. Thank you very much. Jim Forrest is the only person that's mentioned NHS, others have mentioned integration bores, etc., but we've had evidence before from other professionals basically saying that the NHS seems to treat the side monies from the budget as their monies and not IGBs. Basically, the question would be, would you agree with that, that there is still this culture in that particular respect? You're talking about something about 14 per cent of the total budget, so why would not just yourselves but others agree to the fact that the NHS keeps this monies? I think that it's a matter of debate at the moment. I don't think that certainly speaking for Glasgow, there's an acceptance at all that that's the NHS bores money and acute money. I think that the view is that it needs to be debated about how we move as a whole system from the as-is to the to be recognising the difficulties attached to that. As I say, if you are running an acute system in Glasgow that's running at 90 odd per cent occupancy, then the notion of releasing some of that resource to invest in community alternatives is quite a scary prospect, so you need to respect that. At the same time, the system can't be sustained unless you look at that funding differently. We are absolutely committed to looking at the set of side resources differently, to do something different with that, but we recognise that we need a whole system approach and we need to build confidence across the whole system around what the alternatives to the current use of that money would be. From a Lothian perspective, I can only reflect on the experience that we have, that we have been very much part and parcel of the decisions that NHS Lothian has made in terms of the financial position. We don't always agree, but I think that we are part and parcel of that whole in a progressive way forward. I think that it is a complicated issue in terms of the unscheduled care side of things, which is the set of side budget, and what changes would make that would be beneficial to the whole system and, more importantly, deliver the outcomes that we are looking to deliver for individuals who use our service. The other thing that I would say from an NHS Lothian perspective is that NHS Lothian has an unscheduled care committee, which brings together all the acute campuses and all the health and social care partnerships. I chaired that on behalf of NHS Lothian, which looks at unscheduled care operationally over the 12-month period, and we meet on a monthly basis. We also use that forum for putting together our winter plan and using any additional monies that come in that are openly discussed of the outcomes that we are looking to deliver from any additional monies, and that is tracked as a whole system. Don't mean to interrupt you, Jim, but, if you have a very bad winter and flu, for instance, the NHS will use that money in that respect and they are not going to take that in, so, while you can plan for certain things, if you have not come control of that 14 per cent. I do not know that it is as straightforward as taking that money in. I mean that there are certain budgets that are set aside for immunisations against flu, which are done right across the whole system, and we have had pretty good immunisation rates in Lothian. We have worked collectively in terms of—well, last winter was not particularly bad, but the winter before was almost catastrophic for all kinds of reasons, so I do not think that we are taking that money back off you to do this or that or the other. We had to collectively look at pressures on the system and how we would fund additional activity and how we would fund any potential overspends in particular areas. That was not the relationship that we had in NHS Lothian and is not the relationship that we have just now. Sandra Ross. Just to affirm, the approach that we are taking across Grampian is the three health and social care partnerships along with NHS Grampian. It is looking at that whole system approach, and that is one of the key issues that has been said. It is not sure about the budget and that is our bit and that is there, but it is looking at that as a collective, looking at the whole system and then moving that around so that we do not start off with the position of, we need to take this money from here and move it to there, but it is starting to look and say where is that resource best used for the whole system. Another follow-up. Certainly the evidence that we had was that a number of the IGBs would have liked to have a wee bit more control because you get the three years funding. If you are planning particularly in a drug situation and alcohol situation, do any of the panel here have any evidence of money being overtly taken from that budget from the set-aside budgets to be used specifically for acute care? Can anybody put their finger on any of that at all? Funding being shifted from the social care budget? I have not had money shifted from the social care budget to fund acute care. I think that the definitions are that the unscheduled care budget in the main is about acute care and how you spend it and it is about reaching agreement of how you best use that resource rather than taking it from one pot to the other. I have not had any pressure to fire money from social care to provide acute care. There is always a push-pull and it is not as straightforward as saying money will transfer from social care into acute care, but for example the pressure we experience on our care home's budget will relate to demand coming through from the acute system to relieve pressure on the acute system, but equally the acute system will say over time as you reduce some of your social care budgets that impinges on our spending and our spending pressures as well, but no, we have not fired any money from social care directly into acute care. We would absolutely resist that as a counter-strategic move. I do not know whether that is taking it forward or duplication, but I was reading with interest from our briefing papers on that Scotland said that there was a lack of collaborative leadership and cultural differences affecting the pace of change in terms of integration. Glasgow's evidence was also really helpful and quite enlightening. The chief officer, the chief financial officer, experienced very little engagement with NHS Greater Glasgow and Clyde during 2018-2019 in the lead-up to the budget being offered, and therefore subsequently when you look at other statements that Glasgow made that seem obvious, they are saying that today partner bodies budget processes continue to operate in isolation. Both sets of partners will be invested in the budget allocation that is delegated to the IJB, and it will be used for their respective services. The money is not losing its identity. I was sitting on this committee full-time when integration was put on a statutory basis. The only reason that the Government put it on a statutory basis is that health boards, local authorities, several years ago were asked to do it, and they simply did not do it. It is now put on a statutory basis where you have no choice—I am not personalising it to you, I am sure that you are the leaders in the room today—where it is now a duty to get on with it. Despite some really good work that we have heard about today, Glasgow is still saying that money not losing its identity and money put in, you expect to get back out your side of the system again. Where is the leadership in the system to change all of this? Can you point to examples of what has happened in really good practice? Is there a lack of leadership in some quarters? It is not very difficult to identify where you think that there is a lack of leadership, but clearly there must be. Starting with your understanding of your position in addressing those issues, but also more widely, if you wish, we would like to kick off. I can only give my view to the Aberdeen area. I am part of the system leadership team in the NHS Grampian, which the other two chief officers from the integration authority are on as well. That is what it is called as a system leadership team, so that is from acute and the IJBs. There is a strong sense that we are a system, and there is a strong sense that we are in this as moving forward as a whole Grampian with the three IJBs, and that only by collaboration working together that will be there. I would say that there is a recognition from the Audit Scotland report about what was said, but there is also an understanding that that is the direction of travel. I would say that from our own leadership team as well, from my own leadership team, that we are certainly hinging back, anchoring back into the other areas as well, making sure that we have strong connections. Provocate response. Of course, there was in relation to that. Can you point to an example in Grampian where money put in by either a local authority or the health board has been used imaginatively and not just been taken back out by the same partner to spend what they have always been spending it on? Maybe come back to that, because clearly that would make a little thinking. Stephen FitzPatrick I suppose that that is a delicate question, but for me, looking at some of the structural rather than personal around individuals and leaders in the system, if you have a structure where the money flows through, for example, the city council and through the health board, then it is difficult to see a way where the accountability doesn't flow back out of that. Certainly, there has been a conscious effort and we have reflected that in our evidence to lose the identity of the funding within the elements of the system that the partnership controls, as there has been a conscious effort to do that. For example, a review of our occupational therapy services, which we inherited a separate NHS and council component of, and we have brought that service together and we have brought the funding together and so on. That is something within our direct control, but I think that there is a structural issue that is still to be remedied in terms of how the money flows in and out, and that places some constraints around leadership. There is also a cultural point where it takes time to shift and we are on a cultural journey within the partnership, but we live it every day whereas, if you are the councillor, you are the health board and you are sitting outside that and not exposed to it in the same way and you are still inhabiting the same environment, it is not realistic to expect that cultural change to take place on the same timescales, but I think that there is still a way to go. We have some concerns that the conditions do not yet fully exist to give full effect to the policy intentions of the legislation. I think that there is some work to do there across the system. Some of it hinges on the understanding of the legislation so that, if services are devolved, there is still a feeling from the funding parties that they are accountable for certain things rather than this other entity being accountable for it. We have had to work through that and that is work in progress. I think that that is probably at the nub of where we need to shift this culture and attitude and have good governance structures and oversight to allow that to happen. That has been an on-going development. From my experience locally, both from the local authority point of view and from NHS Lodian point of view, I, as an individual with my chief finance officer, have been very much part and parcel of the discussions on a yearly basis. From a local authority point of view, we were very much there at the beginning of setting out a five-year financial plan across all of the local authority services. We are listening to some of the ideas that we put forward in terms of funding that we are taking on board and have been passed on to us. Similarly, although we do not quite have the same time in terms of long-term view from an NHS funding point of view, I have had similar discussions there. I have been able to use money that has come into the partnership and make a decision to say whereabouts in this community model should we spend this money. I have used money to fund additional community support workers for re-ablement service. It does not all necessarily mean that that contribution has come from the local authority, even if it is a local authority-employed staff. I have been able to use money across the whole system to allow that to happen. That is a useful example. I was not trying to catch anyone out. I just generally wanted to get an idea of an example of where the money has lost its identity, so that is helpful. I do not know if you are able to give an example. In Aberdeen, for example, we have done an initiative as part of some of our delayed discharge work. Rather than buying a wing of a care home and putting people there, what we have been doing instead is buying care homes that people would want to go to, we have been buying a cohort of beds in each of them, so that people would rather go somewhere that they do not want to go. There is reserved access from a hospital setting for an intermediate care setting into those care homes of choice. Previously, I am employed by Aberdeen City Council, although I am a partnership manager and I work for the health and social care partnership. Previously, there would have been all kinds of rammies about GPs saying, why are these extra people going into these beds? We have to provide medical cover to them. There are all kinds of debates that would happen there across different parts of a system that maybe would not have talked to each other just as well prior to integration. I have a shared budget now. It is not a council budget. It is not an NHS budget. It does not matter what is on the ledger. I was very able then to talk with our primary care colleagues and agree the appropriate contracts and service level agreements to support the medical cover, nursing cover and so on, to allow the seamless flow and turnover of people out into those care home settings. What historically would have been spending that would have sat on the council side of the business, which is the more purchase of social care within the care home sector, and the more NHS side of the business, which was the community nursing, the GP medical cover and so on. We were able to sort that without lots of go-between, because it literally all came from my one budget, and the money had lost its identity in that bit, because it was about delivering a goal as opposed to who got council bit and who got the NHS bit of the pie. That is one of the things that we are keen to hear from Bob Doris. No, it is helpful. Not for this morning because of time constraints, but some more information on that would be quite helpful. In Glasgow, and I pay tribute to David Williams as the accountable officer in Glasgow, who is hugely respected, the point has also been made that when you have that accountable officer being the head of either a section of the NHS or, in David's case, the head of social work in Glasgow, can that be an issue where the single go-to persons in charge of everything is so closely identified with either the NHS or so closely identified with the local authority? Can that entwine some of those cultural issues that, if it is part of Mr Gilmour, we are talking about any thoughts on that? We have all got to be employed by someone, because the LGBT does not employ anybody. The short answer is yes, but if I take my own situation and be employed by the NHS as I have been through my whole career, I am based in the Civic Centre in West Lloe in this part of the council's executive management team. I am responsible for all of the social work services and I am the go-to person for all of the services that are there. I would probably like to think that through the leadership of my team that those barriers have been taken down and we have been able to move things forward. If that is a similar view, I want to make sure that we cover every base when we are asking questioning, but if that is a similar view, do not feel the need to come in on that. I think that we see lots of nodding heads from both Aberdein and Glasgow, so that is helpful. Finally, an interest of mine has been money spent on housing adaptions over the years, previously in the local government committee, and that freezing of £10 million across Scotland for the social sector has so budget retained, but a real term has cut over a number of years in relation to that. At an architecture level, I have been writing to the Scottish Government and the Integrity Joint Board in Glasgow who point to the budgets that the IJBs have in relation to housing adaptions, and that is what Kevin Stewart would say as the minister. I did get some figures for Glasgow—that is why I was checking my phone earlier—so I think that David Williams told me that in 2018-19, £2 million was used from the Integrity Joint Board for adaptions within Glasgow, so I do not know what it is for 2020. When I wrote to the Government, the refer to parliamentary question that another member had asked previously in relation to business, it was back in March. For Scotland, it was £38.4 million for the year 2016-17, and it was used by IJBs or the joint authorities across Scotland. That was the latest year that the Government had figures for, so I do not know whether there is any—it is difficult to ask any trends or patterns in relation to that, but all morning, we have been talking about how we have a better use of budget to effect, reduce, delay discharge, enable a minute home, do preventative work. There is a really robust good example that is housing tenure neutral convener in relation to how we can do some real good work to sustain people in their homes. Just to hear what the story has been in each of the areas to date and whether or not you capture some of that information, because a number is just a number—£2 million in Glasgow is fantastic, but £3 million is better than £2 million, obviously, but what we really want to know is for £3 million what is the difference we get, do we get less delayed discharge, do we get more people sustained in their homes, how do we measure outcomes from the money spent? That would be really helpful. Because we are tied for time, if I can add to that simply a question, are there barriers to housing adaptations and a lot of the things that we need to take up in order to address those barriers while you are covering them? Yvonne Lawton. We have very good relationships with our housing colleagues and I have developed a joint accommodation strategy to clearly set out our housing needs. It is true that it sometimes takes quite a long time for those adaptations to be realised, so people can be delayed in hospital whilst the adaptations actually take place. One of the considerations is about what sort of interim arrangements can you have in place that will facilitate discharge whilst the adaptations occur, so it is not so much that we have problem-securing funding for the adaptations, it is much more about the logistical aspects associated with that. Penny O'Brien. There is certainly pressure on budgets. There is an increasing demand in regards to that, and I have certainly been involved in discussions in previous years in relation to that. I would say that in regards to process and timeline, I think that we have done relatively well in Aberdeen City in that regard. No matter how you cut it, if you are making structural adaptations to an individual's own home, there will always be a lag of time from the identification of that need, even just simple going from architect to plan to then physical bricks and mortar. There will always be a gap no matter how you cut it in that regard. We are trying to do two things in that regard to minimise delay. Number one, we are trying very hard to get upstream, so part of the work that we have done in embedding social work staff and in embedding work in the discharge hubs is that, for example, if someone is going in surgically for an amputation and we know they live in a tenement three floors up, rather than waiting until they are referred, we are getting housing and other such things done at an earlier point so that, before they are anywhere near being clinically ready for discharge, the fields are already turning in that regard. We also have dedicated occupational therapy staff who are focused on purely this type of work, so we have a pathway out. Our arms length company, Bonacord Care, has a housing occupational therapist whose job it is to do this and to turn this and who has the expertise to try and cut through some of the flack in that regard. The other thing that we have invested in as well is in our housing colleagues, because we work actually very well with our housing colleagues in Aberdeen, where we have invested in where the partnership has taken on the tendencies of two disabled wheelchair-accessible flats within the city. We have adapted them quite significantly so that they can work with a wide spectrum of individuals with different occupational therapy-related needs and adaptations. While we try and constrain the time that individuals require to wait until adaptations and equipment or rehousing is sometimes done, we have a place that is far more appropriate for them than remaining in an acute hospital bed for them to keep their skills and independence up. Also, sometimes for the occupational therapist to try different things in a more modular adapted setting. That helps around there as well. In Glasgow, as ever, it is always a budget that is under pressure. It is one that we have protected over the years while social care budgets have been reducing. We prioritise that. We have a strategic priority attached to our partnership with housing to try to shift the balance of care from long-term care in particular to support more people at home. We would anticipate that, as an outcome of that, the pressure on that budget would accelerate over time. We need to look at how we potentially grow that. However, it is certainly a live issue in Glasgow. Two weeks ago, we had the launch of our joint protocol joint on developing the housing sector around adaptations and housing solutions. We are working very much with that sector to try to drive solutions and make sure that there is a culture across housing and the health and social care partnership to work together to make the most of the resources that are available. It is marginal as a factor in delayed discharge in Glasgow. It is marginal as a cause of unscheduled admissions to the acute system. It is more about the balance of care within the community. We are looking at that particular element. Excellent. Thank you very much. I thank all the witnesses for their evidence this morning. That has been very helpful. There are one or two items that you offer to provide us with further information. We look forward to receiving that in due course. We will briefly suspend resuming public session in two or three minutes. We have one item in public session remaining, which is agenda item 2, subordinate legislation. This is the national health service general dental services Scotland amendment regulations 2019. The delegated powers and law reform committee considered this instrument earlier today and determined that it did not need to draw the attention of Parliament to this instrument for on any grounds within its remit. Can I invite any comments that there may be from members on this instrument? I am a sour. The dentists are happy, I am okay with it. I should agree that the dentists are former dentists and I like being a dentist. That counts as a succinct comment. Are there any further comments? There are being none, as the committee agreed to make no recommendations. Thank you very much. We will now move into private session.