 Welcome to the sixth meeting of the Health and Sport Committee in the Scottish Parliament's fifth session. I ask everyone in the room to switch off mobile phones as they can interfere with the sound system. We have apologies this morning from our convener Neil Findley, which is the reason that I am cheering today. The first item on our agenda today is an evidence session on GP recruitment. We welcome to the committee Gerry Lawry, the Deputy director of workforce NHS Grampian, Leslie McClay, chief executive of NHS Tayside, Dr Miles Mac, chair of the Scottish Council, the Royal College of General Practitioners and Dr Alan McDevitt, chair of the Scottish GP Committee, British Medical Association. We are not expecting any opening statements, so I will move directly to questions. If I can just kick off, we hear a lot from yourself about a GP crisis, so can I ask what constitutes the current position as a crisis? To start with that, my college has been campaigning on this issue since 2013 when we have really predicted increasing problems for general practice. We predicted that we would see GP numbers falling and the real problem was actually delivering the sort of GP service that we want to do. Unfortunately, that seems to be happening. We have got a third of practices here in Lothian who are unable to take new patients. We are seeing an increasing number of practices being taken over my health boards, often with devastating results for patients. We are seeing increasing difficulty in recruiting GPs into the profession and holding them into the profession the longer term in their career. That is what we believe is important. It seems to be completely at odds with the Scottish Government's ambitions for 2020 vision and now for realistic medicine. We are the physicians in the community. We are the ones who deal with elderly people with increasingly complex problems and to enable them to be looked after and cared for at home. We also take great pride in providing the sort of work that we believe is crucial about having really good long-term relationships with our patients and really meaningful conversations with them to ensure that the care that they are getting is meeting what matters to them and providing that continuity in first point of contact. It is on that basis that we believe that it is crucial to be looking at this issue and to ensure that we are making the right steps, particularly tackling the falling percentage of funding that is going to general practice of the NHS fund. It was set at 9.8 per cent in 2005-06 and the last figures that we have got is down to 7.4 per cent. Despite the previous cabinet secretary's ambition to ask health boards to spend more money in primary care, which was a commitment made to us in November 2014. We really are continuing to call for investment in general practice and we have clear evidence that we need that investment. I draw committee's attention to the work by Helen Irvine, who independently of the college has made it quite clear that investment in primary care will reduce inequalities and will provide services for patients at home and actually reduce the requirement for any elective healthcare services. The BME has been doing a GP practice survey every quarter now for some time and our latest figures from September show 28.6 per cent vacancy rate in general practices around Scotland, which is the same as it was in June. We see a substantial change in the number of posts that are still vacant after six months from 42 last year to 80 this year. We are getting clear evidence now of a major recruitment problem. In addition to that, practices cannot obtain locums when they have to go on holiday or for covering sickness and maternity. We have got very clear evidence now of our recruitment problem into general practice, as well as, as Miles has said, the fact that many practices because of that are having to somewhat restrict the services that they provide. In terms of determining what the problems are, we are now seeing them very real and they are actually beginning, I think, to affect patients. I think that that is when it becomes a crisis when patient care begins to be affected by the numbers of GPs we had. The key thing here today is to talk about—although I often talk about the role of other professionals in helping general practice going forward—it is also about making sure that general practice medicine is available to our patients, that in future patients can access a GP as a doctor when they need to. I think that today is as much about that as it is about the total redesign that we are talking about in terms of primary care. I think that the key thing is that the crisis, the shortage of GPs, has now manifest and we are working very hard to change the fundamental nature of general practice to make it attractive both for doctors to stay in and also to come into as a future career. That is one of the fundamental reasons why the BMA is now renegotiating the contract with the Government to try and resolve some of the underlying problems that have made general practice a less attractive career to stay in and to come into initially as a young member of the medical profession. I think that we are all very aware of the workforce pressures, both demographic and in terms of recruiting new GPs that the profession is under. Particularly the amount of vacancies that are going on in the field seems to be the signal problem that we are facing. I just wondered whether the panel thinks that the use of the term crisis contributes to this solution because what I have found in my conversations is that, when this term is used again and again, there is a perception building up and it can be quite off-putting. It is interesting that Dr McDevitt was saying that the language is more temperate to begin with, speaking of a recruitment problem. I wonder if you can unpack some of the challenges beyond just the contract renegotiating towards a GP recruitment. Perhaps, if you think that we can reframe the language that we use, I do not know if I can appreciate where you are coming from in defining it as a crisis, but I do not know if that actually contributes. I would be too keen to hear your thoughts. As we have been around the country preparing for changing the contract, we have talked about changing the mood music. The first thing that we have to do is to change the perception of general practice into being an attractive career for young doctors. Unfortunately, the negative circumstance that we find ourselves tends to make people say, well, I better not go and do that. It is vital to change the mood music. We can look forward to a very positive future for being a GP in Scotland if we can manage to achieve all the things that we aim to, particularly through contract realignment, but also about changing the role of the GP into being an expert medical generalist in the community who is part of a multi-professional team, who can focus on what we call undifferentiated presentations. In other words, if you think that you need to see a doctor and you think that you might be sick, that is basically what that does—complex care, dealing with people with more than one condition, and also being a clinical leader who is responsible for improving the actual outcomes for patients—the things that patients want to happen in their lives in relation to their health and us working together with them to make it better. General practice is a fantastic career. We have to make sure that the role and circumstance of being a GP in Scotland are as positive as we can be. That is how we change the mood music. In response to the word crisis, it is not helpful. When does it become a crisis? It has been a building issue and it will remain an issue for some time to come, even when we are fixing things. I am not hugely fond of the word crisis, but I am responding to the way that people are describing it. There certainly is a major problem. You can call it what you like. That problem will take some time to turn around, and we will all have to work very hard together to fix that. Thank you, convener. Can I say for what it is worth that I believe that we are in an absolute crisis in terms of GP recruitment? I am absolutely comfortable with that language, not least because in my constituency we have not had new medical centres built in 45 years despite year-on-year proliferation of new housing and some surgeries that have had to close their lists. I am very supportive of the RCGB's call for an increased investment up to 11 per cent of the health budget, but I want to explore, in particular, from the panel into the trainee issue. We have heard and we know that not all the trainee vacancies that have been made available have been filled, but what we heard this committee last week, more alarmingly arguably, was that of those trainees, not all of those trainees are domiciled in Scotland and may not then go on to practice in Scotland. I wonder if the panel can bottom that out and just give us an idea of the extent of that issue. I think that it is an interesting position because the trainees that are coming through now are not the trainees that came through when I started in their NHS. Their expectations are very different, their career aspirations are very different. For example, we have a more predominantly female workforce, someone who is choosing to work part-time, but we have some evidence that male workforce is also choosing to work part-time as well. I guess that something that Alan said about how GPs are marketed and sold, the image of a GP is particularly positive. If we think about how it is portrayed in the media and the television, particularly around sorts of soaps, I think that it is a very negative image. We do not create an attractive opportunity for people to choose to become a GP currently. I would just like to bring to your attention the Think GP campaign that the college has just started on. We are absolutely keen to ensure that general practice is portrayed in the way that it should be seen. We have got four videos of GPs across the country, across the UK, young doctors who are working at fantastic levels and just showing the variety, the challenge, the responsibility that these young doctors are performing. It is completely clear to me that it is a fantastic job, it should be a fantastic job. We should be batting people off to get into general practice, just as we needed to do when Alan and I started our careers, when there were far more applications for every post. We were able to get the very best medical graduates into that. I take your point about crisis and the talking that down. I do regret that we have had to talk about general practice in those negative terms, but I do believe that we have to tell the truth, because these doctors are training in general practice. If they hear from my college that everything is roses and that there is enough money, there is enough future sound, yet they are seeing with their own eyes doctors who are working 10-12-hour days who are feeling that their ability to work and their ability to provide safe patient care is being compromised by the level of workforce. It gives me no credibility, it gives the college no credibility and gives none of the solutions that we have come up with, the credibility that we have. I would like to point out just how much positive work the college has been doing on this issue. We were ahead of the game with remote and rural recruitment back in 2012, and we started to explore some of the ideas that we have now brought forward as the GP career flow, which is the idea that if we can't just think about those 100 new places, we have to look downstream of that, what is the career going to be like in the future, how do we retain people, but also look upstream. I have just written a blog for the GMC describing some of the issues about badmouthing general practice in psychiatry in the medical schools. This should just not be happening. It does seem to be happening, and this is the sort of thing that we really need to start to challenge, because it's not fair on the profession and it's severely damaging, and we do need to look right the way through to making sure that we're training the right way. I'm delighted to say that this week or yesterday I had a fourth year medical student sitting in with me who's spending 10 months of his fourth year in my practice, learning general practice. Two of the patients I saw as duty doctor yesterday, I admitted, he now has the opportunity to join the post receiving ward round at Regmore hospital tomorrow to see what happened to them in the ward and follow them back into the community. Actually, if we're looking to see that sort of joined up approach to medicine, this is the way to train doctors, and this is the sort of support that we need, and this is a pilot run by Dundee, but it's just this sort of thing that we're talking about in our GP career flow. So I really apologise if it's been seen that I have seen to be very negative, but obviously one part of my role is to tell the truth and to make sure that a consistent approach across the patch does actually provide the resources for the sort of initiatives that we've been putting forward in the blueprint document that we've provided last June and the manifesto in October. Okay, so thank you very much. So as a board chief executive, I think the first thing that I would say is I fully acknowledge the challenges that are there in relation to general practice and the whole recruitment issue that we have, but we have a number of workforce challenges. And as a board and I think as a kind of system, a kind of whole healthcare, health and social care system, there are a number of strategic plans that we have in place that we're implementing locally. If I just describe our situation in NHS Tayside, so as a board we serve a population of about 400,000, we have in somewhere in the region about 330 general practitioners. Our vacancy level is pretty constant and we'll probably sit at somewhere in the region of about 5%. We are fully aware of the age profile, that is something that is challenging the health and social care system across a number of specialties and I certainly know just now we've somewhere in the region about 15% of our GP workforce is sitting at the over 55. So there is clearly a challenge there. I think there are a number of things that we are doing locally. If I give an example, as a board we have a five-year primary care strategic framework that has been put together through and by our clinical leaders but actually looking at the whole healthcare system. We have taken on board the opportunity through the formation of clusters and that's allowing a clinical leadership model to form locally and so in NHS Tayside we have 13 clusters that are actually there's a level of maturity in our establishing where there's engagement across general practice looking at their data, looking at information and actually supporting in terms of some of the challenges they have and there's a lot of work that we're doing around the extended role of the multidisciplinary team so I think I'm very clear that general practice are the clinical leaders and they sit at the heart in terms of primary and community services in terms of our delivery and our vision over the next five years of what we're doing but I think to the panel I would certainly highlight the role and importance of the wider multidisciplinary and agency team as well and the contribution that they can make in supporting meeting the demands and the healthcare needs of the population we're serving. Eilidh Collin, you wanted to come at this point. Excuse me, thanks very much convener. Earlier answer Dr Mack indicated that the current crisis was predicted so what do you think frankly didn't happen to heed those predictions and what lessons do you think we can learn now in terms of trying to resolve the current crisis? At the core of our campaign strategy was to see an increased percentage funding going to general practice and that was what we brought to the previous cabinet secretary and that was clearly what we believe we've made that argument quite strongly. That is the single most important thing that we need to do to give the resource of general practice to provide the staffing both in general practice staffing but in other members of staff too as Alan suggests we now need to think in a wider multidisciplinary team to deliver this care and there probably are not going to be enough GPs immediately but we do have to have the aspiration to increase the number of GP numbers it's absolutely clear. We've seen over the same period Scottish Government's own press release said 40% increasing consultant numbers that seems to be matched by almost no increased number in GPs and the workforce survey actually suggests we lost 2% in the last two years so it does seem that actually the workforce planning has gone awry that we're not actually investing in the workforce in the place where we should have it to at a time when we're talking about 2020 vision we're talking about more community care to increase the consultant numbers by 40% with no concurrent number of increasing general practitioners and additional members of staff seems to be wrong. I mean I think when I came into general practice we really had only a reception staff and now we have a bit more and I have about six GPs in the practice for 10,000 patients I've got one whole time equivalent practice nurse and half a healthcare assistant and that's the only staff I have to deal with the acute demand as it comes into the practice. Now we have a wild multidisciplinary team but there's been a lack of investment into the structure that supports general practice at the same time as the actual work that we do has become much more complex. In other words we drive up quality that has created increased demands particularly on GP time and so that lack of investment into the broader needs of patients as they present to general practice which of course is where 90% of patient contact occurs. The place where you and your family mainly come in contact with medicine is general practice but we haven't substantially invested in general practice in supporting how that medicine delivers the best outcomes for patients and that strain is telling now on the enormous workload on GPs and we've no one else really to share that with. Now we need to find new workforce and it is going to be partly GPs but we know how slow that will be to come on stream so it's going to be a lot of other professions coming in to join us and meeting that immediate patient need and demand on the front line and for the right professional deal with those patient needs in a way which we've not had the capacity to do before. An example perhaps of how strange it became was that if a patient needed a blood test other say they were at home we were told that that couldn't be done by a district nurse because it was a GP contract blood. Now it was our need the patient had but because of the way people thought about how we worked on the contract it prevented teams working to meet patient needs appropriately. We need to get rid of all that and start working properly as professional teams having the right professional meeting the right patient need and a much greater number of professionals available to share the workload that currently is mainly dealt with in general practice because that is where the bulk of the work occurs right now. So that investment and I suppose we call on the Parliament and the Government now to have to invest in that and it's an absolute requirement for investment. I know how hard the public purse is stretched but this is an absolute requirement if you want to fix this if you want to have general practice for your families and mine this requires investment now in this new model of general practice we are absolutely open for that kind of general practice for the other professions to come in and play their part to have a greater offering to the public when they approach general practice which is the hub general practice is the hub just now where most people come in contact with NHS we want to build up that hub so that there are greater offering of professionals immediately available to the public to meet their needs at the front line and we are up for making that the right way forward but the Parliament and the Government have to now make that investment even though times are hard. I listened intently to Dr McDivitt in regards to the point you're making but I must agree that we've got to look at it and actually I'll bring a word which has been used for a long time demarcation let's reduce the demarcation and let's work together to solve the problem but one of the problems I think it's not just money you know and I agree that that should be looked at but it's you know it's a start we need to start now to get more more people into be a doctor now I have to say I'm working on a particular case for a constituent just now where the boy wants to be a doctor but unfortunately is a few points short to get into university and I've actually went to see the university and I hope they're listening to me today at the you know should we we have to now train doctors and you know what is it five seven years basically the university and then subsequently yeah so basically we have to start now to to train the doctors that we need you know and to to resolve this and look at with the greatest respect each and every situation we've got throughout the country we've got doctors who are working in their own owned surgeries we've got doctors who are working in health centres we've got doctors who are getting paid by the nhs doctors who are basically managing their own practice you know I think they should be doctoring rather than managing if we can use that word so you know I think we have to look at the whole situation and resolve it and we've got to look at money yes but we've also got to look at workforce and how how how we can encourage and if anyone out there can help me to get this boy into this university because he wants to be a doctor and his family is going through a terrible time just now because he he can't get in there because of this few points would you think university should look at this and you also believe that we should look at demarcation within the the gambit that you just spoke about if I if I may yes I mean at the universities I think governments are quite rightly looking to make sure that the recruitment into medicine represents the population and we do know that if people come from their populations they're more like to serve those populations whether it be rural or deprived so absolutely university should do that and government should be involved in doing that it will always be hard to get into medicine because of the competitive nature far more people still although the numbers have dropped want to become doctors than can become doctors and we have that's always going to be hard but I think we have to make sure there's equity of access from across the social spectrum into universities and I think a lot more work has to be done them because it's clearly not having a major impact at the moment so you said that there are actually more people out there who want to be doctors but can't be doctors yes there are there have been consistently that for a long time we're still consistently saying that the numbers applying to medical school are very high what's really sad is that they're dropping off at later stages you're absolutely Alan's exactly right about where people come from we we understand that only 50% of entrance into medical school are now Scottish domiciled so our evidence internationally and this is borne out from the work we did remote and rural work earlier is that people tend to return to the place of a domicile after university and I think it's something which does need to be looked at the other thing is I think you're hinting at is the idea of contextualised admissions which I heartily applaud that actually there's very good evidence and actually some of that's from the Scottish government's own work about removing access barriers to education of reducing grades for people from particular backgrounds who find it very difficult this isn't just from inner city areas this is actually a big issue for remote and rural areas where in some remote secondary schools they won't have the opportunity of doing all four sciences and by default may not have the grades that they're needed they may also struggle to get the sort of experience of nursing homes and what like and we've had a real issue with remote and rural recruitment because of that so contextualising the admissions seems to be a clear way forward and something which seems to bade evidence and actually probably means more likely to get the doctors we need I'll just say one thing about demarcation I think there's a real risk that actually we need to do whatever we can in that in that role but actually we also need to be clear about what the primary care team is I'm very proud of some work that we did with the Royal College of Nursing Royal College of Pharmacy the Royal Pharmaceutical Society and the other members of primary care to try and define what the primary care team is and actually what we can provide that because whereas we don't want there to be artificial barriers what we are going to need is a network group of professionals who understand what their job is understand what they can expect from others and have got really good communication links and some of that will about being defining what we do as doctors and it probably is important that doctors are clear about what our job is uniquely and what it is nurses can do and inverse practitioners can do and pharmacists thank you for that if I may just build on that point I think there are some really good examples around the kind of workforce planning and development around the extended primary care team where where the principal really is about it's not the people substituting but it's actually looking at the workload and the demand and actually allowing certain healthcare practitioners and we use the kind of statement to say to work to the top end of their licence and I think within the nursing profession in particular and particularly in primary care where we now have a number of advanced nurse practitioners we have nurse consultants and previously a lot of the nurse consultants were working quite specialist areas within secondary care but now in terms of medicine for the elderly for example we in one of our deep end practices in Dundee we have a nurse consultant with that background is actually working out in primary care I think there's also some really good examples again where and this has been done collaboratively with the GP so working with the clinical team but looking at our allied health professionals or physiotherapists and them running particular clinics where actually they can be independent with an agreed scope of practice and the last one I think also and I think it's something the panel touched on last week is around the role of the pharmacist and certainly in NHS Tayside we've had pharmacists attached to GP practices for at least the last 10 15 years and that has supported the it doesn't take away the challenges that are there but it does help the demand and the workload and allows pharmacists to undertake work that actually the GP don't need to do so I think there's still lots more work to be done but I think there are some really good examples developing and emerging in the primary community care service where there's that real strength and if I may panel just to just to make reference to you know not just a healthcare professional we'll give some great examples where third sector are inputting and supporting even just transporting patients into the practice that that she can be transported but they don't have access to it to save home visits etc being done so absolutely core in terms of working on that multidisciplinary team but I think recognising the opportunity that health and social care integration is bringing and the relationships with third sector it's about actually looking right across the whole health and social care system to support the increasing demand of population that we have how many training places do we have in scotland for to to someone to become a doctor do we know the current intake is 350 that this year's intake was 350 going into university to become a doctor do we know how many I'm looking for an R1 but if you know how many I don't think I certainly don't have those figures to end I mean Glasgow University when I was there was 200 a year so you can take it from that that was one of the biggest medical schools but can I just share with you I I have the same problems used helping some of my patients children to get into medical school I have exactly the same problem and one of the things we recognised is that it's actually very difficult as Miles said for some students to get access to experience with the GP because they don't know doctors you know so in fact we're trying to arrange in our area to do a swapping arrangement with another practice so that we can facilitate local children getting some experience of general practice to try and help people from our communities get into medicine just as much so I think it's something that we share with you I think I suspect will all have been involved at some point in trying to help children to get into medicine but it's a difficult area and it probably always will be just ask that if we can maybe keep our answers slightly shorter so in Grampian we've been offering a scheme called doctors at work for school pupils who are academically on that route to becoming doctors and we've opened it up for the whole of Grampian we take some students from out with Grampian including those from Arnay and Shetland who would be in that position of not necessarily having that access it's running very very successfully the pupils come for a week and spend time interacting with doctors but also shadow doctors as well so everybody gets a better access one of the things that's really surfacing around that is about individuals values in terms of what their intention is it's not just about your academic ability it's about your values and what you believe in and your commitment I guess to becoming a doctor or a GP in the future can I so I just add one little thing from the back of the multidisciplinary team in relation to physicians associates which I don't see mentioned earlier in Grampian with Aberdeen University we are running a course we're on our sixth cohort we're actually offering these individuals bursaries they come from a different supply they are generally science graduates and they do a postgraduate degree and then become part of our workforce we're highly successful in terms of placing them in fact we could place more and in primary care those who have them are very enthusiastic about them and I think there needs to be more work and support around the physicians associates Alison and direct this first question to Miles Mack when you were speaking earlier you spoke about devastating results for patients when now I might have misunderstood and I'll look back at the record when practices were taken over by the NHS and I'd just like to explore that mixed model a bit further if I may I mean Gerry Lawry you were speaking of the fact that part-time working is more attractive both to men and women which is obviously going to have an impact but I'd just like to understand whether or not the government could be doing more in terms of offering salaried positions or whether you have any concerns about that model number of issues to do with that I think salary posts do seem to be more attractive particularly when doctors are concerned about the general medical services contract not being fit particularly fit for purpose and the level of workloads that's there we do hear we don't have got clear evidence this but people do seem to want to be salaried to practices rather than health boards a lot of the time we do have concerns that some of the practices being taken over by health boards seem to cost an awful lot of money to run sometimes twice as much we're not sure if that's because of under estimate the past or whether it's just because actually self-employed doctors are an incredibly efficient way of doing that the multidisciplinary team is important but obviously with your role of scrutiny make sure you're aware of the review by the University of York was obviously in June 2015 which just pointed out that actually there's not clear evidence that it reduces the overall need for GPs that this role substitution is being widely promoted but the extent to which this will reduce GP workload is unclear and also they also point out the other ways of working about triage and other things seems to be more about shifting work around rather than necessarily making life easier for GPs so we do have to be clear what we're trying to achieve and the multidisciplinary working way of working is not a cheap option they're unable to see in anything like the rates that GPs can and also need supervision and also built into that is the time GPs will need to start to spend more time interacting with the interface with the other members of the team. Oh sorry I didn't see you. Thank you convener. So what you're saying there is that the multidisciplinary team is it's important that we look at this model I mean Elaine McNaughton Dr McNaughton when she was giving evidence last week was saying actually it wasn't new to her it may be in some other areas but while we're looking at this we mustn't look site of the fact that we need to ensure we have enough GPs because this is not a substitute for general practitioners. Can I just ask the Scottish Government have told us that the number of GPs has increased by seven percent now I know that there are three of us certainly who represent Lothian here we've been told that we have 39 restricted lists in Lothian and particularly deep end practices seem to be suffering you know terribly from this so are these extra seven percent of GPs that we're hearing about are they having any impact on health inequality? Extra GP posts are headcount rather than whole time equivalent we've got clear evidence from the workforce survey actually ISD performed that we've lost two percent in two years so it may be that the headcount is increasing but whole time equivalent actually the number of GPs that are on the ground to deliver care is not increasing and actually the trend is downwards. Question very quickly Dr McDivitt in your left you certainly raised concerns about a suggestion that more GPs might work between primary and acute care could you? This comes out of the one of the many variations of hubs that are around in particularly in the 4th valley area where and I think we have worked on this to try and get an agreed position on it but the idea that the future of general practice is a doctor who works in secondary care and comes into primary care and dips in and out isn't one that we find attractive we think we need doctors who work in primary care as general practitioners expert medical generals in the community and we shouldn't we've got a very scarce workforce the idea of sharing it in some intermediate role as those are invited happening in 4th valley worries me at a time when we can't recruit to the core general practice job that we're getting new jobs that take people away from that area and 4th valley was one of the first areas that had a major crisis in staffing practices so we don't see that as a future there are things we can learn from the pilot that's going on there but we certainly don't see that as the future for general practice in Scotland quite clearly it's about having GPs in the community expert medical generals available to everyone in their community is a fundamental part of the future for general practice in Scotland not some other invention of what general practice could be. Thanks very much I'm interested in developing that a little further because I was interested that Dr Miles max spoke very animatedly about the opportunity for his medical student to work in a rural general practice and to follow the patient into the hospital go in the ward around and follow them back into the community and I actually as a clinic myself although my pharmacist not a medic I found you know the quality what attracted me to my job was the quality of care that I was able to deliver and the you know the challenge the clinical challenges and I thought actually being able to move GPs from into more complex care might make the job more attractive so we're interested to hear what I'm smiling slightly because I reckon my job is pretty complex so so so we deal with you know we'll be dealing with people from you know new babies to the elderly pregnancy people with mental health problems because you can't separate mental health from the physical illnesses that affect people so GPs deal with all that every day and the one surgery I'll go from all the spectrums of age all the spectrum disease and I'll have to manage that all along in addition to that the fact that people have multi morbidity now they don't just have one illness or one problem they have heart disease diabetes they've had a stroke and they're depressed you know and they're had a recent bereavement so that's one of the beauties of general price dealing with the whole person and that that I think is the the element of complexity that I would say is what engages me it's about real people with the real problems but as well as that we have an increasingly complex elderly population who we need to look after at home if we continue to deal with people older people with complex health problems by sending into hospital we cannot build the hospitals fast enough so we need to look after people close to home there is no doubt about everyone's in agreement now taking on that complex medical workload is a real challenge not least because there isn't time to do it just now but as well as that we will have to continue to build our skills and we plan as part of the GP contract going forward to build in regular time that's non-patient facing for GPs to continue to upskill themselves in the role that they're taking on that which is going to be a much more complicated role making sure that people are cared for at home the way they wish to be with complex medical problems and the advances in medical technology will allow that to happen much more that's a very complex part of work most GP training actually occurs in hospitals we would like more of it to happen in general practice and that's an issue we need to discuss but we have plenty of experience of hospital medicine what we need is general practice medicine in the communities we need to make sure that's what we're trained in and that's what we're experts in and that's what we train young doctors to do and I have no qualms about saying that's complicated enough to engage me for my whole career for GPs to be caring for people in community hospitals or already saying they do that now and that's about buildings again someone else mentioned we shouldn't get too tied up on buildings here that this is about where the patients care actually the sort of complex people in care community also very similar to some of the ones we have at home increasingly we'll find that the complexity of your problem won't be determined by your location it's your nature and basically we're getting much better at dealing with things at home which in the past we'd have said would have happened in a hospital or in a community care hospital but there are places where there are many parts of the country where for example community hospital is invaluable to the way that that geography works that sometimes it's better to ring the patient to where the professionals are other times you want in a big array of a conurbation to bring the professionals to where the patient is and we need to be absolutely flexible about that the actual placement of care should be irrelevant it's the complexity and quality of care we can provide and the presumption of care should be in your own home we have to start with that and go from there and you should only go elsewhere when elsewhere is definitively going to improve your outcome Just raise the flag for mountain rural medicine where GPs are commonly looking after hospitals and doing amazing work they obviously need extra skills for that and David Hogg who's actually in the Think GP video is an example of that where on the Isle of Arran they're providing all the hospital care as well one of the big problems is actually the recruitment crisis has put community community community be aware put community hospitals at risk we've seen Lockhart hospital closing because the practice unable to cover that as well as the gms workload and that happened to my own practice and it was a deep regret that we've had to stop providing the care to the Rossmore hospital because we're just unable to recruit the GPs we need to do the day to day work safely so you're quite right we have got lots of skills quite right we are invaluable to the NHS at a time when the GPs are short we do need to focus that where it's absolutely essential because no one else is qualified to do the work that we do as GPs For the record there are 898 medical undergraduate places in this year in August 2016 I don't know if the panel want to comment on whether they feel that's enough to provide us with the GPs and the medical staff of the future I would think it's probably more about retaining those into careers and making sure that their career flow is appropriate to where we want to go so actually if those probably we can improve the conversion rate into general practice for Scotland if we undertake some of the ideas that we're proposing in the GP career flow proposals I asked most of the questions that I was going to ask so I'm sorry it's just an observation picking up on the points that Marie made as well and that the work the potential for a GP to work both in general practice and in acute services it's just an observation where I visited a community hospital in the Highlands and Islands where I think there was a rural fellowship was operating and the anecdotal and it's purely anecdotal evidence was that it one of the great attractions was the fact that this GP could work as a GP for two days a week and then was able to go into the local hospital and work there for three days a week whatever the balance was and it was a clearly it was it was it was what made that job particularly attractive because there was this mixed mix working and I just wonder if you had any observations on that I mean we've always done that in general practice I was a clinical assistant in respiratory medicine I've done medical politics I've done all sorts of other jobs as well as being a GP and that's fantastic and that's what we call a portfolio career and we are all myself and Miles a portfolio career GP's that's always been part of general practice but that isn't what GMS and general practice about the core job the to two sessions he does as a GP is what being the GP is the rest is other things you can do and there are lots of other things that GPs can do whether it be working for the benefits agency the government so there's always going to be the capacity for GPs to have other roles what we've often forgotten though is the need to make the core role as the GP attractive that be the thing that the reason why people come into general practice if everyone who becomes a GP only spends half their time doing it we're certainly going to need an awful lot more than we're already talking about so we must make being a core GP a fundamentally attractive and interesting future career because otherwise if saying it's okay because you can do other stuff just isn't a way to make it the future so yes it's interesting it's good that being a GP does allow you flexibility in your career allow you other interests but it's still about being a GP that we need to make the biggest attraction to bring general practitioners into the profession thank you so I'm just picking up a marise point and maybe just building on that one a little I quite like to bring to the panel's attention just some of the work we're doing in Tayside which we classify as enhanced community support and we're putting that in his core service provision and what that does is it builds on the GP practice population but it brings in the medicine for the elderly consultant the psychiatry of old age consultant so these are individuals whose job plans take them both working in the secondary care sector and also in the primary care and what we do there is and we've got good evidence through the pilots we initially did was so we were targeting unscheduled care so we know the challenges older people and unscheduled admissions so it's that rapid assessment from that team that includes the GP dedicated GP time the POA consultant the medicine for the elderly the pharmacist the senior district nurse's social work the the AHP going into the home of that individual and it's an example of where the GP is working with other senior medical colleagues undertaking that rapid assessment often making the decision that person needs admitted but managing their admission in and then managing their discharge back out and we've had a lot of success which we found that a we've reduced the number of unscheduled care admissions and and secondly when people have been admitted their length of stay has been reduced so that is something that after the piloting we were putting that full rollout and it's helping and supporting the GPs and working with that wider primary and secondary care colleagues to to manage that patient journey. Thanks and thanks for coming along there was a couple areas I wanted to touch on. The first was around about spend now you talked about percentage spend then you're keen to get that percentage spend up by two two and a half points or whatever because your top percentage is clearly that means that somebody else is going to have a reduced spend so I just wanted to kind of throw that out there and see what you wanted to see about that and I suppose where I'm trying to get to with that um well first we'll put that in the context the Scottish Government's talking about a shift to primary care so I'm assuming when you're talking about GP spend the way you see the picture is yeah there's money going to primary care but it's not going to the GPs it's going somewhere else in the primary care arena is that how you see it and then I suppose where I'm trying to get to with that is around about the whole concept of preventive spend and do you have an argument that we've heard before from GPs and can you put some flesh on that which is if you invest the money in the GPs you're saving money in A&E and how do you quantify that so again that's the first kind of thing and the second thing I wanted to go through was around about the GP workload concept so we're talking about multi-discipline we're talking about taking work away from GPs and I know you have some reservations on some parts of that but in general the quaffs come away I've talked to pharmacists and they're very keen and very happy that repeat pharmacists and that kind of thing is coming away from GP so there are things that are reducing GP's workload and again has there been any analysis done around about the day in the life of a GP how much of that you would say is stuff that GP shouldn't be doing that can go elsewhere on how much ground have we made going down that road it's just two areas to talk about. Speak about percentage spend I think I'm sure that Scottish Government is going to want to invest in the health service and it's been consistently doing that. I think what we really need to do is make sure we're investing in the right place we're very disappointed with the last budget for instance when the real terms increase of their territorial health boards was 3.8 per cent but the GMS rise was only 1.9 per cent that just seemed to be seem to be strange because of the issues we'd already seen so there's undoubtedly is going to be investment in general in health service in general we just want to make sure that it's invested in the right place. We've got clear evidence from Deloitte surveys about the effectiveness of primary care that's backed up by Helen Irving's work which shows that in the works she's done in Glasgow that actually the it wasn't about lack of resources but actually resourcing the wrong things and by investing a large amount in elective healthcare you actually make inequalities worse. Now this backs up long standing evidence from Barbara Starfield and others which shows that investment in primary care reduces inequalities and it actually improves mortality when actually there's no clear evidence that that always happens when you invest in secondary care. I'm very grateful that Coff has been replaced and I'm very proud that the college came up with some of the concepts particularly the basis of peer-based and values driven approach which underlines that. I think this is going to be a major way forward I think it's going to give us the structure to provide leadership and not only look at the intrinsic quality of the practice but actually the extrinsic factors about how we work within the NHS which has been a key part of the work I've been doing over the last two years. Just to say that in terms I think percentage isn't always the most helpful way to discuss this we certainly need an absolute investment in general practice in particular and by that I don't mean necessarily coming into the GMS spend which is technically where it would normally come because we're actually saying that we don't want to expand the number of staff we employ that we want to have other staff who assist us in doing the work that comes to practice but we don't necessarily have to see that coming through my accounts for example because we want to reduce the burdens of being an independent contractor to make it a more attractive future for GPs. So we need to find ways of making sure that we can agree between us the money that comes that supports general practice in its new role if we get to that stage which is what we hope to with the new contract and we will hopefully with government agree where we say that investment does come to support general practice because as Miles has said Helen Irvine has shown that a lot of the investment that's gone to primary care has made no difference at all to general practice and the work that we do now that's because of a different focus on how that spend works and the outcomes it's trying to achieve. We definitely want investment that improves the outcomes that we achieve through general practice and that's going to require a new look at how we count it as spending that goes towards supporting general practice as well as that that which directly comes through what we call the GMS spend. Yeah I suppose I didn't get the answers to my questions which were if I spend a pound on GPs how much should I save at A&E to cut to the chase and secondly has there been any work done on how many hours a GP spends on stuff that they don't need to be doing. Can I come in the second one I mean there's been a lot of different work it's very difficult to pick it apart because GP patients usually don't come with one thing it's a bit like supermarkets they come with more than five items so basically it's very difficult to say what would you not be doing especially if GPs are extremely efficient. GPs are almost certainly the most efficient single person to do all of this and actually there's a good argument cost effectiveness why simply to do all of this with more GPs because they're remarkably cost effective. Interrupt you there because you've touched on a point that I actually Dr McNaughton brought up last week was saying that you know the cheapest and the most cost effective way is to get GPs to do absolutely everything do all in a winner I think was her expression but that wouldn't give the patient the best service. Well I would disagree I think it gives the patient a very good service and it has done often now there you know but we're not going to be able to do that there aren't enough doctors so we're changing that and I think it does bring new aspects of quality of service to bring other professionals in because they bring in their own skills as well as those that a GP might have but in terms of cost effective as in terms of improving outcomes GPs are remarkably cost effective at what they do but this is probably true based on a number of different people's opinions about 25% of the work that are the things I do in every day someone else can do and possibly do better so that's the kind of scale that we're talking about and that might free up 30% of my time to deal with complex care the new agenda for care for patients we have now and also making the job more humane because many of our colleagues just now say the workload is inhumane and they're deciding to get out of it one way or another by going part time leaving the profession we had 259 GPs under 50 have left the profession in the last five years 200 of those were under 40 when they decided to get out so we have to change the role of a GP to make it a good job that's manageable in humane terms and dealing with the new complex world that we now have to deal with and the best way it is also true that GPs are happier working in a proper multi-professional team I'm fortunate that I still have one and it's a great team to work in and the demarcation issues that you hinted at disappear when a team works well everyone knows what each other's role is how best we are to deal with things and we contribute equally to that effect so once you get a good team working the demarcation issues disappear I've got some specific figures that Delight came up with for us in 2014 about potential savings on reduced A&E attendances and social admissions it was between 26 and 37 million a reduced ACSC admissions between 12 and 27 million depending on low and high ratios decreased alcohol consumption between 4.7 million and 7 and 4.7 and 7 million smoking reduction between 5.6 and 9 million giving a total estimate a range between 48.9 million and 81 million pounds that's based on Delight figures which are online at my website. The basis for this I would presume if this was meant that our campaign call was noted but I'd need to check that. You could send on to the remarks at me super. Thanks very much. I'd like to go back to Richard's point about recruitment and especially how universities are helping to meet that demand. How do you feel the university sector is planning the workforce? I was told yesterday about Aberdeen University's 160 medical places. They've reduced the number for Scottish domicile by 12 for this current year. How do you think we need to do more to say to the universities in Scotland they've got to have a larger percentage of Scottish students going in to study and is that some of the Scottish government's failing to do especially given how we fund universities and international students can actually bring £30,000 per course to that university? So when I started my career in the NHS and I was involved in induction of the new junior doctors leaving medical schools one of the questions I asked was how many of you trained locally and about 95 per cent put their hands up. 20 years down the line I'm lucky if that's 50 per cent of the new graduates that start with us and I'm disappointed that Aberdeen University have reduced the number because we are struggling to recruit not just in primary care but in other areas as well. I would strongly emphasise the need to get local students into the Grampian area. When I mean local I mean north of Scotland I don't just mean Grampian, I mean Shetland and Orkney and Highland as well because there is a bit of a move between these areas as well. To what extent have government incentives like the £20,000 which is being provided as well as the 100 additional training posts going to make any difference do you think? I think that £20,000 is only allocated to certain training schemes so I think that we've only got three in the north in that because we have actually recruited relatively well this year for our GP training scheme but that doesn't necessarily mean that it's always going to be that way. I'm not an expert in this but I mean the universities seem to me they're almost just educational businesses and it's for government to influence how they operate and as you've hinted at there are other routes of them getting funding to go through. It is also true and I think that Miles has done a lot of work that the actual atmosphere regarding general practice in universities and medical schools is not positive towards general practice and it's fundamental that that changes but in terms of the whole workflow of new GPs coming through there are lots of places where our potential GPs drop off getting into university once they've come through the foundation years their choice of specialist training and we need over 50 per cent of them choosing to be GPs and they aren't and then when they do that they're often going out they're going lost to our workforce at the end of the training time so we've got lots of places where we lose potential GPs and we have to fix that. Now we've asked the government and the minister did announce in our speech earlier this year at our conference that she would produce a workforce plan and part of that is how do we produce the number of GPs we need for the future now that's going to be very difficult because we're both changing the role the demands of the population are changing and all the other workforces come into play so it's actually a bit of a black art trying to predict how many GPs you need you certainly need more now and we certainly need to produce more than we're producing through our current system but it likes to be a work in progress trying to say how many in the end do we actually need and universities are fundamentally part of that. One thing just to add to that actually there's really good evidence that training doctors in general practice is good value not only will you provide more GPs but actually those GPs there is some evidence that those GPs who end up in hospital those doctors who end up in hospital posts have got better communication skills better able to deal with risk and better use of resources because of the sort of training that they get in general practice. I think just in relation to that so fully recognise all the factors that determine often where people will then end up after the training but notwithstanding that I still think there's a role for the healthcare system to engage as early as possible with that undergraduate group of individuals across all the disciplines and really entice and encourage them we've got to work hard at that to to retain them in our system. Thank you I'd like to thank the panel for coming along this morning and speaking to the committee I think it's been quite enlightening for all of us and I'll now suspend the meeting briefly for a change of panel. Thank you for that we welcome to the committee Shona Robison, Cabinet Secretary for Health and Sport, Richard Fogo, Deputy Director Primary Care, Gregor Smith, Deputy Chief Medical Officer and Shirley Rogers, Director of Health Workforce all from Scottish Government and I'd like to invite the cabinet secretary to give an opening statement. Well thanks very much convener. I've provided the committee with a written update on the progress that we've already made and what our next steps are in supporting general practice and transforming primary care. It's fair to say and I think I've said this before that general practice is of course at the very heart of our NHS with over 90% of healthcare delivered in primary care and over 24 million consultations in general practice every year. We must ensure that Scotland's GPs get the support they need to flourish. However we know of course as you've heard that general practice is under significant pressure and the scale and nature of demand is changing with an ageing population increasing complexity and of course the continued impact of health inequalities and to meet these challenges we can't continue to look back but we have to focus on a vision for the future so in December last year in Parliament I set out my vision for a community health service at the heart of Scotland's NHS. A wider range of services provided by a highly skilled wider group of professionals working as integrated teams delivering care both in and out of hours tailored to local needs. With Scotland's GPs providing leadership within these teams along with an enhanced leadership role for Scotland's nurses, pharmacists, paramedics and other allied health professionals. In my written-up day I've set out the outcomes and actions that will deliver that vision. We have increased investment in our primary care fund to £85 million over three years and to ensure that this investment makes a difference. We're testing new models of care in every health board area in Scotland with a focus on improving primary care mental health and out of hours services. Over 80 tests of that new model are already underway and of course we've also committed to increasing the share of NHS funding in primary care year on year throughout this Parliament and as investment grows we'll use that to support local areas to roll out the most successful tests. I think this is a measured and evidence-based approach to change. If the future of primary care is multidisciplinary in nature, then the bulk of our investment should be in the primary care workforce. We've already taken a number of actions. We've increased GP training places from £300 to £400 per year. We've invested £2 million in GP recruitment and retention, including a rural medicine collaborative and of course deep-end practices. We've committed over £16 million to recruit 140 whole-time equivalent pharmacists in general practice. In the programme for government we've committed to increasing the numbers of GPs and nurses working in our communities, recruiting 250 community link workers to work with GPs in the most deprived communities and to train an additional 1,000 paramedics to work in community settings over the next five years. I think this is the basis of long-term change but we know of course that the pressures faced by general practice are also here in the short term, which is why in March of this year I committed an additional £20 million to provide immediate support to GPs and their practice staff. That included an uplift to pay and expenses of GPs. It supported the introduction of GP clusters. It introduced occupational health cover for GPs and ensured fair parental leave arrangement for GPs. These were all issues and priorities raised by the profession themselves but the longer term changes we seek cannot be delivered through the GP contract alone. They require changes to the wider workforce and infrastructure but we are working very effectively with the BMA to deliver a new GP contract from 2017. A collaboration which has already allowed us to abolish the bureaucratic quality and outcomes framework and to introduce GP clusters. I know that everyone around this table is committed to the future of general practice in Scotland. We recognise the challenges but I am ambitious for the future of general practice and primary care and I welcome this opportunity to discuss these plans with the committee. Thank you for that cabinet secretary. We will now move to questions. Alex Thank you cabinet secretary and thank you to the rest of the panel for joining us this morning. We had a protracted discussion in the last hearing as to how we would characterise the situation around workforce planning, particularly in the GP sector. I will be very keen to hear from each of the panellists individually as to whether you would characterise our current situation as a crisis given that, whilst more training places are being made available, those are not being filled. When they are filled they are not always from Scottish domiciled residents. Indeed, despite an uplift in headcount in the GP profession, we are seeing a drop-off in full-time equivalent to the point where we may be as many as 900 GPs fewer than we require by the end of the decade. Is this a crisis? It is a challenging situation without a doubt and I have never shied away from saying so, which is why I have spent a lot of my time in fact since becoming cabinet secretary. I have probably spent more time looking at the issue of the future of primary care and its importance in helping us to develop a sustainable NHS than probably any other issue. If I had not recognised there was a challenge I would not be doing that. I think that we have also engaged very effectively with stakeholders in discussing what the solutions to those challenges are. There is no one quick fix. We have already accepted that we need more GPs but it is not just about the number of GPs, it is about what those GPs do. Of course, that is why the new GP contract is so important in looking at a contract that supports new models of working, multidisciplinary models, utilising the skills and abilities of other staff to make sure that we get a sustainable model of primary care going forward. I have never shied away from being clear about the scale of the challenge. What is more important though is what we do about it. You mentioned the issue of Scottish domiciled students and of course in that respect we have taken a number of actions. We are increasing by 50 the number of undergraduate medical places from this year onwards. We have been very clear with universities that we want the widening access agenda to feature very strongly in those additional places and of course we are very well along the way with our plans for a new graduate medical school which will have a very clear focus on primary care and rurality. We are looking at how we can link for example the payment of graduate fees to commitment to work within our NHS. The most important thing here is keeping doctors who train here working in our NHS here. Many who might not be Scottish domiciled do that. They train here and work here for long periods of time. What we want is more of them to choose general practice rather than other specialties. That is one of the challenges and again we have been working with the medical schools to look at how we make general practice more attractive and of course we have increased our training places to ensure that we give the opportunity and some interesting different opportunities there with the GP fellows for example which is attracting quite a lot of interest and the bursaries as well. We have looked at a whole range of mechanisms to try and make more young people go into medicine to choose general practice and to stay working here in Scotland and the graduate programme will encourage a wider variety of people of all ages and all backgrounds to go into medicine. That will be good for the medical workforce here in Scotland. I do doubt the sincerity with which you are approaching this problem but would you characterise it as a crisis? No, I would characterise it as being very challenging. I think that we could sit and discuss terminology all morning. Would that really get us very far in terms of how we resolve the problem? I doubt it very much. What I am focused on is coming up with a range of solutions that gets us to a point where people want to go into general practice, stay in general practice and work here in Scotland. That is not easy to resolve because it is partly about the perception of general practice. It is about how our medical schools work and perhaps some of the perception within medical schools of where general practice sits in regard to other specialities. Those are quite deep-rooted and complex issues. There is not one solution to them, which is why in the written material provided to the committee, why in the remarks that I have made here today, we have touched on a number of solutions right from the recruitment and undergraduate level through to training. The most important thing out of all that is what the vision for primary care is. If we can create a vision for primary care here in Scotland that doctors want to be part of, then many more will choose general practice alongside other professionals who will want to work in primary care as opposed to other parts of the NHS. I hope that that is what we can focus on here this morning. I listen to you. I think that you are starting to get the factor that you are thinking outside the box. My view is that we need more financial help for people to become doctors. Should we have incentives for people to stay or go into general practice, should we have more training places because a number of people fall off? I am trying to get a constituent into a training place, but because he is short of a couple of points, the university is reviewing it and I hope that they do. The point that I was making this morning was that there is possibly a situation of using old-word demarcation. If I walk into a doctor, if I have a cough, I should go and see a nurse, not go and see the doctor. If I have a sore finger, I should go and see the nurse, not the doctor. Is there more things that we can do to try to reduce the amount of time that people are seeing the individual doctor where they can see a nurse or someone within that practice? Get doctors to look at the situation of working only with the patient rather than trying to be a manager and employing all this and that into a sort of health centre setting rather than their own practice. Do we start to think outside the box to resolve this challenge? Yes, we need to do that. I should say that the role of the GP is pivotal. That will continue to be the case. It has been the case and will continue to be the case, but what we are looking at that is new is utilising more effectively the range of skills that sits within primary care and co-ordinating that through a genuinely multidisciplinary team environment. That will allow, if we get it right. I think I heard Alan McDevitt at one point say that he thought that there was 25% of what GPs do could effectively be done by someone else. That is not about a lesser service. It is about recognising that whether it is medicines, reconciliation, pharmacists are absolutely trained to do or whether it is physiotherapists, whether it is mental health workers. It is about making sure that the patient gets the best service utilising the skills of that wider team. Now, there is nothing earth shattering. It is a bit of a no-brainer, but it is about making it happen and ensuring that the contract supports that. The model of working in primary care supports that. That is what we are aiming to do. You mentioned the incentives. Yes, we have put those in place. The additional training places are important, but it is a challenge to ensure that we fill those training places. I have accepted that it is a challenge. However, there are some positive signs in terms of the number of applications. We are in a better place where we stand now than we were last year in that regard, but there is still more work to be done. Making some of those training places more attractive has been important as well, which is why we have looked at innovative ways of doing that with some success also. All of those things that you have mentioned are important. There is not one thing that is the magic bullet here. We need to ensure that we have all of these things in place. It is not going to happen overnight. We are not going to change the perception of general practice or primary care overnight. That is going to take time. We need to ensure that the testing of the new models is delivering the evidence that we need to be able then to roll out that. There is some really interesting data beginning to emerge from those test sites that will stand as in very good stead as we do that. Not one single answer, but all of the things that you mentioned are important. I think that you are officials, and you may want to come back to me. Sorry, I keep pressing this. Is any official know how many people have refused a place to train as a doctor? I am particularly interested in one case, but I am sure that there are many more out there. I welcome anyone who is in a similar position to contact me, but I want to know how many people are being refused a place to train as a doctor. Can I perhaps pick up on a couple of themes that perhaps relate back to your question as well, Mr Cole-Hamilton, if I may? The context that we are operating in is that there is an international requirement for additional medical staff. That is not unique to the UK. It is not unique to Scotland. It is an issue that is around most of the developed world as the population ages and expectations of health increase. Our ability to recruit, train and retain our people has never been more important than it is at the moment. We also have the advantage of having in Scotland five very well regarded medical schools who attract candidates from across the world. I think that we would all wish it to be the case that Scotland's medical schools are highly regarded, highly reputed. We know that Scottish medical schools attract a high number of international students. Coming to the point in respect of selection, because of those criteria, we know that Scottish universities are able to be quite discerning. We know that in the conversations that I have routinely with the Board for Academic Medicine, which is the group representing the medical schools in Scotland in this context, they and I are continuing to work on those selection criteria. We know that we get many more applications to Scottish medical schools than are taken. That is both in terms of Scottish domicile students and in terms of international students. As we would all accept, we want the very best of the best in terms of Scottish medics. We want the people of Scotland to get the best medics that they can. What we have been working with the universities around over the last couple of years has been an identification of issues of access. You are right, Mr Law, that there are people who aren't quite making into that space. We have been working very closely with the universities to look at their recruitment arrangements. Clearly, it would be inappropriate for us to determine those. They have to meet all of the necessary academic tests. We have been very clear with the universities that what we look to them to provide is a partnership with us to provide us, in my case, me for the NHS in Scotland, with a supply of medics into that space. We are very keen to work with them around access. Cabinet Secretary has already mentioned some of the approaches that we are taking in that space. There is evidence now that suggests that Scotland's domicile students are more likely to go on and practice medicine in Scotland. That is the case if you look at the analysis across the UK that wherever you go to university, you are more likely to stay in the place that you went to university in order to practice. It is in our interest to make sure that Scotland is as attractive as we can be. Whilst we are doing a number of things that Cabinet Secretary has outlined to try and make that attractiveness more important, we are also making sure that the attractiveness of the general practitioner role is critical. The point that Alamot Devott made earlier on about the 25-30% of the work that is being done by GPs, not being appropriate for GPs, is important not just because it is wasteful, not just because it does not necessarily give the patient the best outcome, but also it is important because it does not make the GP role as attractive as it could be. The work that Richard Foggo, through the primary care design team, is doing alongside of Alan and Mars and various other stakeholders is to make that role as attractive so that these highly mobile, well-educated and well-reputed doctors are attracted to stay in Scotland. We seem to be making some progress in that respect. Things like the clinical fellows programme has been very important in attracting and retaining people to stay in the Scottish process. If there are people who you believe are at the cusp that are inappropriately deselected, then that is something that I would be very happy to provide some further advice and respect of. I think probably what I will take away from the session this morning is that we will not have a truly multidisciplinary approach if we do not have enough GPs in place. I think that that is absolutely an area where we have to concentrate focus. Figures suggest that the Scottish Government has a 7 per cent increase in GPs, but, as I mentioned in the earlier session in Lothian, there are 39 restricted lists. I would like to understand if that is actual headcount or whole-time equivalence, because I sort of feel that it does not quite add up. It seems slightly contradictory. Also, we heard an evidence earlier this morning about a contradiction in approach. If we want to truly shift the balance of care from the acute sector to the community, what impact are we having on health inequality through—while no one would suggest for a moment that we do not invest in elective procedures, for example—there has been a notable increase in consultants at a time when we are truly struggling to recruit enough GPs. I suppose that is the funding matching the intent. Is the funding and the focus matching the rhetoric? The 7 per cent is headcount. The issue of more GPs—yes, we need more GPs, I have said that we need more GPs, but we also need more nurses, pharmacists and other health professionals in that multidisciplinary setting. The workforce plan that will go along with the new contract and new models for primary care is very important in this context to make sure that we get that as accurate as we can. A lot of work is going on to make sure that, alongside the new models and the contract, underpinning that will be the investment plans and the workforce plans to ensure that we get the right number of GPs to populate those new models, alongside the right number of nurses, physios and other health professionals, to make sure that the multidisciplinary model can work effectively. Again, we have committed to an increasing share of funding going to primary care. That is obviously going to be subject to meeting the needs of the new model of primary care. We are in the process of obviously negotiating the new contract. Part of that, the outcome of that will obviously be that there will be an important funding element as part of the outcome of those negotiations to underpin the new model that will be delivered. All of these things are hugely important. You have mentioned tackling health inequalities. I have said on a number of occasions, I will say here again today that I think that the Scottish allocation formula and the way that we fund practices needs to better reflect the health inequalities dimension of the population that that practice serves. We have gone some way along the road of that with the formula and funding of deep-end practices. I believe very strongly that that needs to be better reflected. Clearly, again, that is part of a series of negotiations that we are having at the moment around the new contract. Obviously, it would be inappropriate for me to get into too much detail around that because it is a negotiation. All I would say is that it is going very well and those discussions are going well. There is a huge amount of common ground and agreement. I think we also need to look at how we better link the primary care workforce with other elements of support that people living in communities of deprivation require. The recent debate you had raised the issue of ensuring that we look at income maximisation, employability issues, all of the issues that surround individuals and families that impact on their health. I think through a new model of primary care, we can link more effectively into the world of integration, into welfare benefits support, into employability advice, all of that. There are some good examples of that. The Westerhales Living Centre, for example, which is funded through the 2C mechanism, provides a one-door approach to all of those services. There have been innovations already even under the existing contract and mechanisms that have led to quite innovative projects like that. I think there is more scope to do more of that and ensure that when someone comes through the door, whatever their needs can be met through that wider team of people who can begin to impact on the health inequalities that are faced by that individual family and community. In terms of funding, there is a difference between primary care funding in general and funding general practice. Does the Government have any plans to increase the share of NHS expenditure that general practice receives? We want to increase the share of spend on general practice and primary care within the wider health budget. We have made a commitment to increasing the share of spend over the course of this Parliament, but we cannot look at the funding of general practice in isolation from the funding of the wider primary care team. If we accept, as everybody around the table seems to have done, that multidisciplinary working is the answer to how we deliver primary care services of the future, then we have to invest in that wider primary care team. Within that, we will need more GPs. I have already said that in the programme for government, we are clear about that. Therefore, we will need to increase the number of GPs and therefore, we will have to spend more on ensuring that we have an increased number of GPs. To do that in isolation from the funding of the wider primary care team would be a mistake because we would not get primary care into a sustainable position. We would not tackle the issue of 25% of a GP's workload being able to be effectively done by someone else, so we would not maximise the efficiency of our primary care model and service if we were not to invest in that wider primary care team. Yes, we will need more GPs and therefore, we will need to ensure that we fund that additional workforce, but that has to sit within the context of an increasing share of funding on primary care more generally, otherwise we are not going to get to a sustainable model that we need. Thank you very much, cabinet secretary. There were two areas that I wanted to quickly touch on. One is about preventive spending. You have heard the same question in the earlier session. Do you have any analysis or data about, if you spend money in GPs or in the wider primary care, how much that saves you by reduced admissions to A&E and into the acute sector? The same thing is about the pilots. There is a great big list of pilots and that is great. You are trying a lot of different stuff, I am assuming, to see what works. Can you elaborate a bit more on the process of how you will evaluate the success of those pilots? What are you looking for in terms of what you are measuring? Is there an issue? I think that we heard in one of the earlier sessions about a lot of the pilots and the funding for a limited period of time. How will that roll out? I am assuming that you will figure out which ones work and then have a mechanism for rolling those out across the country. I will bring Richard in in a minute, just on some more of the detail. We did not magic up those tests. That was done in partnership with localities, with boards and partners, locally, who have taken the direction of travel that we are all heading in and have localised that into a model that they want to test out that meets their localities. There is nothing wrong with that because areas are different, we have rurality, we have deprivation. The multidisciplinary model is the common thread, but the specific application of that will be slightly different from area to area. There is nothing wrong with that. What we are going to do in terms of evaluating the models is to take that evaluation and an ongoing process. We are not going to wait until five years down the line and say, oh well, we think that worked out. It is an ongoing process. Many of those test sites will then be embedded as the way that primary care will be delivered in that locality. We will be getting significant change in visibility of change by as early as next year. I believe, and Richard will say a bit more about that. Over a two to three-year process, we will be embedding those new models and rolling out the practice and the learning from that elsewhere, alongside our funding plan, investment plan and our workforce plan, to scale that change up to ensure that what we see in primary care in the next few years is dramatically transformed from where we are at the moment. Do you want to say a little bit more about your test? I would just emphasise what the cabinet secretary said. At the heart of this is a deeply collaborative model, so the wisdom for this does not lie in St Andrew's house. The first thing to say is that we are working with every health board area, every integrated joint board to determine and support the work that they want to do to deliver those outcomes. In a sense, our evaluation is really supporting them evaluating their local practice. We are working through the Scottish School of Primary Care to put on top of that a national evaluation, which will allow us to identify some of the key themes and then really to determine what is appropriate to be determined locally, regionally and nationally. Again, I do not think that it will be a classical top-down roll-out of one solution. I have considered the evidence today and the evidence last week. There is a multiplicity of models out there to suit rural environments, urban environments and different demographics. Our job, I think, is to determine what the national components of that support would look like. In particular, perhaps workforce supply and infrastructure supply. Some of the IT, digital and data issues, I know that you have taken evidence on, lend themselves to a once-for-scotland approach and do not lend themselves to being done 30 times or 14 times. Again, it is determined by local change. Our piloting work is determined by what locally was already happening. We look to support and get behind that. That means that there is a sense of ownership and a sense of direction, rather than a sense of from St Andrew's house, a strategy that people have to comply with. There is a risk there. There are a lot of tests. There are over 80, possibly up to 100, but that is a distinct advantage. There is a key underlying theme, which is the multidisciplinary working in the context of integration. We will begin to form themes, begin to gather the knowledge and begin to determine what we can do nationally to support those local efforts, but the local efforts are driving the change. The new model of multidisciplinary working and some of the information that I gave to Alison Johnson on ensuring that we provide a joined-up approach through primary care, linking in with other parts of the public sector, if you like, whether that is on welfare advice, on debt counselling, on employability, on educational opportunities. I think all of that is really important in, I suppose, what you would collectively call preventive spend. It is trying to ensure that we are working using our primary care infrastructure and workforce to prevent ill health and intervene early. I think we have not been as effective at doing that as I think we could. I think this new model can help us to do that because by its nature it opens up the opportunity for multidisciplinary working like the Westerhales Living Centre, which I would encourage you to get along to and have a look if you have not had that opportunity yet. It very much has preventive work as it is core. It is about intervening early, it is about enhancing life chances and everybody from the GP through to the welfare rights worker to the voluntary group all have a focus of trying to build resilience within individuals, families and communities, as well as obviously providing a health service. I think there is a lot we can take from that. That will not necessarily be the model for every community because some will be more sparsely populated than the Westerhales is, but the concept of multidisciplinary working is the same, but joining the dots, bringing in all those skills and expertise involving the voluntary sector more effectively to provide a support to individuals, families and communities that I think could be better provided. If you spend a pound upstream, how much do you save downstream? There is available, we can provide that. I am very happy to write to you with that data. Thank you very much. It is very meaningful of the time, so if we could keep our questions and answers briefing to the point, if possible. Colin? Thank you very much. All the evidence that we are getting from GPs and Onisha GP hubs, very much points to the unanimous view that this is the model, this is the way forward, the whole multidisciplinary team approach. Last week, the convener made a comment that there are more pilots than there are at Heathrow. In Audit Scotland, I have indicated that the shift to the new model of care is not happening fast enough. They want to say that the Scottish Government needs to provide stronger leadership by developing a clear framework to guide local development and consolidating evidence of what works. Are there any plans to provide that framework to help local development? When will we move from all the pilots to an agreed position, where this is the way forward, the sustainable model with sustainable funding? I mean, this isn't a case of, you know, we're going to have these pilots and then, you know, we'll get round to evaluating them and then we'll maybe do, you know, carry on with some. It's not like, I mean, a test site is quite different. It is about changing the way things work and then, you know, if that is successful and we believe it will be because it's based on evidence, it's about then ensuring that that change happens across that area. The reason we've given some flexibility, although the commonality of all of these test sites is multidisciplinary working. So we've not, you know, there are none that's outside the thrust of the way we want and have agreed that primary care should go forward in the future. So multidisciplinary working is and the kind of basis of the bids was all around a set of criteria that was common to all, but the application of them took into account rurality, deprivation, the assets of that locality and what that locality believed would be the most effective application of the model. So the national evaluation and the ongoing support is there, Richard made mention of it earlier on, but I'm sure he can give you more detail. We then envisage essentially rolling out that practice with some changes, there will inevitably be changes along the way in the light of the experience of the test sites. We will underpin that new model nationally with the infrastructure, investment and workforce plans to ensure that we can get the people to populate that on a scaled up basis and that work is ongoing at the moment as we build those supporting plans to the test sites. I think the thing I would add again is just to get the balance right here. So where leadership has been needed, it's been taken. So the removal of QAF in the introduction of GP clusters was something that was done, I think, based on evidence but not based on test or pilots. We're seeing that develop. So whether there are opportunities, whether there is collaboration and consensus around steps we might take, those steps have been taken. So the introduction of GP clusters, I think, is an enormously significant move towards a multidisciplinary future. Now those are in a very early stage but that was a step that was taken which is a very significant step which we're looking at at the moment. So there's a balance here between local leadership and determining what is suitable for local purposes and then where necessary through negotiations and broader collaboration taking national steps, I think, to address immediate concerns. So the removal of QAF in the introduction of GP clusters is a very significant sign of leadership in that context. And what about the, can you just add a little bit around the evaluation and roll out the owned? Yeah, so just to build on the point before, we're working with the Scottish School of Primary Care to provide some national support but each project we're working with has its own evaluation and in visiting a number of these sites the local areas are seeing this as part of their own development plans. So this is not something they're doing contracted by us, this is something which from their local purposes that they are developing. So these changes aren't waiting for national approval. Very many of the test sites that you have in the list are test sites which are happening, which we are supporting which would be happening anyway which to meet the changing demand and the changing demographics locally these changes are being made. So we will capture the key national themes and we will provide the national leadership required around workforce and infrastructure and funding in particular but the change that's needed in Shetland, Strunrar, Dumbarton, you know in Dumbart are going to be really quite different. That configuration is a configuration for local partners to determine. Thank you for the panel for coming in this morning. A few weeks ago we had an evidence session regarding GP hubs and those on the panel who were involved with establishing them across Scotland couldn't actually give us a definition of what they thought the GP hub should be and the allied health professionals associated with them. So I'd be interested to know from the Cabinet Secretary what definition she would give a hub and then my second point is regarding link workers. What qualifications will a link worker have? What training and specifically what role do you envisage them having within a hub setting? Okay, well the hub is really multidisciplinary working. The application of that hub of course will be different in different localities so in a rural or very remote area you won't necessarily have a multidisciplinary team all working out of the same premises because of the nature of the of the geography but you can have them working as a multidisciplinary team nonetheless and it will just look and feel a bit different but the outcome should be the same and that all those dots are joined up, the team is working as one with the hopefully bringing in the wider skills whether it's welfare rights, councillor or any of the social care staff all of the things we've already talked about. The hub and that multidisciplinary team model will apply out of ours and the urgent care hubs that will apply in the community health hubs that you've heard a lot about. The common theme here is multidisciplinary working. There'll be a core because again if you look at a remote community and the skills available in that health and care team will be a little bit different perhaps to an urban setting because of the nature of the population it's more sparsely populated smaller so that that range of health and care and voluntary sector skills available will be a little bit different in a remote and rural community than it would be in an urban area but the principle is the same and I would see the core as being that core set of health and care professionals but with that core will be the voluntary sector, will be some of the other skills that can be pulled in. Clearly as I've said already that will vary from community to community but the core of multidisciplinary working will be your pharmacist, your physio, your nurse, you're obviously with the GP at the heart of that pooling all of that together and being the clinical leadership that is going to be so critical for that to work. In terms of the link worker will we already have the link worker model working pretty effectively out there? What we said is that we want to ensure that we increase the numbers of link workers we've talked about and made a commitment to the 250. I know that you've expressed some concern about whether or not they would have the skills needed to address some of our mental health issues. What I'd say to that is that coming back to Alison Johnson's point about how do we ensure that we tackle health inequalities part of that will be ensuring the person gets to the right place, the right person. We will need to, through our investment in the 10 million pounds into mental health in a primary care setting, look at how we ensure the availability for signposting to mental health services. Some of that will be utilising more effectively the statutory and voluntary sectors that exist but some of that will be additional capacity. Maureen Watt is looking at how do we increase the resilience of mental health services within the school environment for example. Again, the link worker's role will be to ensure that the person gets to the right source of advice and that will depend on what their need is. Some of that will be perhaps very early intervention but some of it will be more complex in nature. The link worker I think is the key to the, it could be the glue in making sure that the person gets to the right place. Hi there, there's a couple of things I wanted to ask about. Firstly the issue of data sharing has come up in terms of the challenges that provides to the multidisciplinary team model that you described so I wonder if you could tell us a little bit about some of the solutions that you proposed for and the other thing I wanted to raise was the question of Brexit and the impact that that might have on our NHS workforce. I know that 5 per cent of doctors working in Scotland are EU nationals and 15 per cent of the social care workforce are EU nationals. I know that I represent the Highlands and Islands region and I hear anecdotally from some of the island boards that they think that they have a higher proportion of EU nationals working there in some of the areas that are harder to recruit. So obviously it's causing a reasonable level of concern already and I wonder if there's anything you'd like to say on that. Would it be helpful for the cabinet secretary to perhaps write to us about the legislative changes and data protection issues? Sure, I'm happy to do that. It is a big issue that we need to resolve. I'm just mindful of our time here. I'm happy to write with more information on the data sharing. The issues that you raised about EU nationals and Brexit is an important one. We want to keep people working here in Scotland, whether they are EU nationals or not. Brexit throws up some real challenges there but the message that I would want to put out here and in any other opportunities is that they are welcome. We want them working here in our NHS and we want them to stay working here in our NHS and we will be looking at how we can help to encourage them to do so. Thank you very much cabinet secretary and to the rest of the panel. We will now take a short adjournment so that the panel can change. We have the third item on the agenda today and it is an evidence session on social and community care workforce. We welcome to the committee Shona Robison, cabinet secretary for health and sport, Jeff Huggins, director of health and social care integration, Alan Baird, chief social work advisor and Sarah Gledhill. Sponsor team lead for the Scottish Social Services Council, all of the Scottish Government and I invite the cabinet secretary to make an opening statement. Okay, we'll thank you for the invitation and I think hopefully you'll recognise the importance of this Government's commitment to integrating health and social care to ensuring that people have the access to the right care in the right place at the right time. As people live longer in Scotland and often with complex support needs, we have to work innovatively and collaboratively with colleagues across health and social care and of course with communities themselves to ensure that services support people as far as possible to stay in their own home in communities for as long as possible. We know that that's generally what's best for people's wellbeing and we also know of course that's what people want. Our new health and social care partnerships all became operational on 1 April this year and they have the real power to drive change. Planning, designing, commissioning services in an integrated way from a single budget enables them to take a more joined up approach, more easily shifting resources to target preventative activity and taking more holistic approaches to care and support which will improve the experience and outcomes for all of the people who use the services or need support. We spend nearly £4 billion each year on social care support and it's vital that we use this resource in the most effective way to deliver the best outcomes for the people of Scotland. Health and social care integration provides us with the opportunity to do that and to be more creative and innovative in the way that we deliver care. We know that investing resources in community services rather than acute settings and improving links between care in hospitals and care in communities does improve outcomes. I recently announced our plans for East Lothian community hospital which is a good example of how the different care sectors can work together to ensure that care is joined up and delivered closer to home and family with facilities for day care services. We've already signalled our commitment to resourcing care in the community by allocating a further £250 million from the NHS to health and social care partnerships to protect and expand social care services and deliver our shared priorities. That includes, of course, our commitment to enable the living wage to be paid to care workers supporting adults from 1 October. Services need to be fully flexible to meet a person's needs and to empower them to co-produce and self-direct their support, making choices about how their care can be best delivered. That shift requires fundamental change across the whole system and culture from decision makers to the front-line staff who provide that care and support on a daily basis. To achieve transformational change, it is vital that staff are fully supported. Our statutory outcomes for health and wellbeing, which under pin integration address the importance of staff engagement and support, and partnerships are required to publish annual performance reports setting out their progress in relation to the outcomes. As you've heard from others, the landscape for the social and community care workforce is complex and we all recognise that we must work across all partners and stakeholders to ensure that we have enough people with the right skills to support the needs of people with a variety of needs within communities. We're committed to ensuring that the entire workforce is fully supported. That's why, in addition to the investment that I mentioned earlier, we remain committed to upskilling our workforce. That is a policy that is wider in scope than anywhere else in the UK at the time when the policy was introduced. Around 80% of the workforce did not have any qualifications now through the work of employers and bodies such as the Scottish Social Services Council and the Care Inspectorate. Around 100,000 of the people in this workforce are registered. They have or are working towards the qualifications required for their role and their fitness to practice can be regulated. I think that is progress. We're also working with partners on the Social Work Services Strategic Forum and the HR working group on integration, supporting a range of actions to strengthen this workforce and demonstrate how it's valued. Finally, we're clear that we can't do this alone, so the committee's interest in this area provides a timely opportunity to consider both the progress made and the challenges that we need to work on together with all of our partners, many of whom you heard from at your session on 13 September. Thank you very much, cabinet secretary. We'll now move to questions. Donald? Yes, this is a slightly specific question. We heard from Annie Gunna-Logan, who I think represents the voluntary care providers. It's really about Brexit again, because she said, speaking from memory, that when she asked her staff about Brexit and the implications, one of the points they mentioned was that there was an opportunity in terms of lessening the burden of rules around procurement and tendering, and that was a potential opportunity that was coming out of Brexit. I wonder if you had any observations about that? I think that whatever the arrangements that we have, there will always be rules around procurement and tendering because of the need for transparency and whatever constitutional arrangement. There will always be needs for openness and transparency and to ensure that due process is done and seen to be done in the spending of public money. However, what I would say to you is that, in terms of the concerns about Brexit, is that if you look at the social care workforce and where many of those social care workers come from, I am extremely concerned that the potential loss of social care workers who come from parts of Europe who support our care services, particularly within our care home sector, is something that we should all be extremely concerned about. Again, I would like to take the opportunity to send out a message to that social care workforce that, no matter where you come from, your work here is valued and we want you to remain working here, whether it is in our care home sector or our care at home sector. On that subject, one of the problems that the panel mentioned two weeks ago was that it is very hard to estimate how many non-UK, EU nationals, are working in the social care workforce. Is the Government doing anything to establish what those numbers might be? Well, I think it is certainly very visible to me as I go around particularly the care home sector and, to some degree, the care at home sector, but certainly within our care home sector. If you go into care homes at length and breadth of Scotland and you speak to the staff, you will find that many of them have come from other parts of Europe, both within the social care workforce and our nursing workforce, working within care homes. That is very visible to me. Alan probably will have a bit more data and information on the numbers, but I think that it is not unreasonable to say that the loss of that cohort of staff who do a hugely important job here would be a blow to the sector and one that we want to avoid, which is why my message is that we value and want you to remain working here in the sector. Alan, do you want to say a word about the make-up of the work? I think that it was probably noted at the meeting of the fifth that we do not currently know the numbers that are currently from the EU and beyond currently working in the workforce, but increasingly we will need to understand in order to look at the potential gap that may exist within social care. Jeff, do you want to come in? Two things. First, the point that was made by Annie Gunnar Logan in respect of procurement is an interesting point because part of the challenge that we have around delivering the living wage is the legal framework within which we can specify contract rates. There is a question as to what would happen next in the context of Brexit. I think that the other component of that is that we do not know what the next step beyond Brexit would be in respect of whether that would be a reserved matter or a devolved matter. If it were a reserved matter, how that would be handled in the broader context of UK policy on earnings. We are certainly conscious of the issue in respect of non-UK nationals working within the workforce. In that space, I guess we would also be careful about the degree to which that patterns across the country in different ways and is likely to affect different components of the service delivery differently as you look across Scotland, particularly issues. I think that you were given evidence on this previously around island authorities, but also in respect of more remote and rural authorities, particularly in the northeast. It is an area that we are and will be discussing with the partners group, which is the providers, but also Unison, that we have been working with more generally in Turkey, taking forward some of the reforms. It is right in front of us at the moment. I think that Sarah was going to add a little bit about data collection. As I am sure that you know that the SSC collects annual data on the social services workforce, we are discussing with them whether we might be able to add a question that will enable us to collect more accurate information on this topic. You mentioned the Scottish living wage. Can you perhaps give us an update on progress towards the implementation of that across social care? Before Geoff comes in on that, can I say that people have been working very, very hard across the partnerships to ensure delivery from the first of October, and I want to put on record my thanks to all of them for doing so, because it has been quite a big undertaking. A lot of hard work has been done, but I think that we are in a good place. Geoff? I think to say, as the evidence that you heard previously, and I imagine also as you are hearing separately from the evidence, this is a remarkably challenging undertaking to take forward. We are working directly with CCPS and with Scottish Care, as well as with Unison and COSLA, and I spoke with CCPS and Scottish Care this morning just in terms of both their update, but also sharing our understanding of what is going on. We are working carefully across partners both to triangulate what is happening within local negotiations but also from that to take a national picture. Where we are is that we know in many areas that good progress has been made in other areas that negotiations are continuing, and part of the challenge to this is that it is not simply to find the right number and then roll it out, in that this is built up of hundreds of local negotiations with individual providers who have historically offered different terms and conditions to their workforce, so that is not a small-scale undertaking. We are confident on the basis of the work that we are doing, including work with individual partnerships in respect of how the progress is going. I am speaking with chief officers and procurement officers on a regular basis to understand, but also to ensure that we deliver that. What is clear is that we are still resolving some issues locally, but we are confident that we will meet the commitment that the benefit of the living wage is achieved from 1 October. It is obviously on the relevant reasons that I quite like to pick up on at some of the points. Presumably, there will be lessons learned from the approach that has been taken so far. You make the point that you are still literally working up until the 11th hour to try to make sure that everybody gets the living wage from, which is effectively Saturday. Some of the evidence that we took from Annie Gunnar Logan pointed out the fact that providers were not consulted on the implementation of the policy. It is effectively read about it in the newspaper, so I am keen to know what you are going to do in the future to involve stakeholders in developing the policy to make sure that it is sustainable in the long term. I think that it is widely recognised that the national estimate of £37 million put forward by the Scottish Government underestimated the actual cost. What assessment are you going to make of what the real cost has been to implement the policy, hopefully, from 1 October? I am keen to get clarity on the actual payment for sleepover shifts. Is it the Scottish Government's position that sleepovershifts should be paid at the living wage rate? Is that going to be the case from 1 October? If not, when from? £250 million that we provided for social care was for the delivery of the living wage. It was an ambitious undertaking. Jeff has outlined the complexity of some of that, but I think that there has been a willingness and determination on the basis of all partners to make this happen, because it is a good thing and will help to encourage people to stay within the caring profession and hopefully will bring others to work in the caring profession. The complexity, of course, has been partly that this is subject to the negotiation by local partners, because they are the ones through the commissioning and procurement of services that needed to actually have delivered the mechanism of paying the living wage. While we have provided the resources, the mechanics of that needed to be delivered locally. Of course, in each area, some partnerships were further along the road of already towards the living wage than others, so the distance to be travelled was different in different areas. Again, that meant that the resourcing required by that partnership plus was going to be different in different areas. There has been a complexity to this. That will become easier, because we now have data and information that we did not really have before, both at a local level and a national level. In terms of sustaining the policy in the long term, yes. As I said to your question on the health debate, part of our discussions with COSLA and our partners in the care sector are about ensuring that going forward as part of the spending review, we are ensuring the continual delivery of the living wage. That is an important priority for us. In terms of sleepovers, that is an issue that is still being discussed because of, again, of the complexity of the way sleepover payments are paid. The partners have asked for more time to talk about the resolution of that. As I understand it, the unions have been part of those discussions to ensure that it is resolved, but it is going to take more time to resolve that. Again, we will be helping and working with those local partners to ensure that those discussions are taken forward and taken forward as quickly as possible. Jeff, do you want to add anything? Maybe a few things. You have asked about lessons learned. As the cabinet secretary said, what we have effectively asked partners to do is to use the existing system for re-tendering and re-negotiating. I think that we have taken a number of elements of learning out of that, so I have got a list of about four or five things that I would now take away from the process and think about for next year, because we will be looking to think about how we approach that as time moves on. A key component of that, though, is the change in the nature of the commissioning and procurement relations. Historically, that would have been a local government commissioned and a local government procured service, so this is now an integration authority commissioned service and a local government procured service, and that potentially gives us more of a discussion as to whether we might look differently as to how we take forward the procurement now that it is separate from the commissioning role. There is a key change that has taken place under integration. We are looking at questions like for maybe some of the more niche providers in learning disability or mental health who provide across a number of integration authority areas, whether we should be looking at perhaps a lead procurer for that, but also looking at questions about the degree to which similar providers find that they are being made different offers from adjoining authorities and the challenges around that, so we are learning the lessons. We talked about it with the chief officers when we met with them 10 days ago and we spoke about it. There is one of the issues that was on my agenda this morning with both Annie and Donald MacAskill. In terms of the cost assessment, the information that we lodged in SPICE at the end of 2015 was an assessment in which we were very explicit about the presumptions that we had been made. I know that some of those presumptions were questioned when you met last time. We then, as part of the local government negotiation, would have been challenging to have involved the providers in the negotiation between the Deputy First Minister and COSLA as to what the local government settlement should consist in, although we understand their frustration in that space. We then, as part of that, invited local partnerships to consider what they believed the local cost would be, and it offered our information as support to that as part of the process by which they considered the use of the £125 million. While we put information into the system, we did not say that this was the figure. We said that this is the figure based on the presumptions and based on the knowledge that we have, and we invited local partnerships to make their own assessment of what the appropriate cost would be. Most appears to have done that adequately. The third thing is the process of involvement. We are also talking about how we do that for the next round and for the coming period of time. The process that we have built with the partners group, which is the Scottish Government, COSLA, CCPS, Scottish Care and the unions, we think is a good methodology for taking that forward for future years. I understand fully the complexities that 7,000 social care providers across Scotland and 31 IGBs is a complex process. We have a national framework in place when it comes to care homes. Is there any consideration being given to a national framework when it comes for care at home? It is probably less straightforward because, while the majority of the service that we are looking at here is for older people in terms of things such as personal care and assistance with daily living, once we take a step into some of the substance misuse services, learning disability and things like mental health, the idea that you would have a single rate that covers a range of complexities becomes more challenging. There are also different ways in which services are locally stitched together between health and care, which means that the burdens that may be fall on social care and health services will be different depending on where you are. We are, as part of the reform process, looking at those questions, but it may be less straightforward than it is for residential care. Indeed, part of the work that we are doing on the residential care is suggesting that increasingly the distinctions between different forms of residential care are raising the question about whether we need slightly different approaches there. Ultimately, the objective is to try and provide and fund services in a way that provides support for the different needs of individuals rather than reducing them to a common minimum. Thank you, convener, and I would like to welcome the panel this morning as well. One of the biggest impacts on the environment in terms of workforce planning, aside from integration, has been the advent of self-directed support. I would just like to hear from the panel their reflections on how that has impacted on workforce planning, but we have heard from health boards that a number of us have received briefings from of provider behaviours in response to self-directed support, which has not been entirely helpful. I think that that is a reflection on the impact of self-directed support on the workforce planning agenda in social care. I was the Minister for Public Health at the time when we were taking forward the whole concept of self-directed support in the initial stages, and then, of course, the legislation that has fallen. I think that out of everything that has been done, it has got the potential to be one of the most innovative programmes and concepts. It is all about how many people put in the person in the driving seat of their care and making sure that the services are built around the person who is involved in building the services around themselves, rather than necessarily services that are provided to them that do not meet their needs. The concept is fantastic. I guess, to be honest, it is work in progress that we have provided a lot of support to make this happen. There are resources that have gone in to ensure that we can embed the whole process of self-directed support across the social care sector to build the workforce, to make sure that anyone who wants access to self-directed support to deliver the care that they need has access to it. I think we are in a better place than we were previously around the whole culture of accepting self-directed support. I think initially there was maybe a little bit of resistance to, would this threaten in some way the statutory service model? I think less so now. I think people have accepted that this is a good option for people that is actually not a threat to existing services but can be an enhancement to them. Jeff, do you want to say a little bit more? A couple of things. We find self-directed support being used in really quite innovative and novel ways, particularly in rural communities. One of the examples that I often give is the Boleskin care from the banks of Loch Ness in an area where they find it very difficult to recruit a social care workforce or persuade one to travel that distance. Instead, they went into the community and identified people who would be prepared to do a few sessions a week using self-directed support to provide care for people who lived in their neighbourhood. That worked in a way that was very effective. I will be interested to see how the, because you identified some provider behaviour, largely I would assess driven by the previous approach around compulsory competitive tendering. As we are seeing a move away from that and price and the degree to which quality is in that being the dominant factor and as we are seeing pay increase in the values of contracts change, whether that will continue to be a continuing factor. I think that the question is to whether that as a reaction to CCT will continue to be as forceful and the comments in the auditor general for Scotland's report from last week I think around the impact of CCT are really helpful there. I think that the bigger challenge around this, around some of the services which we also see around day services, is the degree to which there is an increasing diversity of what people are looking for in terms of the support that they receive. That is going to be difficult to work through but it is something that we need to do. I should have added and removed the Scottish Government has invested £58.6 million in transition to SDS between 2011 and 2016-17 and some of that has been very much around building the workforce, the innovation fund. Alan, how do you want to do this? I've spent quite a lot of time over recent months visiting large providers and with local authorities, smaller organisations within the third sector and met with a cross-section of front-line social workers to hear really about their experience. First of all, we're halfway through a 10-year strategy and as the cabinet said, this was a complex. The money that the Government provided to put in place the right infrastructure was considerable. I think that, as a result, we've made really good progress and when you talk to those who are in receipt of self-directed support making the right opportunities from the choices that they have, they are seeing their lives change in quite innovative ways. If you talk to some of the providers, national providers get really frustrated about the number of different sets of forms that exist across Scotland. If you're a national organisation and you're working with quite a number of local authorities, you can expect with 10 local authorities that you might get 10 sets of forms. That's time consuming and within the current resources that we have and what self-directed support ought to be about, I think that it does have a sense of frustration. I think that we're making really good progress. Where you hear from those who are in receipt of self-directed support, there is an issue times where the amount of money that they get has been reduced. Some will see that as part of the austerity that local authorities face, but the other side of that coin is that self-directed support is working well and for the individual they no longer, because their needs have changed, need the level of provision that they maybe once had with self-directed support. I think that we're learning a great deal as we progress and we need to use the next coming months and years to pick up on some of the issues that are emerging. Colleagues including Marie, Todd and Donald Cameron have already brought up the issue of potential impact of Brexit on the workforce. While we're discussing this move of care in the community, the whole thing is predicated on us having enough social care staff. I know that the Scottish Social Services Coalition spoke about a survey of employees that was trying to understand better where people were coming from, but it seems that we have a dearth of definitive data on the number of EU nationals working within NHS and social care. I would just like to understand what steps the Government is taking to establish this number, but what contingencies are being put in place if EU nationals don't have an automatic right to remain after EU withdrawal? I think in terms of our medical and nursing workforce, it's a little easier because we have that data and the regulators have that data, so we're able to provide more definitive information as we have in the medical workforce, which is a concern in terms of the numbers. As I think you heard earlier on, it's less clear with the social care workforce because of the fact that the processing of information, the gathering of information, is work in progress, but Sarah said earlier on what she might want to expand upon is looking at additional questions on the workforce survey to try and gather more information around whether someone is at EU national or indeed out where they come from more generally would be helpful. Do you want to give a time frame for that? The discussions with GCCC will be taking place over the next couple of months on whether we can change the data collection for the next round of data. We are also considering whether we need to do something more urgently or in the shorter term because the GCCC collect data retrospectively, so there's a bit of a time lag between, or they publish the data respectively, so there's a bit of a time lag between the data being published, ready to publish, and the year it refers to. We're looking at whether we need to do an exercise very shortly and then also change the, I didn't include a further question, so that going forward we collect the data that's needed to answer that question. Perhaps we could rate the committee it up. Do you want that? We're clear about what we're going to do. Yes, that would be fine. My question relates to care home places. Audit Scotland have told the committee that Scotland will require an estimated 20,000 additional care home places by 2030, and a PQ, which I got back, has shown that Scotland's lost 3,600. We're hearing from private sector providers that they're finding it difficult to sustain the service, so what works being undertaken to make sure that Scotland's adequately supplied with the care home places that we need? Our make-up of care home places and what we use care home places for has changed over the years, and we've worked very closely with Scottish care around that change. When I was a home care organiser in a previous life, it was not unusual for people to go into a care home setting actually when they were still quite fit. For a variety of reasons, it was a different culture and the ability perhaps of people to and wanting to remain at home. Perhaps people have changed their outlook somewhat, and the demand now without a doubt is for people to want to remain living in their own home with appropriate support. That has led to a change in the care home sector, fewer places but also a bit of a change to what those places are used for. The discussions that we've had with the care home sector is about looking at the needs and now going forward, we're going to need more intermediate care, so looking at what the sector can provide for that. There are great examples and we've hugely expanded the number of intermediate care places, many of which are located within a care home environment. That helps to put the care home sector on to more sustainable footing and provide what is needed, but it also provides a service such as a step down and potentially step up as well, although that's less developed between home and hospital, so that's a really, really important development. I think also it's fair to say that the complexity and needs of people who do end up in permanent care home places is far greater than previously, so a lot of people with very complex needs with dementia and that has meant that the number of places provided and that the care staff ratio required for those, for the complex needs of those people has changed as well. So I wouldn't necessarily see that these are negative developments, I think it's just a recognition of the changing needs of the population, what people demand and the need for the sector to adapt to meet that and we want to help them in doing so. We've got the key evidence from Brady Glasgow and Clyde who are telling us that they're using the private care sector in Glasgow to help tackle delayed discharge, so there was a concern that potential loss of private sector beds there could then have an impact on the acute setting as well, so it's just to be aware of unintended consequences of Scotland losing places. Well we need to have the right number of places in the right places to meet the needs of the population, but all I'm saying is that is changing, so the development in Glasgow, I've visited one of the care homes that's providing that intermediate, that step down facility and it is a fantastic service, something that is needed, that meets the needs of the acute sector in helping to reduce delayed discharge, but also provides some stability and sustainability for the care home sector. It is different from the role that the care home sector has traditionally provided, but I think one that they've actually embraced very well indeed, Geoff, you were... Yeah, I think the Glasgow example is really interesting because it's an example of leverage in that through, by working in that way, more people have returned home than would have historically been the case, which is what people say that they want to do. I think the auditor general's report was also very careful and it said that if nothing changed and if things continued as they are, and as a report I think it quite stunningly made the case for reform throughout the report and that there is a need to think differently about how we approach care and how we meet people's needs. In each of the partnerships that we're talking to at the moment, we're identifying that this idea of using more hours to support reablement, to support step down and to increase people's capacity to continue to care for themselves is core to the changes that we're seeing. That point about reablement is really, really important as well, but in my previous life as a home care organiser, quite often someone's needs would change because of a fall. They could out of hospital and the things they used to take for granted and did for decades themselves would suddenly be done by somebody else, even though with reablement they could get back those independent living skills. The thought processes around that have completely changed and I think definitely for the better. Sarah, you wanted to... It was just to clarify the figures I think when talking about the care homes and while the total number of care homes has fallen quite a lot by 70% in the last 10 years, since 2006, the number of registered places has only fallen by 3% and the number of residents only by 4%. I suppose... The cabinet secretary provided me the written question, suggested that this 42,000 and 26 places now in Scotland, which was down 3,685. So obviously in terms of what Audit Scotland is saying, that extra 20,000, it was a concern that the direction of travel was down in terms of the number available. It's what we use, that's the places in the sector 4 and of course we have seen a big increase in number of care at home hours provided each week. Now that again will be to fewer people because the level of complexity of people remaining in their home has increased so their packages are greater therefore the number of hours overall has increased. So I think what we're seeing is just a shift really in people remaining in their own home for longer. The type of service then provided by the care home sector changing and we want to work very much with the sector in helping them to get on, you know, to provide a sustainable service that meets the needs of an ageing population. I'd just like to ask one final question before we finish because I think this is a really important one. I think one of the most valuable and informative sessions we've had as a committee was meeting with social care workers a few weeks ago both from residential care and from home care. How do we make a career in care more attractive, a more valued career choice in the society that we're in and I'm interested to hear your thoughts on that. That is probably the key question and the most important question. So I think partly the living wage is a component of that that, you know, we have to make sure that we value the caring role and the people working in the care sector whether it's at home or in a care home and the living wage and what people are paid for that is an important component of that as are some of the surrounding terms and conditions and again it's important that we work with the sector to try and improve that but it's also about career opportunities and career progression and we were seeing some really innovative ways of linking through the world of integration opportunities within health and care so for example someone perhaps coming in to the the care sector with an ambition to end up in a regulated profession and being able to do that in a more coherent structured way that there's a pathway should they wish. Now that won't be for everybody but for many I think that would be quite an attractive way of coming into a regulated profession like nursing for example and we have some examples across the country which we can furnish you with it. Western Isles are doing that because they recognise they needed to deliver, develop and deliver their own workforce. They couldn't wait for people to pitch up from elsewhere to meet the needs of the of their population. They were going to have to grow that and part of the way they're doing that is to encourage people within their communities to think about health and care as a profession to provide pathways through one into the other should that be what someone wants to do and I think we need to get better at doing that and when we're working with Nes to develop more coherent pathways through care and health and to share those training opportunities across the NHS that care staff can link into as well. I just want to draw members' attentions to this which is the social services vision and strategies for the next five years and one of the four sections on it's in workforce and it is about the valuing of the workforce that you heard to do two weeks ago. It's about how we actually recruit and retain much better than there's a lot of work currently going on because we anticipated as a sector and some of the people you saw two weeks ago are part of that about how we take things forward around the quality of social care in Scotland and the value placed on that workforce. I'd like to thank the panel and the Cabinet Secretary for the time this morning. We're now moving into private session.