 Good morning, and welcome to the 31st meeting of the Health, Social Care and Sport Committee in 2022. I've received apologies from David Torrance for today's meeting, and James Dornan will be substituting for him. James joins us online, as does Tess White. The first item on our agenda is to decide whether to take item 4 in private today. Are members agreed? Yes. We're agreed, thank you. The next item on our agenda is consideration of a negative instrument, and that instrument is Feed Additives Authorisation Scotland Regulations 2022. The Delegated Powers Law Reform Committee considered this instrument at its meeting on 25 October, and they made no recommendations. The purpose of this instrument is to implement the decision that was made by the Minister for Public Health, Women's Health and Sport in relation to 11 Feed Additives, authorising five new Feed Additives for Placing on the Market and Use in Scotland, renewing, modifying and re-evaluating, or extending the authorisation for six others. The instrument also includes transitional arrangements for the three existing Feed Additives authorisations, and no motion to annul has been received in relation to this instrument. Would any members like to comment on this instrument? Emma Harper I am going to continue to be interested in Feed Additives and any legislation like this that comes forward. It's really important that we know what we're consuming. When we hear about novel fruits and what's happening in other countries as far as trade and issues in my research of hormones and other chemicals that have been added to products that might end up in our food supply chain, and because of our informal discussion with Food Starner Scotland last week, I want to put on record that this is something that is really important and that we should pay attention to. Emma Harper I expect no less from you. I know that you have a long-standing interest in this area. Any other comments? I propose therefore that the committee does not make any recommendations in relation to this negative instrument. Does any member disagree with this? Emma Harper We are all in agreement then. We will move on to our next agenda item. The next item on our agenda is further consideration of the National Care Service Scotland Bill. I have got two evidence sessions today. The first evidence session will focus on the bill as it relates to the future of integrated health and care services, including community health, prevention, local services, rural services and transfer of functions. I welcome those who are joining us in person. First, we have Nick Morris, the chair of NHS Board of Chief Executives and Chairs, Alison White, the convener of Social Work Scotland and Dr Chris Williams, the joint chair of the Royal College of General Practitioners Scotland. We have two colleagues joining us online. We have Patricia Cassidy, chief officer for Falkirk, health social care Scotland chief officers and Alison Kerr, the professional practice lead for the Royal College of Occupational Therapists. Welcome to you all. I am asking and starting things off by asking you your general views on whether the National Care Service Bill, as presented, has the potential to improve integration of services. One of the things that has been put to us in a lot of the submissions from, I suppose, service users is—I will actually quote one— that we have an unpaid carer who said that there is a lack of connection between health boards, councils, social care and public health and no joined-up thinking. That is coming from somebody who is using the services. I guess that is our starting point to look at the gaps and see if the bill provides the framework at the very least for perhaps better integration. I will go round each one of you. We will not be able to go round each one of you for every question, but conveners prerogative, I will allow everyone to answer my question. Then my colleagues will direct questions. For those who are joining us online, if I do not come to you in the first instance but you want to add anything, you have the provision of the chat box online, you can just let me know that you want to come in. Otherwise, if you are in the room, just raise your hand and I will come to you. If I maybe go round everyone in the order in which I introduced you, I will go to Nick Morris first of all. Can everybody hear me? Yes. Thank you very much. There is lots to be said that is positive about the development of the NCS in the sense of it bringing stakeholders together, their voice of service uses more clearly amplified about their experiences of health and social care. Much of that work is understood at local level, we believe. There is significant work going on to engage with stakeholders at local level about their perceptions of integration, their experiences of joint work within social services, social care systems and health, and there are many things to learn from. Our main concern at the moment is that the focus of the bill is forcing people to consider issues of structure and the consequences of structure, some of which are very hard to interpret because of the evidence that is available within the bill. It sits as a framework bill, it does not provide much detail. At this point in time of our system pressures response in both social care and health, we have to be careful about the distraction that provides to us when we need to provide significant leadership to providing a response to those system pressures at the moment. Social care and care services are going through a significant challenge at the moment in terms of recruitment, workforce, et cetera. I think it is right that the NCS should be looking at issues of equity of things like fair work, improving their career progression opportunities. I think that there is potentially a lot to be said for the development of integrated training and development programmes between health and social care practitioners, which supports integration in the long term. At this point in time, we need to do a lot of work to make sure that those staff on the ground are actually providing resilient care to the clients and also are resilient within themselves. At this point in time, that is not the case. Social care services are in significant stress and so are our health and community services too. I think that we welcome the general position of the bill and where it wishes to take things. I think that we would support the integration of health and social care certainly at local level. I have concerns about the fragmentation that might occur with some of the structures suggested through care boards and also we don't know yet how the First Minister might structure departments might be a concern for us as well in terms of fragmentation rather than integration, but we support the general tone of moving towards integration at team levels developed of MTTs. We are not quite sure that the bill hits the nail on the head at this point in time. I will come to Alison White. Thank you, chair. There is much in what Nick has highlighted that we would be echoing in terms of some of the particular challenges in social work, social care at this point in time and around the fact that this level of change at the time that there is this experience of challenges in recruitment, challenges in retention, the fact that we've gone through a pandemic and the challenges that we have around a workforce that is on its knees in places, certainly particularly in the care sector around this and the cost of living crisis that is significantly impacting on frontline care staff. Again, we'd echo that there's much in the bill that we are really supportive of in terms of the opportunity for one of the first times for there to be a really strong conversation about social work and social care and what that means and how it fits in and the importance of those roles. There's been far too much of a focus on what's right for the NHS and how we deal with that, but if we are looking at a whole system approach it's a real opportunity for us to focus and highlight some of the impacts that we have in social work and social care. I'm not sure the bill actually addresses the issues of integration clearly enough, I think, when we're looking at employment legislation, I think, when we're looking at what that might mean. Although I'm here in Social Work Scotland, my day job I have a chief officer of a health and social care partnership, IJB, so I have that integrated service and there's something about that joint role that I have that enables me, the managerial strategic oversight of both health and social work services, that it's difficult to know how that will move forward and embed with the bill, with staffing arrangements being different, the chief officer or chief executive role sitting in NCS rather than having that in reach into NHS services and what that looks like. So there's a real danger that actually in the short term certainly that integration is jeopardised as part of this process, but I do think that one of the aspects that the bill gives in terms of that real sense of co-design and how we have those conversations and what we need to do around making sure that we get that strong voice for people who use the services because I think you're right, people do get a sense of a disconnect between some elements of the service, not all of the time, but I think there is some disconnect, but I'm not sure the bill addresses those disconnect areas unfortunately, but I think if we can use the co-design process really effectively to get that strength of voice, both from people who use services and from people who deliver services, I think there's an opportunity for us to shape something that allows the development that we're looking for in terms of integrated services. That's very helpful because the co-design is going to inform the secondary legislation which should address the issues of detail that you have mentioned so far, but I guess that you're behind the idea of co-design, but the co-design has to be meaningful. A certainly social work Scotland's perspective is that the co-design should come before the legislation rather than after the legislation as well. Certainly social work Scotland has had a strong position that we're strongly behind the development of a national care service, the strengthening of all of the rights-based approaches that are there, the strengthening of staff development and how we support staff in meaningful employment, but we feel that the co-design process and the development of how that service looks should take place prior to the development of legislation rather than after the development. RCGP Scotland first recognised that we have made substantial progress in Scotland in terms of integration of health and social care. During the last several years, there have been some very different cultures that have had to meet and reconcile, so we absolutely don't want to neglect social care. We do need resource going in that direction, we do need governance arrangements that make sense. The Feely report certainly recognised that there are different governance models across Scotland in different parts, including the lead agency model in Highland. At the same time as we have tried to think about the way forward here, in primary care, we have undergone a substantial programme of primary care reform in terms of the new GMS contract. That work is still unfinished, there is still a lot of distance to go before our primary care services are looking and feeling the modernised way that we intend. General practice has had a historical connection to health boards in terms of how we are governed and managed. We do not want to disrupt that legislation currently. We see assurance that that is not happening, but beyond the legislation there is a substantial amount of reform that we cannot foresee yet and how the co-design process will play out. One of the most substantial aspects of the bill is the information sharing aspect. I have had discussions elsewhere with members of the committee about the desire for people not to repeat their story, for parts of the system to see aspects of other parts of the system. The bill can do something about that. There is a larger body of work around the cultural side of things across the health and care parts of our workforce and the investment in information technology infrastructure. We continually underestimate the role played by things that we take for granted in other aspects of life when we are accessing banking, for example, through SNASI apps, when we are able to do other online transactions and things. We still have quite a good way to go in Scotland for that. We wait for the national data strategy to be helpful, but I look forward to seeing what that legislation can do. I represent Health and Social Care Scotland and concur with a lot of the earlier comments. We welcome the introduction of the bill and, in particular, the principles of the bill. We are keen to realise the opportunities that the framework in the bill offers to become a much more integrated system to have that person-centred focus. The bill will allow, potentially, the new community health and social care boards to set the tone and culture for the staff that work to deliver the outcomes in the organisation, supporting and facilitating that culture of co-production and innovation. We need to learn from the current experience and evidence from the integration joint boards and the variation that has been across the system. The challenges of bringing together two groups of staff coming from two organisational cultures into a new organisational culture. The challenge of creating that with staff coming from those organisations. There is an opportunity to create a new cultural organisation that has, at its heart, that person-centred approach and is really, at its heart, listening, working with our communities to shape and influence the shape of our services. The current partnerships, the principal partners are the NHS and the local authorities. The integration joint boards partnerships are much more than that, and that is set within the legislation in terms of the representation and involvement of our communities, carers and service users. It is important that we build on the strengths that we have developed in integration and not disintegrate some of the existing strong relationships that there are. Some of the most interesting innovations have come from those partnerships of several of the local authorities sector voluntary organisation communities of interest to develop new services. It is really important that the framework takes account of that and provides an opportunity for a new cultural organisation, which is a broader partnership than perhaps the constituent parks absolutely with the communities at its heart. I think that one of the tensions in the bill and the difficulties is reducing variation across Scotland but not at the cost of local responsiveness. Some of the real strengths have been at the strategic planning group level, the partnership groups, the links to community planning partnerships and the ability to flex across the system where there are transfers of care but also with some of the infrastructure support that, for example, leisure and cultural services and the local authority housing services, primary care and the health board, that we need to be really careful that we do not risk some of the existing connections that there are and look to how we can reduce and improve our IT systems the way we handle and transfer and use data, the way we interact with people on several fronts. They may see five or six different professionals. We need to have a one multidisciplinary team approach, one shared information that that person potentially holds and shares with us. There is a lot of scope for improvements but it must be sensitive and guided by those good conversations with the people who use our services or not forgetting prevention. How do we get in earlier and realise some of the benefits that we can have in terms of prevention? You mentioned quite a lot of things that my colleagues want to ask specific questions on. I will come to Alison Kerr before I move on to questions from Paul O'Kane. Good morning, committee. I am here today to represent the Royal College of Occupational Therapists. We commend the ethos of the bill whereby there is a shift to early intervention and prevention. However, it is not clear how that will be resourced, measured or achieved. We feel that the bill lacks detail around how we know when we have achieved what we want to achieve. We also have concerns around the use of the word care and we think that that requires greater clarity because care means different things to different people. For a huge proportion of our population, care is being looked after, but is it really care that we mean or is it support? If we want to move to a model of early intervention and prevention, are we supporting people to self-manage and let their best lives? Or are we still in a model where we look after people? Are we doing for people or does the national care service in the future put us to do with people, which is where we would want to get to? I think that the title confuses that and changes expectations. There is also some lack of clarity around the purpose of improving the quality and consistency of social work and social care services in Scotland, as stated in the policy memorandum. That does not describe all of what we are aspiring to with the national care service. So, absolutely, we look to improve and grow our fabulous social work and social care services. What about community health colleagues? We are looking to improve quality and consistency. It is wider than social work and social care, and it should improve and include community health. That takes us to a further lack of detail in the bill, whereas community health is a sweeping statement. We can make assumptions around what is defined as community health, but there is no definition anywhere. Until we have clarity and definition, we risk making assumptions that could be faulty, so we require some further clarity around that. We also need to think about things such as eligibility criteria. At the moment, we are moving towards a model that is changing if we achieve what we want to achieve through the national care service, but eligibility criteria is the gatekeeper to services. Unless we think more widely about how we support people access services, we will not achieve that aspiration. We need to think about how we commission and what we want from that. Is that about outputs or outcomes for people and how we get to a point that we are working in an outcomes-focused way to support people? I am going to stop you there, Alison, because there are specific questions coming your way on all the aspects that you mentioned. I really was wanting a broad overview about the bill, so I am sorry to stop you off mid-flow, but we have a number of questions. I have two questions if that is possible, but they will be directed to individual panellists. Can I just begin with Patricia's comments? I am just looking for a wee bit more clarity on where chief officers are on a number of issues. In many of the submissions that we have had from local authorities, IJBs and health and social care partnerships, there has been concern, I think, that it is fair to say, expressed about what disruption to services will do in terms of integration. I would quote Angus HSEP saying that significant work has already got into the establishment of IJBs, and I feel that a national care service could take away the focus on integration and continual improvement. East Lothian said that it would be damaging and counterproductive to restructure services, again less than eight years since the integration of health and social care. Are chief officers of the view that there has to be structural change to these care boards? Is there a sense that there is not enough detail in the bill to make a judgment about whether we should move to that and what that would look like? We are very mindful of the amount of time that has taken to achieve integration over the last seven, eight years, and we are mindful of the risk that further structural change may bring. A number of contributors have mentioned the workforce challenges and we would be really concerned that there are some elements that we need to tackle quite quickly in terms of securing and retaining a well-qualified, high-quality workforce than some of the challenges that we have had that are well rehearsed post Covid in terms of recruitment and retention across the sector. Is bearing in mind the cost and potential benefits as they are perceived from further structural change if, indeed, that is what is decided? There is not a lot of detail in the bill framework, as it stands. I think that I have already mentioned that we would be quite concerned about potentially losing some of the integration and some of the positive relationships and benefits that have been realised within a number of our partnerships. For example, the inclusion or not of children's services, justice services and some of our well-developed partnerships already have those. The majority of our chief officers felt that that should be within the new structure. However, that is not unanimous. There are other partnerships that are not of that view. There is variation among the chief officers, but in terms of having come through the structural change, there are potential benefits in terms of us being freed, if you like, from some of the bureaucratic demands that we have across the system in the current arrangements, reporting into the council, the NHS board, as well as the integration joint board, and the amount of occasional duplication of effort that that requires, which takes away resource and time from delivering the day job, which is the leadership around integration. There have been tremendous opportunities, particularly with the focus on strategic planning groups and the involvement and links with community planning, to enrich the way that we deliver service to be responsive to local needs. We are required to have strategic needs assessments down to locality level, and those help us with our planning and our targeting of resources. It is about trying to establish how we do not throw the baby out with the bathwater, if you like, and actually take the strengths of the current systems into the opportunities of potentially having an organisation that is planning and managing integrated multidisciplinary teams that are working at that locality level with the benefit of a national infrastructure and an organisational culture that is consistent and is about that absolute ethos on the principles that are held within the bill? I can move to Alison White in terms of... I appreciate Alison's here in Social Work Scotland, so I might not ask her to reflect as a chief officer, but I can ask about Social Work Scotland's view at the moment. Social Work Scotland has called for a pause in terms of the legislative process. Is that about what you said in terms of your comments about co-design? There should have been a process of co-design prior to getting to this point, rather than a co-design in the secondary legislation, and just anything else you would want to add about how Social Work Scotland arrived at that position? Yes, certainly, thank you. I suppose that, slightly touching on your first question to Patricia as well in terms of that, I think that at times disruption can be good, and Social Work Scotland is not suggesting that where we are at the moment is where we need to be. I think that there is a real sense from Social Work Scotland that things do need to change, that we really do need to strengthen the social work profession and how we respond and deal with social care and how we do that in an integrated structure, so there's a strong commitment around that. I think that there is a sense that that level of disruption at the moment, particularly at the point where we're going through one of the worst crises in terms of workforce, the challenges that we're seeing within our hospital settings, the level of delayed discharges, some of the challenges with that, the designs and delivery programmes that we already have across the wider social work setting in terms of the promise and the aspirations for justice services and amongst that, the workforce pressures that we're having at this point in time and the cost of living crisis that we're experiencing that's having an impact both on the people that we support on our staff team, particularly some of our lowest paid staff, but also in terms of the budgets that we have available to us at the moment, it feels as though there is a lot of disruption already going on. I think for us we have a strong commitment and I think the ethos and values that we're seeing in the national care service bill, there's nothing that we would want to be taking away from all of the aspects that we see within that we would be wholeheartedly supportive of, but we do feel that we need to be doing that design process and looking at how we make those shifts collaboratively, rather than having that framework legislation in place. I think certainly when we'd looked across the piece it was felt that that there were some challenges to the framework type of legislation, but we do feel that that meaningful core design process and I think the challenge for us within the timeframes that are being set out within the current legislation, if I take you back to all of the disruption that we're experiencing in the system at the moment for Social Work Scotland and others to engage in that meaningful process is quite challenging at the moment for us to do that, but I think if we were able to set out a really clear core design process at the early stages, looking at those interdependences, certainly if I think about we were really welcoming of the fact that there was a pause on the decisions about children and justice until further work could be done about whether that was there, but the challenges that we then design a process that looks at a national care service and children and justice become an add-on to that rather than centrally ingrained at the early stages about what a national care service should look like if the decision is that they should be there. So I think for us there's just some timing challenges around it, but it's not around the value base or the development of a national care service ultimately, it is just for us the order in which we do some of the work I think. There's a couple of members that have supplementary questions and it will be a supplementary question because we need to move through. So we've got tests first of all if you can aim your question that wants someone in particular test and then I'll come to Sandesh Gohani test. Thank you convener. I've just got one question for Alison White if I may. Alison, I noticed that you say co-design from before the legislation, not after it. My question relates to, you've said that you are concerned that further integration could make adult social care a delayed discharge service. Could you go into further detail as to how that might happen? I suppose I should, as a chief officer I spend my life talking about delayed discharges in a way that it is a really critical issue and it's a critical issue for a number of reasons, not just the impact that it has on hospital care and how we deliver it more generally, but actually at the point that someone is fit for discharge it is right that they are home and it is right that we support them in a meaningful way around that. We already know within adult services that often the issue that we get focused on is delayed discharges so we get to spend less time talking about people with a learning disability, people with complex mental health issues, people in the justice system, people who have substance misuse issues because the primary focus and the thing that we often end up focusing on if we look at the MSG indicators that IJBs already need to focus on it is predominantly focused on that hospital activity for older people and what it means for delayed discharging on occupied bed days. The concern for us in among some of this is that we do just end up being a focus about how we support that aspect of it rather than actually looking at people holistically and actually it shouldn't just be the focus there, if we get that preventative early intervention right, if we support care as well we actually need to see that flow in the whole system and the importance of all aspects of that and there is a challenge if adults end up being subsumed into a national care service without children, without justice, not knowing quite where mental health learning disabilities fit with that. The social work aspect becomes just a purely transactional element of me being able to get somebody a package of care to get them out of hospital rather than thinking of social work as that holistic advocacy based human rights based approach that we're in amongst that so that that's not taking away from the fact that people who are fit for discharge do need to be home. I'm not in any way suggesting that that is not something that is a priority for us but it shouldn't be a priority above all of the other aspects of care and support and the way that we work with people and I think social work Scotland does have a concern about the potential transactional that social work is just that bridge between someone having healthcare and someone having social care and social work as a profession is so much more than that. What are you saying in terms of the co-design? Tess, can I stop you, Tess? Tess, we really don't have time for multiple questions at this point. I'll come back to you. Thank you. Chris, you spoke about the GMS contract just in your opening remarks and I see lots of parallels with the GP contract and the national care service with centralisation, a policy memorandum that was full of aspiration and not fulfilled and a second MOU was then created, issues with highland and rural areas with the contract so detail and delivery is obviously key. The national care service is far bigger than the GP contract which didn't go well. Do you have any concerns that with GP being rolled into the national care service that it will have a negative impact on primary care? There are certainly many aspects of the GP contract that have brought progress and that have brought new parts of the workforce into and around general practice. Part of the importance of that is that we have a shortage of GPs. I suppose that part of the design element of that might be to consider where the shortages are. Coming back to the delayed discharge point, we want to have a community pull. We want there to be support there ready and waiting for when people have finished the treatment that they need in hospital. Otherwise, we run the risk that there are parts of the system doing things that they are not intended to or set up for doing. The processes that don't play out properly, especially in areas of the country that look and feel very different. When we talk about consistency, we want a good consistency. I believe that we do very much want person-focused care. When we start that process of design, things can happen in just within a short couple of years. We see a pandemic come along that changes so many perspectives and changes much of the practice that we are used to doing. Alison mentioned the disruption. There are certain forms of disruption that are helpful. There are certain times where disruption is helpful. The recruitment and retention issues that we face in general practice, in wider health and in social care, they are very much a limiting factor. Coming back to your question, I would very hope that we don't design a solution that we can't staff or that we don't have the infrastructure to deliver. However, in terms of the ethos of the bill and the human rights approach, we absolutely need to embrace that. What does our workforce look like in different parts of the country? What are good arrangements that we can build on? Can we make sure that the links to the various other agencies that improve people's lives? Can we maintain the right links and not disrupt the things that are quietly working away in favour of our citizens? I've noticed that Alison Kerr wants to come back in. I imagine that it's around what was mentioned in response to Tess White. I'm happy to bring you in now, Alison, before we move on. Thank you. It was just too further to what Alison White said about transnational relationships and to consider the need for consideration of the social determinants of health. Unless we think on a longer-term basis around the social determinants that keep us well, so good home, good relationships and good occupations in our lives, we will not change that trajectory of people who end up in hospital and, in part, become our delayed discharges. We also need to think differently about where we support people in the system. I'm keen to understand more about the approach to community health services and where they should sit within the structure. I appreciate that it's difficult at this stage again in the framework to fully understand and discuss that. However, as an opener, I wonder whether there should be responsibility for community health services that are set with health boards or with the new proposed care boards. I might start with Nick Modus, if that's possible. I guess that my answer to that is that I think that it should remain with health boards. I don't believe that they should go to the potential new care boards. There's some understanding of that, which I think that we need to get across here. If we're not careful that they see care boards as seen as a logical extension of IJBs. In reality, it's the health and social care partnerships that have developed the integration at local level. The IJBs have not developed much integration. In fact, when the Audit Scotland did its report, the examples of good practice were merely the fact that the IJBs weren't shouting at each other, seemed to be the good example. So the IJBs, whilst they might be seen as a good construct, some of the governance issues around IJBs are not helpful to both health or social care, but the health and social care partnerships are. I think that there's plenty of evidence that has emerged through the development of community services integration of mental health care, for example, where you can demonstrate significant advances in integration of health, care, cross health and social care services, where you have co-located members of staff working closely with primary care and GP services, staff who understand the relationship between themselves and the acute hospital when people present with specific acute needs. They're able to make sure that care pathway works for people. The greatest risk that I think is going forward, which is why I think I support my colleagues and we've got to do a lot of this design work in advance before we get to legislation. The greatest risk is that we create a further fracture in the health and social care system by creating a care board relative to what we currently have, which is health and social care partnerships. The other risk with care boards is that the current guidance within the framework bill leads to a conclusion that no staff will be employed through the care board, certainly no health care staff will be transferred to the care board, but the care board will be responsible for the development of provision arrangements and the planning and commissioning of the services. We need to work out who's then accountable for the delivery of those services both at an organisational level and at a private level, at an individual practitioner level. So all our staff, OTs, I'm sure Alasie will support me, social workers, GPs, require an understanding of their professional accountability systems and clinical governance arrangements, and they will be completely fractured by an arrangement that puts us a care board in place as described by the framework. Clearly not much evidence, there will be detail there yet, but that's where it seems to be implying the issue. I was going to try and come in on some of the earlier conversations as well when we were talking about care boards because the process to date has not really seen healthcare as a significant stakeholder. We were not involved as a stakeholder in the initial consultation process as a formerly acknowledged stakeholder, and yet one-third of the NHS funding potentially gets transferred into this new arrangement if it goes the way the framework arrangements suggest. That has a major implication on the NHS, and we need to work closely with our colleagues in social work, in COSLA, in the other organisations on a co-design process built around Delphi model processes, which will get us, I believe, to a significant consensus on the design going forward. I don't think that the bill as structured at the moment gets us there. First of all, I will point out that integration joint boards currently have, under the Public Bodies Act, the responsibility for strategic planning and the budgets for community health services. Indeed, they are operationally managed within the health and social care partnerships. It is really critical that we are taking a whole system approach when we are looking at the care journeys and the health journeys of individuals and that we smooth out any of those bumps and gaps between those services. In relation to the potential for the boards to not have operational management of that integrated multidisciplinary team, that has been real win-win within the partnerships that we have been able to bring those staff together to collocate them and manage them together alongside a matrix management with their professional accountability up through to the chief social work officer, nurse director, allied health professional, professional lead, etc. There are models that are already working in that regard. From the chief officer's perspective, we really feel that it is quite critical that we are able to bring staff together. It is a potential issue that we would have staff groups who are on different terms and conditions. There are issues around parity of esteem equality, etc, which is one of the challenges currently. However, in the bill as it stands at the moment, there are unanswered questions in relation to what the detail of that will mean. There is an opportunity to look at that wider public sector reform and actually where could those new care boards sit within that broader public sector and what would be the arrangements in terms of the organisational operational management, but also the way that we work with and employ staff. Thank you for both of those responses. I suppose that there is a culture and structure thing here in terms of the structures around care boards, but I suppose that the culture that is embedded through HSCPs and some of that integration work. I wonder if I can ask Alison just on that point about potential staff transfer. We had Cossill last week, which is obviously very concerned about the local government space and in terms of what might happen to local government staff and obviously representing social workers. Really, just to try and get a sense from you, Alison, about what are the anxieties for the social work profession in this space, about what their future might look like? That is a huge level of uncertainty. Obviously, with the framework bill, some of the questions that people might have answered at this stage and would come through a co-design process, but I think that it does cause a huge level of anxiety. Patricia highlighted the fact that across the partnerships that we already have, there is a range of difference. We know that whatever comes out of this, there will be change somewhere. In some areas, children's services are in and in some areas, children's services are out. Whatever the decision is about where children sit, there will be changes that happen somewhere across Scotland, so there is a level of anxiety. For some people, they are welcoming a level of change. They think that this is an opportunity. They maybe do not feel that they have been as protected and as valued and as an opportunity within a national care service to really have a strong voice for social work and social care, but at the same time, I think that there is that. We are already struggling to fill vacancies, particularly within social work, both at front-line levels, team lead levels and some of the senior management roles. I think that we also have an area where there are people who are close to retirement, who are thinking that they are not wanting yet another structural and organisational change, so there is a real sense that we might lose a level of experience as part of this restructure. Now, people might be saying that and then won't move at that point in time, but recruitment is difficult at this point in time and at any level of uncertainty when recruitment is difficult can be challenging. There are opportunities within this, though, I suppose, in terms of some of the fair work policies and actually as we go through that process for discussion about what that means and how we give that parity and how we support across the piece. I suppose it's also worth mentioning that there are differences in different areas, so what suits for Edinburgh and Glasgow doesn't suit for our colleagues in more rural areas who are already experiencing probably even more significant challenges than those of us who are in more urban areas that are offering that support. It is a bit of a mix, but there are real concerns from a staffing perspective about what that might mean for continuity at this point. The terms and conditions issue is a very big issue for occupational therapists, so we often come into integrated teams from a health background or from a social work background, so we're on different terms and conditions, different pay scales, different holidays, but we're sitting together in integrated teams doing the same job, so the bill doesn't give us any opportunity to explore how we make this more equitable going forward and what makes it work just now is goodwill of staff. The staff will work really hard to cook it over this and make their teams work, but fundamentally their teasing seas are different and, I think, longer term that presents a bigger issue if we don't challenge it. Listening to everybody here, it's really interesting that my understanding of this bill is that it's a framework bill to create a service that's more integrated, there's fair work, there's human rights, there's improvements in quality and equity of service, the Fili report, which I've got these recommendations in front of me, lays out a case for the creation of a national care service, and one of the recommendations is that the services driving focus should be improvements in the consistency, quality and equity of care and support experience by service users, their families and carers, and improvements in the conditions of employment, training and development of the workforce, so there's quite a lot even in that single recommendation. My understanding is that this is about people with lived experience, people that need to have their care to prevent hospital admission, to not just deal with delayed discharge, it's not going to be a delayed discharge bill, so I'm trying to get my head round how do we support the co-production, the co-creation, the innovation, because the framework bill is supposed to set out what the further statutory instruments will come after that, based on people's working together, whether they're service users, whether they're service providers, whether they're NHS leads, whether they're other people involved, so I'd be interested in comments around what Derek Fili's number 20 recommendation for the case for the national care service is, I see, Nick Hasse's hand up. I don't think there's any doubt amongst all the stakeholders that we applaud the principles and the aspiration of Derek Fili's report and the extension of that international care service consultation process. I think we would agree that there are significant improvements needed to be made on the integration of services at local level in order to meet the needs of people with lived experiences. I still think we meet the needs of significant numbers of those people well, but clearly there are lessons to be learned about some of the people that we meet the care less of. I think the reason why we're asking now for significant design work ahead of a bill is for two reasons. One is that the framework bill by default will make us look at the issues that are in the framework bill and the framework bill refers to structures, so it diverts people's attention into conversations about structures that, at this point, are not particularly helpful. They divert us from the task at hand, which is the immediate pressures that we've got both in health and social care. That's a concern, but there is a need to address the issues of integration going forward, so we can't always put off, because of the pressures that we've got now, the needs that we need to do in the future. The other key issue for me is that the most significant improvement that we make for people with significant problems in health and social care is the design of work at MDT level, multidisciplinary team level, at locality level. I'm a psychiatric nurse by background. I spent 30 years of my 40 years NHS career working in integrated health and social care systems, social care as well as health. The most significant things we need to do at the moment is develop those integrated mental health and community teams and GP primary care teams at local level, understanding the voice of local communities and how they respond to them, identification of clients rather than waiting for referrals so that we're more proactive in our understanding of those people at need. We have some clients who will have very short interventions, they can come into the service and they go away, but the most of the lived experience concerns that are being expressed to us are from those people who have multiple issues and their concerns are about being passed around from department, department, multiple assessments, et cetera. The only way you're going to tackle that is by having integrated co-located teams at local level that understand their local community populations, can understand who are the individuals who are in need of care and make sure that they remain captured within the care system to be supported rather than discharge, re-referd, discharge, re-referd, discharge, re-ferd. All that work needs to take place in order to make sure that we have integrated health and social care services. That will lead to a fantastic NHS future aspiration going forward, but we need the structural design to follow and understand what it is that we need to deliver at a local level for people. Picking on what Alison Kerr said earlier, we need to understand the outputs that we're trying to deliver, the outcomes for individuals and what the local requirements are of performance from an individual person's perspective, are we meeting their expectations and then aggregate that up to a national performance framework that impacts on both health and social care and takes us away from some of the focus on things like A and E waiting times, which are important but aren't going to get us through into a healthier Scottish population. They'll deal with the people who are ill, but we need to deal with a healthier Scottish population. We need to start focusing now on an integrated health and social care performance framework that aggregates up from what individuals are required to have for them in terms of preventative care and co-ordinated care within local multidisciplinary teams. My question is for Patricia Cassidy. What code design is already under way with social work and social care staff? Is that presenting opportunities for social workers, for example, to really better apply their own expertise and going forward? Perhaps I'll speak on local practice in Falkirk and NHS Wath Valley. We have redesigned a number of our key services in partnership with people who use our services, with the families that carers and also with our service providers, if that's appropriate. We've undertaken quite significant redesign of our services for people with learning disability. Six or seven years ago, we offered five building-based day services, and we had people who had been attending those services for sometimes 30 years, being picked up by a bus in the morning, a range of activities and dropped off home at night. We had done a whole range of consultation. We used a third sector organisation to be the interface for us with our social work staff, and we did about 14 months of consultation looking at what was important for people, what they would like to do. That informed the basis of a collaborative piece of work redesigning our services. We didn't withdraw our services, we changed the way we delivered services, we changed our staff to deliver much more community-based support and community-based services. We commissioned new providers to come into the area to provide a range of social leisure, training and educational opportunities. We also did more concentrated work with individuals to help them to become more independent, travelling by bus, accessing mainstream services, etc. That was something that was quite challenging for the council at the time to do that level of change. Our local elected members were quite concerned that there might be quite significant backlash in the community, but the work that we did in the co-design and the continual feedback loops into the consultation groups and the stakeholders was such that we didn't have even a murmur of dissent in the community. We transformed the service, reduced our service down to two-day services, which became hubs for some people to come in and out and access support or for people with more complex needs, but had a much wider range of services. The council had a couple million pounds set aside in the capital programme to re-roof one of the buildings that we were then able to close. The council agreed to our request to use that capital to invest in changing places toilets, because we didn't have the physical infrastructure in Falkirk. We had no changing places toilets there, and we've now got five. We've got a spin-off from that group who are working in our communities looking at where we've got another two or three to build and where they should be, and the families are absolutely at the heart of that co-design. That's just one simple example of how we've done that quite collaboratively, and we're at another phase now of looking again at the way we deliver those services, and we're working on that with Health Improvement Scotland, neighbourhood networks, our social work staff, our health service staff to look at the next phase of that. That's just one example of how coming at things differently, pulling in expertise externally and really meaningfully listening and responding. The more we spoke to individuals and groups of people, the more they wanted to know, the more they wanted to contribute, and that's just a wee microcosm of the potential that we can do around co-design. A number of members want to come in if I can ask them to be succinct and focused, because we only have half an hour left with our colleagues. I was on an health and social care partnership when I was a counsellor and I saw the benefit of that joint working, although silo mentality was still very strong then, so I'm pleased to hear that things have improved in the IGPs. I want to ask Alison Kerr a question. This is a framework bill. Obviously, you've all got an opportunity to feed into what you would like to see and co-design it, but you mentioned the specifics about different terms and conditions. Surely something like this would go some way to alleviate the problem of different terms and conditions between the staff and the two bodies that are present. It isn't clear in the bill that we will tackle the different staff from different agencies being on different terms and conditions. My understanding is that we end up with what we have just now, so we still have staff from health on one lot of teasing seas and staff from social work, social care on different teasing seas working together in the same team doing the same job, but we haven't tackled that teasing seas problem. You're at the very beginning of the process, but this is a kind of being made. It's important that we do tackle it, absolutely. Hi, I think possibly Nick Morris might be able to answer this. I'm interested to know does the framework bill give us enough information about some of the legislative stuff around adults with incapacity mental health issues, whether there's enough in the framework bill to help transition with that map? I don't think that there's any evident detail in the bill at the point about that. I know that the design process has just launched a consultation document around mental health related to the NCS, so we'll be keen to engage with that, but I think that it only came out this week. There's lots of potential within the design process to try and pick up the issues related to those significantly disadvantaged people. I don't think that the bill makes reference to that. Again, the reason that we have concerns about the framework bill is because it focuses at this point on some of the structural elements that they wish to eventually bring legislation to bring into place, and it's not allowing us to have the conversations about the design work at a local level or it's discouraging us from having those conversations which need to take place. That's helpful, thank you. We move on to talk about prevention and early intervention and questions led by Gillian Mackay. Thanks, convener, and good morning to the panel. I think I'll come to Alison White first with this question if that's okay. How can the bill help to deliver the recommendations of the Christie commission? Obviously, we've heard concerns this morning about the lack of detail regarding prevention and early intervention. What would panel members like to see included going forward? One of the concerns that we have, I suppose, is around what we would want to see, I suppose, moving ahead in amongst this. We've already got a real strength in terms of self-directed support legislation, in terms of how we have good conversations with people about how we look at choice and control, how we look at people's rights and responsibilities, and among some of that, I'm not saying that that has ruled out in every area as fully as we would want it to at this point in time, but I think we have a framework legislation about how we work with people, about how we have good conversations, about how we work to support people at an earlier possible stage as we can, but I think there's some elements of this that we need to be getting into, so we've already referenced things like eligibility criteria and how we work with that, and I think what we've not touched on today is, well, is the financial memorandum and what that will look like. So, all of these aspects come with a significant cost associated with it, of which hasn't been costed as yet. We haven't done that design work to work out what something new would look like to work out how we would cost it, but often in the times of austerity and where there are budget cuts that are required to be taken, it's often those preventative and early intervention services that end up being the ones that are cut because we end up needing to deliver for those really critical services and maintaining those at that point in time, but we all know and we all feel that that being able to invest in those earlier intervention and prevention services is the right thing to do and actually prevents those crises over time in terms of where we are, so I think it's around us needing to do some of that design to fully understand what the costs of those aspirations are because there's nothing within the Feli report that we wouldn't be wholeheartedly supportive of in terms of thinking that it is the right thing to do for the people that we support in our communities, but we do need to understand the cost implications of doing that and how we share the budget around to allow us to do that. If I may just very briefly touch back on the previous question about the protection issues, I don't think they're fully covered and I think one aspect that's particularly missed within the bill as it stands at the moment is the role of chief social work officer. When we look at those legislative framework, there's a clear role for chief social worker and amongst that. Now, while social workers mentioned, very rarely in the bill or if at all is the role of chief social work officer and that governance around ensuring that we're keeping people's rights safe in amongst that and if we were looking at a whole scale shift of that responsibility to ministers as opposed to them sitting with local authorities and the skill of legislative change that would be required to ensure that we mint in that safety. Particularly when we look at the bill in terms of the data sharing and the health and care record, we need to be really mindful that some of that data that will be stored from a social work perspective is very specifically in terms of that protection agenda, which is very different to the types of data that might be shared elsewhere and we are engaged in those conversations but I did just want to touch on that as well. I had a meeting earlier this week with Alison Bavage about social working within the NCS bill and Alison is a very useful term to describe social workers of essentially the GPs of social care. I'd be interested in your thoughts of how we make sure through this bill that social work is not continuing to deliver small things and gets back to that holistic cross-well-being view that social workers would like to see it get back to in that sort of restoration of the profession. Obviously it's heavily legislative based and this is another piece of legislation coming in to add to that spectrum as well. So just your thoughts on how we make sure we get back to that cross-issue look rather than delivering pieces of justice and then invest the gift of work and other things and looking at the whole well-being piece. I don't know if you've seen the setting the bar report that social work Scotland had undertaken and as part of that report I think that it was very much looking at the workforce issues that we're experiencing and was surveying all of our staff around some of the challenges but as part of that report we really mapped out some of the legislative issues that social work had needed to pick up over the last period and it wasn't quite all of them but it was a really significant shift and change that we're needing to deliver without properly having reinvestment within that both in terms of the skillset that we're looking at and how we deliver and there are challenges at times within social work that some of the pieces of legislation don't sit as comfortably with one another and that you almost choose which bit of legislation fits best for the individuals that you're working within but I think to some extent the national care service and the opportunity that the development of the bill and the role of social work and social care but social work in particular and amongst this is a real opportunity for us and as I said we are not against the development of the national care service and the conversations that we can have. We think social work have that skillset and that real strength to really be able to drive forward much of what we've seen within Feely's report sits within that training and development that we all have had as social workers in terms of how we drive that forward not to say that other professions haven't seen as I mean a mixed profession group at this point in time I'm not suggesting it it's just us that have that but I think there is something in that core value set and how we work with people and those good conversations that actually the Feely report really resonated with most of us in terms of what we were wanting to do and how we were going to drive that forward so if nothing else the opportunity for the conversation and the role that social work can play is really welcomed by us. Move on to some questions on this theme from Stephanie Callahan. Thanks very much chair that was really great Alison I think that's dead dead helpful and also the point on protections for chief social work officers I think was one that was really really malebade and and just to note that that can be heads of service and things as well it's not always at the very very top level there but my question is kind of picking up on on where Gillian's been going there as well you know we do have for example in my constituency we've get in able Scotland that use sds and deliver personal assistant so it's really about focusing on that individual what it is that matters to them and that has very much a well being approach and it has a preventative approach as well rather than kind of picking up from a choice of services that happen to be available there so really really interested in this and you mentioned about the costs associated with that and I know that enable have said actually it doesn't cost more most of the time for us so I thought that was really quite interesting as well but what I'm wondering probably mainly is you know what recommendations would you like to see us making in our report to actually make sure that we do have this kind of front and centre in the bill that we do have discovered I mean I think it's about ticket it is about that co-design process it is around making sure that we have that strong voice of people who use our services people who are caring but actually we we need an equally strong voice for those people who are assessing and our delivering services and amongst this I think there's we understand different bits of the system and I suppose to create something new we need to understand all aspects of the system not just a perception or a part of that system and I think we're all thinking that something needs to change in the system there's some fantastic bits of work out there and patrice has mentioned some good areas of development we could have those stories in each of the different areas but we all also I think equally think there is more that we can do to develop those services so I think it is around that co-design process but giving us the time and the scope to do that properly and to make sure that we've got the right people involved and I think to think about those interdependences this is such a whole scale change when I look at the the plan of work for the NCS there's something like 70 different work streams in amongst them and there are clear interdependencies between all of them and I think to ensure that we have that strong voice and from our point from social work Scotland and from the voice of our members in terms of social workers who are part of that it's about making sure that we get the time to have those really good conversations in amongst that that really begin to shape what we what we need in amongst some of this service to redesign but a really strong commitment that things need to go up but there are some really strong pieces that are already in place we've mentioned the self-directed support legislation there's some really good strong legislation that's already there that might not be fully embedded in all areas but actually it is the right principles the right framework and it is around making sure that we we make a success of some of those areas of work rather than losing some of those aspects because those already have all of the principles we have about co-design and working well with people and individuals really getting to think about what matters to them and what's important in terms of their own outcomes because there is that gap between this framework legislation which will then set the course onto the secondary legislation you mentioned 70 work streams and the NCS or national care system isn't expected to be delivered until the end of this Parliament that that is a fair amount of of time for that process to happen would you agree it is and I suppose the only difference we have is that we would do the co-design prior to some of that set of legislation but yes it's not an unrealistic time frame for us to be doing some of that work but it's the the timing for us that we gained thank you right i'm just looking at our next theme which is about keeping things local and questions led by Evelyn tweed thanks convener you'll be pleased to hear that a lot of my questions have already been answered there's been a lot on co-design already but i suppose my focus is on probably tying in neatly to to what we've just been speaking about frontline staff they're very busy we've talked about the challenges this morning the pandemic workload etc how can we make sure that frontline staff are frontline and centre of the co-design how can we make sure they have the time to fully participate in what's happening and we have just heard that there will be significant time but how do we make sure that at the front of that process and i'd like to ask dr rollins the probably start by saying that initially in the consultation stages a lot of our members the headspace immediately went over to the to the threat that they might be absorbed that the management of general practice might be absorbed into an organization that that is you know that it hasn't got a long established track record of of managing general practice and so i think that you might find those that that sort of behaviour unfolding in other professional groups that when you when you suggest that there's going to be a reorganisation you know have our people ready for that you know our professional groups already speaking and discussing about how can we best synergize our activities you know do we have the right groupings there we've got different hubs we've got cool locations of different services different things but say I yeah we I think we could do well to to spend some effort and energy into working out how we maximise it that the again in general practice one of the issues we encounter is that not having enough time and resource to be able to stop and a reflect on just where we are at the moment, you know, the systems that are continually changing around about us, you know, are we maximising those systems? And Dr Gohani picked up on some of the issues earlier on about, you know, have we anticipated when we're going into these changes, have we got the IT models correctly, are we going to find out that we're paying for software licences for somebody to work in one specific place and then actually it costs a lot more because we're asking one person to work in multiple GP surgeries. So I think there's lots of specifics that people will be able to tell us about that we'll be able to work out how we can build a health and social care service that is better integrated in some of these fine bits of working where there's good economies of scale. I think that if we've got a process so as well as the legislation that innate, I think that once you've got the primary legislation that then gives people certainty that they know what's happening, but yeah, I think giving people confidence that there's been a bit, you know, sort of enough mapping out of what things would look like or where things will need to move from if we're going to find, you know, new structures in teams that look slightly differently or again with my OT colleagues, you know, if you can explain to them, well, you know, this will definitively solve a problem that's mentioned. I think you'll get, you know, you'll find a lot more buy-in and once you can, I guess, remove some of the potential threats that these different professions are feeling. I'd say they may be perceptions rather than real threats, but yeah, if we can remove some of those, that would be welcome and I think the, you know, the history that we've got in Scotland of being able to design person-centred services is a really strong one, but I think that a little bit more discussion in the background would really give that confidence. Some other panels want to come in on this. Alison Kerr, and then I'll come to Patricia Cassidy. Thank you. I think the time is also about getting the right people around the table, so we have time to hear each other's stories and lessons that we've learned, so for occupational therapists in Freeson Galloway, 65 per cent of people who are discharged from hospital and through the rehabilitation programme, regain independence. How do we share that as good practice so that we can scale that up? Again, for occupational therapists from the RCOT, we know that OTs are 4 per cent of the regulated healthcare workforce, but address 35 to 45 per cent of all referrals. Actually, we're not huge in number, but our outputs are significant. How can we be part of that wider dialogue so that we're thinking about how we can all be part of a new future, and everybody has an equal voice around that? This is one of the great opportunities with the national care services to reposition our whole health and care workforce in a value-based culture and recognition of the value of that workforce. There are a number of formal structures in place through our trade unions and staff side, the professional bodies. We also have joint staff forums at integration job board level, where we bring together those representatives, but that all needs to be enriched and augmented with the voices of our front-line and other staff. They know their communities, they know their job, they can see where things could be improved and changed, they understand where some of the solution lies. I would suggest that we need to be talking to our potential workforce, we need to be talking to our young people in schools and understanding what type of employment, what type of rewards and enjoyment and what is their motivation and how we can attract them into those professions and positions because we have significant workforce challenges. How do we then engineer in that we're growing a workforce and a workforce of the future? There are a number of elements there, but critically, we need to hear from staff at all levels and they need to be able to see what they've said, reflected in what comes out through the legislation. The question was about how do we engage our staff in the conversations about the development of the MGS. It's fundamentally important that we have to. There are two things. One is to remind everybody that the systems pressure we're currently under means that most of our staff are struggling to get any reflective time at all, either in the healthcare system or social care system, they're working with the nose to the grindstone all the time. So there's an issue there about the current position. The convener described the fact that we have, I think it's three and a half years now, is it for the end of this Parliament? We should reduce the bill. I think our constituencies would be saying, could be very bit careful about pace because we'd rather get it right than get pace. When the NHS was originally conceived in the 1930s, the original bill that created the NHS was 1938, the emergency hospitals bill, it took 10 years to get to the actual NHS and then it took to the 1980s before we managed to integrate properly community services and GP family practitioner services and even then we'd left social care services after that process into a different arrangement. So all those decades took a long time to get to even where we are now and we'd rather build on where we're going than distract from it. And the last point raised is about the fact that we are currently in a recruitment problem and I think people looking to join the health and social care practitioner's workforce will want to have some understanding of what they're walking into. So at this point in time, I think it's really difficult for them to understand who's their accountable manager going to be, who's going to own them as a body. I think we need to be very careful about the constructed structures because that potentially detracts from our ability to recruit at this point in time because people will not know what actually they're signing up for. Thank you. Evelyn, do you have an additional question or am I able to move to Tess? You can go to Tess. Thank you. Tess Wight. Thank you, convener. Dr Chris Williams, for the NCS risks taking power away from local decision makers, what impact do you expect this will have? Thank you. That's quite broad. I'll maybe start by answering from a general practice perspective. So general practice generally is set up as independent contractors. I mentioned earlier that there's primary care reform that is still unfinished business, so we've still got a lot to concentrate on in general practice. We general practitioners have been on the health and social care partnerships in terms of playing a positive part in trying to help to navigate these meetings of cultures. I think that many of us sitting round the table here don't mind reorganisation as such, especially when that is generating a positive direction where there are then discussions that are enabled. Part of what we've just heard is that at the moment there are a lot of parts of the system that are too busy to be having a good clear focus on some of the new design that's required, that people are trying to keep the ship afloat, and there's a flotilla of ships out there that we're trying to keep afloat. So again, just coming back to what I was saying earlier, if you can provide our various professions with the confidence that there's enough thought going into the structures that are envisaged and that these will be resourced and that building elements of one part of the system won't rob other parts of the system or won't... Again, just coming back to the change that we've seen in general practice, I'd mentioned bringing new parts of the workforce into general practice, into pharmacists, physiotherapists that weren't working there before, that have got new roles, that are doing fabulous new things, but there are a limited number of pharmacists and physiotherapists in our care system across Scotland, so we need to be careful in our workforce planning as to the pace that we think we can develop at and again which different parts of the system that we can simultaneously build and remodel and modernise. We are rapidly running out of time, we have about 10 minutes left in this session, so we'll go to our final theme, which is about rural areas and questions led by Sandesh Gaghani. Thank you. The Scottish Association of Social Work has raised concerns that these national care service proposals could exacerbate recruitment issues, and as Dr Williams mentioned in his earlier answer to me about a system that we cannot staff, so obviously this is coming to Alison. Do you agree with the assessment and if so, how would it exacerbate the issues? I think we're already experiencing recruitment issues at this point in time, and I think certainly colleagues of mine that work within rural areas are very vocal about some of the challenges that they're experiencing, and in many cases it's not just, certainly in rurality kind of issues, it's not just the issues around the volume of staff that are there, but it's about having affordable housing, it's that broader community planning aspect about how we support our workforce and staff in those areas, it's not just the issue of attracting people to those posts, certainly a colleague was highlighting that they'd been able to appoint someone, but the person ultimately withdrew having spent six weeks trying to find accommodation in the area and not being able to find that, so it remains critical whatever we do that we work in that broader community planning environment to ensure that things like housing and the broader issues that we've got are available for people and amongst that, but we are experiencing those issues and I think any level of increased uncertainty can add challenges and amongst that those issues, it's not just rural areas that are experiencing those problems, and hopefully as we go through this process and we're looking at the fair work agenda certainly that there are real opportunities and amongst this and looking at what that might mean, what is a fair wage, how do we manage that, but there are significant differences between the urban and rural areas that we need to be mindful of in that planning stage. Thank you, and rural and island communities face significantly different challenges to the rest of the country. What impact do you anticipate a one-size-fits-all approach of a national care service would have on these communities if I can come to Nick Morris? I think that the logical conclusion of the NCS at the moment would suggest to the island communities that they would have less control of the NHS elements of the care, is it all going to a care board? I can't see the reason why it would have a care board and an NHS structure on one of the islands at the same time, they just duplicate effort too much, so it's likely that the NHS planning and programmes of work would be planned from one of the mainland boards, we don't know how many main on boards might be retained but we'll assume they'll stay roughly the same as they are, but on the island communities are likely to only have a care board under the current arrangements, I think that worries people about the degree to which they can then influence, through their locality arrangements, the structure of NHS care for their own population, so I think that's a concern. I think that that does get replicated on two rural areas as well, where we have significant distance from the urban central belt and in many ways places like Donfries and Callaway reflect the same needs of rural communities and in DNG we've created an integrated IJB that actually includes all our acute hospital services as well as our community services and we would foresee that that model is something that we'd like to retain because it gives some sovereignty over the degree of health and social care integration from primary care right through to potential referral into tertiary care. Now some of the more populated urban areas of Glasgow and Lothian might be able to develop a different model but I think we would see that some of the rural areas, Highland might want to get on this as well, might want to develop a model consistent with what is being considered for the islands which is a signal integrated health and social care system from primary care right through to secondary tertiary care. And Dr Williams, can I just ask when if we are looking at a fully integrated service, GP primary care in general needs to be part of that but with the change happening with the IJBs and if we're looking at particularly the lack of GPs and other primary care practitioners that we have in Highlands and rural areas, does the national care service pose a risk here? So I think if it destabilised, I think if it just in terms of what Nick was saying about the way that boards are configured differently when they're different sizes, so from a general practice perspective it's difficult to know looking at the framework legislation, it is what we build through that legislation that's going to either build confidence or give me other thoughts, but at the moment in terms of how much resource we have for these different parts of the system, how we build on what we know about the changes that have occurred over the last couple of years, that's probably going to be more informative. So going back to the terminology used earlier about admission prevention and how general practice plays its role in the advanced care planning perspective, the way that we're able to speak to people about to try and understand what their wishes are looking ahead, those conversations happen in general practice lots, and if we can find better ways, more efficient ways to be able to feed that into the social care side of things, all the better, but coming back to the original premise, general practice is a busy place right at the moment. We have all sorts of workforce challenges and there's lots of things that carry potential threat. Just on that, I just want to pick up in terms of workforce challenges, obviously the recruitment of GPs is an issue, but also recruitment of the ancillary staff that are currently provided as part of the GP contract. Do you think that there's potential with the national care service to have a drive to recruit more people into the sector, given the parity esteem between care and national health service? That's something that's come out in quite a lot of the consultation. I mean, there's no one solution to that, but I'm happy to hear from anyone on that. Dr Williams? I might reflect on our experience in general practice. When the new contract came in, we didn't go for a big bang overnight change. There was this iterative multi-year approach and health boards were allowed to select their own priorities about which parts of the workforce they were intending to develop. Actually, a lot changed over that period, but there was throttling up in different parts. There was development and there was some degree of reflection of what was working, which one of those new changes was bedding in well. We saw other things. We thought that the Scottish Ambulance Service was going to be providing a role, and ultimately that didn't all pan out as expected. Efforts around urgent care took different directions, trying to make arrangements for unscheduled care. I think that there is something to try and replicate in terms of if we can build different parts and pause and learn from what is being built, that might offer more comfort rather than some large overnight reorganisations. Nick Morris? I think that every potential that developed at the NCS and the focus on social care and social work could increase the recruitment potential into those care areas if we recognise that social work is often not at the celebratory end of what goes right. They are often at the but end of when things have gone wrong, and yet social work practitioners deliver tremendous things on a day-to-day basis, nobody ever hears about. It is an opportunity to bring into the public's perception what social work actually does, the positive contributions it makes to supporting and navigating people through into their communities and helping them to prosper and develop meaningful lives. Then there is an opportunity to enhance the role of social work and other social care practitioners. If we tie that in with core and branch training programmes for people that might enter a certificate level that might want to work up to a degree level that mean people can branch from social care or healthcare or whatever, that is a really strong opportunity out of the NCS developments as well. That was very nice reference to all the social work. I think it links back to the fair work. I would agree that NCS has a real impact on this, but I suppose it is about making sure that we get it right in terms of that training, development, the opportunities and the fair work and pay and the terms and conditions, probably less so for some of the social work staff, but I think particularly for social care, given that myriad of providers that we have out there, if we want to attract people in, we need to be able to see this as, yes, I think if we've got a parity of esteem in terms of that real focus, I think there's a real benefit for that, but it's not just about that parity of esteem, people still have bills to pay and mortgages to pay and everything else that goes in amongst that. It's the parity full stop, it's not just the esteem that we need to be looking for. Thank you, that's very helpful. Final questions from Emma Harper? Thank you. It's just basically to pick up on what Nick Morris said about it. The national health service was created 70 plus years ago and obviously it's a work in progress as well when we see what changes are happening. I take on board what you're saying about the creation of a national care service needs to be done with consideration and we need to do it carefully and we need to make sure that we get legislation right. But it brings me back to the beginning, this is a framework bill that we need to make sure there will be amendments probably for after the stage 1 report when we take it forward. I'm just interested in how we bring everybody along with us, especially I think it's great that we should be singing the praises of social workers and we can use this to value that work and that could be done using national approaches to skills development, education and things like that as well. Just interested in your thoughts about that. If you listen to the contributions that we've made from ourselves, including Patricia and Alison on screen as well, there's far more that we have collective understanding and agreement on than we have differences on, but we do have differences of opinion and there's often a perception that social workers, medical staff, nursing staff, whatever disagree with the children that's a wrong thing, but if you're going to get a multidisciplinary team to work well, you have to bring those different frames of reference into the conversations about patient care in order to do the right thing for the patient. So I think my concern about the framework legislation at the moment is that these conversations we're beginning to have and bringing it onto this table now are the things we need to do in order to drive the future of the legislation and it just feels that the framework legislation potentially gets in the way of doing that because it's focusing, it's on conversations around structures, care boards, et cetera. We all aspire to having a national care service. I would agree with the First Minister as an initial aspiration to say we ought to have an NCS that builds on and reflects on the significance of the NHS in 1948. That's a fantastic aspiration, but we need to understand what the NCS is because it isn't going to be a coexistence of all healthcare systems like the NHS, that's all provided by one organisation, social care is provided by thousands of organisations, so it cannot be one body, it has to be multiple bodies. So the NCS is a structure for bringing those things together and if we're not careful we'll end up having conversations about governance, management, entities, all those sorts of things before we've had the conversations about what actually unites us, which is the individuals on the ground who need all our contributions to support them. So I don't knock the NCS concept at all. We fully applaud it and the aspirations of the Feely report as well. We just feel it has to be very carefully delivered and these conversations from grassroots up to senior leadership level need to be bringing together what that consensus looks like so that we can inform the bill. So that's my position on that, I'm afraid. Important that we capture the value of allied health professionals in the national care service, we've talked a lot about doctors, nurses and social workers, but allied health professionals are absolutely key to that going forward as there's rehabilitation. So how we enable people to have the skills to live their best lives and re-ablement to help people to regain loss function, rather than depend on care, help people to regain function and to regain their independence and not need the support of a national care service, a rehab and EHPs as key to the future of a national care service. Thank you. Thank you. We've reached the end of our time with our first panel. I want to thank each and every one of you for the time that you spent with us this morning. It's all been very helpful. We're going to suspend for a 10-minute break. We now move on to our second evidence session, which is focusing on the independent review of adult social care, which was commissioned by the Scottish Government, and certain recommendations from which have been incorporated into the national care service Scotland bill and the accompanying policy memorandum. I welcome to the committee Derek Feely, the former chair of the independent review of adult social care, and we'll move straight on to questions. Thank you for joining us, Derek. The case for a national care service formed quite a number of recommendations in the report. I just want to summarise for everyone watching, but accountability for social care support. We discussed ministers. A national care service would be established as a statute. It would oversee local commissioning, procurement of all services, and there's a list of services that should come under its remit, and it should oversee social care provision at national levels of people whose needs are very highly complex. The driving focus should be improvements in the consistency, quality and equity of care and support experienced by service users, their families and carers, as well as improvements in the conditions of employment, training and development of the workforce. Mr Feely, do you feel that the bill encapsulates those recommendations as it stands? Yes, I think that it does. As you said, the kind of things that we hoped a national care service would be able to achieve was that clarification of accountability. One of the things that the pandemic taught us was that the public hold Scottish ministers accountable for what happens in social care, but the way in which our system of social care support was set up could not provide ministers with all the levers that they needed to give effect to that accountability. It was difficult for people like yourselves in the Parliament to hold any individual or individuals to account. I certainly remember as the director general for health and social care being regularly in front of this committee and the finance committee around healthcare matters, but never around social care. A string of those accountabilities seemed important to us. I think that the bill captures that. The idea that we ought to be able to set some kind of national strategy funding in direction or social care support, I think, is well captured in the bill. I think that there are a number of areas where much will depend on not how the national care service is established but what it does. We would all expect the national care service to be interested in removing some of that variation of what people called the postcode lots right to us as we discussed that issue with them. To pay some attention to portability of support packages across geographical boundaries, which is a challenge. Currently, you mentioned the importance of fair work in national terms and conditions. Some of that is difficult to co-define a bill and will depend very much on how the national care service operates. However, in terms of a basic infrastructure on which we can hang some of those things, I did not see anything that was particularly missing. You may be aware of previous sessions that we have had people representing their views that they think that there is not enough detail in the bill. The approach that you took when you were doing the review is that you have worked with people who are accessing the current services and people who are working in the current services. The proposal of the Scottish Government is to do a similar process of having a framework in place and then going to the stakeholders, various and many stakeholders, and involving them in a co-design process that will inform secondary legislation. Do you think that that is the right approach? It is always important to involve people with a lived experience of social care support. We did that in our independent review. Again, some of that was done in the consultation process that preceded the publication of the bill. I am never going to argue against further co-design with people with lived experience. I would like to see the bill as strongly represented as is humanly possible at every level of the national care service, including at the most senior levels. I think that there is a need now for some pace. It is 18 months or so since we published the report. As I have conversations with people in disabled persons organisations, for example, they would like to see things moving. There is going to be a balanced care that needs to be struck between that essential co-design and keeping up the pace of the reform programme and process. That is contrary to what you are hearing. People want to see pace increase and maintained, yet some people have had people today as well as last week calling for a pause. How does that square with what you are hearing from people? I am not sure. I was not able to listen to the evidence later, so I am not sure who is calling for a pause. The folks that I am hearing from are people who have lived experience, who are in disabled persons organisations, for example, who feel as if the creation of a national care service is the right thing to do, and they are anxious that some of the benefits begin to accrue. That is what I am hearing from those people. I wonder if I can just pick up on that point about the framework bill and the way that that has come. I wonder if some of the previous witnesses have said that the concern over a framework bill is that co-design could have happened prior to the publication of the bill and the bill could have been co-designed, and that you would have a different discussion in many ways. In terms of those calling for a pause, that has been fairly well documented. I mean, Social Work Scotland, Unison, the union, COSLA now. I am keen to get your views, Mr Filion, should there have been a co-design process prior to the bill. I do not think that anyone disagrees with what you are saying about people wanting to see intangible benefits. Do we need more pace around other parts of your review, for example, the removal of charging for non-residential social care support, investing money now and not waiting for the delivery of a national care service potentially by the end of the Parliament in order to move the dial on those things? I would suggest that there has already been a fair amount of co-design in the conduct of the independent review. The vast majority of what you see in that report is our views and proposals that came from people with lipids. I watched again this morning just to get myself ready for this, the short video that we produced to go along with the report. If members have not watched that, I would recommend that you go back and watch it again. The language that people use there is definitely the language of co-design. There is a lady in it who says that it is time to stop seeing disabled people as part of the problem and start seeing them as part of the solution. A good deal of co-design in the report itself is a lengthy and substantial consultation process that followed the publication of the report that has led to the publication of the bill. I am not sure that I would agree with any characterisation that there has not yet been any co-design. I think that there has been some. People might have different views about whether that is sufficient, but I think that there has been pre-existing co-design, which has got us to this stage. I am not suggesting for a second that we ought to stop that process. I think that we should continue that process during the bill's progress through the parliamentary procedures. I think that that needs to continue. I also think that once we get our national care service established, we need to switch from co-design to co-production. Those voices need to continue to be elevated and amplified and central to the decisions that get made about how we allocate resources and what are the priorities of the national care service. I turn to your second point about the other things. I am glad to hear your recognition that there were other things in our report, apart from the creation of a national care service. We recommended a completely different way to think about social care support, a new narrative for social care support, which is something that we could be changing right now without legislation. We recommended a whole host of changes to the commissioning process, to the implementation of things such as self-directed support, to the support for unpaid carers. Again, that is something that is really encouraging to see in the bill. However, there are probably some things that we could do right now without the legislative infrastructure that the bill provides. It will be a matter for the Parliament about whether the work on the bill is paused. I really hope that we continue to make the changes that people ask us to make on their paths. I appreciate that response. I appreciate what you say about co-design. I witnessed some of that myself in a previous role prior to becoming an MSP in terms of your review. In terms of the bill, as it stands as a framework bill, does it meet your expectations and the expectations of those who have lived experience? My contention would be that what people want is detail, to help co-design that detail and to do that through the legislative process rather than after the fact. That feels like a very structural bill rather than being about culture. It is very difficult to capture culture in a bill. Whenever anybody talks to me about culture, I refer to the work of Edgar Shine. Edgar Shine says that the only way to change culture is to solve problems differently. We need to get outside of the bill and into what a national care service is going to do. How is it going to do it? How are people with lived experience going to be listened to in that process? How are we going to remove some of those variations that exist? How are we going to make sure that we can scale up and spread promising things in Scotland, of which there are many? That is how we will change the culture. I do not think that the bill is a good vehicle for changing culture. I cannot speak for the authors of the bill, but I am pretty sure that that was never the intent. The bill has to do what it has to do, which is to create some kind of structure around which we can hand the creation of a national care service. The real work will start when we have a national care service and it has to completely change the narrative about social care. It needs to make sure that all the good stuff about that exists in Scotland, such as self-directed support, gets properly implemented. It needs to make sure that promising practice is available to everybody in Scotland, not just to people in pockets. That is how we will change the culture. Two questions from Tess White is also remote. Thank you, convener. The bill has been described by the convener of the Finance and Public Administration Committee, Kenneth Gibson, that the NCS bill is like using a sledgehammer to crack a nut. Can you comment on that, please? I am not sure, but I am well qualified to comment on that, to be honest with you. Some kind of bill is required in order to establish a national care service. I think that the combined wisdom of the bill architects and the parliamentary process is how we ought to establish whether the bill is fit for purpose. I do not feel well qualified to make that judgment. My second question, convener, for Maze. The Finance Committee again had serious concerns about the financial memorandum accompanying the bill. What is your view of that? I think that we made a very deliberate decision as we were creating our report, which was to deal with financing as, if you like, a large order issue. The first thing that was important to us, and I think that it is the case with the bill, is what do people who rely on social care support need and want? That, for me, is the most important thing. The gearing is deeper understanding as we can get about what people really need and want and how they would prefer to receive it. What kind of system do we need to build in order to deliver on those people's aspirations? That is at least in part what the bill is trying to do. Third order question, how do we pay for that? I think that unless and until you do the work on any deep understanding and then being able to describe the system architecture that will get you that, it is probably too early to say anything definitive about finances, the finances will need to be sufficient in order to do those two things. I would be the first to admit that the job that we did in the independent review on financing was incomplete. The best we could in the time that we had available was to try and identify things such as on-net needs, to try and identify what it would take to rebuild some of what had been lost through the pandemic, but it was very difficult for us to do things such as fair pay, for example. I am not sure whether a financial memorandum to the bill is either a really great vehicle for being able to make some kind of assessment about what it would take to pay everybody in social care or fair wage. That is a roundabout way of saying that I think that the financial memorandum is going to be difficult to create until we have some kind of definitive answer, including to some of the questions that Mr O'Kane wrote. We now want to ask questions around the human rights-based approach led by Stephanie Callaghan. I have heard some criticisms at times that the bill is not sufficiently focused on prevention and early intervention. There is not much mention of it there in the memorandum, too. I wonder whether that is something that you see as a bit of an issue, or do you feel that that is part of the human rights approach to the bill, or is there something else that we should be doing there to put prevention and intervention more at the centre of the framework bill? I certainly think that the human rights approach should be absolutely essential to everything that we do around the creation of the national care service and the on-going improvement of social care support in Scotland. I think that it is absolutely essential. In the principles that are outlined in the bill, there is something, and in the creation of a charter, again, there is something. I think that those things can always be strengthened. Human rights is one of those issues where, unless we are absolutely explicit about what we mean and what we want, there are opportunities for that to be prioritised. Anything that the committee and the Parliament can do to strengthen the explicit nature of the human rights requirements would be welcome. I ask you, as well. Obviously, human rights is absolutely at the centre of that approach to social care to be delivered. Quite often, it seems to be at odds for some people with the constraints of finite resources that we have there. Is that always true? Is that your experience of it, or does that kind of investment in that approach mean that people are not necessarily reaching crisis? I noticed that you said earlier on about that shift in focus to prevention and early intervention really strengthening the human rights approach to social care, and the fact that the informal community initiatives that are going on there and that can underlie things as well often mean that smaller issues are not grown into much bigger issues, because that supports happening locally. I think that it is wrong to assume that our human rights approach is more costly. If we think about some of the rights-based approaches, for example, like the panel approach, it does not really cost us anything to enable people to participate. There is no additional cost in enabling people to feel that someone is accountable for their human rights. Non-discrimination is likely to be less expensive than discriminating against people. Enabling people to do more for themselves and to live the independent lives of them probably on balance likely to be less expensive than more expensive. That enablement point is connected to the barrier question that was about prevention. There are a few things during the course of the independent review that really struck a chord with us and made us craft our recommendations in a particular way. One was when a young man in a conversation that we were having with a group of people with learning disabilities said to me, that he was thinking about this entirely the wrong way, that social care support should not be a safety net, it should be a springboard. The second was when I spoke to a senior executive in one of the voluntary sector organisations, and they told me about the fantastic programme that they had developed that was about the early detection and early intervention with people who had dementia. They had been able to demonstrate that through that early intervention they could delay people's admission into care homes and enable them to live where they wanted to live, which was at home for most of them. They could do that less expensive in a less costly manner than admitting them earlier to a care. It was like the kind of perfect trilogy, and I said to them, that is fantastic. They had that in two or three local authorities. How are we going to get that scaled up? He said, well, I am going to have to go sell that to 32 local authorities. One of the things that a national care service ought to be able to bring is an ability to identify those promising early interventions and bring them to full scale in a much more effective and rapid kind of way that would chime with people's expectations around their human rights. I think that there are some huge opportunities. I also think that it is incredibly encouraging that we are having this conversation about human rights as well. I read some of the research that your parliamentary colleagues had done. We did a fair bit of that international research ourselves as we were doing the review. There are very few places in the world that are having this conversation with a human rights focus. I commend the committee for doing that, and I encourage you to continue. I have spoken to people who rely on social care support and would want you to do that. Just a short question, thank you very much for that. Is the bill introduced then? Do you think that it will create the conditions for innovation? Is co-design and co-production well enough understood? Is it broadly enough understood right across health and social care? You will probably get as many definitions of innovation, co-design and co-production as people that you spoke to. Again, I am not absolutely sure that a bill is the right place to do that, but I have some kind of definition of what we mean by co-design, co-production and innovation in the explanatory notes or in the policy memorandum. It would be no bad thing, but whether you could define that in a bill, I am not sure. For me, what we meant when we talked about innovation in our report was that innovation is the bridge between an idea and implementation. We do not really need a lot more of creativity in Scotland. There are plenty of ideas. Our challenge is turning those ideas into things that get implemented reliably. The self-directed support is a great example of that. It is a fantastic idea. It is groundbreaking, it is world-leading and, according to the report that was done by self-directed support Scotland and the Alliance during the course of our independent review, it is implemented properly for about 50 per cent of the people. James Dornan, what are the innovations that can get us to 100 per cent? Apologies, I cut you off there. That is always the danger of when you have a remote participant. No, I had financial issues. It is always technical and I have asked me a question about innovation, which I am passionate about and I probably spoke too long. Can I bring in James Dornan? Thank you, convener. I would suggest that, in that example that you used to Stephanie, you just showed the benefits of centralisation. Can you tell us what you think are potential risks associated with that, the essentialisation of accountability? I think that the main risks lie in a couple of areas. First, we separate the national structure and system of accountabilities too far away from individual needs rights and preferences. That is why, in our report, we recommended that we mitigate those risks by ensuring that people with lived experience get a voice at every level of the architecture of the system. One of the things in the bill that I am somewhat nervous about is the idea that the national care service at the national level ought to be a part of government. We recommended very specifically that we ought to set up some kind of arms-length body to hold the national care service. That arms-length body should have people with lived experience on it, should have unpaid carers on it, to make sure that we do not have that separation of central national level accountability and individual needs rights and preferences. That is the first risk that we would have to manage, but I think that it is manageable. Secondly, Scotland is quite a diverse country in terms of rurality and social determinants of health and wellbeing. We would need to make sure that a centralised national level entity paid juvigard to those kinds of things, but that is why, in our report, we recommended that integration joint boards or some kind of form of those ought to continue. I am assuming that that is the intent in the bill around the care boards is that they are able to capture some of that local diversity in fact of the minute. With any kind of system design, you are going to have some risk. The risks of the current design is that it gives us what we get, which is enormous variation and a real challenge in doing anything that works at a national level. We just have to manage the risk. I get that. In the process of your investigation into your report, you have come across a barrier to the idea of centralisation from the dentist. I do not mean that in a critical way, but, like some people who are doing the jobs just now, did you find that they were opposed to centralisation because you thought that it might take some of the influence and power away from them or that it might damage the service? For a large part of the work that we did on the review, it was quite difficult to have those conversations with people because folk were unsure at that stage about what a national care service was. People had a different sense about what it might be. It was not until quite late in our review when we started to begin to pull our recommendations together and test the ideas that we could have some of those conversations. It was no surprise to us that our recommendations were not universally well received, because we were recommending changes to the status quo, and that is always difficult for us. The encouraging thing for us was how well supported the recommendations were by people who relied on social care support or folks who represented those people. To be honest, Mr Dornan, they were my primary audience. They were the people that I was most interested in hearing from and in satisfying their requirements. That was encouraging for us. The other thing that amplifies that a little bit is that in the consultation around the recommendations, the vast majority of people seem to be supportive of that as a direction of travel. There will be some people who fear the changes to the status quo and what that means for them. However, our guiding principle should be to dismiss the needs, rights and preferences of people who need social care support. What are we saying about what we are doing? For the most part, as I said in my initial response to the convener, they remain committed to the idea of a national care service and to the other things by and large that we recommended in our court. Some of them are getting impatient and want us to get on with it. Obviously, in your work on the independent review of adult social care, you were taking evidence from service users, from those who work in social care and things around that. Obviously, there are a lot of work streams in the bill and in the co-design going forward. What would be your reflections on how we ensure that this is sustainable for people to be able to maintain giving their input and participating in that co-design, given the number of streams, so that we make sure that this is coherent across the piece and does not fatigue some of those voices and some of those really important stakeholders who maybe have small teams working behind them? I think that we need to make it as easy as possible for people to engage. What people told us during the course of their review was that you could bother down just the four things. They said to us, hear our voice and see us as a partner in all of this. What we do too often with people is we bake something, we construct something and we say to them, what do you think of this? That is not what we spoke to today. That is not really what they want. They want to be engaged as an equal partner. They want to hear and have their voice heard. The second thing that was really important to people is that we need to take into account, as we do in the various work streams that you described, the conversation that we were having earlier about human rights. A basic human right is the right to participate. We need to give people that right and honour other human rights in that kind of way. The third thing that people asked us for was, can you just make this a bit easier for us, please? That eased my way into those discussions. Anything that can be done around just describing those changes in ways that are meaningful for people will help us a bit. In another way, when we did our review, which was right in the heart of pandemic during periods of lockdown, it made it easier for people. It meant that we could talk to many more people than I could ever have done if I had been meeting them face to face. It democratised that process a little bit. I suspect that a lot of people spoke up or put strings in the chat that might have been good news in a face-to-face meeting. It will give people multiple ways to engage, I guess, is what I am suggesting. The fourth and final thing that I have already mentioned is that people want to be seen as part of the solution and not part of the problem. My experience is that folk will not come up with fantastic ideas if you just give them the chance to do that. There is something about the way in which we engage there that seems really important. Emma, you have a question before we move on to the next theme. Thanks, convener. Good morning, Mr Feely. Just a quick question about the national care service charter that is part of the bill in section 11 and 12 that talks about the creation of an NCS charter so that it is publicly available and it also includes the monitoring of the charter or reviewing over five years. I will be interested in your thoughts about including a charter in the bill, specifically as it relates to the human rights approach and supporting people, especially in the receipt of care, because this is about embedding support for folk with lived experience, as I understand it. I am very supportive of the charter being in the bill. As I said to one of your colleagues, if we could make that even more explicit about human rights approach, I think that that would be a good thing. I think that it is also an opportunity in the charter to emphasise that new narrative that we described in our report that talks about social care as being preventative and anticipatory, as being about relationships rather than transactions, as being about a vehicle for independent living rather than a place for services. The idea of a charter is something that I support. I invite the committee to think about making it as explicit as we can possibly make it so that there is no regular room for people once we come to give life to what the charter says. We are now going to ask questions about leadership and accountability, led by Evelyn Tweed. The independent review highlighted that we should move towards accountability for social care to ministers instead of local authorities. The Scottish public expects ministers to be accountable, and it was a reasonable expectation given the impact on national wellbeing. Can you outline for us the benefits to people, Scottish people, of this move? There are a number of things in our mind as we made that recommendation. The first was to try and give parity between the national care service and the national health service, so that people would feel the same way about a national care service as they feel about the national health service. We all appreciate how precious the NHS is to people, and we want them to feel the same way about a national care service. There is something about that parity of esteem between health and social care that was really important. The second was about the nature of those accountabilities to which you referred. Again, the context in which we were doing this was in the context of the pandemic. Social care, especially care homes, were on people's minds like almost never before. The people who were being held to account for that were Scottish ministers. However, they did not have the powers and the levers to fully exercise those accountabilities. They could not make directions. They could not be sure what they thought were the priorities for resource allocations were shared priorities. It was challenging for us to have a parliamentary scrutiny that we will be able to have in the future. Again, as I suggested earlier, as a countable officer for the NHS budget, I have welcomed that level of scrutiny, but it does not exist in social care just now. I do not have to tell you this, but you are doing this on behalf of the people. That is another way in which this will strengthen accountability directly to members of the public through their elected representative in the Scottish Parliament. It will give social care a profile that it has not had previously. The third thing that we wanted to see was a truly national strategy for social care, a proper plan for social care that was informed by what the public told us they needed. Again, that is an opportunity that presents itself that we have not had previously. I am encouraged by what it says in the bill about the need to produce both national and local strategies. You said earlier that this is a groundbreaking world-leading approach in the way that Scotland is looking at national care service. Can you expand on that? Can you tell us why? I think that much of what is groundbreaking already exists. Self-directed support as a vehicle for social care support is ambitious, as you will see anywhere. The idea of Scotland's commitment to an independent living fund when some of the other countries in the UK were abandoning theirs is much in the existing system that is already groundbreaking. The problem that we have is implementation. Historically, what we have not been able to do is turn those groundbreaking ideas into something that every single citizen in Scotland could count on every time they had a need for social care support. That is the missing ingredient that a national care service can help us to create. If we could get some of those groundbreaking initiatives that are implemented at full national scale, Scotland would be way beyond what other countries aspired to. I can pick up on your response to everyone's tweet about accountability and this Parliament holding being accountable for social care and the minister being accountable. Would it be your view that social care currently is not being held to account by elected members and councils, and also by appointees of health boards who sit on IJBs appointed by Scottish ministers? I think that the concern that COSLA would take exception to that in terms of how councillors are connected to their communities and then hold social care accountable. Is not the principle of local accountability at stake, to some degree, if we focus everything on this place? I think that this is in part about what is the right balance between local and national accountability. It is also important to recognise that, at least in our report, we envisaged a continued and very important role for local government as providers of care services as partners in integration joint boards or in care boards as the place where you would expect to see a lot of this innovation happen around residential care and prevention. We envisaged a really important continued role for local government and therefore a continued need for local accountability. We recommended that social care ought to be seen in the same way as healthcare as something that had national accountabilities in Scotland. We wanted to be as clear as we possibly could about how those accountabilities would work. This fell important enough to us for our Scottish Parliament to be the primary place where those accountabilities would be excellent. One of the questions that remains unanswered comes from Reform Scotland, which felt that there has been an adequate explanation about why simply removing local government from social care will lead to an improvement in delivery. They pointed out that the loss of local understanding and accountability, especially in the more rural areas, were highlighted as risks to the proposals. The part of the responsibility of care boards, however, will be to provide that local understanding of particular local needs. I think that, as Paul O'Kane alluded to, I was attempting to respond to that. There will always be some kind of balance of local and national. I guess that it is about finding the right point of balance. That might well involve some kind of rethinking around how we constitute those relationships between national and local government. The main things that we saw in local delivery that we wanted to have a national care service resolve were around variation. Lots of variation in terms of eligibility for care, whether they could get into the system or not. Quite a lot of variability about whether they would be charged for services or not. Quite a lot of variability around the nature of the provider organisations that were in that particular locality. We saw an opportunity for a national approach to deal with some of that variation. The second thing that people asked us about was portability. Why was it that their care packages were not portable if they had to move? They had to start the whole process again in a new locality. Couldn't we do something about that? A national approach seems more likely to be able to resolve that issue than a local one. What is the idea about whether we could better scale up and spread promising practice at a national level or whether that would be better done with 32. Our view was that we were more likely to get national application of promising practice through a national approach rather than through a localised one. However, there is always a balance to be struck in these matters. I think that the challenge for us is to find the right balance. We have a question from Sandesh. One of the interesting things you said was to set up an arms-length body. I think that it is clear that the bill, having spoken to the bill's unit, will not happen. This is not what is going to be happening here. It is a £1.3 billion set up. Audit Scotland says that this could be more. So, as far as taking that money away from those local areas and local governments, do you feel that amount of money would be worth while in setting up the national care service and taking away the potential from places like local government to lose units that they were saying they might lose their lawyer unit because of the work that would be taken away from them? The main reason that we recommended that the national care service got to have its own border governance was to make sure that the voices of service users and unpaid carers would be heard around the top-most decision-making table in the national care service. If there are other ways to achieve that, people should consider what those might be. That was why the underlying rationale was to make sure that in making decisions about strategy for allocation of resources in the national care service, the voice of lived experience was represented in those discussions. In setting up any new organisation, there will inevitably be some changes to people's roles and functions. It strikes me that there must be at least an opportunity for greater efficiency if we do things at a national level that ought to be done at a national level. As I said earlier about the question of balance, we continue to do things locally that are better done locally. However, some proper and detailed analysis of what we should do once for Scotland and what we should continue to do at either a health board or a local authority level is probably a useful thing to do at this stage. Some questions about the workforce and fair work are included in the bill in the first section that the national care service is to be an exemplar in its approach to fair work for the people who work for it and on behalf ensure that they are recognised and valued for the critically important work that they do. In the previous session, we heard from Nick Morris that the national care service should allow the raising of greater awareness of the work that social care staff and social workers do. I would be interested to hear in your comments about the fair work principles that are included in the bill and whether you think that anything still needs to be added. Are there any gaps? I think that this is a really important issue. Whether we spoke to it in the course of our review, people would say to us that they invest in one thing and invest in the workforce. That came from service users and organisation, which is anything that has much came from the trade unions and others with an interest. I need to invest in the social care work. We identified a potential vehicle for fair work in a rethinking of the commissioning and procurement process and the introduction of an idea that came from one of the trade unions around the notion of ethical commissioning. The bill makes reference to ethical commissioning. What we need to be sure to keep on the table is the connection between those two things. We ought to use a redesigned process of commissioning and procurement as a vehicle for fair pay. Assessive, what we would be saying to care providers is that, if you are going to receive public money, here is a set of expectations that we have of you. One of those would be that you pay a fair wage. A second might be that you are transparent about your company's profits. There is a set of things that we set out in the report that we identified as potential conditions for ethical commissioning and procurement. As long as the bill is explicit about the commitment to fair work and the bill sees that ethical commissioning and procurement as a viable route for securing better pay for social care staff, I think that that will be satisfactory. For me, as a former clinical educator, I liked the national pathways, skills development, the ability to look at how we measure the same quality of care that is being delivered whether you are in Stranrair or Stornoway. I would be interested in your thoughts on establishing national recognised career pathways so that we can focus on recruitment and retention so that career development helps to focus on value in the staff and what care they are providing. It would be interesting to hear your thoughts on that. That is really important. People begin to see social care as a viable career. I think that we also need greater certainty for staff that they can and will be released for continuing professional development. Sometimes it is a bit of a challenge for some other way. I also think that we need to be thinking now about new roles. One of the ways in which we could give effect to the underlying case in the independent review and in the bill for integration is at the point of service. From the end-user's point of view about what I really need here, is it necessarily someone from healthcare and someone from social care, or is there some kind of hybrid, integrated role that we might imagine? I think that that might well open up some of those career development opportunities to which you refer. Carol, you have questions on unpaid carers. I think that we can all agree that traditionally as a group who have been quite undervalued, but we really are recognising the great contribution that carers make. I wonder if you could give us a little bit of your feel for the bill as it is introduced, how that will support carers. Do you think that there is sufficient information about how they can help in code design? If we go on, how they can become full partners in any forward-going national care service? I welcome what is in the bill about, and that was one of the things that unpaid carers asked us for. I feel that we need a different term for unpaid carers, because it does not seem to do justice for me to what those people contribute to our system of social care support. However, I think that that is what people are calling themselves. Maybe we should just part that issue and return to it. They are foundational to the way in which social care support works. I think that there is no exaggeration to say that the system would be swamped without them. Anything that we can do to make it easier for them to continue to do the kind of stuff that they choose to do or to be encouraged, respite is one of those things. In the numerous conversations that we had with unpaid carers and their representatives in the bodies during the course of the review, they asked us to be heard. We have got the somewhat dath situation just now, where unpaid carers can be part of integration joint boards, but they do not have voting rights. Why would an unpaid carer not be able to vote around a board table in the same kind of way as everybody else? We should just make it as easy as we possibly can for people to continue to do the kind of things that they want to do. There is a lot of really good stuff that is already available. The introduction of carers plans was a massive step forward. Again, the challenge there is implementation. Not every carer has a carers plan, although they should. The big challenge there is let's get that fully implemented at a national level and remove against some of that variation that currently exists, where, whether you have a proper plan and support package is somewhat dependent on where you live. Just come back with one more thing. Thank you very much for the information. In terms of carers being able to get breaks and support with breaks, do you think that there is anything that we need to add into the legislation to make sure that that is a statutory responsibility? I would need to look again at the bill that I did earlier, but I can't remember exactly how explicit it already is in the current draft of the bill. I guess that the same kind of approach that is referred to for human rights might apply here. Anything that we can do in the passage of the bill to make that as explicit as it can possibly be, the unpaid carer community would welcome that. Final questions on ethical commissioning, which we have spoken about a little bit, but from Stephanie Callaghan. We have said quite a bit about the ethical commissioning procurement already. Could the recommendations of the review be made within the current model? Why don't you consider alternatives such as public social partnerships or alliances? Is this radical redesign of social care commissioning absolutely necessary? I think that a redesign of commissioning is absolutely necessary. There are very few things that everybody we spoke to absolutely agreed on, but one thing is that the existing system of commissioning and procurement is not working well for anybody. There are some things that can be done outwith the bill, and there may well be some things that will need statutory underpinning to give them effect. We did make reference to other potential reforms and other ways such as alliances and public social partnerships. There is a fantastic publication that we drew on from one of the voluntary sector organisations, the CCPS, that outlines a whole range of possibilities around different ways to commission. If you have not read it, I would recommend that we drew heavily on it for our report. However, the short and straightforward answer to your question is, do I believe that radical redesign of commissioning is necessary? I note as well the cause of submission to us. It talks about the bill failing to address the difficult issues that were set out in the independent review and adult social care about profit in the sector and private sector provision in the account for 76 per cent of care homes, so it has really been about profiting rather than reinvestment. Should the reform and non-residential and residential care funding be included in the national care service bill? One of the things that I was looking for on the bill today was something specific about the market oversight function that we recommended for the care inspectorate. We recommended in our report that the care inspectorate duties ought to be extended to enable them to conduct some financial oversight of the market. I feel kind of bad talking about social care as a market that shouldn't be that way. However, I couldn't find it in the bill. It may well exist and I've just not found it, or it might be that it's been determined that it doesn't need a statutory change that might be able to be done administratively, I don't know. However, I still think that it would be useful to strengthen the powers of the care inspectorate to examine the finances and the financial viability and conduct of care providers. Then what we were recommending was that ethical commissioning and procurement ought to be the vehicle that we used in order to get some greater transparency about profit. It's very difficult to get any kind of handle on exactly how much profit is being made and where it's going. Given that this is largely public money, we ought to be able to get that sort of information. That was part of the new deal that we were trying to set out in the report that, in return for the receipt of that public money, people would sign up to greater transparency and as well as fair pay. Thank you very much. That's all our questions. Derek Feeley, I want to thank you very much for your time that you've spent with us this morning. I'm really tying the report and the bill together in terms of intention. It's been very helpful. That concludes the public session of our meeting today. Our next meeting, the committee will continue our scrutiny of the National Care Service Scotland Bill with the further two evidence sessions, but that's it for today.