 Gweithdoedd, wrth gweld, provided fear. The meeting off the health and Sport committee in 2017 can ask everyone in the room to ensure that their mobile phones are not silent It is acceptable to use mobiles for social media but do not take photographs or record proceedings. The first item on the agenda is around table evidence session on care home sustainability I will introduce myself and then we will go to the clock-wise round the room if people could briefly introduce themselves. before doing that, I apologise for tempature in the room, there's been a problem with the heat sensors today it's a bit colder but hopefully it will heat up quickly so my name's Neil Findlay, Hanaways Jeice the Health and Sport Committee and i'm MSP for the Lodian region good morning my name is Ash Denham, i'm MSP for Edinburgh Eastern and I'm the deputy commander of the committee hi i'm Pauline McClay home rydw i'ch bod yn oedden nhw fel dawnod o'r mynd yn dyfodol. Rydw i'n gweithio yn cyd-rhywun allanol o'r wladol�� Videos i gychydigol i gyrdd ymlaen sydd yn cyd-rhywun allanolol o'r sylwgr. Rydw i'n crossedrwyddol o'r cyd-rhywun allanol a'r cyd-rhywun allanol o'r cyd-rhaen o'r blaen sydd yn cyd-rhywun allanol o'r cyd-rhywun allanol o'r cyd-rhywun allanol o'r cyd-rhywun Good morning. My name is Gordon Paterson. I'm the chief inspector for adult services at the Cairns factory. Good morning. My name is Emma Harper. I'm at MSP for South Scotland region. Morning. I'm Brian Logan and I'm chief executive of Beald Housing and Care. Hello. Alison Johnstone at MSP for Logan. Hello. Annie Gunnar Logan, director of the Coalition of Cairns support providers in Scotland. For transparency chair, I should also say that I'm a non-executive director in the Scottish Government, but I'm not here in that capacity today. Hi. Ivan McKee MSP for Glasgow Proven. Good morning. My name is Michelle Miller. I'm the interim chief officer for the Edinburgh Health and Social Care partnership. Good morning. I'm Brian Whittle. I'm a conservative south of Scotland MSP and party sportsman health education lifestyle and sport. Good morning. Sandra White MSP for Glasgow Cailfin. Good morning. Sheena Simpson, policy lead, Scottish Federation of Housing Associations. Good morning. I'm Colin Smyth MSP for the south of Scotland. I'm also a Labour spokesperson on public health and social care. Okay. Thanks very much. This morning, we obviously want to keep this as free-flowing as possible, so if people just indicate to me, I'll try and bring in as much as possible. There's two sections we really got. We've got what to start off with looking at specific issues relating to Beald Housing Association itself and the issues around that. Then we want to talk about wider sectoral issues that have emerged on the back of that. Alex, you want to begin. Good morning to the panel. I'm very grateful to you for your time this morning. Specifically to Brian from Beald. Thank you for coming along today. Obviously, this is an issue that has garnered a lot of attention in the media, not least this morning. Indeed, it has in terms of case work to, I'm sure, all of my colleagues around the table in one way or another, either through residents in homes in our constituencies or through relatives who are concerned about those. I think that the first question I would ask is why was so little notice given to families and residents about the intention to close and in some cases that people were being accepted into placements in these homes just weeks before the decision was taken? We made our formal announcement on 10 October at the amount of time that we've given to residents, their families and indeed to our partners in health and social care to find alternative accommodation is, in many cases, six to nine months. We started having some discussions confidentially with health and social care partnership colleagues in mid to late summer. So, contractually, we're only bound to give 90 days notice of our intention to withdraw from a service. We feel that we've given more time to residents and their families to find alternative accommodation. In some cases, up to nine months, we're working very hard with other organisations to try and find alternative solutions, whether that's a transfer to an alternative provider or to find alternative accommodation. The minute you make this type of announcement, business starts to fall away and staff will start to leave. Once we had made the decision, we wanted to move on it pretty quickly. That's the timescale that we're working to. We also have a financial imperative in there as well. We are losing significant amounts of money on our care home business and have done that for a number of years and have subsidised that from our reserves. We needed to take action and we needed to take action quickly. Thank you for that. The follow-up to that is what comfort can you offer those residents, for example, in my constituency in Dunsbury Court, which is an assisted living facility, not a care home, that there is no threat to addition of the other kinds of facilities that you have in the social care environment? The facility that you're talking about in Cersdorffan is a retirement housing complex. That's the bulk of our business. We have over four and a half thousand properties that we manage of that nature. There is no impact on any of those residents living in those retirement housing complexes. Those services will continue as they are well into the future for the Siebel future. The final question is to widen it up. Do we need to change the rules that Government care homes in the amount of notice they need to give to their residents and the families who support them when a closure like this happens? How hostile is the landscape? How many other organisations are in this kind of trouble? Or do we know? Certainly there is an issue in terms of the availability. I can only speak for Edinburgh, but at the moment we're running at a pretty steady state of between 60 and 70 care home places short in terms of the need. There is an issue there around general availability. What is the analysis of the reasons for that is probably complex and multifaceted. I'm not sure that I would be able to come up with just a single answer. Cost is inevitably an issue, however. We need to think about going forward what a reasonable and realistic rate would be in relation to care home places. I really don't think that we can just look at that in isolation. I think that the care home contract has served us well over the years, but given that going forward the model of service provision needs to change and is likely to change and I think has to reflect the aspirations of people who perhaps don't want to be spending long periods in the latter part of their life in what has been traditional residential care and what does that mean? What does the personalisation agenda mean for the shape of the market? I think that we need to look at it beyond just individual residential care issue and look at the whole of social care provision for older people and what that might look like and then within that what are the realistic expectations both in terms of standards and in terms of affordability and I think that is a question that goes beyond individual partnerships and their budget arrangements, but it is a wider discussion to be had across the piece around what care we want to provide, what does it look like and how much is it going to cost us and how much we can afford in terms of that public resource availability. Final one for me just before I can see other hands coming up on that, but just as a corollary is that the 60 or 70 people who are waiting for beds, what is typically happening to them right now? Are they sitting in hospital or just at home? Perhaps you don't have the figures for that, but how do you measure that? The majority are in hospital because typically if people need a residential care placement it is because their level of frailty and dependency is very high and I think the challenges in Edinburgh in terms of people delayed in hospital waiting for alternatives is well documented, so the majority will be there or some might be in short term provision that is also very high dependency but is not a long term solution in terms of residential care, so that's where we get our figures from. The 70 become 90 to 100 when these two close? Not specifically. In Edinburgh we are hoping that the provision for the people currently within Edinburgh care homes, we are hoping for a transfer and we are still looking at that. But the capacity is coming out of the system? Yes. So that's going up, you'll likely increase the number of people waiting, you take 28 places out of the system. Well so in theory in straight numbers yes, although as well as the 60 to 70 people waiting for a care home there are vacancies across the city but actually at costs that are well beyond the national care home, right? Okay, Jenny. In the Scottish Care Submission, Dr McCaskell, you say that the numbers employed in care homes have fallen slightly since 2008, thus an overall staffing reduction is in itself an issue of concern. But on page 7 of your submission, Brian Logan, you say that you have essentially a higher staff place ratio, so for example in Glenrothes where I represent in Ffineven court you get 24 service users with 25 staff, but if you look at some of the other figures from across the country, Westport and Llythgo for example with 14 places and 25 staff. In the Fife, Health and Social Care Partnership submission it says that we continue to have capacity within care homes, we have no other sustainability issues. So Brian Logan, I'd like to ask a direct question. Were staffing levels sustainable? The staffing levels that we have in place were suitable to deliver the services and that's why consistently we were scoring high grades with the care inspectorate. Our staffing levels will vary depending on the size of the care homes, the physical layout of the care homes. Sometimes the care homes were designed on the basis of a particular staffing model. We will have made changes to some to make some efficiencies over time, but in others because of the physical layout of the building we simply weren't able to do that. That's why there will be variations in terms of those ratios. We feel that the levels of staffing that we had in place were appropriate to deliver high quality of care to our residents and certainly the feedback that we've had even through this very difficult period has been the quality of care that has been first class in our services. I suppose that the wider context before focusing on the build issue and that's to reflect the fact that there's been shifts in the market over the last five years. In 2013 there were 905 care homes for older people in Scotland providing over 38,000 beds and in the five years since that's reduced by 56 care homes coming out of the market. Now that's reduced the numbers of beds by 883. One may have anticipated that with the demographic challenges that are being faced and notwithstanding the policy to try to support people to live at home for as long as possible that we would have seen an increase in the number of beds. That potentially said something about capacity and sustainability issues. In relation to the build situation particularly, we have found it quite unusual to see a situation where a first sector provider has decided to withdraw from the market and to withdraw 12 well-performing care services. We've seen closures of care homes over the years, we've seen single care homes being closed as part of a corporate company but in terms of this situation it's most unusual that we haven't encountered that as far as I'm aware in recent years. Why do you think it is then that it's happened? It's a combination of factors. I mean, I've been able to have conveyed them in their submission. I think that it's partly to do with the service model that they sought to deliver, which was better designed to meet the needs of people who were far less, who had a greater degree of independence than the current clientele. I think that it's to do with the environmental model where they have flatlets with large rooms and it's more difficult to provide the support to those people, to those residents. I think that it's something to do with rising costs not being matched by increases in fees, so I think that it's a combination of all those factors and be able to have outlined them very effectively in their submission. I just want to respond really to Mr Cole-Hamilton's comment about the hostile environment. I think that that's an unfortunate term, if I might remark, because the environment is fragile. There are a number of organisations and the Scottish Care submission has articulated this, who we know are at the point of making decisions about whether or not they need to withdraw from the market. Those are on the constituency that Gordon has highlighted from the voluntary and charitable sector. The basis for that decision making will be on the basis of financial viability. Can they continue to deliver dignified, rights-based, person-centred care on the allocated finance? Increasingly, organisations are, despite the degree of commitment from local authorities through the national care home contract and increasingly coming to the point of deciding, is this sufficient given increased dependency, increased demand and the huge difficulties that we have? We might want to come to talk about that later on with recruitment and staffing. Is it possible to sustain yourself in the sector? It's not appropriate for me to comment about Beald, but I know a number of other significant players who are profoundly concerned about their sustainability in the next calendar year. Jenny, do you want to come back? Just as a supplementary and really quite specifically to the constituency I represent, Fiona Mackay and your submission, you talk about there being a buyer found already for the care home that is affected in Glynothus. Are you able to share with the committee who that is? Are there any more details on that? Are you able to tell us a little bit more about the two care homes that are affected and confirm on that? That might bring yourself in Brian Logan again. Lastly, you note that the working group is going to reconvene in early December. Has that happened yet? The future of those particular homes, how a new buyer can make them viable when the previous one couldn't? For Glynothus, which is from Avoncourt, yes, it has been bought by Kingdom homes and they have written out to the relatives saying, now it's not all concluded yet because these things take time, but at the moment, the letter that we've had from Beald is that that home will transfer and we will support the relatives and families and the service users to make sure that that happens smoothly. We know the person or the company that's bought that and they've got quite a lot of care homes in Fife, so we're confident that if they can see that through then it will be a good opportunity for them. Round about, Fenevan has quite a bit of land and we know that the provider in the past has, when they've bought other homes, they've developed them, so they will look at a refurb I would think because, as Brian said, the care home in Glynothus has a different model to actually the care homes that the provider already has, so there probably will be work done on that to actually probably bring up more beds in it than it is at the moment, but it's good news that we've been able to do that. Dunferman's a very different situation because Beald have said they want to retain these buildings, but the people cannot stay, so we have to look at a different provision for them. Luckily, we have quite a lot of new-build happening in Fife and we're building care villages ourselves. We have a care village due to open in April in London, which isn't that far away, and we also have our own provision. We were developing a new model of care in our own care homes and we've put a halt to that, so we are now sitting with between eight and ten beds in a unit and we would hope to see if people can transfer en-masked from the care home and when we've done the reviews of all the people, lots of people want to go to that home, so it's really pleasing that we maybe have a good outcome from that. We have a task group set up and actually meeting today again just to look at everybody who's been reviewed and what their choices are. Brian Hitton, why could Beald not make it work in another organisation? If I can just first of all comment on the situation in relation to Glenrothes and Dunferman, and then I'll come back to that. In relation to Glenrothes, feeling is absolutely right. We are in advanced negotiations now with Kingdom to transfer that property across to them. We've had some discussions with them. We've had an offer in place and we're now going through a due diligence process, so we're very hopeful that that transaction will be concluded as soon as possible to give certainty to the families and the residents and indeed our staff within that particular facility. In relation to the smaller care facilities in Dunfermline, we haven't had any expressions of interest in relation to those two properties. We've had numerous expressions of interest since we made our announcement across our suite of care properties, but no interest coming forward in relation to those two in Dunfermline. Obviously, if those came forward, we would have looked at those, but nothing has come forward to date. Fiona Mackay just said there that you wanted to retain the buildings. Is that not the case then? Hold on, I'm just coming to that. Those two facilities are adjacent to existing other Beald services, so they are attached. They're integrated services and they're attached to existing retirement housing facilities. We would obviously do an options appraisal, as we will do for any surplus assets that we end up happening. We will undertake some sort of options appraisal as to what the best solution would be, but given that we have retirement housing, which operates very successfully in those two developments, it would make sense for us to extend through and provide additional retirement housing facilities in those care homes. Now it would require a bit of investment to achieve that, but we think that that can happen relatively straightforwardly. Yes, there is something that we can do with those assets. We can retain them within the Beald suite and keep some services delivered for older people in the Dunfermline area. In relation to how others can make it work, clearly it's not for me to comment on how other providers would make those facilities individual. You know the business, you know the market. I'm coming to that. How are they making it work and you can? I'm coming to that. If I were starting from scratch and coming in, these are two private operators that are taking over the facilities from us as a charitable organisation. If it were me, over time I would move those facilities to all self-funders, which provide a higher income level. I would potentially increase the level of the level of fees within those facilities to make them stack up. I would look at pulling staff resources and, in particular, in relation to Kingdom, where they have a number of facilities in a very narrow geographic area, their ability to move staff between those facilities and not use agency staff, which are very expensive, is much greater than Beald hands. We have 12 care homes scattered across seven health and social care partnership areas. Our ability to deploy resources efficiently and effectively has been pretty limited. Again, as Fiona Hynig alluded to, I would look to increase the number of units within those facilities. We've done that in the past. We've looked at a number of the care homes to try to increase the number of units and we've achieved that, but that requires significant investment. Given the level of losses that we have suffered, we feel that it's not an investment that Beald would be prepared to make. I want to make it clear that the first thing that you said was that you would move out people who are funded by local authorities over time. You would ensure that there are more self-funders to increase the income. That, to me, doesn't sound very charitable, I have to say. If I were a private sector operator, that's what I would do. That's not the business that we are in and that's exactly why we have taken, or it's one of the reasons why we have taken to come out of the market. We are a charity. We have a social purpose. The whole reason for setting those care homes up in the first place was to provide good-quality care for people most in need, not people who could afford it. If we are moving to wholly self-funding in order to make them stack up financially, that's not the business that we would want to be in. I feel that there are two strands to this particular conversation, the biggest strand about care homes and staffing. If I could just ask Brian Logan, and I must say that I declare an interest to my mother and father in a Beald home, but a residential home, can you perhaps clarify for me that residential homes will continue, but it seems to be the very sheltered and high-dependency homes. Since you entered into that market, that seems to be where the problems have started. I just want to be a bit of clarification on that aspect, because everyone is talking about residential care homes, but nobody has mentioned the very highly dependent sheltered homes, which has been mentioned previously about people being in hospital. It is important to clarify at that point that residential homes and high-dependency homes are entirely different. Basically, what I am asking is that, when you went into the market, if you pardon that word, of high-dependency, high-sheltered, is that where the problems began? For clarity, there are essentially three different types of service that we provide that are accommodation-based. Many of you will recognise us as sheltered housing. We have rebranded those to retirement housing and we withdrew housing support services within those sheltered services some time ago, but we continue to provide an element of support to the individuals, making sure that those individuals within retirement housing live comfortably and securely. There is no change to those properties as a result of this strategic change for Beald and for the 4,000-plus residents in those services. As I said to Mr Cole-Hamilton, no change there whatsoever. The second tier is what we would describe traditionally as very sheltered housing, which is that higher level of support. Traditionally, where we will have provided a bit more of an on-site staff presence and we will have provided a meals service. We are making some changes to those services at the moment. We are, again, because of pressures in housing support funding. We are withdrawing the housing support element, but we will continue to provide a meals service in those facilities, so we would hope that there would not be a substantial change for service users in those properties. Our difficulties in terms of the financial position have come about in the residential care home sector, and that is the 12 care homes that we are talking about, which affect 167 Beald customers. It is those that we are looking or seeking to withdraw from, because we feel that we do not have a place in that market. When we entered the care home market 28 to 30 years ago, it was, as a natural extension to our housing offering as a housing association, as a provider for older people and, as has already been mentioned by Gordon, we were providing a level of service to people with far less complex needs than those who are being admitted to care homes nowadays. It made sense for us to move into that market, because it was still promoting independent living for older people. That is why the flats were designed to double the space standards of what the care inspectorate would look for now. They all have their own front doors, their own letter boxes, their own kitchen facilities. For that reason, there was an expectation that people who were being admitted to those care homes at that time would be able to live independent lives. That is not the case now in terms of people who are coming in. They have far more complex needs, often dementia. In terms of us as a housing provider, we no longer feel that that is the market that we should be in. As well as the financial loss that we are suffering on those particular care homes, there is a strategic decision that has moved away substantially from the original intention 20 to 30 years ago. Just for clarity, the people have contacted myself and others. I presume that even if what has been asked for about the national care contract or extra monies, Beale would not be intending to continue with this type of care home in the future. No matter what we would say or do or offer, it would open it up to other providers. That is for clarity. We feel that it is not a market that we can operate in any further. We are keen if it is possible to keep those care facilities going. That is the best solution for the residents, families and our staff. We will do whatever we can to try to facilitate that, but it is not something that Beale would want to operate. There is no way that we in this committee or people out there, users, will be able to save the care homes that you have under very shelter, the high dependency that you are withdrawing. We are not withdrawing from very sheltered, so again, for absolute clarity. We are not withdrawing from providing those services. Those services will continue. They will be reformed, but those services will continue. We are withdrawing from the provision of registered care homes, the 12 registered care homes, so we are coming out of that market completely. I wonder if I could broaden this a little bit in speaking to some care homes who have gone into administration within my own area. As I understand it, what has happened is that the value of the business over the very recent history has plummeted. I know one, for example, who, five or six years ago, invested a serious amount of money in developing and extending the care home against the value of that business, and then the business plummets in value. With the squeeze on the income, the then purchaser out of administration will not be saddled with the same amount of debt as the previous unit, if you follow me. That means that, for that period of time, it becomes more sustainable, but surely over a longer period of time, that is not a sustainable model. What does that speak to in terms of investing in this sector in the future, if that all made sense? I might add to that in terms of the finances of that. I wonder if you could clarify with us what we were able to make a profit last year, and do they have reserves? If you do, what are they? First of all, in relation to sustainability, particularly in the scenario that you are talking about, which is a private sector situation, it is probably for others to comment rather than me. Our properties at the moment are debt-free. In terms of the transfer, there is no mortgage sitting on those. We have some arrangements in place in relation to repayment of housing association grant, which would have been given to us to build the facilities in the first place, but that is something that we are factoring into our financial calculations in terms of the running of the business. In terms of the generality of your point, Mr Whittle, I am assuming that there is nothing in there that I would particularly disagree with in terms of further investment in those properties and what that would then mean in terms of those being sustainable longer term. In relation to Mr Finlayne's question about Beald's position, I think that we have said in the submission that, particularly in relation to the care home sector, we have lost something in the region of £370—I will come on to the overall position—in relation to the care home sector, we have lost something in the region of £375,000 last year. We have lost a similar level this year, and we have made losses in care homes for the last five years, which we have withstood through use of reserves. In relation to Beald's overall position, we have reported in our annual accounts an annual surplus of £1.7 million. I can say this as an accountant. The bottom-line figure in relation to the accounts is an artificial number, international accounting standards, and I am not going to go into the intricacies of accounting treatment, but it has rendered the bottom-line surplus that we are reporting much less meaningful than it was previously. We have had to undertake a number of paper transactions around how we account for housing association grant, how we account for pensions, how we account for plan maintenance works, and how we account for shared ownership sales. I think that what is more telling is that, if you look at our accounts, and in particular our cash flow statement, you will have seen last year a net cash outflow from Beald of £3 million. Obviously, part of that is in relation to the losses that we have incurred around registered care. Again, if you do a comparison with the 25 other largest RSLs across Scotland around operating surplus— Mr Logan, I asked you a very straightforward question. Did you make a profit last year and what is your reserves? That is all I am asking. I have given you the surplus position, which is £1.7 million. In relation to reserves, our reserves position is over £60 million, but the bulk of that is made up by our housing assets. The only way to realise those reserves is to sell our housing assets, which means that we have no business left. In terms of free cash reserves, we have an investment pot of £5 million. Do you have no debt of £60 million of reserves and £1.7 million profit? As I said, we had no debt on our care homes. We are carrying some loans, but the loans are of a relatively small magnitude in comparison with other housing associations. Thank you, convener. This morning, I think that this is a topic that we could discuss over the course of several weeks. I am particularly interested in the— Michelle Miller from Edinburgh, but I think that your submission suggests that there is perhaps an increasing gap in the quality and security of care available to those peering privately and those supported by public funding. That seems to be a theme in your submission. Annie Gunnar Logan pointed out that providers like Bielder are unwilling to run services at a deficit, and you really make a very strong point that you are re-emphasising that it is not the result of a general improvement in the funding situation for social care. It is the result of providers either declining to enter the market in certain circumstances or withdrawing entirely, which obviously has a big impact. I think that you are pointing out that local authorities cannot afford to subsidise inefficient and or unsustainable business models. We have been speaking about facts and figures, but we are here to represent the people who are impacted by those decisions. Campaigners who have heard on radio this morning articulating the case of grandmothers—much-loved grandmothers—who are going to lose their home, the campaigners are citing the right to respect for home under article 8 of the United Nations, the UN principles for older people, the fact that relocation stress syndrome is recognised in North America. I think that we need to have a national conversation about what we can fund and how we are funding this, because it seems to me at the moment that it is certainly insufficient. But what about the people at the heart of this? Do Bielder, for example, recognise relocation stress syndrome? What is going to be in place for people who have perhaps sold their homes, thinking that Bielder was a long-term alternative? We certainly acknowledge that this type of move can cause significant distress and anxiety, not only for the residents themselves but also for the families, which is why it has been such a difficult and tough decision for Bielder to take, why we have wrestled with it over a number of years and why we have tried to put in place many measures to avoid us being in this particular situation. We absolutely get the distress. I get it day and daily now in terms of the stories that are coming in to me, and I hear those reports on the radio as well. That causes me significant distress. It is not a situation that any of us would have wanted to have been in, but we feel that we are at the position of last resort. Obviously, what we are now keen to do, our focus now is to make sure that the transition, whether that be to an alternative provider who will take over the care home lock, stock and barrel, or whether it is about transitioning individuals to move to other care accommodation, our focus now is on making sure that that transition is as smooth as it possibly can be. All credit to our staff on the ground, they have tried their very best over the last number of months. Successfully, I think, to continue to deliver a high-quality care service and not to provide any anxiety or disruption to the residents. They are trying to keep it as calm as they possibly can. I will bring you back in. On a number of points that have been raised, because I think that they are really important this morning, in the context of your question about how one organisation can make something work when another one cannot, you could equally ask why any number of third and independent sector organisations make the national care home contract rate work when public authorities cannot for their directly provided care homes, which are generally funded at a much higher rate. I think that that is something that we might want to introduce into this discussion. In non-residential care, service contracts are transferred all the time because authorities retender them in pursuit of cost savings, and some providers come in at lower rates than others. That is to do with, at the point at which we now have the living wage in care. The wage competition is not so great, and that is a great relief to everybody, but there are still issues around pension provision, organisational overheads, the amount of supervision that staff get. These are all bits that can be cut to make a service cheaper. As our submission advised, more and more third sector providers are declining to enter these competitions for all the same reasons as Beald, and people are losing their trusted supporters. In this case, they are losing their home, but people lose their trusted supporters every day because a service contract will be transferred from one organisation to another, and not all staff are tupid across. It is important to make that point. On the point of profit, just to be clear, charities can make operating surpluses. They can make profits. They are non-profit distributing, so that means that any surplus that they return has to be reinvested in the organisation or the service. Most charities have a range of activities. Some return a surplus and some don't, so the extent to which you can cross-subsidise one area of activity to another is a matter for that charity and is a matter for the funding route through which that charity gets its money. For example, if one council is funding a charity to a break-even or a surplus position, I think that council would have something to say about it. If that charity then transferred that money to prop up something, another council was not funding to the same degree. The point here about charitable organisation is the extent to which we would expect a charity to be propping up a public service from either charitable income or from its own resources. That is absolutely critical because, for me, these are public services and need to be publicly funded. I think that Annie made some really good points. There was a point made by herself in relation to the tone of my submission saying that national care home contract bad provided good in terms of standard. I think that inevitably, if a service costs between two and three times the national care home contract, there will be opportunities there for that quality to be improved. I recognise Annie's point. For me, the issue is less about the immediate debate about which model is the better and how can one organisation do something when another cannot. In actual fact, I genuinely believe that the system overall is underfunded in terms of what it can deliver. Within that, we can argue about the different models and how they might be more efficient. Can you just stop me there, because we are coming on to wider issues in a moment, but I really want to keep us on the billed issue just for the next few minutes, because we are halfway through your session. If there are other issues specifically on billed, can people indicate now? No, so we want to move on to wider issues. Alice, do you have any final points that you want to make? I feel that there is a bit of conflict here about prioritising quality individualised care over economies of scale. It feels in this discussion that it is not being needs driven, it is being finance driven. I am very concerned about that. I would really like to hear more from perhaps Cosla and Michelle Miller about how our local authorities are working together with integration too. How is this working together? It is certainly a very challenging picture that we are being presented with today. I suggest that there are a number of questions that I have, and others may have in relation to be specifically, but we will write to you afterwards with those, if that is okay. I would then like to address the issue that Alison has just raised. Donald, do you indicate that you are working? It was actually one of Ms Johnson's earlier comments. She is quite rightly, as a number of us will have heard, the very heartfelt stories on the radio and on the television this morning. Ultimately, nobody works in the delivery of care if they do not have people at the heart of their concern and attention. However, you are also right in saying that this is a human rights issue. As somebody whose background is essentially within the human rights realm, this is human rights week. Sunday was human rights day. We are profoundly talking here about the lives of individuals, but we are also talking about the priority that we in Scotland give to the care and support of older people. Michelle is absolutely right. Build is a symptom of a disease, and that disease is the current underfunding of social care in Scotland. That is not just the case for the care home sector, which we are talking about today, but it is profoundly the case for care at home, housing support and other areas. It is extremely important that, whilst we are honing in quite rightly on the individual stories of pain, distress and emotional trauma that individuals experience when they are home, because that is what a care home placement is, is somebody's home, is taken away from them through no control or fault of their own. It is quite right that we concentrate on that, but we also need to concentrate on that bigger picture, which is how much—because in the end of the day it is a financial question—how much are we prepared in Scotland to pay for the support and care of some of our most vulnerable citizens, be they in a care home or in the community? I think that most of us would all agree that that is the nub of the debate. The reason we brought Bill before to the committee is because, if such a long-standing, incredible and well-established provider like Bill is in trouble in this, is that an indicator of problems underneath and the whole of the system. That is what we want to get to today. Scottish Care's written submission highlighted just that. Bill has a long history of dedicated person-centred care. They are not members of Scottish Care, but I have known that reputation and I know individuals like Ms White, who have been residents. I find it deeply concerning that if a charitable organisation like Bill is unable to deliver and continue to deliver the care that they have thus far done so, it is raising a profound concern. You are quite right, chair. There are other organisations that are seriously thinking. Can we, at the present time, given what public authorities are able to—I want to state that, to date, the national care home contract has enabled a level of contribution and sustainability in Scotland, which has not been possible elsewhere, but that sustainability is now profoundly under question. Paul, I wonder if I could ask you a comment in terms of the cosless position. You have said a lot about the national care home contract. I know that people will have specific questions about the contract itself, about the rate and about the whole system. I do not know whether you want to give me individual questions. I suppose that it is about the fundamental issue that we are discussing, about the sustainability of the system that all the people here are operating in. I think that cosless submission on the spending review on fair funding for local government is really clear that we have significant concerns in local government as to whether social care is sustainably funded in the round. We would look to the Scottish Government through the spending review to give assurances and to support local government to support social care and to provide fair funding and to invest in those services, which are critical to all of our communities. In my submission, we highlight our grave concerns about the future sustainability of social care in the round. That is to do with keeping up with demand. It is to do with the complexity of care. It is to do with demographic change. It is to do with workforce pressures and a combination of those and our ability to respond to them as local government when our core budgets are being cut and additional burdens are underfunded. Perhaps additional burdens are being put on local government at the same time. Having made that statement, I think that I agree with everybody around the table about the need to prioritise and ask more fundamental questions about how much we are prepared as a society to pay for social care and where we can get that resourcing from. Local government is in the position of making very difficult budget choices at the moment. We historically have been prioritising social care budgets. We have seen real-terms increases over the last 10 years in social care budgets, despite seeing other aspects of local government's funding significantly cut. However, there is a question as to how long we can continue to offer that prioritisation and protection to social care funding, at the same time as acknowledging that, despite having done that, we are not keeping pace with demand and are having to make difficult choices. In the scope of those difficult choices, in the round, when looking at the system, we are having to say that, in supporting businesses, in supporting third sector independent providers, how are we ensuring that we have a balance between covering and meeting the demands of our communities, the number of people in the system asking for and needing support against how we support individual businesses that perhaps, over time, have not kept pace in terms of their business model with an efficiency model of doing business. I know that Bielder has highlighted the size of their businesses, the historic configuration of the capital and so on as being issues with their own circumstance. Those are difficult choices. Within that, each local authority and each IJP are very concerned to protect individual outcomes to look at what is best for the older people who are receiving care in those institutions and to make sure that they are supported should something like Bielder happen to manage their transition so that you do not have relocation stress and so on. However, those are the symptoms of the overall underfunding in the system. In terms of the national care home contract, I want to have on record that local government in Scotland has prioritised and protected its relationship with the care home sector. We have seen, over the last 10 years, year-on-year increases in the national care home contract rate. It has gone up over 42 per cent over that period. That is in stark comparison to the UK, where 81 per cent of local authorities have reduced their care home rate and over 50 per cent of those have reduced it by over 10 per cent. Local authorities have got a strong record of valuing and being invested in as partners the sustainability of the care home sector. However, the environment that we are in is shifting. We need to understand the sustainability and what it will take to be sustainable into the future. Some of that is about the business models that we have, some of it is about the models of care that we are using. The need in the system is changing. It is becoming more complex, it is looking at more complex needs within the system that have to be responded to, and integration is in that space of looking at how those people who are currently in hospital can be better supported by different models of care within care homes. We are looking at shifting the balance of care, but even within that we have further pressures on the system that are not all about the rate. It is about workforce in different parts of the country. It is about our ability to, in Edinburgh, find the people to provide social care provision. Both those issues are working and the provision is shifting. All of that contributes to sustainability in the round alongside the rate. The national care home contract rate is and has been a good foundation for care home sustainability over the last 10 years, but we have recognised as local government that a single rate in a single contract is in itself perhaps not sustainable into the future. We have different markets in different parts of Scotland. Both in terms of market competition and actual capacity within the market capacity is in some areas meets the needs and in other areas does not. In some areas you need to invest in other areas you do not. We need a more sophisticated model and that is what we are looking to reform the contract in order to respond to it. Scottish providers have historically been relatively stable and protected and I think that you touched on that in your answer. That is partly due to the care home contract as you have just spoken about. We know that there is a programme at the moment to reform it and to develop a cost of care calculator. How do you think that the cost of care calculator will help the sector? Does there need to be additional reforms as part of that development? The cost of care calculator is at its core a way of both providers and commissioners having a shared transparent understanding of what it takes to provide a care home place. However, it is very difficult as you have seen there are different business models that are different markets across Scotland. Even if we have a shared understanding of how you would break down a single cost of care provision in a care home, even if we have a shared understanding of that it may not reflect the specific business pressures of each care home facility in each local authority. What we are looking at alongside that cost of care provision is how we enable the variation of that contract to respond to different models of care, be they enhanced nursing or enhanced residential, so that we can give and provide for integration authorities the tools to commission more responsive models within their care home and the transparent funding basis upon which they can come to an agreement as to how those will be paid for. It is a mix, it is not just about a cost of care calculator, it is about a mechanism to vary that according to the models of care that you would like to commission to respond to the needs in your community. Ivan? There was some prompted to go into a roundabout types of model that are out there in integration, but first of all, it is okay, I just wanted to pick up on Dr MacAskill's comments, which I am interested to explore a wee bit further. You said that there is an underfunding issue, which I understand. Clearly, when an environment where the provision of care becomes more expensive due to various issues year by year, you will have seen evidence of that over the past five to ten years. I would quite like you to quantify how big the underfunding gap is in the current year and what it looks like in the next five to ten years as the trends continue with the ageing of population and the change in the profile of needs. That is a good question, I wish I had noticed that. Unlike Brian, I am not an accountant, but the Competition and Marketing Authority issued its report on the state of care homes in the United Kingdom last week, or a fortnight ago. Talk specifically about Scotland here. Yes, and they indicated £1 billion with the shortfall across the UK. Now, in Scotland, because of, as has been highlighted by Paula from Cosla, we are not facing the same degree of percentage differential in terms of what a self-fundar pays compared to somebody who is funded by the public purse. However, if I can compare this current year's deal, which was a 2.8% increase in the national care home rate, 1.8% of that went to statutory duties relating to salaries in the national and the Scottish living wage. Yes, there has been an increase of 18% in the last three years to care home providers, both charitable and independent. 72% of that has gone to paying salaries for the workforce, and I know that we will go on to talk about that in a minute. We would estimate that, if you take last year as an example, the 1% which went to non-salary-related costs fell short by 7%. We are working extremely closely with our colleagues in local government to draw up a transparent cost of care calculator. What I mean by transparent is that if I go into a care home, I should know what my money is buying. If I buy that provision as a local authority or as an integrated board, I should know what I am buying. If I am a provider, I should know whatever business model I have and what it is that is expected of me. Transparency is extremely important. One of the insights of doing that exercise is showing us that, although we have fundamentally had a sustainable model, we are profoundly concerned, together with our colleagues in COSLA, that that issue of sustainability is facing us very sharply in the face. As I said earlier, it is not just about numbers, it is about people. I understand all of that, but I am going to press on that. If I was there at McKay and I was sat here in the budgets coming up this week, and I asked you for a number, what number would you give me? If you are talking about the whole of social care in Scotland, I would estimate that we are certainly talking about north of £1 billion needing to be invested across the realm of social care to enable our integrated joint boards to properly fund the delivery of social care. The COSLA has, in its submission, highlighted that the promised set-aside monies to be transferred from the acute sector into community and primary care has not happened. That is £500 million. We have not, in integrated joint boards and by implication providers and by further implication, people who receive care. We have not seen that transfer from the acute sector in the NHS into the community. That highlights the gap that exists there in terms of sustainability, in terms of maintaining the services that we have. Never mind developing the rights-based system that the care and spectra in the new national care standards wants to see developed, we are at some distance away. I am more than happy with colleagues to go away and do some thorough ar-of-metical exercise. Your job is not to understand this stuff, and I am getting a lot of words, but I am not getting much in the way numbers, and the numbers that I am getting are all over the place. You are talking about a billion extra needed across the UK, and you are talking about a billion for Scotland. Can you be quite specific? The billion extra for the UK was the care home sector across the UK. Within the Scottish context, I would conservatively estimate, in terms of the gaps of social care provision and the whole of social care from children to older people's services, that we need a further billion pounds over the next three years. You are talking about an extra billion pounds over the next three years? Yes. So, whatever it is, a third of that per year or approximately? Yes. One of the reasons I say that is that, for instance, the Government has committed £500 million to early years provision. That means the creation of 20,000 jobs in 18 months, in the next 18 months. We are faced with a critical shortfall in social care. Nine out of 10 providers are having difficulty recruiting. You can earn more for stacking shelves in a supermarket in Edinburgh than you can for caring. We are going to face in the next 18 months with an even greater criticality. The only way that we can hold on to carers and to the workforce, the only way that we can build caring as a career of choice is if we have fiscal investment across the board. You are talking about more than £300 million this year just for social care. Yes. That is on top of everything else that is getting added in the health sector spending and what is happening in childcare, education and so on. How would you fund that? I am not a politician and it is inappropriate for me to comment as to what mechanism is used. That, with due respect, is up to the elected members around the table. In moving forward, you understand, because it is your business to understand that the changes and requirements over the last five, ten years, if you project that forward, what sort of percentage increase do you think would be required to maintain pace with the changes in elderly age profile and requirements? We know that demographics are only going to go in one direction and that is great. We also know that people are living longer and that is fantastic, but we do know that one of the consequences of that is that people are living with multiple conditions much later into life. From that perspective, I would have to say that what we need to do is have a grown-up debate, a non-party political debate, around how we fund social care. To be blunt, Mr McKee, nobody in Scotland has done the analysis of what the true cost of social care is. At the moment, we do not have the arithmetic and I can do analysis from my perspective in terms of what care at home and housing support and care home for older people are, but the totality of the picture of how Scotland is going to be able to afford to care for our most vulnerable, nobody has done that arithmetic. Sorry, is it not your job to understand that? You are the head of Scottish care, I am asking you, based on historical trends so far, what percentage increase you have seen in the past? You understand the demographics, you understand the age profile, you understand the cost pressures, are you not able to put a number on that going forward? I have just put a number on it and that is in my estimation that we need £1 billion over the next three years to grow the percentage increase year on year going forward beyond three years. I would not want to do that because that would be inappropriate. Sorry, I have not just in case we want to open up to anyone else. I wanted to throw on and it is broadening that out a wee bit, but there are a couple of things. Clearly, when you look at the range of provision there from hospital provision through staying at home and everything in between, we talked about sheltered house and various sheltered houses and the different care home provision and so on. Is there an issue there? Of course, what bill we are providing was one aspect of that, which sat between the very sheltered and the more traditional care home provision. Is there an issue there in terms of the way the model is configured that has not supported that? Is it clear that it is more expensive or is there an issue about that provision itself that is not needed in the model? The second point is to throw into that, which people may or may not want to pick up on. In a couple of the submissions, there were issues about, and it has been mentioned just now, the transfer of funding through the integration model. There was talk about that there is bed blocking going on, which is clearly very expensive, more expensive than care home provision or at home provision, but there seemed to be a suggestion that despite integration, there were issues about how that funding was getting the mechanisms for transferring that funding, which clearly when you look at the whole system is problematic, because the money is not going to the right places. It was just to add a point of information that Audit Scotland, in their recent audit of social work, estimated that social care, if nothing changed in how we provide it, would need 16 to 21 per cent more invested by 2020. Obviously, as part of that, we cannot continue without looking at how we change our models of care, if only because we want to have the workforce to just continually grow what we do. That is assuming that all things stay the same and we cannot stay the same, but it does give an independent analysis as to how much pressure there is in the system. I was just going to add that much as an extra billion pounds over the next three years would be fantastic, my concern would be that if we use that money simply, and I use the word advisedly, to shore up or to fund the historical model that has grown and that we have now, I think that in three years time we will come back and say, can we have another billion please, or another billion, or another billion after that. There is something fundamental that I think we need to do, and the integration authorities have the absolute, not just opportunity to do that, but the statutory responsibility to do it in terms of their strategic planning, their shaping of the market, to say, we need a different model of care that one that is focused on individual choice, self-determination, control, prevention, a whole wide range of different issues that will end up creating not just a system of social care that individuals aspire to and want, but one that is also sustainable. If you came along and said, here's a billion pounds, just fix the problem, I think that actually our answer should say no, we need to spend that billion pounds very differently, and it's not just about changing the model in order for it to be affordable, it's about changing the model because it provides something that is better that people want more of rather than what has gone before, without that implying any criticism of what's gone before, but it's a changed world. What people tell us is that we want more control, that the voluntary sector has been really the driver in terms of a lot of innovation, but we shouldn't be relying on individual small pockets of innovation and change, we should be thinking about that whole landscape and how we kind of garner all of the resources that are available to create that different picture in terms of social care going forward and use the input of people who use our services or people who care for the people who use our services to help shape that model rather than just promote something that has always been. Annie? Yes, thanks. Conrina, I just wanted to come back to share some of Mr McKee's frustration about the numbers around this, each of our member organisations could tell you how much more they would need to keep their operation going and their services sustainable, I could add that all up and put it into the committee, but I don't think that would get us very far. For me, coming back to what Michelle is saying, integrated joint boards and their duty to plan strategically for their future care needs, that is part of what this is about. I think that it is still early days for that, but if we are looking at the pan-Scotland picture here, a number of organisations including user-led organisations have pressed Scottish Government for a number of years to look at a commission for the funding of social care or some kind of exercise that would gather all the information that Donald could give, that I could give, that Michelle could give and everybody else and actually look at that as a whole systems picture, but it's never happened. I think that this committee could help us in that respect by pressing for that. The Scottish Human Rights Commission in a lecture published on human rights day on Sunday made a very strong, passionate case for that funding commission around social care to be established in Scotland. Alex, do you want a brief point then, Colin? Briefly, it's quite visible that the politicians around the table are recoiling the idea of having to find £300 million every year for the next three years and then additional percentages on top of that, but it's not just as straight black and white as that as well, because there's a virtuous circle here, because if you're thinking about 80 patient or 80 people waiting in hospitals at perhaps £400 or £500 a night, then that frees up that capacity and indeed the flow within the health sector as a whole, which has impact just right across the spending chain. Am I right? Absolutely, I'm not... But that's, on the one hand, one of the real opportunities of integration, the levers to shift those resources, and currently, although it is early days, the weakness in that we haven't achieved that shift, so I think that we absolutely need to focus on driving that change, because that was part of what was... The basis for integration in the first place was to say, we've got two big organisations essentially, big bureaucracies, trying to do similar things, but actually there's an awful lot of duplication and there's an awful lot of preservation and so on, and actually we need to be the grit in the system that changes that and that allows those very significant shifts from acute to community to prevention and so on that will make a difference. So we have the framework for that to happen, but it hasn't happened yet, and I think that that's one of the really important unlockers in this issue. Okay, Colin. I mean, two points that have been made is about the need for change. In fact, lots of people have made the point about the need for change, so what exactly are the barriers to those particular changes? If you look at the national care home contract, all the submissions that we've had and most of the submissions that we've had have said that serve its purpose, but frankly, it's no longer fit for its purpose, it needs to be reformed, and Paula mentioned the reforms that are taking place at the moment around the calculator, but when will we actually see those reforms being implemented, when will we actually see the changes taking place, and what exactly are the barriers to those changes? So the national care home contract reforms, we've been working on them for over 18 months. That work is coming to a head, but it's not complete. Where we are, we've made a commitment to local authorities, IJBs and providers alike to circulate a progress report by the end of December and to take a decision on whether we're going to progress with a reformed national arrangement by the end of January, and thereafter to complete the work that needs to be done as part of the reform. So there are some things that won't be delivered within that timescale. We won't have all of the answers about how we will configure variations to the contract by that time, but we will have made a commitment that this is how we want to approach our relationship between commissioners and providers over the foreseeable future. If that work does not get endorsed by our respective partnerships, we would be looking at local negotiations and the contract and its national configuration would end. Why would IJBs or local authorities not endorse a model that would reflect the additional services that they would require? Is it purely financial? No, those are all choices to be made collectively, but Scotland isn't one market, so people have different conditions locally that when they look at the national arrangement, working up, they will need to reflect on whether it is suitable for them and whether it gives them what they need. Hopefully, we have done our job in terms of engaging with consulting and surveying our members, and we will have proposed for them a solution that everybody will endorse, but our constituencies will have to make their own choices in that respect. As COSLA, we often have no guarantees on that. Just in terms of the wider point, what other barriers are there to the changes that we need? You are not going to get the best will in the world that there is a major need for a substantial increase in investment in social care. There is no question about that. You are probably not going to get £1 billion over the next three years, and you have said that, if you got that in the current model, it still wouldn't be enough. What are those changes and what are the barriers to those changes? Why are they not happening? It is our inability to shift the balance of care at present from acute into community and social care, and it is our inability to utilise the budgets as per the Public Bodies Act. That is a major barrier to the future sustainability of social care. Is that because of the lack of transition for cash to make that happen? It is both transitional cash and our ability to shape and utilise the unscheduled care budget. I completely agree with that point. Just in case hairs were setting off, I was not asking for £1 billion to be spent on the status quo to reform the system, which is what we are talking about. There is a considerable degree of unanimity between providers, commissioners and people who use services that we need to do things differently to reform that. That is what I was asking for. The real challenge, and it goes way beyond finance, is that even if we, and I hope we will, and there is a lot of energy to get us across the line at the beginning of the year, even if we do that, will there be people out there who want to care? Every day I get an email from somebody saying, I am handing back work because I cannot find the staff willing to care. I got an email this morning from somebody who said that she was at the point of having to make a decision. Her husband, living with dementia, his behaviour had deteriorated to such an extent that the local provision could no longer support him. There wasn't another care home in the local remote area that could do so, so that she was going to have to make a decision with her husband for him to be placed in a hospital setting, which will deliver fantastic care but at a distance from that person. The reason that is not able to be delivered locally isn't money, it's people. Fundamentally, we have a problem in that there are not sufficient people out there prepared to care. It's maybe not surprising when, as a labourer, the national average is 1150, but in care the average is 845, going up to 875. That's the bigger picture, which goes way beyond care homes into the fabric of care itself. Emma Cymru. Thank you, convener. Donald touched on staffing, and that's what I'm interested in. In the submission from Scottish Care, you talked about how nurses are critical to ensuring safe and effective delivery. My first job was in a care home before I started my nurse training. When we look at the statistics for nurses who are given up their registration or other statistics about how to recruit for this year compared to last year, obviously we've got major challenges about recruitment. My question is about are we seeing recruitment challenges across rural care homes as well as urban, and what would be the impact of the exit from the European Union as far as our care home staff that are providing care right now? The impact of Brexit is already happening. It's going to be quite profound. We estimate that the care home social care nursing constitutes about 8 per cent of individuals who come from the European economic area and 6 per cent of social care staff in general, particularly in older people's care and support, and that is inclusive of care at home and care homes. We have really profound concerns. We have a 31 per cent nursing vacancy level in social care, and we are actively seeking and working with the chief nursing officer to address some of those issues. Fundamental to all that is the report out this morning from the Royal College of Nursing, which is highlighting the degree of distress and emotional fatigue that the job of nursing is leading to. I would suggest that that is even greater within the care sector. We produced a report last month called Fragile Foundations about the mental health of our care staff. It was harrowing and it's disturbing, and we need to start caring for the carers otherwise our present recruitment difficulties will appear to be small in comparison. I support earlier issues about models of care as well. We have seen technologies supporting the delivery of care. There is inter-egg funding across Ayrshire and Arran under Freeson Galloway, looking at MPower and cosine. We need to invest in the technology for delivery of care as well, which might support, but that is not the whole answer. Absolutely. Technology has a role in enabling care, but technology can never replace presence. For many individuals at the end of life, for instance, we have to remember that most people are in a care home for about 18 months. Many of them will die in that care home. It will be their last place, which they call home. They will be supported by very dedicated palliative and end-of-life staff. In that role, technology has a place and a presence, but ultimately most people will want at the end of their life to have a human touch there. Providers are among the most innovative group of individuals—entrepreneurial—in order to make care more person-centred. We need to maximise technology to enable care, but it will never replace presence. Sandra. A very small one, because some of my questions have been answered, chair. It is regarding staffing, and obviously you have answered that particular one. Would you agree with the fact that people who are going to care are frowned upon? It is not a sexy type, but people do not seem to think that it is a career that they want to go into, and it is predominantly women as well. One year you have to have a decent wage for them, but surely at this stage, when you are talking about a commission looking at it, we should be looking at training up and making it a career for people to get into the care sector, rather than something that people just happen to get in and out of. My big worry is regarding agency nursing. Why are so many agency nurses being used, rather than being able to use a nursing bank? Can I ask you to hold a second, Donald? You have had quite a say. Is there any else who would want to respond to Sandra on those points, if not, I will bring in Donald. On that, I think that you have to acknowledge that there are 200,000 people working in care now, and not all of them are miserable. A lot of people are doing a fantastic job and really enjoying it. I think, for me and Convenor, forgive me, but it is never long before I start talking about commissioning. If we commission services in which people get 15-minute visits in and out, that is not a particularly attractive thing that people want to do. If we work much more with providers collaboratively to look at all the different models—we have talked about different models of care in the future and the changes that we need to make—if we did that more collaboratively, we could redesign care in such a way that people would be very, very attracted to it. I think there is quite a difference between, for example, services supporting adults with a learning disability, and there is doing 15-minute visits for older people in a very tiny, tiny way. I think that is where a lot of the very acute recruitment problems are, because it is not the way that we commission this. It is not a particularly attractive job, so I think that we could go much further up the chain here in sorting this out. I just thought that I was trying to say that we put a lot of emphasis and money into training up apprenticeships, so surely a care career could be similar as well to one product, perhaps even leading to nursing as such as well. The other one, perhaps, is for a later time about the use of nurses if you want. Miles? Thank you. Obviously, on the back of this committee, we have done a piece of work on making a career and caring a career choice. I do not think that we have had a response from the Government in a number of points, which we have suggested. I wanted to look at developing this further in terms of the future and some of the issues that we know are coming. Donald MacAskill picked up on this point that the Government has a focus of 11,000 people going into childcare, not adult care. How is that going to impact the panel's feel on the potential pool of people who might be looking to take up a career? Secondly, the Government is bringing forward a safe staffing bill, which will also cover the social care sector, including nursing provision. I was interested to find out from the panel what your thoughts are at this point before that bill comes to Parliament. It is a very short time, about seven minutes left, so if you are responding, can you be quick? Anyone would like to come in on those points that Miles has raised? There are very good questions. The point that we would make in terms of workforces is that we cannot look at adult social care in isolation. We have to look at the social care workforce across children and adults, and we have to position them within the labour market, the local labour markets that exist. If you look at some of the burdens that are here and are coming in terms of workforce pressures around the earlier's entitlement, around free personal care extensions and so on, they do ask a significant question about where we are going to find these people from. In terms of older people's care, there is a significant question about how older people's care can be competitive against, for example, children's workforce. That tension is going to really affect our sustainability over the immediate and foreseeable future. In terms of safe staffing, I would say that a present, a causalist position, political position, was to be very disappointed that the safe staffing legislation was extended to social care, but I am sure that we will be back to discuss that in some detail in the future. A couple of responses to Mr Briggs on childcare. It is speculation, but I can tell you that there is some anxiety in our sector that those jobs will in fact be populated by people who are currently working in adult care. That is something to do with the promotional activity that has gone on around about it that is missing from social care. Donald and I and a number of other people have made exactly that point in relation to an initiative that is currently on-going as the national workforce plan for health and social care, and we have made that point very strongly in that forum. Just to back up on what Paula was saying about safe staffing, I have to say that the first that CCPS and its constituency of third sector providers knew about this, that this was going to be extended to social care was about three weeks ago. There was a consultation that was done much earlier in the year. The terms of that were framed entirely around nursing in midwifery, so we and our members did not prioritise that. Social care has been brought into it very late in the day, and we share which causes concerns about that. I wonder if I could ask a few things just to finish off. This committee has got a real focus on health inequality. In Edinburgh's submission, it talks about, on the one hand, that we see providers in affluent areas in the city who can charge top dollar to cover all the costs of well-trained staff and provide excellent service, and on the other hand, we have a market where provision tends to be clustered in older buildings in less affluent areas of the city with increased challenges in maintaining their grades, recruitment and all of that. Are we now seeing a growing gulf in the inequality of care surroundings, facilities and the whole package being provided to people on the basis of their income? I think probably yes, but I think that it is much wider. I think that the gap in terms of inequalities is growing generally across the board, and I think that the potential, the negative potential of that is really significant. There is an awful lot of talk and strategic intention around reducing those inequalities and the impact that that can have, not just health inequalities but inequalities across the board. However, what we do not seem to do is focus our resources on doing something about that. All the research shows us that tackling that equality gap has a disproportionately positive impact on the whole population and all of the issues than just leaving it or letting it grow. It is about how we turn that research and what we know into strategic planning, commissioning, action and resource allocation to tackle that. That is what I was trying to get out in terms of some of that longer-term visioning that we need to do around what the system needs to look like and how we might then have more detailed discussions about how we fund it. We hear a lot of rhetoric from leaders in the sector and it could be Government, it could be civil servants or whatever about reducing the health inequality gap. However, in that regard, the rhetoric is not matched up by reality on the ground. Is that correct? I think that the rhetoric for me seems to be about the intention but what we do not see is the action and the resourcing and then the evidence that that is making a difference because we are looking at an increase in that inequality rather than a reduction in it. So, there is something in there fundamentally that is absolutely want to applaud the intention but need to do something proactive about it that will make a difference rather than just talking about it. Can I ask a Daft Ladi question about the charges for care? If you have self-wonders and local authority-funded places in the same care home, why is one much higher than the other? When people presumably are getting the same service? They are not necessarily getting the same service. The Office of Fair Trading has made it quite clear that there has to be a differential to justify if the provider is charging an individual more than their business model. The provider will ascertain and claim, as we have heard around the table today, what the true cost of care is. That is why we are doing the work on the true cost of care model so that for everybody, whoever is self-wonder or publicly funded or local authority funded or private or charitable funded, there will be a transparency as to the true cost of that care. That is what we hope to have completed by the end of January. Do we have the situation for a large number of people who are publicly funded in some way, living next to someone who is self-funded, but they are paying exactly the same rate? Does that exist in large numbers? In Scotland, according to the most recent research, we have about 33 per cent of individuals who are self-funders in total. The majority of care home provision in Scotland is individuals who are paid for by the public purse. I will ask a very specific thing here. Someone who is paid for by the public purse next door to someone who is self-funding is getting the same service. Are there significant numbers of people like that who are paying exactly the same rate? Are there significant numbers? If you are a self-finder, you will be paying more than the public rate. Irrespective of whether you get the same service or not, you would be required under the law to receive a better or a different service. We talk about inequalities and health inequalities, but what we are talking about here is about a care inequality. I agree with you, convener. It is unacceptable that, because you are able to pay, you get in effect a better quality care in support. I am being very careful. The quality of care that you receive meets the criteria of the care inspector, and Gordon wants to come in in that regard. Additionalities are having a cinema, being able to go out and engage in activities. All those extra things that make the difference for individuals are not going to be possible to many individuals in a publicly funded care home, but they will be possible to individuals who live in the part of Scotland and they have resource to enable that to happen. I agree with you that that is inequities. That is part of what the national care home contract discussions are looking at. How can we transform the system so that we create care equality? Gordon, do you want to come in in that point? Yes. Just to say that, although the care inspectorate does not have sight of the extent to which people who are receiving care, how they are funded and what contractual arrangements are, we concern ourselves with the quality of care, regardless of that, and do not have a locus. However, using our grades as an indicator of shifts in quality in the care home market for older people in Scotland, we have seen improvements since 2013, when 7 per cent of services were attracting our lost two grades to the situation this year, where only 2 per cent are attracting those grades, and 34 per cent previously would have attracted our top two grades, now it is 41 per cent. Against that backdrop, we are seeing improvements. That might well be because the poorly performing care homes are no longer operating, they have exited the market, or it might well be a consequence of our commitment as the regulator to support improvements, support sustainability and to seek to advance a number of means to do so. However, we do not have sight of whether or not the situation is different in relation to the experiences of people who are state-funded relative to those who are self-funded. I would certainly be very interested to see what the differentials are of people in those properties and what difference there is for that extra money. However, what we are really saying here is that for people who are publicly funded, they are getting the base-level service, and everyone else who is self-funded gets an additional enhanced service. That is what we are saying, is it not? In the national care home contract, what we ask for is that the rate covers everything that is required to meet that individual's needs, according to the quality standards that the care inspectorate applies. We are not paying for substandard care, we are not paying for less care, we are paying for care that meets the individual's needs at the rate that is there. I would say that I am not negotiating the national care home contract that is going to pay for cinemas, but that aside. What are those people who are self-funding paying for? That is a question for providers, but because self-finders get more for paying more does not mean that local authority paid for people are getting subset, they are not. We are not paying under the cost of care for substandard care, we are paying for high-quality care to meet individual's needs. However, they are missing out on something. If somebody is getting something, they are not, then surely they are missing out on something. Sorry, convener, as Paula has highlighted, the national care home contract delivers high-quality care, but other individuals, because they have personal resource, are able to purchase additional services and provision. In the same sense that all of us, if we have greater wealth, are able to exercise a degree of choice, then somebody is missing out on something. The critical issue here is how can we improve the already good level that Gordon has articulated to such an extent that individuals are able to exercise a greater degree of control and choice? I can just ask a final point on this, but the option for them is not to purchase those additional services. That is what you said. It is only to purchase additional services because they are self-financing. They cannot go in at the same rate as someone who is publicly funded. That is what you told me earlier. No. It would be unusual for somebody who is funding themselves to be charged the public-funded rate because the organisation would normally be delivering additional services. If you are in the national care home contract and you need additional services, then there is provision for those to be funded. Each individual's needs are assessed on their own particular outcomes. Bearing in mind that the majority of people in nursing care are going in with particularly high-level clinical needs, it is those that, particularly the national care home contract at the moment, are enabled to focus on to deliver high-quality care. In residential care, where somebody might be moving in on their own volition and choice for maybe four, five, six years, then that is the sector where there is a greater differential in terms of rates. I think that we could be here all day on some of this stuff. What I am going to do—we are really way over time already and we have a very important session to come next—is to spin round the table and give people 20 seconds to have their final say, final ask. Could I also ask each to comment on any suggestion about there being a major commission by Government on this, led by Government? I know that different political parties, led by commission and other parties have done that. It is a very informative process. People could comment on that as well whether they think that that would be a good approach, but just a final whizz round the table and you have got 20 seconds no more. Paula, do you want to begin? Thank you. Cozzler's position, both on care homes and on social care in the round, is that we need to have a look at whether there is sufficient resource in local government, generally, but also in local government for social care to meet the future needs and demands. How we do that is another question, whether that is a commission or something else, but we need to have more reassurance that both the core budgets that are there and the additional budgets agreed generally through financial memorandums that support legislation that they are adequate at the time they agreed and on an on-going basis thereafter, where we see increases in costs. I just really welcomed the discussion. I think we really do need to look at a major commission going forward. I think what we struggled a bit with is we started to deliver new models of care and we need the GPs to be part of that. With integration, I think we are starting to have better conversations, but when people are coming into a service or a model for maybe just four or five weeks and then moving on, that is a big ask for a GP to keep picking up, especially if they are not in their vicinity. I welcome looking at that major commission. Scottish Care would support Cozzler's statement that we need to seriously look at the overall funding of social care. In addition, we would argue that, whilst applauding initiatives and individual policy initiatives, we need to join those up. As one of the early signatories for the call for there to be an independent commission looking at the funding of social care, which includes what the role of the citizen is in that funding, we would certainly support that. It is different from looking at the system and how we reform it, because we are all involved in that, but nobody is really looking at how we are going to pay for it. We have been trying to advocate an asset-based approach in relation to the individuals who use care services to not define them according to what they lack, but to see them as citizens who have ambitions and hopes. I think that we need to think of the social care system in the same way. I think that we need to see it as a positive rather than a drain, an investment rather than a cost. We need to see it as the career of choice, where people are rewarded, remunerated and have security and fulfilment. Do you support that suggestion? Yes, I think that we would support the idea that we look more forensically at some of those challenges and opportunities. To reiterate, convener, that this has been an intensely difficult decision for Beale, but if there is any good that has come out of it, it has raised this issue up the political agenda. It has opened up the debate, and hopefully the outcome might be an on-going, sustainable solution for the future of social care. Yes, that would very much support the suggestion of the commission. Three things in 20 seconds. Sustainability is a real concern. It is not just care homes, it is right across care and support. Our submission said that 33 per cent providers have withdrawn from service in the last year, and another 10 on top of that are thinking about doing it before the year ends. This is a big first thing. Second thing, the commission for funding. I have brought it to the committee's attention, but I cannot claim credit for making the call. There were a number of us who did that through an initiative called our shared ambition for social care support. Critically, that initiative was led by independent living in Scotland and Inclusion Scotland, user-led organisations. This is a commercial pitch here. This is from people who actually use services who are looking for this primarily. Last thing, the third sector provision in care homes and much of other adult care and support, and I think Gordon will bear me out on this generally speaking, achieves a higher quality than either the public or the private sectors. Our main focus is on publicly funded places, convener. I think that that is why we should all be very concerned about what has happened at Beild and they are not alone in this. I certainly would support the proposal in terms of a commission. I would hope that, where it will take us, it is away from what I think sometimes feels a slightly sterile debate that is very diametrically opposed that says local authority bad, voluntary sector good, NHS good, private sector bad and those kinds of very strong positions. Fundamentally, what we all want to do is try and achieve a model of care and quality of care for people who need services. That is something that we can all contribute to and subscribe to. I certainly want to have that debate. The last plea would be around absolutely let's make sure that the outcome of that, hopefully, is that we fund those public services more effectively but not to fund the status quo and to fund something that is both more visionary and more anchored in what people who use the services are telling us that they want. I would just like to echo some of the comments that have been made around about looking at new models of care. That is something that our members that provide care and housing support would want to do. The majority of our members provide general needs housing, but that is where an awful lot of people are. If we are looking at preventative services and adaptations to homes that need to be adequately funded, that is something that we very much welcome a bigger debate on in a national conversation. I echo Cozzler's point as well around the locality planning. Housing providers are very keen to engage with IJBs on how we can make that work. Okay, thank you very much. It has been a very interesting and informative session this morning. I will suspend briefly to change the panel. Thank you. Agenda item 2 is NHS governance. I am looking today at NHS clinical governance. Can I welcome to the committee Fraser Morton and Ella Brown? At the start of the committee's work on NHS clinical governance, we heard from Fraser and Ella at our informal evidence session with NHS patients about their experience of the NHS. I would like to thank both for coming that morning and this morning indeed. I think that your willingness to share information on such a very difficult and emotive personal experience is greatly appreciated by all of us on the committee. I will provide a brief introduction to both of your experiences before we begin. First of all, Fraser Morton, Mr Morton's baby son Lucas, was still born at Crosshouse Hospital in Kilmarnock in November 2015. Mr Morton and his wife, June, were one of a number of families calling for a public inquiry into infant deaths at the maternity unit. The cabinet secretary subsequently instructed an investigation by Healthcare Improvement Scotland into the management of adverse events in the maternity unit. The report from that investigation was published in 2016 and made a number of recommendations for both NHS Ayrshire and Arn and for the whole of the NHS in Scotland. Ms Ella Brown lost her father following a fall in Victoria hospital in Fife. Since then, she worked with the NHS board to bring about changes aimed at reducing hospital falls. That has included falls call-to-action events, which brought together staff, patients and carer expertise to aim to reduce harmful falls by a fifth. They did this through improving practice, patient care pathways and the hospital environment in general. Over recent weeks, we have taken evidence from a range of stakeholders at NHS clinical governance and we are keen that both Fraser and Ella were provided with a further opportunity to speak to the committee to comment on those themes and the issues relating to NHS clinical governance, which have been raised at those sessions. We are going to move to questions, hopefully until probably about 22. We will try to wrap up then. First of all, you are very welcome to the committee and thank you very much for coming. Who would like to begin our questions? Thank you both very much for being with us this morning and for all the evidence that you have provided. It has been very helpful indeed. I think that my first question specifically I will address it to Mr Morton. In evidence recently, Professor Leitch, I know that you are following the evidence very carefully. Professor Leitch confirmed that there is no central monitoring of serious adverse events and he suggested that the definitions of an adverse event are so broad and varied that centralised reporting might not be helpful. He believes that we have to rely on the boards to have processes, including clinical quality committees and regular morbidity and mortality meetings so that individual clinicians can discuss cases. How do you feel about Professor Leitch's comments? I do not understand them to be honest because my understanding is that there is a national framework for adverse events that came out in 2012 or 2013 and it has been recently updated. I believe that there should be some standardisation of what is an adverse event. After the 2012 HIS review and NHS Ayrsharn Arran, I believe that the health care improvement Scotland describes adverse events as the springboard into which they drive improvement to make sure they do not happen again. If that is the case, I believe there should be some standardisation to identify adverse events. That would then help us identify any recurring themes or trends within Scotland. In terms of reculation or statistics, that is not happening. We were told at a meeting where we were at with the HIS review team that everybody is basically doing their own thing, despite there being a national framework in place. I think there has to be some sort of methodology or standardisation put in place to create these statistics so that we can then address them and target finite resources because, based on what we are talking about here, adverse events are things that will be wrong, badly wrong, and fatalities. That is not just a statistic. I wonder if you would like to comment. I was always aware that adverse events, from what I knew from Fife health board, were just one thing. There was not all this different things going on, but I have no problems with what they do. I see all the false reports every month of every ward in every hospital in Fife, and things are improving. There are blips, there is up and down, but I think I have too much charts and different things. It is all about people, nurses, doctors, everybody is speaking to each other, working together, not all the paperwork. I think the nurses are complaining about too much paper, but half the time they are filling in forms. We need to get back to hands-on things. I have no complaints about NHS Fife, but I have heard different things. I have picked up things at the last time I was here that not all the health boards are working the same. There are great gaps in what is good and what is bad. I do not think that you will ever get everybody in Scotland working to the same hem sheet that will not ever happen. I would like to understand to what extent witnesses believe that inadequate staff levels or staff training are a factor when things go wrong in the NHS. I am very aware of the campaigning that Mr Morton and other families have done will ensure that multidisciplinary CtG training becomes mandatory, for example. I wonder if you could comment on that. Staffing levels were not good when my father failed in factory school, because I campaigned after I started to work with the NHS and we got six more nurses on that ward funded by the Government. There is still more funding going into things like that, but it is to do with staff levels. The staffing levels, Mr Morton, seem to have increased markedly as a result of the work and the campaigns of yourself and other families. Can you comment on that? In the evening, my son died, to be able to hold. Initially, the staff levels were short by 30 per cent in the maternity unit. If we go back to missed opportunities, if you correctly monitor, collate and, to use the buzz words, roll down any adverse events, it should be possible to identify recurring themes. One of the recurring themes is inadequate staffing. Just to actually give you a kind of overview on that, nationally, the each baby counts campaign identified at one in four. Stullbuff and Neonatal Deaths can be contributed to lack of resources nationally. There is a problem with staff levels and resources. In terms of missed opportunities, over and above the adverse events that are produced, the Embrace UK produced Stullbuff and Neonatal Death statistics. I believe in 2013, NHS Aeosran Arun, or one of the worst in the UK, if not the worst in the mainland UK, second only to Velfast for obvious reasons. They were red flagged for that, for the statistics, and that basically commits them to doing an internal review, an internal investigation, and I've read that internal investigation, and it was very outward looking. It was like a scattergun approach. They looked at multiple deprivation, they looked at drug-taking, they looked at obesity, they looked at smoking, they looked at everything apart from themselves. It wasn't inward, it wasn't an introspective, and I believe that's an opportunity missed. That was conducted in 2015 because of the lag, collating statistics, etc. Only two years later, as a result of the reason, his review, we now have, I believe it's 16 additional midwives, two scenographers, one additional consultant, and a Labour suite risk management midwife, or something to that effect within place, and for that huge amount of staff, I believe that could have been, should have been identified earlier, you know, if the adverse events were correlated and monitored properly, and if a proper investigation is done into the red flag figures from 2013, from Embrace, I believe that those shortcomings should have and could have been identified earlier. Good morning. I just wanted to ask you a little bit about how you feel levels of accountability for boards are. We've heard during the last few weeks that whether it be some kind of serious event or whether it's just a different type of complaint, boards are both investigating those things themselves, and they're also responding to those themselves without much, I suppose, higher level involvement in those. Do you think that boards are sufficiently held to account for what they're delivering? The quick answer to that is no, to be honest. The NHS Air Sonarin's definition of clinical governance is that it's a statutory obligation and there's a framework through which NHS Air Sonarin is accountable for continuously improving the quality of the services and safeguarding high standards of care by creating environment in which excellence in clinical care can flourish. Despite my best efforts, I've still not been able to establish, you know, if it is a statutory obligation, which piece of statutory legislation covers that obligation. In terms of accountability, if they're indeed accountable, I don't know who they're actually accountable to. I can only speak their own circumstances in NHS Air Sonarin, but if you look back, you know, the terms clinical governance and adverse events were obviously alien to me and my family until November 2015, but I quickly became aware the intervention by the first of three cabinet secretaries in 2012, the first of three his reports in 2012. If you go back further still in 2009, NHS Air Sonarin actually admitted to having difficulties in actually applying the management adverse event policy. From 2009, I can take you back further still and I've looked at action plans come back to 2006, these action plans have produced on the back of adverse events and these action plans, I was actually shocked to see the same themes and trends, the same failings and care in 2006 in terms of staffing, training, handover, communication. In 2006, these were the same areas that failed Lucas in 2015, so during this period, we've had the intervention of three cabinet secretaries, I believe Alex Neil actually stated in 2012 that he actually challenged the non-executive directors in Air Sonarin and the wider NHS Scotland to apply a greater degree of scrutiny to the executive management team. Rawls had an investigation by the Reyn Strafclyde Police in Air Sonarin in the 1940s suspicious deaths. On top of that, the Scottish Government, according to Jason Leitch, actually later looked at the adverse event statistics by looking at the board papers and again, I think someone made the point, it's difficult to do that, there's five, six hundred pages, you know how you can lift that information out. If that's indeed the case, I don't know how they missed the fact that Air Sonarin were averaging 19 adverse events per year, which Robbie Pearson stated in his report in 2012 was low, he says that was low, the following year it was zero and this is happening during a period where there's supposedly a national framework, there's supposedly greater scrutiny by the Scottish Government, you would like to think there'd be greater scrutiny by the actual board or the health board, you'd like to think there'd be greater scrutiny by HIS who actually implemented or helped to implement this policy, but this went, you know, this went missed, this was missed for a period of three years. Ella, do you have a comment? My experience is I've worked a little with patient relations and that's how I've got to know the health board and all the things that are going on, and I see all the reports and I work with the patient relations a lot and I think they're doing fine, I mean it's five years ago since my father and dad, we've moved on all the time, gone and spoken at conferences and all such things, got out into public domain, spoken to people, get them to speak to each other, my thing is a hands-on thing, I don't know figures or facts, I just work off my own thing, I was so angry when it happened I felt I had to do something and that's why I started and I just did it and I still feel driven to do it and I just, that's my way of approaching things, but I believe it's speaking to people and keeping it in the public domain and I do feel my experience with life is working very hard in patient relations who do the major amount of work between all the different departments and it is, nothing's perfect but it is a lot better than it was five years ago when it's still improving. Mr Morton, can I just follow up that by asking you after your last answer, so do you think that the boards should potentially have less discretion then over how they manage these and that there should be some other way of managing it, do you see that as being maybe more central control over the boards, how would you visualise it going forward? I'm not a health care professional but I think the board obviously missed an opportunity, the senior management missed an opportunity but I believe the way it worked in NHS Ayrsynarn is you've got the clinical, the kind of silo system of the clinical directorates and then it's progressed to the risk management committee which I believe the CEO Ayrsynarn actually chairs, then it's then put forward, the adverse events that is then put forward to the healthcare governance committee which I believe non-executive directors of the board sit on and I believe the final decision whether it's a adverse event or not is then taken by the clinical, sorry, the medical director or the nursing director, so the system is in place and I believe it has been improved in Ayrsynarn and definitely has been improved but if I go back to 2012 you know it was definitely missed by the executive management team, it was missed by the board, it was missed by the wider NHS Scotland or if you can call that the Scottish Government, it was missed by Healthcare Improvement Scotland, nobody was actually curating if these events are the actual springboard to which we drive safety and improvement, you can't improve but you don't measure, they weren't even being curated and if you look at the disparity in the figures throughout the 14 of Scotland's health boards it's clear that there's no kind of standardisation and it's clear the national framework has not been implemented. Okay, thank you. Brian Whittle Bring to the committee's attention that Mr Morton is a constituent of mine and I'm working in the house case specifically. Good morning to Mr Morton and Mr Brown. I wanted to ask about the HIS investigation and do you reckon that was instructed in response to immediate attention or was the Scottish Government already aware and managing the issue can we start with that? Brian Whittle Far as I'm aware, you know, I wrote to, I found the failings that deep, that widespread between the NHS and the Aresland Arran that I believe you could say that we as a family circumvented the complaints policy, I wrote to the clinical, sorry, medical director, I wrote to the CEO, the response wasn't what I hoped, I then wrote to the cabinet secretary, I got a response from I believe someone within the office, I wrote again, you know, and then reluctantly after a year, a year of trying that I wrote to everybody, during this period I was also dealing with the Scottish Fatalities Investigation Unit and then we reluctantly, you know, sought media attention and as far as I'm concerned the intervention was only actually initiated after the adverse media publicity. In terms of the, if we go into the actual HIS review itself, I think the question I'd really like to ask is, is HIS fit for purpose in this particular arena? The neat answer, no, if we can expand on that a wee bit, this, we've had three HIS investigations in Aresland Arran. 2012, the fall of 2013, which missed the fact that Aresland Arran had already decided to circumvent the recently embedded management of adverse events policy and the decision to do that basically negated any chance of learning from the failings, you know, and put measures in place to prevent them happening in the future. I thought what was actually interesting was that, you know, HIS themself, they also stated that they expected, this is in 2017, the expected material progress to have been made since the previous failings were initially identified in 2012. Now you might not be aware of that comment because that was in the draft report, which I received from an FOI and that never made the final report report. I don't know why, you know, you can judge by yourself why that never made the final report, but HIS seemed to be like the, I don't know, I've described it before as Mission Creek, they're like the Acme NHS Scotland, they've got a wide remit and I think they're just taking on too much. Can I ask about in both of the cases, so there would be guidance and standards that medical staff are supposed to be guided by, which presumably were not adhered to. And then you then come in and you raise a complaint, was that at the ward level at first or did you go to a higher level initially, did you go straight through the complaints process? Was the complaints process adhered to, so was there a failure in guidance, was there a failure in the complaints process and ultimately how did you get to bring about that change? I answered that one first, I didn't go through all the committees and different things that you have done, I just went, my father was in that ward for a hip replacement when the Victoria hospital changed over from the old to the new and there was lots of problems with that. When he was in that ward I could see that it wasn't totally understaffed and I told him that my father would wander and they said, oh yes, yes, and different things, keep it all short. I told the nurses watch him, he'll wander and the shots storyated, they didn't watch him and the next night he went to the toilet, fell, fractured his skull so he died. So I was very angry at the time, they were very good with me at the time with different people helping me and I went away home for about a month and I thought, this is no good, it's getting to me, it's going to destroy me if I don't do something about it. And the social worker who was my dad's social worker said, right to the new, the organisation just started patient relations, just right, I mean I was hurt and never contacted me during that month, I never came to the funeral, I never did anything at all, I was just abandoned. So I wrote a six, eight page letter, I pulled the whole lot out, sent it off to patient relations on, say the Monday night, Tuesday morning, nine o'clock I got a phone call from patient relations, absolutely horrified at what happened and that started working through them and it was all done through them. And patient relations are they part of NHS 5? They're part of NHS 5 but they're not totally independent, they look at it from both points, they take your points to the higher ups that you're complaining about and that's where it all started. They're not a totally independent organisation but they do care for the patients and what's happened there, sort of a buffer zone between the public and the health board. So initially when the incident happened and you presumably horrified at what happened, did you raise that with ward management at that time? No I spoke to the nurses and the doctors came and spoke to the nurses. And that was largely just dismissed? No it wasn't dismissed but they dealt with it but I still didn't think, I saw there was a lot of problems there, they had to be addressed and I wanted to address them. They did what they could, they were very sympathetic, it took 10 days for my dad to die and they were very good during that time but I just knew there was a big gap and there was lots of problems and I just felt so angry, I wanted to address them. In terms of the root, the complaints process, I was within, I was a likestine, I was really uneasy about what occurred and actually done a bit of research and I came across the 2012 review where NHS Ersin Arran, according to the papers were accused of suppressing adverse events. I downloaded the policy, the management adverse event policy and I familiarised myself with it. The care we got, I must say, from the individual staff, following like a step was setting on, it was great, I can't fault that. We were assured that it would be taken very seriously, there would be a serious investigation. What kind of spurred it for me, the final straw for me was that we were giving a death certificate stating unknown and due to previous family deaths I was aware that certain deaths have to be notified to the Crown Office, the Scottish Fetal's investigation unit sitting now is, I quickly gave them a call and they had no record of Luxe's death and that resulted in myself and my partner's room actually being interviewed by two police officers, actually split up within weeks of Luxe's death, split up on her home and I have no complaints about Police Scotland by the way, it's just process. It was awkward to go through that to give her statements and Luxe's death should have been notified to Crown Office and I can pick up on that later. But again, then I lost all faith in the complaints process, that's what initiated my complaints to higher level, that's why I circumvented the complaints process based on what I'd learned about the history NHS elsewhere and based on what I perceived to be shortcomings and then notification of her son's death, that's when I took it to the board and further afield into political domain. Ivan Ewing, you're welcome. Hi, thanks very much for both of you coming along this morning because I know it's very commendable that you're pursuing your respective issues to generate benefits across the whole health service. I just wanted to compare and contrast and I'm sure there's shades of grey in here but looking at it from the outside, it looks like there's been two tragic events. In one case, we've seen with regard to Fife that after a while they've embraced your perspective on it, they've involved you in the process and from what I've seen they've made significant progress in terms of the way processes and procedures are changing to the benefit of everybody whereas in Mr Lawrence's case it seems to be the opposite of him not mistaking him to have been kind of kept at a distance and it's more of a kind of confrontational outcome. Is that fair comment and do we think that that really comes down to the different leadership in each of those respective health boards as to how this thing's been viewed from their side? I think so because the staff were all very shocked and horrified at what happened at Fife and they were very kind to me in different ways. I had the police investigation and all the rest of it but they didn't depute up any barriers. I was welcomed in from the minute and I said I wanted to work with them. I got letters and different things and phone calls on people but they said I would come and work on their committees and different things. Would I come and do this? They changed all the boards and lots of things took me round to let me see everything and I'm still working in different ways and different committees with them NHS Fife five years on and they're not at least and that was the time when NHS Fife was battered daily in the papers of everything and I just thought this has to stop. Somebody's got to do something about it and that was why I'm trying to get the staff and the public, everybody to work together and talk to each other and not put up barriers and be frightened of each other and that has worked. It's a fair comment up until fairly recently. It's recently yesterday. I met with John Buns from Ersin Arran and I'd like to think that they're turning the corner but in terms very recently that would be fair, that was your experience. We were held, definitely held at arms length from the process. We received a root cause analysis report that basically 12 words summed up the summation is we could not find a root cause for this event. That's what looks as if it's an event and that would have been, that's where that would have been left at. His death could have been unknown in terms of the National Register of Scotland and the hospital did not find a root cause for that event and it's only through our efforts that it's taken us all, it really has to take us all, myself, our family that we've got to where we are. The last few days that there's been a change in attitude or a communication? Only yesterday I met with John Buns and a member of the board. I wonder why. May I suggest that it's no coincidence the fact that you're being here today and Mr Buns was here last week. I'm no going to speculate. Let's not speculate but it's good news anyway that things appear to be moving on. What came from that conversation, if you don't mind, as I ask it? Mr Buns, he gave me an overview of the implementations, the changes that we're doing and I believe they're actually putting things in over and above the recommendations from his review and the commitments from the Cabinet Secretary and the Chief Medical Officer to make multidisciplinary CTG training mandatory. If you look international figures, the medical legal costs relating to CTG are enormous, they're huge. It seems a false economy scrumping this and I believe that now, and this hasn't always been the case, the basically CTG training is all but abandoned in NHS Ayrsynardin due to insufficient staffing numbers and I got that confirmed again through a LNPFY process when I had to appeal with the commissioner to actually get that information. It was abandoned for 13 months. That started in December 2015 for 13 months. The month after Locust died when we told everything, no risk, we never had it again. But again, significant changes being put in place and I believe they're actually trying to embed in is mandatory, what's called the prompt training which is nationally, internationally recognised in terms of improving outcomes and reducing fatalities. Can anyone else want to come in? I welcome you both to the committee and I think over the course of the work we've been doing, the work which you've both done has really been shown to make a huge difference, but specifically in those hospitals where these incidents occurred and it was really the culture of our health service which we keep returning to of covering up some of these incidents or not really engaging with it because it's seen as a failure. I just was interested to know your personal views about the culture having seen it and actually seen it change in both those cases. My experience was that NHS Fife at the time it happened was absolutely terrified of the Sue society. We'd admit to nothing, see nothing, not talk to anybody, not raise our head above the parapet in case somebody sued and I said to him right at the beginning, I had no interest in suing anybody. I just, money wouldn't bring my father back, I wanted to improve things and that made a difference and it's got braver and braver as the years have gone on and there's a totally new atmosphere in NHS Fife. Even when you go to the, I can only speak about going back and forth to the Victoria hospital and you go to the front door it's totally different and it's, I've done training videos with them, I've worked on the duty of candor these videos, they've asked me to go and speak at conferences and just get people to work together and do training and how the patients feel from the patient's perspective so I have no complaints about them at all. We're all learning all the time. Can I ask in terms of that, how have management within the health service specifically changed, do you see? You know, it's very much front line staff you've referred to. But front line staff and all the senior directors of nursing I work with and the higher people as well have all changed at all, much more open. I've not found any problems that some of the Tysia Marwix now in charge when it used to be all in burns and different things but I don't see any difference. It's still the same, working the same way going forward all the time. In terms of what you're saying about the legal culture, your experience was somewhat different. We were actually challenged Tysiu, I believe that's the best way I can describe it. We were actually challenged Tysiu, why don't you just Tysiu is and I believe that's in response to questions we're asking, difficult questions surrounding the failings into our son's death. Yeah, sorry, I've got Jenny first and then you. A little supplementary, Ms Brown just to Miles Briggs line of questioning, why do you think that cultures change because you alluded to NHS board chairs changing, that not having an impact? What do you think has been the impetus behind that shift in culture? Secondly, do you think what happened to your dad could happen again, are you quite confident now that there are structures in place or that there are changes that have been made that would make you feel confident that that couldn't happen again? I think it can happen again, all the different things have put in place and what I see with being on the falls board from coloured wristbands to falls protocols to all such things. We meet every two months to see that happening and I don't feel there's been a backward step with top management changing, things have been ignored, I've shoved in a drawer and I've forgotten about it still on going and all the committees I'm involved in are still on going and they're still from geriatrics, clinicians to everybody's on these committees and they're all speaking, the doctors are all coming on board with the nurses and it's all working really amazingly well. I'm not saying it's perfect, nothing's perfect but it is improving, quite confident. All of the practical things that happened, the real things that happened, we hear a lot of people saying all we all work together and when we ask them what is working together mean sometimes they can't tell us what that means but what kind of practical things happened in the wards on the ground that fills you with confidence or increases your confidence that it couldn't happen again? My father had an early Alzheimer's but he also had a fractured hip she was putting to an orthopedic ward and all the orthopedic nurses weren't used to dealing with elderly people with dementia and different things so they started to bring dementia nurses and things on to get water in the hands like call bills all sorts of things all that change it's still on going yet and they've evolved that way in different areas working together. And was there changes within systems that had to be rolled out across the? All the hospitals in Fife work from the same systems. So did that require a whole module of training for them? Yes, there were people brought in to do training from the psychiatric hospital that's with Eden to other different to St Andrew's Hospital as well as on different to Victoria but they were all given training, training managers, training plans set out and so on that for myself and they're all sent to me to be scrutinised. Excellent, that's good. You've told us more about how some of these things roll out than some senior managers and senior executives. I'm just a people person, I don't do reading brochures, I just talk to people and watch and pick up things. Could maybe do be you as a chief executive, I have any chess board. I feel him. It's just a quick question and thank you for coming today. You've described that culture has changed in both places even if it's a recent change in Ayrshire and Arran. Nationally, for me my background is clinical education and nursing and I know there's learning modules about falls and falls prevention in both the community and acute care so it might be that the development or the roll-out of training, whether it's learning or face-to-face delirium assessment is something that does occur in orthopedic units now but I'm interested in how you would see the national picture evolve. How would you want to see the best culture portrayed nationally across all boards? Culture is really improving. I don't think anybody's actually arguing against the point that a culture of continuous learning improvement is a way forward to improve patient safety and quality care in Scotland but I don't see any reason why that can't happen within a regulatory framework which is currently missing. I believe that regulations set goals, set objectives and the community force when the objectives and goals are not achieved which I believe is the case or case. A behaviour is governed by regulations but you know currently I don't believe the regulatory structure is there. You know when the culture improvement in learning falls short is achievements and goals and I've liked something like that in place. How that's put in place I don't know but nobody's asking for a CQC-style organisation to be uplifted and embedded within NHS Scotland what's now. I think we need to recognise we've got first certain people in certain organisations need to recognise we've got a Scottish problem and we need to find a Scottish solution to that. I think just very succinctly, are you confident that the lessons learned and each of the health boards you're describing around the terrible, terrible circumstances you encountered, are you confident that that has been passed on to every health board, every one of the 14 health boards in the country or as this committee is repeatedly encountering is it still victim to the very siloed culture of the 14 health boards where what works for one isn't often replicated in another. Are you aware of how much that best practice has been passed on? So from what I've seen coming to this committee and speaking to the MSPs before and what I've heard and what I've heard of other people trying to complain about things at nine meals hospital and can't get anywhere, I mean I can really only speak for my experience at five but I don't think it's passing on because I've tried to say oh call patient relations they'll help you but some of the places they don't seem to have patient relations so it's not passing on I don't think. There's a long way still to go. I go to Oslair Srenar and I don't see how an organisation that admits to having problems issues with the management adverse events was then allowed in 2012 to formulate and try and embed in their own policy when they've previously admitted to having serious issues where and I believe that's the responsibility of health care improvement Scotland to actually you know create a culture of learning across entire NHS Scotland and I don't think that happened then if we're specific to adverse events which I've looked into in great detail they're not related in a standard way by each of Scotland's 14 health boards they're not routinely monitored by health care improvement Scotland I don't believe the greater NHS Scotland or the Scottish Government I'm not sure how you kind of diversify between the two looks into that by monitoring the board papers I don't think that's possible that's a really untidy in a kind of awkward way and you're actually getting which should be a simple collation of figures to draw down into and look for greater learning but so you've got a kind of tripartite failings there if I go wider if you look at some of these deaths in terms of Lucas the Crown Office do not even relate the number of deaths and any themes patterns or trends for the deaths that are then notified weeks of Scotland's health boards to the SFIU or the greater Crown Office the other deaths again we're back to his again they've got the death certificate review service so out of 57,000 deaths for example in 2015 over 47% of the death certificates were found not to be in order which is roughly 27,000 deaths. Out of that 27,000 deaths I think it'd be fair comment to actually suggest that some of them possibly make the criteria for notification to the Crown Office and the guidelines issued by the Crown Office and again I've got an FY pending to see if that's the case to see if any of these 27,000 deaths have been retrospectively submitted to the Crown Office for greater scrutiny and if you look back into the I don't know going into great detail but if you look back into the findings of the shipment inquiry that's something we need to have in place that's the important safety net in your society that I believe is missing. Thank you. You're saying that 27,000 went how long was that over what period? 2015 47.1% of deaths this is the deaths are this is medical certificates that are sent to national regs of Scotland and I believe there's an organisation I don't know what happened before then if anything but from 2015 an organisation called the death certificate review service which is under the umbrella it is starts to the sampled 5% and out of that 5% they found it 47.1% in 2015 but not in order and has that work been continued? Yes in 2016 it fell slightly to just below 40% I don't know what processes and improvements were put in place to actually drive that improvement but it fell down to 39. something percent in 2016 and within that have they identified what the issues are? Well that's it I mean if adverse events are indeed a springboard from which we drive improvement and again if you look at patterns you're talking about you're seeing inaccurate death certificate yeah so therefore have they identified what those inaccuracies are? No not in the document I looked at no okay that's helpful thanks. Sandra are you okay? Yeah my question's been answered thank you. I've noted at the start that I have a relative working in NHS Ersin and Arwm so apologies for not saying something like that. I kind of wanted to go back I think what's interesting here is we've got two completely different experiences here I think for me the key here is the implementation of recommendations once we get to that point and from reviews and from your own experiences and I wondered again if we could highlight the differences in the way that these investigations have been implemented I'm also very aware of Mr Morton's case but you seem to have a much had a much much better experience and I think for me that's the key to this. Yes I did and that's why I wanted to bring that to him and I came down the last time as well is to prove that I had got a much better experience I was not abandoned well I was for the first month but after that I was much more accepted and done what I wanted to do and still I've been taking on to do interviews for patient relations jobs and just anyone that we've come along with and I'd just like to do things like that and just get from the public perspective and I feel they're much less frightened of suing and everything else now they've come right from behind the barrier and getting in touch with the public. So your experience is the implementation of those recommendations that come out of that are they positive? All of it's been very positive. Okay and Mr Morton you would perhaps say something slightly different. Immediately when the terms of reference to the recent review were announced I believe there were two in a row. I believe the time frame is too short the time frame was based on improvements made by NHS Airson Arran and then we find that one of the findings of review team is that you know they would expect material improvement so again in the terms of reference only looked at the maternity service and the adverse event policy covers every directorate so right now at this moment we actually don't know the full extent of the avoidable deaths of NHS Airson Arran because it's a common policy and they've concentrated in one small area. So who's set the criteria then? I believe that was the Scottish Government in conjunction with healthcare improvement Scotland and if you look at the time frame as well it conveniently missed encompassing the 2012 review. It's almost if healthcare improvement Scotland didn't want to actually look at their own partners process that's how it seemed to me and I wrote to the Cabinet Secretary and I wrote to Robbie Pearson you know and if you go back there's a lot of talk there now if I kind of digress a wee bit there's a lot of talk on the Parliament about health and social justice or sorry health and justice you know a collaboration asked for the terms of reference to be expanded asked for a memorandum of understanding to include the health and safety executive to include the crown office and also include an expert in human factors because one of the things we were told specific to our own son's death is that we can't see what happens inside people's heads when we question why my partner June was not escalated as per the guidelines so I think it was a reasonable request for an expert in human factors the health and safety executive who actually found that agreed there was systemic failures and failings in clinical governance and that put them the HSE and a diametrally opposed view to the actual health board and it's just been left at that you know they agree clinical failings the hospital initially did not admit to any clinical failings but we just move forward without anything being addressed and in terms of memorandum of understanding that was reasonable that was a feature in a more conveying inquiry so I don't know how it could have been expanded within the recent review within Scotland okay we've come to the end of your time can I sec me greatly appreciate you coming forward I think you've done your families very proud not just by giving evidence today which is obviously a difficult thing but by the fact that you are pursuing the issues that you care so passionately about and hopefully will change the system for the better so that other people do not have to experience what you have experienced so thank you very much for your evidence this afternoon and I think we're now going to private session