 GwELin hynny yw gwaith y 20 eich byddai gennym y Ffwrdd Yng nghymru yn 2017. Felly dydych chi'w wnaeth i'r fawr o'r mewn rhai pa yn fawr. Felly mae hwn yn gweithio gweld.] Mae'r ddechrau gyda'r fawr i'r dyna pan pwysig, gyda hwnnaedd yn ôl y cwerth gwrth. Fawr angen eu cyfrifoldig yw Alex Cole-Hamilton a Tom Arthur. Mae'r angen i bob Dorris i'n gŷn eich gwelio i'n fawr, ond hefyd seguid yn rwyf. The first item on our agenda is subordinate legislation with one negative instrument to consider today. That instrument is the Carers Scotland Act 2016, prescribed days regulations 2017. There has been no motion to annul and the Delicated Powers and Law Reform Committee has not made any comments on the instrument. The committee first considered this instrument at its meeting on 5 September. I agreed to write to the Scottish Government for further information. A response has not yet been received, which is disappointing and we will be writing to the Scottish Government about that. I could invite any comments from members. Agenda item 2 is NHS Governance, and we are looking specifically at staff governance. We have round an hour for this session. I welcome to the committee George Doherty, director of human resources NHS Tayside, Jennifer Portes, director of human resources and workforce development NHS Western Isles, Alain Mead, chief executive of NHS Highland and Kenneth Small, director of human resources NHS Lanarkshire. Can we move directly to questions? Thanks very much, convener, and good morning to the panel. Can I begin by asking a couple of questions about the NHS staff survey? Much of the evidence that the committee received so far suggests that the results of the staff survey, even when the high light concerns by staff, are largely being ignored. The perception is that very little action is being taken as a result of the staff survey. Do you think that that is a fair criticism in your health board area? Thanks for the question. I think that we have got to look at this as a progression. The annual staff survey, as it was, is now no longer. Historically, in response to your question, because we did run a staff survey for many years, there were a number of areas of frustration with the staff survey, but I do not think that responding to the messages that came from the staff survey were one of those frustrations. The biggest frustration for me and Lanarkshire and colleagues who can speak for themselves was the ability to get significant numbers of staff completing the survey, despite the power of partnership working with our trade union colleagues, with our managerial colleagues, with our clinical colleagues in encouraging staff to complete the survey. In Lanarkshire, over the years that we ran a staff survey, we managed to move our staff participation in the survey from the low 20 per cent to the mid 30 per cent, despite significant effort no higher than that. I think that our collegiate approach to the staff survey has always been that we ran the survey. We got the results of the survey from a national engine room that developed and ran the survey. Our response to that was on an annual basis to, again, in partnership with trade union colleagues and all of the staff to develop an action plan. The staff survey action plan would draw down the particular challenges that were coming back from the results of the staff survey, as well as the positives, and we would prioritise action against that. The staff survey action plan was an integral part of my governance framework, so at the staff governance committee, which involves non-executive directors, trade union colleagues, managerial colleagues, HR professional colleagues, etc. That staff survey action plan was regularly considered, the actions reported and where appropriate, a redefinition of priorities for the next period were agreed. No, I wouldn't agree that the staff survey's results were ignored. I think that they were used to inform priorities for action and priorities for improvement. I echo everything that Kenny has just said. Kenny has highlighted similar experience in Tayside in her response to the survey, but a similar experience in response from individuals to the survey itself. Likewise, our best-ever response rate was about 35 per cent to the survey as we look now at iMatter. iMatter is a tool that talks more to the individual's experience in terms of their day-to-day workplace, in terms of their team, as well as their views of the organisation. We are looking at response rates of 68 per cent, so there is a much higher level of engagement because it is a much more meaningful exercise for individuals. The board can still take those key messages because it takes the summation. It receives its own global report in terms of the totality of responses, but the key differences that are made are made on a day-to-day basis in relation to what the experience is of working within the team, the discussions that happen within the team, they are led by the team and the changes that they can act, they do. Through our area partnership forum, with our staff side, as we did with the staff survey, we similarly do with iMatter with regard to a global action plan that is monitored by the board in terms of our response, about those things that are common themes that are emerging across our organisation that we need to take action on globally, as opposed to looking to the teams to individually take that self-leadership. We had similar experience in NHS Highland in the response rate to the survey, but we are very pleased with the response that we are now having to the iMatter approach that we are taking. Just to echo George's views, I think that the fact that the action plans are developed with the local teams by the local teams gets a lot more engagement and people take a lot more responsibility for that. That is a real change in the approach to staff governance certainly across NHS Scotland. We have the same arrangements in NHS Western Isles. We had action plans following the survey, which were, as Kenny said, embedded in the staff governance action plan. Now, having implemented iMatter, we are pleased that we have an employment index of 76 per cent and we are now focusing on the team action plans that address the issues of the staff directly at team level. It is important to recognise that iMatter as the replacement for the main components of the staff survey across the NHS in Scotland is now achieving a range of staff responses of between 60 and 70 per cent by comparison with the Scottish average, which was about 35 per cent for the staff survey. The participation does not tell us what staff are saying. It just says that they are saying something. Can you give me an example, therefore, if iMatter is something that you find more effective? Can you give an example from your health board of a tangible change that you have made as a result of feedback from staff on iMatter? Certainly from TSA's perspective, and you will have seen in the written submission about some of the key domains that are being reported back with regard to the sense of individuals' involvement. For us, a strong response was the extent to which individuals felt that they were involved in local day-to-day decision making within their teams. An area that was identified through iMatter, but we needed to strengthen together with our staff side, was the sense in which individual employees felt they had a voice within the board's overall strategy. As a consequence of that, one of the steps that we have taken is to move beyond area partnership forums and to put in place local partnership forums for us. At a local level, I am having joint staff forums with our trade unions and our line managers to ensure that local plans, local budgets and local strategies and local workforce issues are considered within that service. That is a very clear example of where the iMatter outcomes have created, for me, a strong position in local governance that the staff surveyed not. One of the concerns that we had from the response from iMatters was the visibility of management. As a direct response to that, some of our actions have been to encourage and support particularly middle managers to be out on what we call the GEMBA, the place where work happens. To have them out with teams on a daily basis, they are budded up with wards in particular areas. Their visibility is now much higher, so staff can see senior managers, middle managers, on a regular basis. We already had that arrangement for an executive team to be out. That is over and above the walkarounds that we do for things like Scottish patient safety programme work that we do. This is getting back to the place where work happens. I am hoping that that will next year improve that result in our iMatters survey. Obviously, we have not seen detailed results from iMatters yet, but it is still being implemented. When we see those results, are you saying that there will be a substantial improvement in staff satisfaction ratings and a whole range of things compared to the staff survey when that is published? The difficulty with that is that you are talking about two different systems, and the ability to compare and contrast will be challenging. In time, giving iMatter that absolute corporate commitment across NHS Scotland will allow us to look at trends in boards, to look at trends right down within boards into departments and clinical areas, but also corporately for the NHS in Scotland. I think that iMatter, as a tool, has the potential, provided that we give it longevity. That is one of the issues. Let us give something a chance to properly work and to build that confidence in looking at trends. I think that iMatter has that potential, where it can drill down much more riddly than you ever could within the old staff survey. Just one final question. Do you think that there is any benefit at all from having an independent scrutiny element of the work that you are doing around iMatters and the staff satisfaction survey? I suppose that depends on you. My answer would be yes, I see no reason why not, because I think that we should be absolutely confident that what we are doing is the right thing and has the potential to make a difference. I would argue that already the old survey and iMatter get independence scrutiny because we all take the results of this, including the action plans through our staff governance committees, where we have non-executive directors. In my case, we have our chair and our employee director as an integral part of that arrangement, who are looking at, from a governance perspective, the results, what we are doing in relation to the results and what a difference that is making. We also need to come in at this point. Is it my also? With experience, I think, with all panel members here in terms of the committee members, we have met constituents who have gone through a whistleblowing situation. The fact that there is no independent investigation is internal is always being raised. I just wondered what your specific views were on how that could be improved in the future, as has been mentioned with establishment of independent whistleblower hotline. For that, it is to be done outside of the health board. That point would be, and I will say thankfully that I have limited experience in relation to whistleblowing. In Lanarkshire, if you look at the last three years, our whistleblowing occurrence has been nil. The involvement that I have had in relation to whistleblowing within the NHS in Scotland was really acting as chair of the national HR director's group. I was asked to support another board in terms of investigating and responding to a whistleblowing case. From an independent contributor, as that was seen as being, that was accepted by both the whistleblower and the board. I think that there are some benefits in having a level of objectivity that sometimes can be difficult to achieve from within a board. At the same time, in most situations of whistleblowing, it is important that we engage locally, as well as have that level of objectivity, because arguably we get the better result in that way. All boards have—it may have been presented in evidence already to the committee—a non-executive director who has pointed independently to act as a whistleblowing champion. In the case of my own board, that is the vice chair of the staff governance committee. My staff governance committee is co-chaired by a non-executive but also by an employee director who is the staff side chair as elected by the trade unions. We bring a report every six months to that committee. We are in and about all whistleblowing issues that have been raised. The role of that whistleblowing champion is to do two things—give assurance around about our handling in terms of due process, but also to ensure that, whether there are any concerns, those are escalated, whether that be to our chairman or beyond to the Scottish Government. From our perspective, I would agree that it is important that individuals have confidence when they raise concerns under the banner of whistleblowing, not just in terms of wrongdoing but also in relation to risk that that is being dealt with appropriately. I know that that is an ethos that surrounds all the boards, each of whom we have been asked to identify as a whistleblowing champion and have them appointed. That person does not investigate the incident, they simply oversee it. That person does not directly investigate, but their responsibility is to ensure that any investigatory process is taken forward, to ensure that any matter raised has been addressed and their accountability is to the board to give assurance that any matter that has been brought forward under a whistleblowing under our policy has been addressed appropriately. Investigated by who? Again, it depends on the nature of the issue. In circumstances of a clinical issue, you would be looking around the clinical governance lines in terms of the key officers, whether that be the medical director, nursing director or other, to take forward in that instance. In relation to individual instances where issues are wrong doing are raised, that would be through appropriate policy. We also have as boards in place fraud liaison officers who work with the counter fraud service. Similarly, in any issue of wrong doing, it is through the fraud liaison office that these matters can be escalated to the counter fraud service also. So not independent? The counter fraud service is an independent body altogether. The previous, when you spoke about clinical or other issues, they would be investigated by someone within the organisation. They would be investigated in line with our agreed policies with our trade unions, and the role of the... Let me compare with this. They would be investigated by someone within your organisation so it could be a senior manager, it could be the manager in that department or whatever. Would not be an individual who is connected to the case. It would be taken forward in a policy to ensure an independent investigation. Again, that is one of the assurances of the whistleblowing champion to the board. It is not an independent investigation if it is someone within the organisation. It is an independent investigation under the terms of our policy to ensure appropriate due process. The committee has presumably taken evidence on the existence of a national pin policy on whistleblowing. That is a policy built up nationally within the partnership between the NHS boards and the Scottish Government and the trade unions. It is that policy that George is talking about, which we corporately apply. Again, I would suggest that that depends on your definition of the word independent. That policy that people have raised concerns about, and we have taken evidence, sorry males. It is okay, no problem. I really wanted to know as well in terms of this. How many people are on permanent gardening leave within your organisations? Do you have those figures, or could you provide that to the committee? How many have not returned to the health boards after this investigation? My starting point on that would be that we do not, to my knowledge, cross the NHS in Scotland of anyone on guard what is deemed gardening leave. There will be times when an employee is suspended. When an employee is suspended from duty, they are always suspended on full pay, they are always suspended without prejudice, and they are suspended for a reason that they are made aware of, and there are support mechanisms and regular review of that built into our normal policy approach. Invariably, the reasons for suspension are to do with disciplinary action. Very rarely will it be for health reasons, because normally someone on health for health issues would be off work because of a sickness absence and as a separate arrangement, separate policy for that. The answer to your question in relation to Lanarkshire at the moment is that we have four members of staff suspended from employment. All of them are subject to an active disciplinary investigatory process. They are kept well informed and engaged and involved in that process. We, to my knowledge and have never had anyone who is permanently on what you would deem gardening leave because that is a misuse of public resources. Anyone else want to come in on that? We will. If any staff on gardening leave is the same arrangement as Kenny's Outland. But you may have staff who are suspended on a long-term basis pending an investigation? Not on a long-term basis. If we have any staff suspended, it is a consequence of an investigation into a potential disciplinary matter. Yes, yes. The same would be for us who would follow our policies and procedures and have people suspended as necessary. Just to come back, I would not like to give the impression that suspensions are not on occasions for quite a long time. As the old man of the panel, I have been in NHS 40 odd years and that probably the longest suspension that has ever taken place was approaching two years. Again, that is not because we have forgotten about that individual. It is because quite often, particularly if you are dealing with senior clinical staff, the act of investigation is complex. When you start an investigation, you end up in areas that you had not predicted at the beginning. There are times when suspensions can be for long periods. We seek to actively and proactively manage that to the minimum, while balancing the need to suspend with the appropriate nature of a comprehensive investigation. The norm is nothing like two years. The norm will be a matter of weeks, sometimes months. I want to come in a little bit on the back of this and clarify some of the evidence that we have just heard. I am coming at this very much from having been staff side in the NHS, just so that perhaps some of the other committee members who are not as familiar with policy and procedures in the NHS get clarity around about this. If a member of staff is suspended, they are suspended using the policies that are underpinned by the PIN guidelines and that are agreed in partnership with the trade unions. Is that correct in all of your NHS boards? As you say, if a staff member is suspended, suspension is not a punishment. Suspension is there to protect them and to protect the integrity of the investigation. Would that be correct in all of your boards as well? Yes, exactly. That staff member is supported throughout that time that they are off. They have a contact person within your HR department and they have access to a trade union representative if they are a member of that trade union. I will make direct contact with our occupational health services in case there is other support that the individual would require. I would like to go back to the issue of the independence of the whistleblower because that has been a concern raised in some of the written submissions. Sir Robert Francis in his earlier evidence said that the concern that some people have expressed and which I think we have to look at is that a non-executive director has a corporate responsibility to the running of that organisation. Can you just clarify that you are allowed to appoint someone who is not a non-executive director to the whistleblowing champion role? As we have earlier said, we adopt, as we are required to, a national whistleblowing policy, PIN's partnership information network policy—we will talk about PIN a lot possibly—and that is the policy that we are expected to apply. That policy sets out an arrangement for the investigation and decision making in relation to any case of whistleblowing. That policy, as it presently stands, does not provide for what is in your mind in relation to that level of independence. It provides for an individual or a panel to investigate from within the current employment arrangements or connection arrangements, including non-executives, of a health board. Can you see why some people might have concerns about the independence or lack of? Absolutely. I can see why that might be the case. What I would seek to do to such an individual is to say to them and convince them, if I can, that the arrangements that we would put in place would be sufficiently distant from those concerned or involved in the subject of the whistleblowing case, and through that hopeful confidence to bring a level of reassurance around objectivity to them. Do you think that it would be possible to improve this process and policy so that no-one was left in any doubt whatsoever as to the independence of the individual appointed as a whistleblowing champion? I think that we would be foolish and naive not to think that we couldn't improve on lots of things. I wouldn't disagree with you that that's a potential for building and sustaining greater confidence. Has that been discussed within any organisations to make this a more robust and independent process that there is an appointment from someone not within? Can I go back and make that suggestion, Mr Small? That might be a good one. I could just say that, in relation to the campaign, that same agreed-in partnership in the Scottish Government in 2015 wrote out boards to appoint a non-executive whistleblowing champion. Whereas, as Kenny says, we can always improve and feed into opportunities to improve. When it's agreed-in partnership at Scottish partnership level, our role is to ensure that we implement the pins. I suppose that, speaking from experience, as a non-executive director on a board, I personally think that it could be improved if the person was absolutely independent of that board, because they do have a responsibility. They want to see that board perform well. My own view is that that's a concern that we need to look at further. I would like to go on to the issue of blacklisting. In our evidence, we had written submissions where two doctors detailed their experiences of whistleblowing and consequent difficulties when they went on to apply for future jobs. Whistleblowers aren't legally protected from the actions of a future employer. In your view, does the NHS operate a blacklist? Absolutely not. Why would you think that it was the case that two of the written submissions from doctors that we have suggested that they have suffered? The Employment Rights Act 1996 protects people from suffering a detriment as a result of making a public interest disclosure. We have written submissions and I have met people personally who believe that, in making such a disclosure, they have suffered thereafter and found it incredibly difficult, if not impossible, to gain employment again within the NHS. That's a difficult one to answer. I think that people's perceptions of their reality and the acceptance that that's different from the position that, as an employer on the NHS board, would take. On occasions, it may be difficult to rationalise and bring those two things to a common agreement. I can only repeat that, to my knowledge—or working in many health boards, but north and south of the border—there is no such thing as blacklisting. I would play no part in that, personally or professionally. That's a view shared by the witnesses this morning. Yes, we have to bust recruitment procedures that would include that. I don't think that there's a blacklist either, but you only have a small number of boards. It only takes a few calls between human resources staff, or whoever, or directors, or senior managers to say, don't touch him or her. Does that happen? Experiences like Kenny, I have worked in a number of boards across NHS Scotland as director. That is not anything that I have ever encountered or that is not anything that I would ever sanction within my team. That has not been my experience. If I can add to that, as chief executive, I have not had any experience of that happening. Certainly, my HR directors would give me clear advice about not being able to do that, nor would we wish to. We want to appoint people on their merit. In fact, even recently, when I was appointing a director, I had no knowledge of who the people were because we redact all of the personal information about those individuals before they are circulated to have the panel even shortlist. There is no way, even if that was to be frustratingly, that we have no way of knowing who people are when we are shortlisting them for appointment. That is interesting, because I know that I do not want to identify the person. However, in one particular case, a person who raised serious concerns about clinical practice was suspended for five years, had a previously very clean and unblemished record, and then applied for one of 12 vacancies in a health board area. When the application went in, very shortly thereafter, all the vacancies disappeared. The jobs were no longer presented, and that person has never worked in Scotland again. That might be a conspiracy theory, but it seems a bit of a coincidence for that particular individual. Sorry, Brian. Thank you, convener. In this particular interest to me, we heard a lot of evidence in the Petitions Committee around whistleblowing. There was a petition brought there, and we took a lot of evidence. Whatever was perceived or otherwise among NHS staff that whistleblowing 1 is going to be ineffective and will not be able to affect change, and 2, as has been alluded to in here, the perception is that that will blight or blot through their copybook for future. Given that we have already looked at the policy good or otherwise, as it currently stands, what do you think or should you be doing more to encourage NHS staff to come forward? As you have said, there are very, very few doing that. That would raise a flag for me, I have to say. My immediate reaction to that is that if I was sitting where you are, I would see the world in that way. I don't because I see whistleblowing as a failure. I think that when a member of staff gets to the stage where they resort to a whistleblowing arrangement, then our processes around staff engagement, openness, honesty have failed. Again, representing my experience in Lanarkshire, I think that we have very solid and effective arrangements for staff engagement at a whole variety of levels, corporately right through our operating divisions, right down to clinical teams, wards, departments, et cetera. We have a number of strands to that, which are driven through our approach to staff governance in the main. Our relationship with our staff side colleagues is the starting point, because that relationship is a highly constructive one and is a highly open one. We have staff side members as an integral part of our board, as an integral part of our corporate management team, and they are working with us in an open book environment where, if we have a problem, be that a financial problem, a clinical governance problem, staff side are well aware of that to the same degree as managers are. That message, we do everything that we can to pass down through the organisation. Our non-executive and executive directors are out on the wards, are out in the departments on a weekly basis, conducting patient safety views, conducting visits. The integral part of that is to promote their profile, to promote access, so that if staff have got an issue, they virtually know that people by name, not just from a picture on a website. We also go to the lengths of having HR surgeries that go out into the organisation. I personally have a separate email address, which is called umatter, just to link that to the umatter concept, where any member of staff in Larnachshire can email me at any time of the day or night to a umatter account and they will get a response within 48 hours and they can ask me anything and they often do. Whistleblowing is a failure because people who have issues or concerns have got numerous routes and numerous opportunities to raise issues, I hope, confident that they will be responded to. Obviously, I look at it slightly differently. I always think that, one, I don't like the term whistleblowing, I have to say, but I would have thought that it was an opportunity to go back in and have a look at the systems that are in place to see if they can be improved. For me, if someone has to whistleblow, that's because other systems that are the routine embedded systems have failed, because somebody should feel free and feel confident in raising that issue, usually as locally as is possible, sometimes as local fails and therefore it's orchestrated up the organisation, but I would hope rarely into a whistleblowing situation. I concur totally with Kenny. In the Western Isles, we have several methods where staff can raise complaints. We've got datex systems where staff can enter complaints or issues or concerns, and that can be done confidentially and then a response is given to that. We've got normal complaints procedures, we've got grievance policy, we've got dignity work policy, and, like Kenny, the use of whistleblowing policy is a last resort. Those formal processes are supported by the patient safety walk-rounds, chief executive open meetings and availability of directors to receive comments and working in partnership with staff side through iMatter and the various HR forums across the Western Isles and across the islands. Whistleblowing is a last resort and we work closely with staff to ensure that any concerns are raised at as local level as possible, so is the issue can be resolved as locally as possible. We took a session with middle managers in the NHS and they were very frank about the pressures that they were feeling at this moment and about the way in which pressure from on top to meet performance targets was driving everything and the innovation and things that were being raised within the ward by their staff were often set aside because it was the target driven culture that was everything and they had an off the record session with them and they were very open and frank about that. Do you agree that that target driven culture is what is driving behaviours in the NHS that might end up being negative behaviour and impacting on staff who are on the front line? Maybe I could start. I think it is all about the culture of the organisation. Clearly we are there to deliver on the targets and the objectives that the Government sets for us, but importantly we are there to serve the local people and to protect both our patients and our clients, so there is a responsibility for all staff within our organisations that if they see something they need to say something and we would encourage that part of our local highland quality approaches is to encourage staff to be open to work with integrity as part of teams and we would triangulate what we are hearing in the boardroom by being out as I have described already at the shop floor talking to staff, so I think it is that accessibility. I do not doubt at all that middle managers feel under pressure in the system and feel squeezed for sure, but they know that the most important thing is to protect the people that we serve. Their argument was that they were saying that they had ideas within the service, within their ward, within whatever service they were providing that were being stifled by the target culture and the pressure from a top on to them as individuals who were very frustrated by that. I am sure that they could feel frustrated by that, but in fact what we need to encourage staff to be doing and we are in NHS Highland is to take responsibility for their own work and make the changes in their own workplace. Now that takes time, but we are certainly encouraging local staff to take every opportunity they can to not only do their job but to change their job for the better and in fact they feel more empowered, more engaged to do that and I come back convener to that being a cultural thing in the organisation that we have to live that as well as say that and that is really important for the staff to know that they will be listened to but also that they can influence the way that their jobs are working and the way that their services are run and organised. A third to say that the responding positively to the statement staff role was consulted with changes at work, a third, 41 per cent would not recommend that the NHS is a place to work. Largest numbers talking about bullying, significant numbers anyway, 15 per cent talking about bullying and harassment at work, that is the kind of thing that I think that those managers were getting across to us. Is that something that you recognise? Right, like Elaine, I recognise that the life of the middle manager, not just the NHS probably in any organisation, is always a pressurised life because you got pressures coming from the staff that you manage as well as from the staff who manage you and that is the life of being a middle manager. I echo Elaine's thoughts that are present within the NHS, there are lots of pressures, there are clinical pressures, there are public expectations and there are financial pressures and these things come together to make that a demanding role. I do not recognise the statements that you are making either. I think that middle managers are doing a very good job in a very challenging environment at difficult times. Again, speaking for Lanarkshire, I think that my middle managers are very motivated, they are very committed staff and they are very good staff. Statements that were made by people who were given evidence to us. I completely agree with Kenny. One of the differences between the staff survey and I matter is the sense in which everybody belongs to a team and that includes our professional middle managers. Like Elaine, NHS Tayside is driving a process of cultural development that is values based and has empowerment and leadership at its heart. As we look at the matter outcomes, what corporately starts to talk, around about 76 per cent in relation to the extent to which individuals are treated with dignity and respect, increases into the 80s when you look at the environment in which they work every day as a team and that includes our middle managers. I completely agree with Elaine. As an organisation, as with any organisation, you are required to deliver outcomes and those outcomes in our case are throughput in terms of treatment. But underpinning all of that is the overall responsibility that we all have in terms of the quality of the care that is delivered and the clinical outcomes that sit alongside them. It does not matter if you are a chief exec, if you are me, if you are a nurse on a HP, a domestic. We all have a similar responsibility and we all have equally similar goals in relation to ensuring that that is the case. Do you reference the DATIC system with regard to risk? Again, the DATIC system is to do exactly that at any level within the organisation. I am allowing an individual to report where they believe that there is an emerging risk so that that can be addressed within the organisation. At every level through our organisation and TACE side, those DATIC results are scrutinised, are reported and are reported transparently to our board to ensure that, if there is any case, there is a team that feels that the pressures upon it exceed their ability to deliver that we are able to take action. Felly, on from that, a recent poll in the BMJ found that 91 per cent of doctors who responded believed that healthcare managers should be regulated in the same way as doctors. You have just said that healthcare managers take the same level of responsibility. The poll was accompanied by an editorial that quoted Sir Robert Francis, which said, When we look at what really goes on in a hospital in the engine room, we have consultants and alongside the managers. Together they are meant to manage a service and yet one side is subject to a regulator and could be in jeopardy for any decision that they make whereas the other side is not. I will be interested to know whether any of you think that being a regulated profession might make a difference to the career of a manager or the quality of management that the health service has and if you do not think it would make a difference what do you think would start? I think my colleagues are looking at me. Mary, I am very interested in this personally. I think there is a real opportunity here for the validation of management in the NHS. In fact, I myself continue to maintain a personal development plan which could be looked at by anybody from internally or externally to show that I keep up to date in what I do because I think we all have to be able to evidence what we do. It is not something that is, as you say, there for managers at the moment, but my experience is most managers continually do learn. We are not subject to that external validation, but personally I would welcome that. I think a lot of other managers would be very happy to subject themselves to the same sort of scrutiny as our clinical colleagues, both nurses and doctors, are at the moment. I was an AHP as you know. I agree entirely with that. We now would also point out that it depends on your definition of manager because many of our managers are already members of regulatory bodies. Whether there be ward managers from a nursing background that are regulated through the NHS, whether it is our AHPs or ourselves as HR practitioners, we have a charter institute body, as does financial colleagues. It depends on what you define as a manager, but I would agree entirely with Alayne that, from my experience, all the managers that I have worked with are intensely keen on their on-going professional development and their own practice. That is an area that I suggest that all boards are active around that. Adding to that, it is also important to recognise that the vast majority of the managers, be they clinical managers or generic managers within the NHS, operate under a performance management cycle. They are not individuals who are not held accountable, whose performance is not regularly and routinely scrutinised, who do not have objectives set for them and are measured against performance on those objectives. Those objectives are on occasions numerical, but they are also qualitative and personal style. They are about coming back to the original subject of today, and they are about how they lead and manage staff under the terms of the legislative staff governance standard. We adopt a very disciplined, robust approach to that that does a good job. Do you think that at the moment that the career structure attracts the brightest and best, or do you think that more could be done to improve that? I know that that is hard. I think that that is a difficult one. I think that the answer to that would be in part, but we could do better. There is an initiative currently being led by Shilly Rogers within Scottish Government, who is the director of workforce within Scottish Government for health, which is looking back at our performance around leadership, leadership development, succession and talent management and question, fairly robustly questioning, whether we have got that right in the past and in the present. I think that there is a recognition that we could do better, and there are some thoughts developing. There is a meeting on Thursday this week at St Andrew's house to look further at how we bring together a series of initiatives on that front that will, I think, if they are accepted by, they still go through chief execs, et cetera, but I think that if they are accepted, that will put us in a better place to more confidently answer your question. Can I ask another couple of different questions? This one is for you, particularly Elaine. NHS Highland operates the lead agency model, which is different from all of the other health boards. One of the advantages of that model, as it has been described to me, is the clear governance lines. I wondered if you wanted to expand on that, and if your colleagues maybe wanted to comment on how it is different in other health boards. Yes, it is a model unique in Scotland and, inevitably, I am biased about the model. I would say that the clarity that we have about single management, single budget and single governance over the whole continuum of health and social care makes it very easy for me to be the accountable officer for the whole system. I will only speak for my own system, but I think that the challenges that we thought we may have in transferring the employment of staff from the local authority to the NHS, with staff partnerships support, were very easy to resolve. We now find people working as genuinely integrated teams. Even more than we anticipated, the benefits of working with those teams have been beneficial to patients and the clients that we serve. I think that integration of health and social care can work in many different ways. We have a separate model, as you are aware, in our Gail and Bute, with an integrated joint model. Fundamentally, we have been able to change the whole culture of the organisation with one team working and one organisation, as opposed to two different groups of staff working with different terms and conditions and policies that make it more difficult for a single approach. As I said, I accept that I am biased about the lead agency approach, but it has been beneficial for us, I believe, in NHS Highland. Does anyone have any other? I will talk from a TSA perspective. We have a different arrangement, as you have already highlighted. I would describe that as us being on a journey at this point in time. It is a partnership, and it is about partners coming together. The integration for us is about mutual learning. We are two different systems, and I think that we recognise that. In governance terms, we are, as a health board, however, very, very clear on where our accountabilities and responsibilities lie, whether those be clinical or on, given today's agenda, staff governance for NHS employees. All our actions and all our reporting covers the domain of those members of our team that work in the health and social care partnership as much as it does for anyone who, for example, is hospital based on the acute side. There are learning on both sides. Again, there are things—you cannot oppose a culture from one organisation to the other, and I think that everybody recognises that. I think that there are some really, really good examples, for example in our Dundee health and social care partnership, which, whilst operating still as NHS and local authority, are coming together and acting as single teams, looking at themselves as single teams, and, if I can link the agenda a little bit, going back to iMatter. The iMatter tool is being applied across our health and social care partners. They are as keen as we are to understand what the experience is as a local authority in terms of their social care staff and how it can be made more effective in terms of their day-to-day experience working alongside their health colleagues. We are acting as a single system. In that sense, there will always be issues about purse strings in some of that, but from a governance perspective and a staff governance perspective particularly, we have quite a strong story. This one is aimed mainly at Elaine and Jennifer. As well as purse string streams, there are real challenges with recruitment in the Highlands and Islands. One of the ways that we have tackled that in the past is with targeted campaigns in Europe to recruit European health professionals. I wonder if, just seeing as we have you here today, this is definitely a huge underlying cause of staff stress. I wonder if you could give me your thoughts on how we are going to manage that situation post Brexit. In the NHS veterinarials, we were pleased a couple of years ago to lead in another periphery project in our recruitment retention, which included the Arctic countries. We were the only health board in Scotland, and we worked in close liaison with Greenland, Iceland and Norway. Whereas we think that we are remote when you experience healthcare structures in these countries, you have a second thought about that. We have some very good learning from that, but the main outcomes were for remote and rural areas, the key challenges are twin-track, social isolation and professional isolation. You cannot address one without addressing the other. If you focus on one, such as a campaign for particular career opportunities or particular learning and development, you do that at the cost of social isolation, which means that it is not sustainable. Likewise, if you focus on the social issues such as housing schools, it is not sustainable. We have been working to look at having a twin-track approach to that. We are working with the medical director and the nurse director particularly to look at opportunities with my colleagues in the north, particularly in Scotland, on periods of time for staff professionally to be supported by the bigger boards. At the moment, we are working with Shirley Rogers and our team to look at ways that you can implement such best practice across Scotland. It is not an easy solution. I worked on various health boards in Scotland when there were campaigns in the eastern European countries for professions like dentists. They might work initially, but unless you have an infrastructure in place to support it long-term, it is not effective. I have worked in schools. No-one for the NHS ever came into school and spoke to kids and said, this is your career. I have never seen a TV campaign saying, come and work for the NHS or a newspaper campaign saying, this is the career of the future. Does that happen? I am happy to pick it up. We have a placement scheme for school pupils to taste jobs in the NHS, which ranges from catering to nursing. We are also starting a medicine for school children programme to encourage young people who are interested in going to medical school. We currently have 90 places a year where young people come into the school. We do local careers fairs in the schools across the islands. We go down to Uist and Barra. Nationally, there are also careers fairs. Currently, there is one in Liverpool. We met on Friday to speak to the GPs who represent the NHS there on what material they are going to be using for focusing on remote and rural areas. There is a two-pronged approach to that. We have the on-going placements for our local schools and colleges to support an understanding of the kind of jobs that are in the NHS. We are focusing on encouraging people into jobs that they might think they would not be interested in, such as engineering and so on. We have the national campaigns as well. It does not appear to be very in your face. We have private sector employers who have very obvious—they use all sorts of different methods of trying to recruit people into posts, but the NHS being the biggest employer in the country is well below par. I am going to support everything that Jenny has just described. It is a similar story in Tayside, not quite as picturesque as Uist and Barra, but nevertheless, in terms of our engagement, it starts at school. Equally on my own board, we have a very active modern apprenticeship programme. The cabinet secretary was here or in Tayside earlier this year. I am celebrating that fact. We have some pioneering apprenticeships in relation to social care, payroll, hospitality and healthcare. We are very active in our promotion of those, certainly locally and across the Tayside region and beyond. We average about 500 applicants per place, such as the demand to come and work in the NHS. The point is well made in relation to opening up an understanding of the wide range of roles and professions that exist within the NHS. We can always be better at doing that, we can be better collectively doing that, as well as individually, but we are very active in our communities and we tend to take a high-profile approach around those. I want to go back in touch with the high-matter survey and how it compares to the staff survey, and to follow on from that. The high-matter is described as a continuous improvement tool, which is great. I have experienced that in previous work, and I think that it is very valuable that you are going down that direction. If you look at the staff survey, there is some clear metric that should get out of that in relation to whether the NHS is a good place to work or not, whether you consulted or not. I know that Kenneth mentioned that high-matter would be different in regard. There would not be a direct comparison. Are we going to see those direct questions at a top level that allow us not only to have the continuous improvement stuff working, but also to take a view on how the whole system is performing? The high-matter approach is embedded locally, but it also has a corporate structure to it. Every health board will ultimately, and ultimately is this end of this year, will ultimately have a staff engagement score for the health board. That staff engagement score is built from a kind of pyramid of contributions from the local action plans and the local participation by staff. Will it explicitly say how good you are at staff engagement? It will not give you a score for that, but it will give you a general staff wellbeing feeling on the basis of your medical score. The reality is, however, that within boards we can—an ISHR director can see as many of the action plans and the focus of those action plans as I wish to, and there is an administrative approach within that that will allow me to do so. At the end of the day, there is nothing to stop individual boards to also be picking and choosing certain things through the staff governance action plan, because we are not doing away with staff governance action plans as part of this, so we will have corporate, divisional and local staff governance action plans that we will also be feeding messages down and priorities down through. If I have a perception by being out and about and listening and looking at things like why people are unhappy or aggrieved or they are sending me e-matter emails, I will say in 2018-19 that I would like to see embedded within the action plans a series of actions and thoughts in relation to staff engagement or enhanced staff training and development or whatever the priority topic of that year might be, so it is about listening, but it is also about feeding and informing. Right, but it does not be there for this dashboard that we can sit down as a committee next year or the year after and say, less than I have scored x per cent on this question and Glasgow scored y per cent on that question the way we can just now. We are going to lose that, is that correct? I think that we are gaining rather than losing. We are gaining something else, but we are losing that. It is something different, but I think that something different is embedded in greater participation, therefore greater feeling of being informed and ability to respond to what the staff are saying. There is one other thing that I should add because we have not mentioned this yet. As part of a national exercise, we have looked at what i-matter covers. It is a series of questions and those questions are largely what was in the previous staff survey, but they are embedded in an i-matter in wellbeing quotient or score. There were elements of the previous staff survey that were not caught in the i-matter questionnaire and they were largely around things like areas of interest to you and to me, around things like more of the kind of hard-or-edged, shall I use that term, issues like bullying and harassment and some of the health and safety type of questions that were in the previous staff survey. At the end of this calendar year, we are doing a supplementary survey and we have managed this as carefully as we can because we do not want to confuse staff that we are just running another part staff survey alongside i-matter, but there is a gap in the current staff engagement around issues like bullying and harassment and the enduring violence, be that verbal or physical at work etc. So there are some of these kind of hard-or-edged that will be conducting a supplementary survey. Again, I agree with the Scottish Government as a corporate process across the NHS and that will then feed into its own action plan aligned with a supplementary to the i-matter. Okay, so just in summary, there is a lot we are gaining, but we are not going to have those hard numbers that we can sit as a committee and look at and say, this is the score to last year, how it compares against different health boards at a top level. We won't have that. So going back to what Kenny has just described in relation to the i-matter outcomes at a board level, the staff governance action plan and in a Tayside context we have a people matter strategy that is built on top of that. All of that is published in the public domain for us. So any member of this committee can go and look at where our position is, year to year, what we are doing about it and the key issues for us. We do that through our staff governance committee and health business. Well, I am still not sure. Does that mean that we will have a chance of data to look at or not? For my on-board, yes, you will be able to track our problems. I mean, the moment I can sit here and look and I can say that Wethlen Ells was the best on this question and I can compare 2013 to 2015 across Holy Scotland or by health board, will we still be able to do that or not? That would be a matter, I guess, for Scottish Government to determine how they was to use the data, but as Kenny has already explained in relation to each board, they have a staff engagement score overall that is published and will be published. With the outcomes of the survey, the Pulse survey that is going to be brought forward at the end of this year, there will be outcomes commonly reported across all boards in that domain. I think that in the art of the possible that could happen, but, as George says, it would need the Scottish Government as the parent body to analyse and interrogate and create that report for you. The individual boards have their scores and build action plans corporately and locally in relation to those scores, but somebody else would need to create the aggregation of that. To my knowledge, it is not routinely in the planned system at the moment. NHS Highland, in its evidence, gave a comment saying that staff governance standard was implemented at a time of growth in relative prosperity when financial challenges in the NHS were not as significant as they are today. Engaging staff in times of austerity where there are real budget and staff pressures and the requirement for significant organisational and service change to ensure that services are sustainable is more difficult. Is that not the nubby where we are at the moment? Many of us, our constituency caseload, we get lots of NHS staff coming to us saying that they are under pressure like they have never felt before. We have heard that in evidence from people. You mentioned people not being released for things like training and events. My wife works in NHS in her shift last week. She walked 10 miles and had two 15-minute breaks and a 12-hour shift. That is not unusual. Things like breaks, people don't get them, routinely don't get them. There is all of that kind of thing going on where staff are feeling real pressure, not enough of them to do their job, relying on bank staff and all the rest of it. Is that something that you recognise the way in which staff are coming back to you saying that we really are feeling the heat here? May I respond so that I would absolutely recognise that? The reason that I am asking that is that that has not come over in your evidence, because what people have said has come over in your written evidence and I think that your written evidence is really good. The general feeling that I am getting from the panel today is that the questions that we have asked you are putting on a very positive gloss on everything. That is your job to do that, of course it is. However, I do not think that there has been a recognition of those massive pressures that people are feeling on a day-to-day basis, and I would ask you to comment on that. I am very happy to comment on that and, of course, to thank our staff who are doing a fantastic job every day, and I think that that is important in valuing our staff. However, the NHS has to change. The current models of care are no longer sustainable, and I think that we are increasingly understanding and accepting that. This is a time of great change, and change causes some uncertainty for staff. We need to engage the staff in that process of change. As we are transitioning from the old way of working to what will need to be a new way of working, with potentially different models, that will feel very uncomfortable sometimes for staff to do, and that means that the staff governance arrangements and our partnership working, in my view, is more important than ever before. I do not think that any of us have pretended anything other than the NHS is a pressurised environment for all at the moment and probably has been for many, many years. Is it more pressure now than ever before? I think that it is a different pressure, and I also increasingly think that, with a fair wind that we see an opportunity through the national delivery plan to create a light at the end of that tunnel. From a Lanarkshire perspective, we have a history of being fairly pragmatic, sometimes being brave, and at the moment we are having a fairly challenging but constructive conversational government around budget and from budget capacity, and capacity to deliver targets, to deliver care and health improvement in the way that we would like to. We are saying to the Government that some of the targets that you have set will not be met, because we do not have the budget or the resource or the capacity to do that, and we are having an adult conversational government about the art of the possible within that capacity. Our calculations take into account the demands that we put on staff, our ability to recruit and retain and provide staff in certain areas. The islands are not unique, there are vacancies all over Scotland, there are vacancies in general practice and primary care and community care, etc. One of the approaches that we have taken to our ability to maintain capacity has been to engage with the very staff that you talk about who are enduring the pressure to say to them, what would you do? Give us your ideas as to where we can make efficiencies, we can improve performance, we can reduce costs, based on their knowledge and experience of the front line and where it matters. We have a very rigorous approach of staff engagement down from our employee director through staff side colleagues into wards and departments to build ideas and build the initiation of crescent efficiency savings. The reality is that we will never have enough money—public demand, public expectation, clinical expectation in terms of modernisation and new models and use of robots and all that people would like to do within their clinical world will almost never be affordable. Therefore, we need to make the best of what we have, and part of that for me is about where I am part of the west of Scotland. How do we in the west of Scotland make more sense of our joint capacity to use the scale and the complexity of the west of Scotland to improve our ability to deliver? That will bring challenges back to politicians, it will bring challenges back to the public, because services in your backyard are possibly no longer affordable, therefore we need to aggregate and we need to create economies of scale where people will get better care but will not necessarily be within the same geography. The second item on the agenda is two evidence sessions on the draft budget 2018-19. We have less than an hour now for the panel. I welcome to the committee Andrew Strong, assistant director of the Alliance, Aileen Bryson, interim director for Scotland, the Well Pharmaceutical Society, Richard Meadhead of Policy and Public Affairs, Mary Curie and Carlin Lockhead, public affairs manager at SAMH. You are all very welcome. There is a view that integration is making the delegation of funds complex and difficult to assess whether the allocation of the health and support budget meets the Scottish Government's stated priorities. In the submissions that we have received, I think that Mary Curie has noted that no additional or specific financial resource has been committed to support the Scottish Government's health and social care delivery plans commitment to doubling the palliative and end-of-life provision in the community and that IGBs are expected to meet that within their own budgets. SAMH notes confusion over the allocation of new mental health funding and that publicly available detail on spending varies greatly between IGBs. I would just like to ask the witnesses if I may. Is available information on the health and support budget adequate? Is it detailed enough? What would support better scrutiny? Richard Meadhead. Absolutely. The health and social care delivery plan, which was published at the end of December 2016, was really welcome, particularly that commitment for doubling the palliative care resource in communities. Unfortunately, we have seen no sign of any additional resource for that. We have been told that integration authorities are expected to find that within their own resource. For us, we engage with 30 out of the 31 integration authorities and it is not entirely clear to us where palliative care sits in terms of their priorities. Just a cursory glance at their strategic plans, many of them do not even mention palliative care yet we know it is a national priority in a letter to integration authority chief officers on December 15 from the Scottish Government listed palliative care as the second priority yet we do not always see that in their strategic plans. There is no necessarily any evidence of additional resource being put there and I think we are yet to see any real strong movement on the ground to match that national intent and ambition. Just a general point, we lobbying advocate for changes where we feel pharmacy profession can actually make a difference to patient outcomes and where we can see that there is a space for more efficient use of NHS resources, but all the draft budget can do is tell us where there has been an uplift. It can't tell us whether any of that uplift will be spent on any of the areas where we have made recommendations for positive change. We can make comparisons. In the old draft budget, we could see that the only contractual body out of the four independent contractors not to have an uplift was pharmacy, so we could question that if our negotiating system, the organisation that does the negotiation, would probably question that. It is much easier for us to track the progress when the money is allocated to a particular work stream. For instance, the new money that was allocated for three years for pharmacists in GP practice, which has now been baselined and we can see where that has gone. That is very helpful, but the budget itself is not particularly transparent. In terms of IGBs, we see very different levels of detail in the reporting on mental health and the plans for mental health. It is quite difficult to compare, because there is not a consistent structure being used across all of them. It is quite hard to see exactly what is going in where. At a more national level, while we welcome the £150 million investment that is being made or being announced for mental health, we have found it very difficult to follow that from when it was first announced to the more recent announcements about what it is going to be used for and how much of it has been allocated and how much of it has not. Both in IGB and at national level, we could really do with some more clarity and transparency. I agree with all the points that have been made. We are one year into the integrated system. As we know, there is some good partnership working happening between the third sector and the IJBs, not least through some of our members like Red Cross and Food Train and RVS. Obviously, against some of the financial pressures that have been felt by IJBs, rebalancing some of the investment in primary and social care, there is going to be a challenge in terms of supporting and protecting that type of preventative work, largely delivered by the third sector. One of the elements of that is the integrated care fund. Just in advance of this meeting, trying to find out what integrated bodies have used the integrated care fund for. Again, patching different approaches to making that type of information available, I would be interested to see how they have invested that money, which organisations have benefited what the outcomes have been. In terms of their health and social care delivery plan, one of the things that was made clear at the time when the delivery plan was published, there would be a financial plan made available as well. I am not aware of that having been made available, whether that has not been publicly available or not, but perhaps the committee could make that clear to the Scottish Government about that. A recurrent issue has been the mismatch between local authority and health port budget setting timeframes. COSLA has suggested that they be brought more in line, and the pain association has said that this misalignment causes real difficulties for commissioning services from the third sector. I would just like to understand if you were finding this an issue and if you understand what the reasons are for this mismatch and why it cannot be resolved? For us, the vast majority of the contracts that we have with NHS boards, as they are currently, are three-year long-term ones. Over the next year, we will be negotiating our first round of contracts with those integration authorities. We will not really know until that happens if the whole process is working. In a sense, once that first round is through, we will have a really good idea of how well the integration authorities are working under their new health and social care, bringing together the different budgets and the different routes for commissioning. Anyone else would like to comment? Audit Scotland has suggested the benefits of longer-term budgeting. You have mentioned three years there, which is clearly longer than some opportunities that you might have had in the past, but is that short-term focus inhibiting the transformational change that we would like to see? Short-term focus is really difficult for the third sector in particular. We have contracts of various different lengths, but where we have one-year contracts, as we do have, it is really difficult to retain, to attract staff. It is really difficult for staff to work with those contracts. It makes it hard for people who are using the service to feel safe and secure and to have an understanding of the plan. A longer-term plan would help across the board, and I think that it is very much needed. I would agree entirely with what Caroline just said. We are fortunate in the vast majority of the contracts that Mary Currie has are at least three years, but on those occasions that we have had 12-month contracts, we have had the same issues in terms of recruitment of staff, retention of staff, being able to deliver on the service in terms of what we have looked to deliver in terms of our outcomes, which is not satisfactory for us or for those who are commissioning us. Long-term contracts are much more successful in terms of allowing us to invest in staff. It is crucial in terms of what we are trying to do in things like shifting from the acute to the community, innovate. We have more time to innovate, develop and redesign services as we go and invest in those if we have long-term contracts. Short-term contracts are almost fighting fire from the very beginning in terms of how do we keep the service going? Will the service exist from now? Can we retain our staff? Do we have to recruit staff that we have lost because they cannot afford to live off a short-term contract because they need more job security? Long-term contracts are absolutely the way to go, and that was one thing that the whole third sector welcomed in the programme for government is that commitment that third sector contracts will be or should be three years at least. I say at least because longer would even be better. It is not just for the third sector across NHS, so I would say that sustainability always comes up as an issue. Three years is better than one, but even three years, when you get towards the end, that can be a problem. That is not an easy one to answer, but we need to be thinking much longer-term and general terms strategically. Pilots are done, and we have no transference into longer-term contracts even for a year after that. It does impact on whether you can get staff and how you can retain staff. The impacts are absolutely vast, so I would agree with everything, and it cuts right across everybody. Andrew. Just to reiterate Richard's point, the issue is significant for the workforce. If you get one year funding model and then you are within six months having to renegotiate that, we were talking in advance of this meeting that has particular implications for people who work for third sector organisations who are then challenged about, can I continue working for this organisation, do I need to look somewhere where there is a bit more certainty about what is going forward? I wonder whether there are implications for the Scottish Government's workforce plan around social care, particularly given that £850 million-worth of social care is provided by the third sector, whether there needs to be some sort of recognition of the role that people who work with third sector organisations provide in significant levels of social care need some sort of reassurance about the future of their jobs. In terms of the transparency of the budget, Scottish Government is involved in an open government project that is across transnational open government programme. I would have thought that one of the key aspects of open governance is to be able to understand the budget. Do you think that the people who use your services could pick up the Scottish Government's published budget and understand whether the money going into the services has gone upward or down? That is a very broad question. Some people are good with figures and some people are not, but it is a complicated document. I would look at it and think that it is a complicated document. My background is not finance. How long is a piece of string really? I think I would just agree with my colleagues. I think one thing to emphasise is not always about interpreting in terms of how much is being spent on services, but I think sometimes the public would be more interested to know what does that service deliver and how can it improve my life if I need to use it. Is it available? More around understanding and health literacy around services and what they do and how they support people. I think that is much more important than ex-amount is spent on this service and it has gone up by Y or down by Z. I completely agree with that. One of the things that I would like people to be able to pick up a Government document and understand is what difference has this made and in mental health that is really difficult to find. We do not measure outcomes in mental health. We measure things like waiting times, expenditure and important things, but we cannot tell you if anybody is any better at the end of many of those services, particularly in psychological therapies. I think that that is something that we are waiting for the results of the target review that Sir Harry Burns has been leading. I think that that is something that we really hope can be changed as introducing an element of outcomes monitoring into mental health. On the health literacy point, we think that that is a very important thing. When you look at early years, how do we actually teach our young people how to use the NHS, how to navigate the NHS? From a medicine's point of view, how do we understand that medicines cause harm, that there is risk and be able to go to the right place at the right time? I think that there is a big piece of work around health literacy that would feed into what you have just said as to how people then understand the outcomes and the services that are provided because I do not think that there is a clear understanding of that in general. Andrew. Despite my glib answer earlier on, I will go a bit further than that. One of the things that obviously the committees asked the IJBs around a bit, linking budgets to outcomes, and I think that is really important somewhere where they need to go to in the future. The Harry Burns review, my understanding is that is going to be out in the next couple of weeks and it will look at outcomes and targets in a bit more detail. I think that is an opportunity to look again at the indicators under some of those outcomes, particularly the national health and wellbeing outcomes, which were drafted when it was developed. It always said in the guidance that they were a work in progress in terms of the indicators underneath those outcomes. In our view, they do not provide a comprehensive set of indicators for the national outcomes. For example, whether health and social care partnerships are contributing to the reduction of health inequalities is judged by premature mortality rate and emergency emission rates. I think a more complex understanding of outcomes is probably really needed in terms of understanding where investments go and what difference it is making. Can I ask a very specific question of Carlyn with regard to something that you put in with your submission about the Kings Fund document about mental health share of expenditure in NHS England? I was just wondering if you were able to tell me what that budget covers. That is the NHS budget in England, which would cover mental health expenditure. I think that the subtext of your question is, are we comparing like with like, and the answer is hard to know. I am keen to know if you know that so that the committee is then able to compare like with like that. Obviously, that is what we are talking about today. Absolutely. That is one of the things that is difficult. We have said that it is difficult to compare IGB budgets and allocations. It is also difficult to compare across Scotland, England and other areas, because without a very detailed knowledge of both systems, it is very hard to say that we are absolutely comparing like with like. However, I have no reason to think that it is dramatically different in terms of what is covered, hence why we provide that information as one point of reference. Clearly, you will want to look at other points of reference in terms of how Scotland is doing in its mental health budget. For example, we know that the budget share has begun to reduce in the past year. In terms of your understanding of those figures, what does that cover in terms of mental health services in England? Is that a mental health service in its entirety, right through from primary care, from CAMHS, services in mental health through to older adults? My understanding is that it is the majority of NHS mental health services in England, whether it is all the way from, as you say, absolutely all the way through. I might need to check and come back to you. That would be really helpful, because it is interesting if we can get a comparator between the two, whether it is community mental health or whether it is tertiary services and so on. I think that it is fairly well known that my belief around the third preventive agenda will be delivered primarily by the third sector. I am just on an act that would give the Government a challenge, because they are predominantly the funders of the third sector. How can the third sector better align itself in terms of working in partnership with each other in the delivery of the preventive agenda and making it easier, if you like, for the Government to fund them? Currently, where do you sit in terms of being able to properly fund preventive agenda? I think that we see some good examples of partnership in the third sector. I think that through, for example, the alliance, which many of us are members of, through some of the ways that we work already, it can be very challenging to work in partnership, because, of course, in social care commissioning, where many of us are working, the prevailing model is one of competition, so contracts will be awarded, tenders are put out, and that pushes you down a road of competing with each other. We would very much welcome looking at how we can commission and develop services in a different way so that we can work in partnership with each other. I would say that we do work in partnership fairly well. It would be good to look at how preventive services are being commissioned and are they being commissioned in such a way that it makes it possible for us to work in partnership. I would turn that round slightly and say how we can look at the commissioning process and see whether that is supporting partnership working. I agree with that. There is a real opportunity here through the integration agenda in terms of strategic commissioning plans and treating the third sector as a genuine partner in that and bringing us to the table as soon as they are considering their plans in terms of how they, for example, might deliver pallet and end-of-life care services. Are they involving all of those key players from the third sector and bringing us round the table to have those discussions so that we can come up with plans together rather than potentially what could happen is that the statutory partners decide what might happen and then bring in the third sector quite late and say that this is what we have got and how can you help us involving us as early as possible in that process. With any other relevant partners, it is much more likely to lead to genuine partnership working, not just between third sector organisations but between the third sector, the statutory sector and the independent sector as well. Again, I echo colleagues' comments. I think that one of the previous committee sessions, you talked about the Christie commission and the 40 per cent potential saving that could be made when preventative investment is made, I think that at the moment there is a significant demand on services and a lot of those services provided by third sector organisations. That demand is not completely met at the moment so what we are likely to see is organisations like the really good morning service which is an alliance member providing services which relieve pressure on health and social care partnerships. One of the things that I would kind of want to push back to the committee is say while the 40 per cent saving that was mentioned in the Christie commission is admirable and something we need to work towards, that was alongside the need for a reinforcement of the point that people need to be involved in the design, the delivery of services rather than forcing people into predetermined systems. I am not convinced we have made enough effort on that side of things yet. There has been investment in terms of preventative services but I think we would like to see more work done around how people can shape services, whether that be through things like participatory budgeting or other models. I know that some health and social care partnerships are doing that already and I would probably contend that the committee's own report on work with IJB stakeholders that came out last week reinforces that need to some measure too. I think that is an element of what we need to see that as a bigger picture rather than just if we invest here we will save there. I know that that is a very valid point but the true partnership working is very important and we cannot look at just the third sector. It has to be partnership working. There is a huge untaught potential for public health and prevention within the NHS working with the third sector. I would just like that question to be thought of in terms of the third sector alone. Although I understand where you are coming from, I completely agree on the social prescribing exercise and everything, but look at the principles of realistic medicine and the themes that have come through about how the NHS has to change and that means that absolutely everybody has to be involved in that to get that traction on the preventative agenda. You highlighted there that there is a competition for budget within the third fact, not just the third sector. That budget is siloed almost between the NHS and the third sector. I think that you highlighted a very good point in that it is much bigger than that, but I think that I will go back to this idea. I think that if I could ask around some of the third sector delivering similar outcomes and competing for each other. Part of the element is from this side of the table to ensure that you are properly funded, but the other point is to make sure that you align yourself in a way that makes it easier for the Government to fund. I suppose that I would say that I feel like we do work jointly wherever we can or whenever the process allows us to, but I would come back to the idea of the process. It is up to the commissioning process to make it possible for people to work together and to ensure that, as a commissioner, you are not funding the same outcome multiple times. I feel like that is really down to the commissioning process. I suppose that there are different ways of looking at that. Of course, we have moved away from the traditional commissioning model in some areas, so we now have self-directed support where it should be possible to fund a number of different providers to achieve a person's outcomes. I think that that would be a good example of somewhere where we could see some change and a slightly different approach in the system to recognise the importance of mental health in that. We know that people with mental health problems only make up about 5 per cent of self-directed support payments, so we could look at how do we actually invest more in that side of the system so that people's outcomes are being met, because of course those are the most important outcomes at all of an individual's outcomes. I was just going to add, I think that it is also with highlighting that there are lots of examples of good practice where the third sector work complementary in partnership. Certainly for us in pallidate and end-of-life care here in Lovian, through the Lovian redesign programme, our Mary Currie hospice in Edinburgh and the St Columbus hospice work very closely together to ensure that we provide city-wide hospice cover, often speaking, often sharing and potentially working on the same referrals and making sure that people get the right care for them. I think that there are lots of good examples that we can look at, but it is, I think, as Caroline says, you've got to go back to some of those commissioning arrangements and those very early conversations between commissioners and potential partners in delivering services. Andrew. Yeah, there are examples, and there are examples outside of health and social care that we can look at. The employability programme, which is now in the process of being commissioned, there are a number of third sector organisations coming together to make bids separate from each other, so organisations are working closely together, and it's maybe how the commissioning process has been managed there, because there might be some lessons for health and social care. Marie. Convener. Just as you guys were speaking there, I was thinking about an example. I came across them in the last couple of weeks of precisely that sort of partnership that you're talking about and collaboration that you're talking about. There's a pharmacist in Sky who works as palliative care pharmacist who is employed by, you know, the post came about because of a collaboration between the NHS, Boots the Chemist and McMillan, so third sector industry and NHS statutory organisations. Now, I have to say, it's not the only example I've come across in the Highlands. We do tend to get cross sector working in the Highlands. Are we ahead of the game, or is that happening all over the country? From that area, the palliative care, there was some work done in Glasgow as well, which I think Highland either followed or don't know who followed who. You're ahead of the game in that it's not happening across the country, and that's a theme which we have for everything. I think we would all agree on that, that we have really good pockets of really good work, and what we want to see that translated to something nationally, get the data, get the outcomes and then actually take that forward. If we could see something in the budget that would translate to that, that would be really useful, because the outcomes from that particular project are fantastic for individual people, and it's very person-centred. We heard you hear about district nurses, but we don't have a district pharmacist, and that was almost like a district pharmacist. They followed the person and patients around where they needed the help, and it was a really good example of the cross sector working. If we could model things like that for various different therapeutic areas, then that would be an excellent way of bringing a third sector in partnership working together. It seems to be palliative care is an obvious one, where the general public, when asked, all of us say that we don't want to die in hospital, and yet in quite large numbers that's still what's happening. Is there any shift in the direction of that? You're absolutely right. We know from the evidence that's available about one in four people who need palliative care every year who die miss out on that care, and we know that around or just over 50% of people die in hospital, yet the vast majority would like to die at home or in the community. We know that there's a great deal of work to be done. The Scottish Government has made an ambitious commitment that everybody who needs palliative care will have access to it by 2021. We've talked about the commitments in the health and social care delivery plan, but what we really are lacking at the moment is good data and evidence to show the progress we're making towards achieving that vision and ambition. Now I know that the Scottish Government, again, is committed to developing better data to support palliative care, but I think that's true and it's not just a palliative care issue. I think we need better data to understand what people's outcomes are being achieved. Is the investment we're putting into services and policies actually delivering on the ground and making improvements to people's lives and can we actually see trends in that progress? In palliative care at the moment, I would say we don't see that. We do just look back to that. We know that one in four are missing out. We know that 50% of people are dying in hospital, but what we really need to see is data to show that that's improving and that there is progression. Also, it's not just about outcome because it's not necessarily a fair proxy to say if you've died in hospital that you've had a bad end of life experience. That's not necessarily true. What we really need to capture, as well as some of that, is quality of care and personal outcomes for people. For some people, dying in hospital is where they want to be. A follow-up to my colleague Brian Whittle's line of questioning about engagement. Community Pharmacy Scotland has said that the new health and social care partnerships are still working through how best to engage and manage their budgets when we're finding this challenging. Equally, we find it challenging to engage. Has that been your experience in terms of engagement? Do you know who to go to, who to speak to? Firstly, I would say it has improved over the last 12 months, but it has been a real challenge. Obviously, as I think I said, we're present in the 30 out of the 31 local authorities, and we've really struggled to engage. A colleague of mine said last year we didn't even know who to ask. Well, at least now we know who not to ask. It is getting better, but it is quite a challenge in terms of finding the right person. They're still internally trying to work out who sits where in terms of commissioning budgets and in terms of commissioning plans. I think, as I said before, the proof will come when IJBs and integration authorities start to actually start commissioning services that have been on existing contracts. I think maybe 12 months from now it might be worth this committee coming back to looking at how service-level agreements have been developed with integration authorities, especially with the third sector and how they are working out. I think that that would be a really good line of inquiry. Just an additional point to that. I agree with that. We are still seeing how it's going to work out. There is a specific point for the third sector. We have the third sector interfaces, which exist in each of the IJB areas, and have the role of almost representing the third sector in that area to the IJB. That is a very challenging role for anyone to do. I think that trying to take the views of the entire third sector, which does many, many different things at many different levels and scales, and represent those in a way that is meaningful, is extremely challenging. I agree with what Ritchie said about the difficulty of knowing who to go to and how things work. I suppose that there's a particular third sector angle to that. I think that I've made this point to the committee before, but the third sector interfaces aren't well funded to do that either. That means that a lot of the local work is not, perhaps, getting that representation at the IJB level, whether it's localised work on national third sector organisations that are working in particular areas. I think that there's something to be looked at in terms of their capacity building. When you've written submissions, you've all made strong pitches for additional investment in particular areas. I think that Marie Curie emphasised the need for investment in pallative care, the alliance for more investment in social care, SAMH, specifically referred to psychological therapies, and I think that pharmacists argued about the importance of the role of the minor ailments service. Do you think that we use evidence sufficiently in the NHS and the health service when we're making budget decisions? That's an interesting question. I probably would like to flag up some work that's actually going on around that particular area, that Glasgow Caledonian University is doing just now. They're developing a framework for making difficult budget decisions in health and social care, and that's integrating the concepts of health economics and decision analysis and ethics and the law to come up with this framework around the context of shifting the balance of care. That's being tested with four health and social care partnerships, and I think it would be interesting to look at what that's finding, what sort of recommendations and analysis that's making. In terms of our members, many of them have described frustration at having well-evidence activity that then forms an essential part of health and social care pathways, but find that that works not necessarily reflected in strategic commissioning decisions. Our self-management fund, which is £2 million a year, that could be funded ten times as much, and it invests in innovative forms of self-management support in the third sector to work in partnership and a number of different programmes in that, but it's often, even though those are well evidenced and well piloted and come out with some great outcomes, it's often difficult to find them funded through statutory resources, and we've long been concerned that that good practice that emanates from the third sector doesn't then lead on to wider scalability. One of the difficulties in mental health is that there often isn't a lot of evidence to follow, so I mentioned earlier the lack of outcomes being measured in some areas of mental health that you made reference to the psychological therapies part of our submission. I think that's a good area where a great deal of effort has been put in to setting up new systems to monitor how long people are waiting, at what point the clock starts and stops, and a lot of really very technical things that's had a lot of effort put into it. We know that at the moment we are not nationally meeting that target for 18 weeks of access, and only 72 per cent of people are seen within 18 weeks, but we don't know whether, after receiving their psychological therapy, whichever one that happens to be, people feel better at the end of it, and I think that's quite important when you're choosing where to put your budget. If we look at the increasing access to psychological therapies programme in England, they do have a way of measuring recovery rates. Their target is that 50 per cent of people will achieve a recovery rate that is measured through measuring mental health as they move through the programme, and they are achieving that. They are on target to achieve that recovery rate. That is an example of the kind of thing that we hope that we can move to so that the NHS actually does have better outcomes-based evidence to make those decisions on. I agree that the evidence is sometimes difficult to find. I think that the committee would probably struggle to find it. We, with a lot of key stakeholder engagement, find it difficult to find discrete pieces of work that we know are going on across the country. There's a real method of bringing all that best practice together so that we can then gather the evidence. The things that we law before are where we know we can make a difference. That's great when we can engage with the committee to talk about those issues and actually take them forward. Where you do have evidence also takes a long time to get that changed into practice or to take cognisance of work that's going on in other parts of the UK. One of the things that we are now going to look at is care homes, where we know that we've seen evidence from other parts of the UK where we can actually make a difference to patient care and make savings for the NHS. I think that there's a jigsaw there and it's trying to bring everything together. I can understand that that's a challenge for the committee, because I think that we all find that a challenge in our various areas. In the submission from the Royal Pharmaceutical Society, you mentioned that you speak about the funding for pharmacists and GP practices, and you emphasised what a positive step forward that would be, but you also say that it's nowhere near the level of resource required to provide every GP practice with access to the expertise of a pharmacist, as promised by the current Scottish Government in the SNP manifesto in 2016. Are you discussing that with the Government at the moment, and are you hopeful that that will be progressed? Since we've been submitted, we actually have this new document from the Scottish Government achieving excellence in pharmaceutical care, which lays out a lot of the things that we have advocated in our manifesto. Our concern would be how will that be implemented and how will it be enabled without any additional funding, because previous really successful strategies like the right medicine in 2002 did have extra funding for that. The Government, it depends on the wording, we would like to think that people do have access to the expertise of a pharmacist and some of you have all signed up to our manifesto so that everybody has access to pharmaceutical care. If you have a good local arrangement and people are all speaking to each other, then GPs and pharmacists have always worked really closely together. There's not one size fits all, so how much access a practice would need is very much dependent on their geography and the setup of that practice. Each GP practice is very different, but we know that the funding is still not enough overall, even to maybe give a half-time pharmacist to every GP practice if that's what they wanted. It was originally for 140 full-time equivalents, and they're now working towards that, but we know it won't be enough. A lot will depend on the expectations. We need to have more workforce planning and a clearer idea of the roles and remits and exactly where the Government wants people to work. We know that if we get the pharmacist in the right places, both in primary and secondary care, we can make a difference. Okay, folks. Thank you very much for your evidence this morning, and we will suspend to change the panel. I welcome to the committee Dr Andrew Fraser, director of public health science, Scottish directors of public health, Kim Ackerson, chief executive officer of the Scottish Sports Association, Sheila Duffy, chief executive, Ash Scotland, and Alison Douglas, chief executive, alcohol focus Scotland. We have around an hour for this session, and we'll move directly to questions. In order to scrutinise the budget, it's obvious that it has to be clear and accessible, and the written submission suggests that people aren't always finding it clear and accessible. Alcohol focus is noted that the budgets of alcohol and drug partnerships have become harder to track, and the Scottish Sports Association has noted a lack of detail on how the sports budget is allocated. If you were listening to the earlier evidence, that was a view that was coming across from Sam H and Mary Curie, too. It would be interesting to hear from this panel if available information on the health and sport budget is adequate or detailed enough. As I alluded to Alison, the concern about alcohol and drugs funding is that it's always been rooted through the health boards. When we saw the significant reduction in funding, which happened two years ago, health boards were asked to make up the difference, or at least to ensure that there was no loss of support available to people. It was clear that, even prior to that, it was extremely difficult to track funding. Alcohol and drug partnerships would tell us that they wouldn't always have control over the funding that was indicated that it should be available to them, but it's always been the case that that funding should have been topped up by local partners. Basically, it has always been difficult to track where that funding has gone and how much has been invested. That's got more so now that the health boards have been asked to top up. Brian Whittle, as you'll know, issued a freedom of information request asking health boards whether they had made up that shortfall. The figures that came back at that point indicated that about half of health boards hadn't made up the shortfall. I think that even some of the figures that we saw, we would have questioned the accuracy of them. I think that there is an issue there about transparency. Obviously, we strongly welcome the additional £20 million that's going back into alcohol and drugs that's been announced in the programme for government, although it's not clear yet how that money will be allocated. The tobacco control budget was fixed for the lifetime of the five-year strategy that was issued in 2013, so it remains fixed for this financial year. That is, in real terms, an on-going decline. It is less than 1 per cent of the total health budget, but I have some concerns in that the funding for stop smoking services, which used to come through the tobacco policy budget to services, is now going into health board bundles, which cover a much wider range of issues. It is then hard to track the prioritisation at local level and whether enough information is getting through for them to understand what a massive impact tobacco has on health. I suspect that, as was mentioned in the earlier discussion, some people are better with numbers than others, so I do appreciate that it can be tricky. I think that the widest challenge from a sport and physical activity point of view is that actually 90 per cent of investment in sport and Scotland goes through local authorities. Obviously, there is continued investment from the Scottish Government and a £2 million additional investment this financial year, which was very well received, certainly by our members and I am sure colleagues in wider physical activity and sport. Understanding the wider contribution of a local government challenge is particularly part of that. We discussed it with Derek Mackay before I know he presented his statement in Parliament around the rates relief review of business rates and the potential £45 million hit that was proposed in the Barclay review for local trusts in sport and leisure is a bit of a challenge if that comes through. There are a number of parts to that, and I think the third strand of that is in terms of lottery, so lottery makes up a significant proportion of the investment in sport and physical activity in Scotland, and again that is decreasing on the further hit that comes into sport and physical activity. So there are a number of challenges in understanding the collective actually what is being invested in sport and physical activity, but also understanding that I think there are other partners that contribute to that, so there is a huge contribution from the health workers, and again we think that more could be done in terms of that, but there is an investment I am sure in workforce and things there, the same would be true in terms of active travel. So the announcement to double the active travel budget was obviously very well received and certainly optimistic that that is a move towards the prevention discussion that certainly we have had many times and that that could be replicated in broader sport and physical activity. So there are a number of challenges I think within that in understanding what all is spent where and how we can maximise and optimise the contribution that that makes. Thank you. You will know well how budgets are distributed in the health sector. The health budget overall has been relatively protected but is under pressure, increasing pressure, and health topics such as public health are no exception. It is always quite a challenge to pick out from the global sum that is allocated to boards and so on what goes to protection, there are estimates made and various of the submissions you have had, and within that how well people use their time or the resource for prevention over other activities. For instance alcohol brief interventions is an intervention which has benefit, is mainly rooted in primary care and similar community based settings, is a brief part of a wider intervention that people would have on an individual basis with a health professional, but it is very difficult to separately identify the cost and benefit equation around things like that. That is the main point that I would make about the health budget, but the other point that I would make to support Kim's point is that a lot of health related spend and public health related spend is not in the health budget. It relates to other sectors and the way that they allocate resources and local authorities being a particular area of interest. Thank you all very much for your responses. I think that I am paraphrasing here slightly, but Dr Helen Irvine, when she was speaking to us a couple of months ago on the preventative agenda, I think that her view was one that GP funding could be considered preventative spend. If we fund that service properly then it prevents more acute cases and people presenting it A and D. You were speaking about the difficulty of placing prevention above other services. There is always that tension, is not there? We feel absolutely compelled to address symptoms when they present themselves, whether that is at A and E or in the GP practice, and that often means that we can invest in prevention in the way that we would like. Obviously, there have been some discussions around the need to have more evidence for that prevention. The health budget is very much demand led, but do you think that there is a need for dedicated funding for preventative measures? Are we focusing enough on that or is that funding always removed and does it go to the area of greatest need at that time for fairly obvious reasons, I suppose? I think that the answer to me is both and. There are various areas, and both Sheila and Alison will be able to talk to them about identifiable funding for programmes. I would go along with Helen Irvine's general premise that primary care is in many ways prevention of secondary care if it is adequately resourced and adequate. We also have people, and Sheila and I were talking to a colleague yesterday in the area of obesity, who will get feedback from primary care and say, well, prevention is not part of our task. We are just dealing with disease. I think that there is a spectrum of perspectives on whether primary care is prevention. Again, it raises the issue of what is prevention. Is it primary prevention, stopping diseases happening at all, secondary prevention, early detection and nipping things in the bud, tertiary prevention, which is rehabilitation and getting people better from diseases that already have. I would like to shift towards the primary secondary end, rather than dealing with the tertiary end, and I think that we all would in that respect. When you are talking about primary care, are you talking about GPs, or are you talking about the primary care service? To me, health visitors are certainly there to be doing preventative work. I readily admit that. I suppose that I had a GP feedback in mind when I was quoting that particular instance, but there is investment and ring-fenced identifiable investment for health visitors. As there is a huge effort, we were talking to AHPs yesterday, and their contribution to prevention, particularly amongst older people, has been particularly energetic in that area. They are looking to much more effective prevention in all age groups throughout the life course. It is certainly not confined to general medical practice, and I would include dentists and pharmacists as people who really have a great contribution to make here. A significant part of our response was looking at the national performance framework itself and trying to look through some of the structure and saying, do we think that we would make changes? I guess the idealist in us would say, you know, we don't maybe not talk often enough about healthier, about life choices, about prevention, and certainly from our point of view about increasing activity as part of that. There is something idealistic about the health prevention or about the health service about promoting good health, as well as treating bad health or poor health. The notion which so often is about people living longer lives, the idea that they should be longer, healthier and happier, certainly seems like a broad mixture, and again something I think that collaboratively we could work together on. In terms of, I know the previous discussion again, talked about conversations with Sir Harry Burns, and again from our point of view, Sir Harry Burns, when he was the chief medical officer, said, the best spend in public health is sport and physical activity, and the key indicator of life expectancy is how physically active you are. And yet again, we seem to not correlate those when we talk about prevention, when we talk about health prevention, in a wide number of areas, the key indicator, and again if you look at the programme for government and indeed the national performance framework, it talks about life expectancy as being one of the fundamental indicators and then doesn't link sport and physical activity as part of yet that, yet the former chief medical officer has quoted in saying that. So I think there is the challenge as ever about moving upstream and not downstream, but I think it's trying to work out where we all have responsibility for that. So I know the Scottish Government as part of a working group that we're sitting on, having some really, really interesting discussions about well who is responsible for helping us to make the inactive active if that's the biggest benefit. And it's certainly not this small 33, 34 million pound budget called sport and physical activity. I'd like to think it's the whole breadth of the workforce that Andrew talked about as well. And I know there's been work again in trying to add questions to GPs when they're meeting with patients. So again, so often the people who are most likely to meet with the inactive, and yes they get asked if they smoke and yes they get asked if they drink, but why does it cost more to ask a third question to say how physically active you are when only 4% of the Scottish population know how physically active you need to be for your own health. So we talk about self-directed care, we talk about life choices and what people can do to make the changes themselves. Yet only 4% of the population know how active they should be in their own to demonstrate and improve their own health. So for me this isn't just about the small budget called sport. Prevention is about looking at cross-budgeting in a way that I just don't think we've seen as yet. And then we look at, you know, there are change funds and there are innovation funds. I'm not aware there's been a change or an even innovation fund that looks at sport and physical activity. Now that's not to say there's always new research that needs to be done, but I don't know who holds this research. Who is the, you know, the guru in these areas and certainly I know as the convener of the cross-party group on sport, one of the co-conveners, Alison, although our next meeting of the cross-party group on sport will have Professor Nunet Mewtry there, who is the UK's leading expert on the benefits of health from sport and physical activity. So there are a number of people that have that information, but we don't pull that together and really look at that as we would see it in terms of the contribution that sport and physical activity can make. Sheila. We know that in Scotland there are 10,200 people dying every year from a disease caused by smoking and tobacco. And we know those deaths are preventable. This is the major preventable cause of disease that we're facing. Behind each death there are 30 or more people living with chronic disabling disease. And this is not about this year's smoking figures. This is about decades past experience of smoking. So if we are concerned about ongoing sustainability of our health care system, we must invest in the future. We must be looking at prevention, and we must be looking at prevention that works. So we know that there are certain measures that you can take in tobacco control that are highly cost effective and that do work in reducing smoking rates. But I think we should also look beyond the figures, and I think we should be looking to, for example, many medications are half as effective if someone is smoking. Can we routinely advise that people stop smoking in the way that we routinely advise that they don't drink alcohol when taking certain medications in order to make those medications more effective and cut the costs to our health service? Alison Neill. So I think inevitably at local level when there is discussion in an alcohol and drug partnership around the profile of prevention, treatment and support services that they're undertaking, because the principal cost is around the treatment services, I think that's really where the effort is focused, and that's also an historical thing, because up until about 2009 really the ADACs, as they were, were very much focused on the treatment end. It was only with changing Scotland's relationship with alcohol that the emphasis on prevention kind of came into that portfolio, and I think that there's a sort of patchy effect across the country. So I think both at national and at local level, because the organisation, because of the intensity involved in commissioning and delivering treatment, and trying to get that right and to have the workforce there to deliver it, I think inevitably that's where the focus of attention goes, and so that's why I think you need to give very clear direction about what preventative activity you're expecting local alcohol and drug partnerships to undertake, but I think that a really important part of the picture also is the preventative activity that really essentially doesn't cost anything, and that's the whole population measures. We've seen this Parliament provide leadership around minimum unit pricing, but equally we need to be addressing marketing and availability, which are the other two highly effective low-cost interventions. Those don't cost much, if anything, perhaps a court case, but hopefully you'll get the funding back for that when you win the court case. But those are the things at that population level that will have the most impact. Those are the primary preventative measures, so that has to be part of the mix. Alison Johnston, have you any idea where the Government thought that the alcohol and drug partnerships would find the money to make up what was taken from them? Did they have stuff down the back of the sofa or piggy banks full of cash that they'd just go and say all that? This is what we had this saved for. The cabinet secretary made clear to health boards that they were to ensure that there was no reduction in the delivery of the outcome, so that was either through delivering efficiencies or by making up the shortfall in resource. That was the expectation from Government to health boards. Using an analogy, if you got a reduction in your wages, you could continue to provide the same things for your family or your house than you can with the wages that you had previously. I think that the committee knows very well the pressures that health boards are under in all facets of delivery. So what we're getting to is that you think that that was an incredible approach in order to sustain the services in such a vital area of work, like drug and alcohol work? No. Thank you. Brian Whittle. Good morning, panel. There's got a sports association in the Earth's permission quoted a Scottish Government document saying that physical inactivity costs the NHS Scotland £91 million a year. And yet further on, we look at the costs of things like obesity and diabetes and mental health and smoking and drinking, and that's the thick end of £30 billion. And it strikes me, and all of these conditions are in part helped by being physically active. All of them are, all of them are, all of them are drivers. You know what, if you are physically active, you're less likely to smoke, if you're physically active, you're less likely to drink, to access, you're more likely to have control of your weight, you're less likely to take to the diabetes. And so, if £91 million is what the Government are working on to make the preventative health budget in terms of the sports budget, do you not think that perhaps that is, they're misaligning where the spend should be? Because for me, the preventable health budget and being physically active is around the £30 billion that sits around the preventable health conditions that we currently are. Would you agree? Fyllenneth, I'm quite keen on that question, thanks, Ryan. There's very recent research done, commissioned by our colleagues at the British Heart Foundation, which hasn't been formally released as yet, which is by the eminent UK professor in economics around health prevention, a chap called Dr Charlie Foster. And the research that they're looking at at the moment estimates that it's £77 million per year from a Scottish budget point of view that impacts or that could be reduced through physical activity and sport. However, they've only been able to measure that against five health factors, which are heart disease, diabetes, serobrivere disease, gastrointestinal cancer and breast cancer. So fundamentally does not include dementia, fundamentally does not include mental health. So by the time you add that in, it's very well recognised. That is a very, very conservative estimate. So that is something that will be picked up in the next meeting of the cross-party group on sport again, which I know you'll remember, Brian. So I think it's trying to understand, A, there's economics behind it, so that yes, we know that physical inactivity is the fourth leading risk factor identified by the World Health Organization in global mortality. We know that 30% reduction in all causes of mortality is if you are physically active and it reduces the risk incidence over 20 chronic health conditions. So we know all of that. And yet, we're still a developed world nation where 2,500 people die every year due to being physically inactive. 2,500 people. So I think it's about how we better align that exactly as you've said, but I think the economics and the numbers are one side, so I know at the last time we were in Convener, we talked about the Let's Make Scotland More Active, which says if we were all 1% more active, we would save £85 million over a five-year period, but we'd save 157 lives every year. And how do you put numbers on those facts and figures? The numbers on the quality and quantity and the extent of somebody's life, and that's the hard part. But I think somewhere it's, and I think it was exactly the point you were making, Brian, it's about understanding the integrated nature of prevention and what that sits as. So hopefully when across the health care workforce, they're not saying, do you smoke? How much do you drink? And hopefully are you physically active? It's a little bit of a combined answer to say it's not one other or the extra. It's actually what does that look like because we will all benefit and population health will all benefit if we all understand those interactions. And I don't think we're quite there yet, but the potential I agree is absolutely enormous. You're talking about 91 million on the sports budget and 12.2 million a year on tobacco. So your question makes me think we should be spending more on tobacco, which a recent UK select all party group report suggested an average turn of 1,110% on spend. And we can send you the evidence for that. But I'm not into arguing for sharing the pot. I think we need to be coordinating because you're talking about diseases which all these factors contribute to. And you're talking about energy coming in from all our organisations to try and address people's health better. And I think the cross-party group which you remember of does that well in that it brings together many NCD risk factors and discusses how we can learn from each other, join up what we're doing and share what we're doing. Many people are suffering from multimorbidities. It's not, I don't want to squabble about what caused it and who's responsible. I think we need to be working together to try and address it. Yes, Brian. You've highlighted exactly what I was talking about in that when you look at these things in terms of the cost to the Scottish economy of half a billion pounds of smoking and the cost in terms of if we were more active you would save £91 million. What I'm trying to get at here is this whole cross collaborative function here is that if you had all those smokers and you could persuade them to be more active, the likelihood is that they wouldn't be smoking or they wouldn't be drinking. That's where I was getting at in terms of when the Government are looking at this budget and they're looking at these budgets, they have to look at the behavioural drivers towards the reduction in the preventable health. Alison, do you want to come in? Thanks. Yes, I don't have the research to hand, Brian, but I think there is some evidence that participation in sport is actually linked to increased alcohol consumption. Increased alcohol consumption, yeah. I can look into that for you. Well, I mean, I know you wouldn't be an example of this, but I think there is a lot of sort of socialising post-sport that is alcohol driven, but I can look into that and get you some information. I'm just going to come back in that if you don't mind. I would suggest to you, and perhaps you would like to hear your comments on this, in that when we say alcohol consumption, I'm having a poor relationship with alcohol and alcohol consumption are not the same thing. Yeah, I would totally agree with that, but 14 units per week is six pints of beer. I would hazard that there's a number of five-aside football teams who may be consuming that after one game. Oh, we need to have a proper debate about this. I need to have that debate, but I think it's unfair that we would assume that it's five-aside football. Football are one of our members that are a huge, huge number of people that participate in sport, and there are a huge number of initiatives around walking football and a wide, wide range of other things that they are doing to tackle a wide number of things. So to build again on your point, Brian, I think one of the things that you were saying is yes, we know that sport and physical activity is a way of improving health in its own right, but it's also a vehicle to assist other people in doing a wide range of other things, and we see that in a wide range of mental health practices. We see it around some of the work that's been done with Alzheimer's Society across a wide number of our members. A wide number of our members have relationships with a number of the cancer charities for things, so there's a huge amount of things that happen through sport and physical inactivity in its own right, but also as a vehicle for that. So I just think that's an important point. That wasn't what I was going to lead with, though, convener. I think the point from our point of view was just kind of understanding that the cross-budgeting that you're talking about, Brian, is also a big, big challenge at local authority levels. So yes, we understand it at national government level and sure everybody would agree there could be more that could be done, and I think government colleagues would say that themselves. But one of the biggest challenges for sport and physical activity is at local authority level. So again, as I said, 90 per cent of investment in sport in Scotland goes through local authority budgets. There's an increasing prevalence that local authorities are now running through trusts. The trust budgets so often are being decreased. There are 13,000 sports clubs in Scotland. I figure I'm sure many of you have heard me quote before, but again, many of those clubs are supported in the work that they're doing, whether that's sport for its own right or sport as a vehicle for other benefits, is so often supported by local sports development officers that are funded by the local authorities. So every hit to a local authority budget, every hit to a trust budget is undermining the ability of those clubs to provide the invaluable support that they provide. And importantly, I think, to two areas of people. So there's a huge, huge focus on getting the inactive to be active. There's a 20 per cent difference in the most active and least active people in their activity levels, and that is really important. But as important as that and the bit that we so often I think don't touch upon is keeping the people who are active active. Knowing that we have an aging society, keeping those people active is prevention in reverse, if you permit, convener, in terms of saying if we're not those 900,000 people who are currently members of sports clubs, if that number decreases, then we're going to have a less active population, it's going the wrong way round. So yes, we need to focus on getting the inactive active and the contribution that everybody can make in doing that. But we also must focus on those areas which are keeping those people to be active and encouraging them through a wide range of different kinds of activities who can keep them active throughout their lives and we need to make sure that is of equal priority. On that point, local governments had half a billion of cuts. I would think the last thing local government and the sports organisations and trusts and all the rest of it within it now need is a bill, another bill on top of that. What kind of impact is that going to have? Probably two parts to that convener. I think the first part is the point that was made earlier and I think the point that was made in the session before is about long-term budgeting. It really is understanding that while a cut to health and sport or the sport, button, physical activity budget might seem like an easy solution today, your physical health in X number of years' time, we understand there will be a strong impact on that point of view. Yes, it takes a little bit of understanding of the evidence that I know Alison talked about earlier and understanding the benefit of that from a physical health point of view that the benefits may take time. But the benefits from a mental health point of view, which I know was discussed by our colleagues at SamH in the earlier group, are much, much faster. If at some point one in four of us will suffer a mental health issue and 30% of the population are anti-depressants, then there's savings in every possible respect, whether that's financial, whether that's in really qualitative personal life. I think the second part to that in your point about business rates, we had that conversation with Derek Mackay before he made that announcement and we're really pleased to have that discussion. I think the challenge in terms of the bill, which is estimated at £45 million from the Barclay report, is a significant question. Would we estimate that therefore local authorities are likely to say, ah, well, we'll put £45 million back into the trust if that's going to be the cut? I think we'll be a significant challenge. But if that doesn't happen, then we are potentially looking at the closure of facilities. We are potentially looking at clubs that are not able to facilitate somewhere to play and therefore being able to participate. But also the many, many programmes that are run by local authorities to help to get people active, to help providing you opportunities for people to find things. So there is an understanding, I think, in the report that we need to support community sports clubs and obviously our members are delighted about that and that is really important. But if we're not also supporting the work that local authorities and wider trusts do, there will be no facilities for these clubs and the places where so, so many people are active, whether that's within a facility or a park or a playground or whatever that would look like, will be a big challenge. So the scale of that is work that I know our colleagues at Sport of Scotland are looking at. But we understand it could be a really significant convener and we are concerned. But we are very pleased that we've had that conversation with Derek Mackay, we know our colleagues at Sport of Scotland have had that conversation with Derek Mackay and that his announcement was about consulting more and understanding the inadvertent consequences of that. So we're optimistic to continue those discussions. Did you want to know, Andrew? It's partly related to something that Cibs just said, but it's to try and broaden the issue. It's not just about single factors and single... There's a lot of people who are more likely to be drinking more or more sedentary, but they usually have a lot of common factors. A common factor approach would say, well, what is it? What is it about people's lives? And also single solutions. It's not one thing to be fair to everybody in the room. Nobody's suggesting it's one thing that is going to sort this. But I'll just quote to you a piece of research from Glasgow Centre for Population Health. Go well. Their main focus was regeneration and health. And they posed the question from their data is what makes people go for a walk? Because it supports one thing, but mass activity, mass, even fairly lowly types of activity is what's going to get us away from the precipice we're in in terms of health and health burden. And the answer to the question is you want to leave a house that you're proud of, so you've got a place which is nice and tidy. You want to go for a walk in a nice... along a nice path which is well kept and you feel safe. You want to go towards something which is not just a good facility but a very good facility. And it could be a sports place or it could be a shop or it could be a bus stop. So it's these things, it's these components which are going to make people get up and go. And the components of that are housing associations, there are community associations, there are local authorities, there are inclusive economic growth policies operationalised into good rows of shops etc etc. This is a huge impressing issue in activity but we're not going to necessarily solve it by identifiable budget. It's cross working and one thing that hasn't been discussed so far but I'd like to introduce is where are community planning partnerships in this because it may not be a central focus of the government at this level but their ability to work and influence budgets and the allocation of budgets at local level I think are the key to many of the issues that have come up here. How we allocate towards alcohol and drug partnerships, how we allocate towards the priorities that are local in terms of physical activity and sport will be increasingly determined by organisations or associations and alliances like this and I think they need to be given the expectation as well as the ability to make decisions and see through towards outcomes, good outcomes the sorts of things we want to achieve. Just to move on from that, I obviously walking is something that's very accessible, a huge amount of work by our members at Rambling Scotland they've had 7,000 people access their medal routes app so a significant number of people trying to find ways that they can walk a little bit more but I think it's also about providing a diversity of activity so one sport does not fit all absolutely and I think we need to be proud of the diversity of sports that we have in Scotland and I think quite a number of governing bodies of their own volition are actually working to try and identify how people who may want to start by walking but may have a passion for something else how they can enable the accessibility that walking provides for so many people with something that might just be a different kind of motivator for people so a huge amount of work on walking football there's now walking netball there's walking basketball being introduced and again sports are looking to say well how do we appeal to different people people who might be motivated by something a little bit different some people might like walking for the outdoors again that's great whether that's for travel or for their own purposes but some people might like to have a social aspect where they meet other people and there's an engagement so I think that's a priority and I think link to that is the chief medical officer's start act to stay active guidance very clearly says that there is a dose response to sport and physical activity so unless you're an older adult at every other age there is a dose response so the more active you are the better the health benefits you will reap from that so yes we absolutely need to start people active but again going back to my part of keeping the active active we still need to focus on that as well and I think the point that links to what Andrew was saying is the health and well-being health and well-being outcomes that have been identified do not currently require the integration authorities to report on their contribution to sport and physical activity cos it isn't one of the outcomes that they focus on there would be an opportunity going with the point that you were making earlier convener around local authorities and the opportunities that they have if that was one of the outcomes then again we would understand better about the integration that Brian was talking about and the contribution that they can play but that collectively we can all play together as part of that Cymru, it's a very simple point and the tight moment is almost past it's just when then as somebody who's spent 20 years working as a specialist pharmacist in mental health when you mentioned that 30 per cent of the population was taken anti-depressants my ears pricked up because my understanding is that it's nearer 14 per cent I just wondered if there was anything you could my understanding that it certainly was increased my apologies you are right is it's 30 percent of GP consultations my apologies are mental health related 14 per cent of the population my apologies thank you very much thanks very much convener can I just come back on a point raised by on the discussions you've had over the back of the review and the impact this could have on sport in your discussions have you also highlighted the fact that a number of local authorities at the moment have chosen not to go down the route of trusts or establishing allios because ultimately the establishing of allios was a tax loophole being pursued but those local authorities who haven't gone down that route are currently penalised because they have to pay rates so you currently don't have a level playing field between an allio and a local authority has that been discussed at all in your discussions you've had with with the finance secretary so the membership body for trusts in Scotland is sport of Scotland and we have had a brief conversation with them and I know they've spoken with Derek Mackay so I'm sure that has part of that and I would like to hope that our colleagues at Vocal who are the local authority sports colleagues will have had a similar conversation so I understand the nature of why they've said it's a level playing field and I'm not arguing against that but at the same time I think there is a halfway house for one of a better phrase that has been identified with universities in saying there are areas of the university which are core businesses of what they've been funded and resourced to do versus the areas where they may be competing with a private market I would like to think there's a halfway house somewhere there for the local authority sports trusts to be able to say well actually you are doing fundamental work to create more people to be more active to help people in being active and to be providing vital support around sports development officers, facilities and a wide number of other things that they do that again prevention would move in reverse if we were to lose those so I'm not arguing against the level playing field and I appreciate this is somebody else's area rather than mine but I do think we need to try and make sure we're not backpedaling and going significantly backwards by that what I think is hopefully an opportunity is there's a forthcoming consultation on modern sewage rates I know the review is on that at the moment modern sewage rates do not allow the vast majority of sports clubs to access rate relief so the definition is charities and community amateur sports clubs very few sports clubs are either charities or community amateur sports clubs so again your point of level playing field we don't see a level playing field that operates for sports clubs from that point of view that is a conversation we're having with government and keen to have that discussion to say the definition that's been been retained in the Barclay recommendations which we hope that Derek Mackay will continue with will actually be adopted in the modern sewage rates that will provide that level playing field I want to another subject everybody has I'm taking a careful note of the number of times you've used evidence or figures to to back up your case and I'm noticing that the written submissions you all use various various figures do you think we use evidence enough when it comes to making decisions around health spending and that how do you actually get to a stage given the number of competing interests and the number of competing evidence how do you actually get to a stage where you're able to make judgments based on all that competing evidence I mean my part of the clinical specialist is built on evidence and the presentation of evidence and we want people to pay due heed to it there are all sorts of issues with the usability and also the quality of evidence and no evidence is perfect because it doesn't tell you specifically that such and such a thing will work in a particular context but I think there is a lot of evidence out there of things that might work but I think the bar is set much higher for preventive interventions in fact there's quite a bit of evidence for this the bar is set much higher in terms of scrutiny for preventive interventions to succeed into what public provision might allow than it is for clinical interventions and you'll certainly see in this committee all sorts of issues around interventions of marginal benefit for very high cost low volume interventions which has an opportunity cost if you're going to have them you're not going to have other things the other thing about preventive interventions is it sometimes deals with people's personal decision making or a population's decision making and it then gets into people's individual decision making which is an area where sometimes they don't want to go and certainly backed by the media they certainly wouldn't want to go so I think there are is a bit of a double think about preventive interventions and the evidence relating to them I think we're given quite a hard time over the desirability and the ethics or the the standards by which we measure things and I think sometimes it's in the too difficult pile and more distinct issues of individual decision making about marginal interventions tend to be easier but not any cheaper to resolve I think it's a really interesting question and it's one that we struggle with because Ash Scotland went down the line that evidence-based medicine was taking and we said published peer reviewed evidence will give us some objective measure of this is not just a few people's anecdotes this is actually can be generalised so I think published peer reviewed evidence is a good foundation for the decisions that we make and then on top of that you find that you have to listen to experience because it goes beyond the evidence because the evidence will take four years to get into the public domain and be published and peer reviewed so I think as decision makers you will get some very very good stears on the evidence and how it relates to each other from bodies like NHS Health Scotland in terms of anecdotal experience I think there's a need to be very careful because what we find is that some people are very vocal and that tends to be the people for whom something has worked or the people who are being incentivised by commercial interests to put forward the view that something works and the people for whom it hasn't worked tend to be less vocal and we've seen that in some of the social media consultations that have happened with the committees so I suppose it's an on-going question that we wrestle with and I sympathise Do I come in Alison? I suppose I would highlight minimum unit pricing as an example of an extremely effective preventative intervention which because it was something that hasn't been tried anywhere and because the effect of it was based on extremely detailed modelling that still took a long time for people to reflect on that evidence and to be persuaded by it and that's a kind of in terms of the range of options available to us that's one of the the single most effective ones so that's an example of where even with very strong evidence it takes a while for people to be persuaded and as Sheila mentioned you know there are those who are trying to deflect and distract by proposing alternatives like community alcohol projects which you know are massively invested in by the alcohol industry but have been evaluated to show that they have very little benefit Colin, you finished? Yeah, Brian? I think just following on from that your sort of preventative spend is one of the issues around how do you quantify money you won't spend? You know how do we how do we get Government to commit to a spend and talk about if you spend this if here's the money you won't spend? I know for example we were looking at dementia and we've seen the projections for dementia cases increasing not continue on the trajectory that was expected and the best guess is that's because of heart health campaigns so I think you can look at some of the things that have happened perhaps and you can quantify a little bit but I think going back to Andrew's earlier point there is a need to do both there's a need to deal with the immediate stuff and the people who are sick and there is a need to say if we are interested in the health of our children and our grandchildren in Scotland we have to act now to put measures in place that will impact on that so it's a bit like if you're a small farmer and you have to decide to grow cabbages to feed you next season but you might also want to plant oak trees because in 50 years time you're going to want to build a house Andrew this won't help you at all but I mean I'll just I'm just thinking as she spoke John Crofton was the person who founded Ash Scotland in the 70s and in the 50s he was busy battling he's a respiratory physician of great distinction he was battling TB and he pretty well conquered it in Edinburgh and then he switched his attention to another wave of respiratory-related illness and that was followed as this has dwindled but not gone by asthma and we're now dealing with the respiratory effects of all sorts of other things including air quality so the problem is if you fix something something else is going to come up and my health economics colleagues would say you can't necessarily say if you deliver 50 000 alcohol brief interventionals you'll be able to shut a ward because other things get move into that ward for care which have been waiting in a sort of informal unseen queue to get attention so it's very tough to say for a given intervention you'll make a saving of this distinct amount because cost shift and other priorities need to be addressed Vine, yeah? Mid to the point the point therefore is that we're not suggesting here or I'm not suggesting that you save money for the NHS what I'm suggesting is that that money can get reallocated to other priorities that's kind of where what was getting at yes but the explicitness of that decision making is I think a big challenge because for a given investment and given savings and what we want to achieve is more as Kim was saying earlier on longer healthier lives so longer lives spent away from requiring costly healthcare that may be so but there's a lot of people needing care because of democracy and expectation tomography, expectations and technology briefly yeah I think the I agree with everything you've said and I certainly not saying it's easy but again it was your part about holistic budgeting is whether you save in terms of being able to help people in healthcare who maybe weren't able to receive it before or whether it's other areas of the wider budget so we know that people that are more physically active have 27% fewer sick days we know that they have if work performance can increase by 5% when employees are physically active and we know that staff fitness programmes can reduce absenteeism by 15% so it makes more productive nations so are we saving in terms of the wider health budget that's somebody else's question who's better enabled in economics than I am but again and I'm sure we could quote over all the areas it will increase productivity and savings in other areas that if we look holistically at that budget in a way that I don't think we are at this stage there could be savings in other areas that make that a wider package that's worth doing Andrew, you said that your specialism is based on evidence Brian and I probably come from a different place and Brian is talking about individual behaviours driving change I think it's structural change in the economy that needs to happen in order to impact on people's health and wellbeing particularly in deprived communities so given that you spoke about evidence base is there any evidence whatsoever of significant resource being shifted from areas that are more affluent to areas of relative deprivation in order to bring about that structural change that will impact on people's health and wellbeing This is mixed a couple of things to that Kat Smith who's an academic in Edinburgh has looked at evidence in the way we treat it and because upstream I'll call them upstream interventions that's the causes of the causes are that much more difficult to study downstream interventions or risk factor interventions studies which are more numerous and more straightforward to do and find endpoints such as smoking related conditions have been much better studied and therefore the evidence base behind them is much firmer than complex interventions at community level so that's the first point second point is Audit Scotland a few years ago looked at the distribution of primary care services and dentists and pharmacists came out better than medical services so we have the distribution of primary care based facilities strictly speaking in the health sector we've got a challenge there to skew that towards people who are proportionally greater needs and communities but it needs to be again back to the community based priority setting and skewing and you mentioned business rates earlier on whether greater business activity is whether there's less need and skewing resources towards whether there's greater needs is probably where there's less business activity so we need to find ways structural ways upstream ways of diverting resource to people who face the greatest needs and communities who face the greatest needs and that is something we need to keep a very close eye on and again I would venture suggest that community planning and the allocation of resources at that level may help us but not at a macro level that's a sort of meso level we need to do all these things in order to shift resource towards where it's most needed thank you Kim talked about releasing equity in other ways for example in the health of the workforce one in three adults in our 20 per cent most deprived communities smoke compared with one in 10 in our 20 per cent least deprived if we could take action and reduce the smoking rate by 1 per cent in that 20 per cent of our deprived communities from 35 per cent to 34 per cent we'd be releasing £13 million a year disposable income back into those communities and I am certain it would not be spent on anything nearly as damaging as tobacco okay, Andy I also want to come in yes, please do my view is not quite as narrow as that I think I think it I'm more of a holistic I'm sure we'll hear your view developing over time as the rest of committee has influenced over here I'm sure yes, sorry Alison just one other thing that we haven't touched on at all is about generating additional income and the committee will be aware that we had a public health supplement on large retailers who sold both alcohol and tobacco and that that has lapsed we think that there's a strong case for reintroducing something along those lines but not necessarily where premises are selling alcohol and tobacco but either alcohol and tobacco or both and that would be a way of generating some additional revenue that could be predicated specifically for tackling and preventing those health harming behaviours just finally we'll take it as a given that in the budget process all of you want more money let's just accept that that's a given but what are the other asks that you would have given that we've to report to the Government in relation to the budget what would be the other asks that you have you can get a minute each it'll take less than a minute less waste of resource that we are devoting to marginally beneficial activity and these are very tough sorry for example things without a proven evidence base that they work and Alison and others have produced some very high cost drugs without sufficient evidence that they work for very few people or marginal evidence and I think people need to be very searching about the quality of evidence behind some of the decisions people take to allocate these drugs the opportunity costs of making these decisions are a very major on comparatively low cost programmes prevention programmes that we've been talking about are areas that you've mentioned there that are in common parlance amongst your peers then it may be worthwhile forward a name to the committee in terms of identifying specifics okay that would be helpful come to that a couple of things confusion please one I think I think that from sport and physical activity and I think in a wide range we talk about spend but I also think there's a language that's a culture of investment which I think is exactly the point that Sheila was making earlier and again that would be across prevention areas but again particularly you know we see local authorities and leisure trust being tasked with income generation and you're saying but surely the whole point is that anybody that's being active in that way is an investment so there's a language that we need to look around I think there I think there's a focus on helping to keep the active active so because we've got again an increasing and an aging population maintaining our levels of physical activity and sport is actually because we're increasing them if that makes sense so that's a win so I think there's recognition there our members will always talk about physical literacy so again going back to education which I know we've raised with the committee before but the two hours of not just number of hours of PE but that young people will come out of school and be physically literate and they are able to then be healthy in whichever way they choose through sport and physical activity through the length of their life a conversation we had at the Scottish Government when they were reviewing the national performance framework was saying it's all well and good looking at each of the indicators in their own right but where do we horizontally look at the opportunities for working more collaboratively so whether that's extra budget you know facilitation that creates that or it's just better spend I think we could do more of that through a range of areas and I think the last thing is I know a topic that was raised in the previous session about sustained and longer-term investment so many organisations work on annual budgeting and it would be a fascinating exercise across the voluntary sector and I'm sure other sectors to understand quite how much of that time was spent trying to work out next year's budget and where that was coming from and actually we could be far wiser in our spend of budget if we identify what our priorities are and we can actually provide sustained and long-term investment in those Sheila I suppose three points for me I'd like to see us ensure that we maintain targeted stop smoking support particularly to communities where smoking rates are high those with mental health issues in prisons where we're aiming to go smoke-free and in our poorest communities and I'd like to see that backed by mass media to encourage the whole population to quit smoking because we know that 67% of adult smokers wish they weren't and also just to remind people that second hand smoke is toxic and encourage smokers to take it outside of the house and I suppose the third thing is for me it's about joining up because at a time when we've all got really limited resources we need to be smarter and wiser about how we use them so for example we are working actively to take a co-ordinating role around no smoking day activity and the intended mass media stop smoking campaign that the government's planning for next year just to see how we can maximise the impact of these initiatives Alison So top of my list costs nothing it's marketing restrictions particularly to protect children and young people and looking at availability and how the licensing system is supporting managing the widespread availability of alcohol in Scotland both of those things are perfectly deliverable without any spend at all Secondly, I think it's extremely welcome that the funding for alcohol and drug partnerships looks like it's going to be increased again but I think there should be a clearer message about the expectations on them around preventative activity the emphasis is too strongly on treatment Thirdly, like Sheila there's a real gap in terms of public communication We know that 80% of people are unaware of the low risk drinking guidelines and 90% are unaware of the link between alcohol and cancer so we really need to be giving people the information to make better choices and finally I think we should be looking at mechanisms of ensuring that the health harming industries that are driving some of these problems are actually contributing to the cost of preventing and treating them Okay, thanks everyone very much for your evidence this morning as agreed previously we'll go into private session Thank you