 Good morning, everyone, and welcome back after the summer recess. This is the third meeting of the Health and Sport Committee and the Scottish Parliament's fifth session could ask everyone to switch off their mobile phones as they can interfere with the sound system. First item on our agenda is a decision on whether to take agenda item 4 in private. That item relates to the implication of the EU referendum and the work of the committee. The paper is an approach paper for future work, and such items are usually taken in private, so can we agree that, please? The second item on the agenda is subordinate legislation with three negative instruments today. The first instrument is the Food for Specific Group Scotland regulations 2016, SSI 2016-190. There has been no motion to annul. However, the Delegated Powers and Law Reform Committee did make a comment on the regulation. It noted that the regulations are meant to make further consequential amendments to the Food intended for use in energy-restricted diets for weight reductions regulations 1997, which are required as a result of the changes to the 1997 regulations introduced by regulation 6. The Scottish Government accepts the amendment made by regulation 6 has not led to sufficient clarity in the 1997 regulations and also notes that it is undertaken to further amend the 1997 regulations at the earliest available opportunity. Can I now invite any comments from members? No, somehow I didn't think so. The second instrument is the Food Information Scotland amendment regulations 2016, SSI 2016-191. There has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. I again invite any comments from members. The third instrument is the National Health Service free prescriptions and charges for drugs and appliances Scotland amendment regulations 2016, SSI 2016-195. Again, there is no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. I again ask any comments from members. The second item on the agenda today is two evidence sessions on delayed discharge. I welcome to the committee Stephen Fitzpatrick, head of older people services Glasgow City Health and Social Care Partnership, Katrina Renfrew, director of planning and policy, NHS creator Glasgow and Clyde and councillor Mackayr, executive member for social justice Glasgow City Council. We are not expecting any opening statements from the witnesses, so I move first to questions. We have a large committee, so it would be appreciated if both questions and answers were brief, so we get through as much as possible. I might be opening up myself. Yesterday, we heard from the cabinet secretary who was praising Glasgow City Council on the reductions that it had made in delayed discharge and the progress that it had made. Can you give us an indication of how that progress has been made over what looks like a relatively short period of time? I appreciate that. That is nice to hear. It has been a short but intense period of change in Glasgow. The story probably goes back about four or five years when the delays numbers were probably at their worst in memory running probably about 300 over six weeks in Glasgow. We recognised at the first stage in the process that it was really important that the health board and the council recognised that that was a strategic priority that together we had to address. That was a really key point of making the change. We then spent a couple of years working really closely in partnership between social work as was pre-health and social care partnerships, the CHP, the community health part of the system and the acute system to try to improve the existing system and performance around that. There was a lot of managerial attention given to trying to improve performance and what we have seen from the period from around May 2011 to the middle of 2014 was an improvement down from that level of about 300 delays over six weeks to probably about 100 to 150 delays at that point. What we recognised at that point was that we had exhausted the potential for the system to improve performance just through a managerial approach that we had to reform the system fundamentally. There was a recognition in 2014 that we had to do that. One of the issues that we had to deal with at that time was what we described as almost a tale of people who had been delayed in the hospital for quite a long time. The only way to deal with that was one-off investment in care home placement, so the council, at that point, agreed to find somewhere in the region of £3 million to effectively create a steady state so that we were only dealing with demand as it came through rather than the residual demand that had built up over time through that historical challenge that we faced. At that point, I recognised that there was a need to reform the system and, fundamentally, what we decided to do in Glasgow was to introduce intermediate care at scale so that no-one was being assessed for long-term care wherever possible from a hospital bed. If they were fit for discharge, they could move to an appropriate environment for the long-term assessment to take place. One of the key underpinning principles was that assessment in a hospital because of all the system pressures tended to lead to poorer assessments and, otherwise, would be the case. Intimidate care and the provision of that space at scale across the system was key. Part of alongside the introduction of a target of 72-hour discharge for older people, excluding some categories, AWI and so on, where the needs were more complex, but for your typical older person coming through the acute system, we would apply that 72-hour target and move someone into intermediate care. We do not always achieve that, but it certainly made a huge difference in terms of the throughput from acute out for social care assessment for long-term assessment. There is a whole lot, and I know that you have asked to keep the answers brief, but we will probably come into some of the details as we go through about what underpin that cultural change system, pathways, processes and so on. That was the fundamental system change, and principally, again, we needed investment for that to happen. That could not be done from within existing resources, so the integrated care fund before that, the change fund, the Scottish Government allocated local partnerships, was invested principally, and the priority was around delayed discharges and trying to develop a system that would affect that throughput. What we have seen in that time is a significant reduction in older people's delays across the city. We introduced a 72-hour target in Glasgow on 1 December 2014. We had 117 people, 65 people, plus they were delayed more than 72 hours. As of the numbers fluctuated, but the lowest recently was in March this year. We introduced that to about 15, 14 or 15, so there was an 80 per cent reduction in that time. That was in short what we have done. That is just a brief point on specifics of intermediate care. What does that mean? Where does that take place? What type of sense? It is step-down care for people who are deemed fit for discharge, so they no longer require acute medical care. They go to a number of care homes across Glasgow. We have six at the moment across the city. One of the key features of intermediate care is that it is for people to cooperate for families and for patients to cooperate with the move. It needs to be somewhere local within their community, so we need a geographical coverage across the city, which is why we have it in different places and locations. There is also an optimum size for it to work because, by definition, those are the people who are most complex. They cannot just go home with home care or lower-level packages of support. They tend to be the people most likely to be assessed for long-term care home care, so there is an optimum number beyond which the care homes themselves struggle to cope. However, it is all independent sector, privately provided care homes that we use in Glasgow. Thank you, convener. I would like to ask a question about the submission from the Integrated Joint Board. I thought that it was quite an interesting response to question 8. The question is, what do you identify as the main barriers to tackling delayed discharges in your area? From my experience in Lothian, it is often lack of a care package or, frequently, home adaptations have not taken place. However, I was quite interested in the response, which is continuing professional and community culture of risk aversion, rather than risk management in relation to the care of older people. I wonder if anyone on the panel could flesh that out a little. Who is first? I'll give Stephen a break, if that's helpful. Essentially, there is a series of cultural issues about whether people can go home or not. There are a series of expectations that families have that once somebody who has had a pretty significant hospital admission is, in our view, ready for discharge, a family's expectation is often that they are not going to go home or that they are going to go straight to a long-term care placement. I think that what intermediate care has done for the city is created a space between an acute hospital episode and a final discharge decision from inpatient care, so that a patient can move into a care home environment, but without an expectation that they will be there for the rest of their lives. The risk issue is often a difference between different kinds of professionals about what is suitable to send people home with a package, and if people have come from difficult home circumstances or have issues about their physical health, the social care view is that they should be able to make a decision to go home when we try to put a package around them and minimise risk. The family expectation may be quite different, and sometimes hospital staff expectation is quite different. What intermediate care has delivered for us is a bridge between the two, because somebody is going into a care home, but they are not going in with a lifelong expectation. There is further intensive rehabilitation and further assessment to see whether they can then be got home. If I can just emphasise the numbers, if that is okay, convener, very briefly, that if I went back to our peak of delayed discharges and we count them in lost bed days, because that is what is significant to the hospital sector is how many beds are consumed every day by delayed discharge. In 1112, we had 109,000 bed days in Greater Glasgow and Clyde that were taken up by patients waiting for social care outside hospital, not just the city, because we deal with eight or nine different local authorities. By the time we got to April 2016, we were down to 31,000 bed days. The change is dramatic. From my point of view, and from an acute NHS point of view, there is still a long way to go, because those 31,000 bed days are still a big issue for us in terms of how we are trying to run the throughput for acute, but that is a transformational change in four or five years, both for patients, for acute services and for what the social care teams have been able to do. Are you optimistic, the 31,000, that the remaining discharge, will you be able to tackle that through education, stakeholder engagement—you speak about that in response to the next question—or is that a resource issue? Mr FitzPatrick, you are pointing out that sometimes the private care homes are full. What happens then? The 31,000, if you like, is going to be a mixture of a whole series of different things. Resources are really important. When we talk about the funding for the health service, if social care services are not funded at the level that they need to be, then the health service cannot function. The balance across the whole system of care in terms of investment and resources is absolutely fundamental. Hospitals cannot work without social care, community services, not just social care, but community services and, indeed, GP services, more generally being funded and integrated with them. I think that resources are an issue. I think that there are still issues about some of the more complex patients and finding non-hospital solutions for people with acquired brain injury, for example, with some of the more complex physical disabilities. They make up a chunk of the 31,000 bed days. There are still challenges around patients who do not have capacity in getting them out of hospital. However, if you ask me whether I am optimistic, we are working with our partners in the HSTPs on all those areas. One thing that has changed—I think that Stephen highlighted it in his introductory comments—is that we are all on the same ship trying to address that problem. In the five, ten years that we have improved things, I think that people have come together much more to see this as a genuinely shared problem. However, resources are a huge worry, because if there is no money in community services, hospitals cannot function. The other caveat to add to that is that we need to reduce the acute sector. If we shift those patients, the money that is in acute beds needs to shift into supporting patients better in the community. That is a major issue for us. We are trying to reshape our acute hospitals to reflect that change in delayed discharges. That is very politically challenging for us and very publicly challenging, because the public still sees hospital beds as the kind of denominator of a good health service. It is not necessarily some of the services that Stephen has talked about that are being provided in the community are much less visible. Is that fair? That seems to be absolutely a little bit into the political, I guess. It has been a bugbear of mine. This is my second stint during the social work job in Glasgow, and I left the post at the end of 2013 just as integration was getting itself moving, if you like, in terms of the new act. I have come back to it six months ago and a lot has changed, but some aspects in terms of the resource issues have stayed the same. However, the cultural change has been fantastic in that period. When I came into post in 2010, in the social work post, the CHCPs in Glasgow had just broken up and just failed. That was a very difficult moment for us, for all of us. Those two guys were very involved in things at that time, and they will know far more about the matter than I will. I walked into a situation that was very difficult indeed, and slowly but surely we had to rebuild certain relationships at a higher level, because a lot of the working relationships were okay anyway. If we are honest with ourselves, at a political level too, it was difficult to patch those things up. Getting that side of the culture thing helped us going into the new act. However, the other cultural challenge that I alluded to in terms of the professionals and the public as well feeds into Katrina's final point about how we look. That is a collective problem for the political classes, if we are honest with ourselves. Politicians of all parties and the media as a result of that, or maybe those things feed back on themselves a little bit. We have a tendency of looking at NHS and looking at care as being hospitals, as measuring success in how many beds we have, how many nurses we employ or how many doctors we employ, rather than measuring success in how healthy our population is. That is a really challenging thing to see out loud for a politician. I understand all the difficulties of that better than many, but I am sure that many of you have come across these sorts of difficulties of your own constituencies. It is not an easy discussion to have with the public, but it is an honest discussion that needs to take place. We need a genuine transfer of resources not just to social care, but community care in the round, because we want to break down the barrier between health and social care itself properly. We need to talk about building this integrated service from the ground up. I have to say, in terms of the consultation response, I will be back in a day to the Public Bodies Act. That was one of the concerns that we raised in Glasgow. We get the principle, we support the principle of the move to integration, but we just felt that a better approach would be to start at the very beginning in the communities. Where are our GPs? Where are our community nurses based? Where could our social workers be based? Where could our other care professionals be based? Building it up that way. That is not to say that that is impossible now, but it is very, very possible. However, we need a clear—we need to build a political consensus around that, quite frankly. We need to think very carefully about how that whole lot is funded in the future, because it is tricky. I would like to focus a bit on some of the numbers, and I thank Katrina for clarifying, because there are some questions on that. I think that you have answered them. I think that 31,000 number that you are talking about is your annualised number. It is 1516, so the financial year just ended. That was the total for that year. Great. Going on from that, I want to talk about the financial implications of that. If you look at the integration agenda, a big part of the justification was £150 million, or whatever it was, savings across a number of areas, one of which delayed discharge. If you look through the data that we have got from the NHS information service division, they are coming out of their number of £214 per day for average costs, per bed and in acute. I do not know if that number reflects what you are saying. I suppose the question is how much is the cost if you move somebody into intermediate care in comparison with that? Given the substantial reduction that you have had, have you seen those numbers flowing through? If not, why not? If I can start just with hospital bed numbers, we have less acute beds now in Glasgow than we had in the early 2000s, mid 2000s. Part of the financing of opening the new Queen Elizabeth hospital was to increase efficiency and therefore to have somewhat less acute beds. I think that I have not got that figure to harm, but I think that it is about 150 less acute beds. There is a flow-through of having less delayed discharges, so having less acute care. I think that where the challenge is now coming for us is that we need to look at sites because reducing beds in hospitals and in big acute hospitals is not a particular economic way to deliver care. We want to achieve maximum transfer into community services and match rights. It is not just social care services, it is GP services, it is community health services and social care services by looking at the costs and the whole of our estate across NHS Greater Glasgow and Clyde. We still have acute older people services on seven or eight sites, and we do not see that as a viable model going forward as we start to further develop the kinds of services that we are talking about. I am not making a political point at the capital P, but a public political point is a very challenging discussion. I have to say that the counterside to the reduction in delayed discharges is that there are pressures in a number of our hospitals on admissions. Unfortunately, as is often the case with the health service, nature abhors a vacuum. As quickly, to some extent, you feel as we have cleared delayed discharges, more patients have presented themselves for emergency care, not true across the piece but true in parts of our patch. You can probably see that from the ISD data. On the number, do you have the comparable number? Does the 214-sound right and day have a comparable number for care homes? The general rule of thumb is that a hospital bed costs twice as much as a social care bed is the general rule of thumb. You reckon that you have seen those savings coming through, because it comes to whatever, £8 million or £10 million or something? In terms of the intermediate care places, we roughly pay about £740 a week for an intermediate care bed. Obviously, we have not done the exact comparison in terms of ancillary costs and so on. I think it is also important to say in terms of the overall efficiency idea around this. It is not that this has not just been motivated by more efficient discharges from hospitals, but we are also trying to shift the balance of care in terms of the number of people going home. By definition, those who were entering intermediate care were most likely to almost 100 per cent when we started. I think that 99 per cent of the first cohort that went through intermediate care went into long-term care. The most recent two periods have had four-week periods and have been 30 per cent to 42 per cent of people going home, and that has been a big shift for us. We would expect to see the economic benefit of that further down the care pathways for those individuals. It is quite a complex picture, but we think that we are moving the right way on it. We are moving towards trying to get out of acute hospitals anyone who does not require acute care, and that would require a smaller hospital base. Just to put it in context, it is not just about delayed discharges for HSCPs. There are all sorts of other delays in systems in acute hospitals that we are trying to address as well. People are waiting for imaging, for example, or waiting for results, or waiting for the ambulance service. We are working really hard across acute to try and get people out quickly and also to try and shift unplanned care to planned care. If people can have an urgent outpatient assessment, for example, they do not get admitted, they come back the next day. We are trying to change the system of care and delay discharge for community services is just one component of that. At our residential away weekend this weekend, we had a presentation from the National Clinical Director who walked newbies like me through the idea of what causes delayed discharge. It was very useful. He gave an example of an elderly woman who had taken a fall and spent 10 days in hospital, but only required 10 days of care. However, because her normal social care package at home had been stopped for the duration of her hospital stay, she had to stay in hospital for a further nine days while that was reinstituted. That, in a nutshell, is the cause of delayed discharge. He then went on to explain that the way that they dealt with that for this patient was, in fact, the introduction of hospital at home. When she had similar circumstances further down the line, she did not have to leave her house, she had the same standard of care, but none of the problems associated with the delayed discharge. I wonder if the panel can give us your reflections on innovative practices such as hospital at home and where they fit in to the mix. Obviously, not for everybody, particularly in very acute cases, but for where they fit in. I think that they are part of that, creating a much broader spectrum of care. I have worked for NHS for over 30 years. When I first started, you were either in hospital or not in hospital or in a care home. There were only three. It was a pretty short algorithm. Now, the algorithm across Scotland and across the UK will have a whole number of nodes of delivering service. We can continue to develop new models of care. One of the critical pivots of all of that is the role of GPs. That is a real pressure point for us at the moment, that the demands that GPs have in their own practices just keeping on top of the daily work is huge. GPs are now willing to be part of some of the more innovative models of care, because most of those patients still need some kind of medical oversight. If it is not being done in the hospital, you need GPs to be a core component of those sorts of services. Going forward, for us, one of the worries is GPs' time capacity and interest in being part of those kinds of teams and those kinds of models. I think that that is essential to make them work. I do not know if you agree, Stephen. I absolutely agree with that. As you shift the balance of care, people still have needs. If it is met in a more efficient way, your whole system needs to change around that. That is always straightforward and it takes time, and there is risk through that. That comes back to the point about we need a system to be willing to embrace that change in the risk that comes with it to manage those. It comes back to the point that I made earlier on about how GPs fit into a system. I think that they are overworked. I do not necessarily say that they are overpaid, but they are certainly overworked. They are not rationally distributed, if we are talking about tackling health inequalities. There is an issue about how our GPs are distributed around. There are issues about what the NHS can do to influence that. It is not always a straightforward exercise at all. I think that there is something about how, if we are trying to rebuild this thing as a truly integrated service, we need to think a little bit about where GPs are and how we integrate services around them. Ideally, the ideal is this one-stop shop kind of placey. It is interesting that, for example, you gave about somebody being in that situation, being a hospital coming back out in the delay because the service had gone. I would hope—I always say that this would never happen in Glasgow, but I would say something that I would be less likely. Partly, I would say that I am quite proud to say this. The council's company, Cordia, provides the case. It has, I think I am right in saying it, around about 90 per cent—96 per cent—of the work. It's scale gives us a huge advantage in being able to deal with, first of all, new cases coming into the system, because just the size of the organisation means that it can actually—sometimes you hear stories that a large organisation can't react like that. In this case, it works because we've got the staff, we've got well-trained staff, well-paid staff, properly resourced, and they can then take on that extra case when required. It also means, in a situation like you've described, that we could also get the service back in place relatively quickly. I would hope that that kind of scenario would be less likely in our area, I would hope. I think that that's fair. I think that we were talking outside about some of the problems in providing home care services that local authorities or HSCPs outside the urban areas have. That is a real issue for us, because we are distributing patients back from acute care all over the west of Scotland. We notice that contrast between the reliability and the durability of home care in the city and the more urban authorities and much more challenging for rural authorities. I think that that's right. If I went through today's list of delayed discharges, I would not expect to find patients certainly from the city, from our more urban areas that are delayed for that reason waiting for home care. There are some from other authorities outside Glasgow, but that's not necessarily an unwillingness to provide home care. It's a recruitment problem. It's a scale problem. Thanks very much. I'm interested when you talk about the issue of delayed discharge. I'm very interested in the idea of preventing admission in the first place. I imagine that that's where you're focusing to try to reduce the last 30,000 lost days. Do you want to tell me a little bit about what you're doing to avoid admission? I wonder if you're using your interim beds, a step-up beds, or if there are more flexible palliative care packages and things that are being delivered at home, or what sort of things are you doing to avoid admission in the first place? It's not being delivered at home, so if you look back over three or four years, the investment in rehabilitation at home is significantly greater than it was. Our geriatricians are doing more outreach, so rather than being solely focused on acute care, they're now working with Stephen and his team to look at intermediate care models and being part of the team. The way that old age psychiatrists have traditionally done for a longer time, so a lot of patients in nursing homes would still have some oversight from an old age psychiatrist, so our acute geriatricians are beginning to develop that model. At the front door, we're looking at things like assessment and discharge, urgent outpatients, ambulances doing treas, there's a whole range of different things that we're doing. I think that one of the anxieties that always needs to be on the table is that we need to make sure that older people are not deprived of acute hospital care that they actually do need. We're always very careful of saying unnecessary admissions. It's different ways of managing that particular need at the time rather than saying, let's try and stop older people getting acute assessment and top quality acute care, because we need to deliver that. When they are admitted, we need to get them back out quickly. That's where Stephen and I probably part company a bit, and I probably part company with the Government, which is unwise. The idea that 72 hours is a success, for me a success, has been when somebody leaves hospital when they're ready to go. If you're ready to go on Tuesday, going on Tuesday is what we should deliver for, you're not going on Friday. I think to be fair, although you talk about 72 target, when we're in our detailed discussions, we are looking to get people out on the day that they're ready to leave, medically, not on that day plus three. If I was setting targets, I would be much more focused. That's why we use bed days, because that's a real measure of the resource lost. We need to get people out on the same day that they're ready and change that culture a bit. I don't think we disagreed too much on 72 hours. 72 hours is a notional target. The aspiration, I think, is to get people out. We recognise that hospitals, once people have had their medical needs attended to it, is not a healthy place for older people to be. That's really driven a lot of our change in practice and system. On your particular point, we have step-up beds in the city. As we move, we're progressing with a tender now. We developed it as a proof of concept in procurement terms, but we're now moving to implement a tender in the city for our intermediate care. Those beds will be used flexibly for step-up and step-down. We have systems and processes to try to ensure that the right people are going in because someone stepping up tends to have different medical needs. It's much more acute medical intervention, if you like, for those people. We have that developed over the past couple of years in the city, and that will be across the city. In strategic terms, the big focus, as we've talked about over the past number of years, has been around reducing delays and delayed discharges and notwithstanding the 31,000 bed days across the border area, which will continue to be a priority. Increasingly, our attention now strategically is on unscheduled care and preventing admission in the first place in diversion. A whole load of different initiatives around that and trying to build on the momentum that we've built up around delays and an appetite for change and doing things differently, which we hope to apply in relation to our unscheduled care strategy. We've got some new statutory duties around strategic planning for that, which we're working through with partners in the acute system and other HSCPs in the border area, but step-up will be part of that, as we'll anticipate to the care planning, as we'll be how we configure our multidisciplinary teams in and around the hospital and trying to divert people who might turn up at any. We're working with care homes who are big referers to acute hospitals, so it's multifaceted and we've got a whole detailed plan, and I'm happy to share that, but we're working through that, and it will take time for that to bear fruit, too. It's maybe worth referencing your point on palliative care. One of the things that we're trying to do as we move away from NHS continuing care, which we're working our way out of, is to transform those beds into community-based palliative care, but for people who can't die at home, so that we can offer something other than the hospice movement, which is a tiny number of beds, for people who are in end-of-life care and who previously would have had to die in hospital, because they couldn't necessarily be looked after at home. The move away from continuing care, we're already seeing benefits of being able to offer in care homes more extended packages of support for patients, again with the geriatricians providing input to that that we wouldn't have done in previous care home models. One of the things that would be key to delivering a change like that, I would say, is back to every current point, and that's having that honest discussion with the public, whose services it is. A lot of people in their grannies know well that they expect her to go into a residential care home, and it's not necessarily the right thing to do, but it's maybe what we've all grown to expect over the years. It's not to say that it isn't right for some folk, of course it is, but we have to change that mindset amongst a lot of people, and that's not an easy thing to do, because you're dealing with people's lovelins, you're dealing with people's lives, and it's a difficult conversation to have politically. I'm sure that all of you have had case work on things like that, I certainly have, and it's a really difficult conversation to have with some folk, and trying to reassure them that you can genuinely give them a life and a support that they need and they deserve in a setting that's hopefully more comfortable and safe than a hospital might be, not that I'm seeing hospitals are not safe. You're getting my bite. That's how we challenge those politicians, I would say. Is it ever a problem in terms of beds that the care homes that people might be going into, either in the interim system that you've described or the more longer term residency, is the number of beds available ever an issue, or are you able to place people? In Glasgow, it's not an issue, I know it is in other parts of Scotland. I say that. Edinburgh, for example, it's partly something about land values and speculative building and so on, so in the extent of Glasgow, we have a very high concentration of care homes and care home places because it was relatively cheap at one time to build and develop, and we don't commission that as an authority, it's a marketplace, so we have never had an issue in terms of capacity. Glasgow has a current capacity running around 80 to 90 per cent across the system, which always gives us that room for manoeuvre, if you like. I've got to say this, but I'm duty bound. The City Council itself, over the last few years, has invested £100 million in new counselling and run residential care homes for the elderly, so it's not that we believe that that isn't a need for that kind of support in the future, but what that does in having our own in-house service is that it gives us a good position in that kind of... We're not in a position that some authorities have found themselves in, to go for their own, but they're at the mercy of what the market might provide. As Stephen has said, the market, so to speak, doesn't always provide here because of the land prices and what have you. There is a strategic case for local authority investment in that, at the very least, to have a foothold in that to keep things honest. One of the problems around care homes is the public perception. There's still a sense that that's privatising healthcare, so when I still engage with people, and indeed when we engaged in changes years ago around some of our sites, people remember maybe Cow Glen in places, there was a real sense that healthcare was being privatised because the contracting would be done. Out into care homes that were quite a lot run by charities, to be fair, but were not run by the public sector. I think that's still a real issue when you engage with the public. We're in a debate at the moment about the future of acute beds that we've got at Lightburn hospital, and part of the reprovision if we proceed with that would be local care homes. Now, they're good because they give you a very local service, much more than we could do off acute sites. They've got very good facilities, they're good providers who've invested in their facilities, but the public perception will still be that that should be in the public sector, it shouldn't be in the private or charitable sector, and that's a challenging debate sometimes with patients or patients relatives. The response to the questions that you say you don't record expenditure solely for the purpose of reducing delayed discharge, how do you know how much you need? This is that straightforward thing. I'll leave the science back to these guys in a moment here, but look, there's an issue here, but there's been two different cultures actually. I've given them, sitting between them. I don't get a hard time off of both of them now, but there's been a difference in cultures and how councils run their budgets to how the NHS runs its budgets. It's a different, and there are long-term reasons for that. It's just not been possible for councils to run overspends in certain ways in the way that parts of the NHS have been able to do, and I can feel continue looking at me now. Over the years, there's been an expectation, frankly, that the successive governments have been able to then stand behind the relevant authority and build them out, and I don't mean that too negative, it's what needs to happen, but that's not necessarily happening in local authorities. The mechanisms that we work under are quite different. To give you any example, my last stint in social work, a third of Glasgow's council spend went on social work, so it's an awful lot of money. Not enough, but it's an awful lot of money, right? It gives you some sense of the scale and need, certainly in the city, but I could tell you that now we could spend it twice over. We got to the point that I remember, I think it was in January, and I was reporting to the Executive Committee, or at least the City Treasury, the Executive Committee, and looked at the probable outturns for the various departments going forward. A probable outturn at that time for social work was to be £18 million over spent, and that was there at the same time as he was reporting that the council's reserves were sitting at £18 million. To say that was a scary thing, we put it mildly, and to say there weren't difficult discussions that took place after that is also put it mildly. That overspend can happen really, really rapidly in something like social care, as it can in NHS. You can have one secure placement for a child, and that can be, that's £200,000, like that, gone. In an authority with our kind of scale, these sorts of placements, these sorts of costs, are not at all unusual, so things can rapidly get around. I would say that we've got some, given the difficult experience that I've had in hanging on to social work budgets in Lavia, we've got some really good officers wanting for us who managed to watch that spend all the time, but I think the point that was trying to be made, if I'm honest with you, in that answer, was that actually we're approaching this not as a cost-saving exercise, because that can't be what I'm around. It was actually one of my wee, I know it wasn't the focus of the act in fairness, but it was one of the things mentioned was that there would be three quarters of a billion potential savings in this. I think we are kidding ourselves on if we think that there will be genuine savings for the public sector doing this. What will happen is that, yes, acute might, we might get to a point where acute spends less money, but the money will be spent in other ways, because demand is not about to fall any time soon. We have an aging population, and as a population gets older and they get to the point where they do need help, those needs are ever more complex, and those treatments are ever more expensive. So there are a number of complex challenges. I'm sure you're always a committee very well aware of, but I do think that for successive years there were not really getting to the bottom of this. They're not going to realise savings through this. Do you see if you're freeing up bed space because people are moving elsewhere? Is that just being filled up by others? I think that the core issue for the NHS is that the NHS inflation runs at very high rate. You'll see every week in the paper new drugs that costs potentially hundreds of thousands per patient, you'll see new treatments being announced. The complexity of the NHS is the rate at which we can do more for patients if somebody gives us the money. If there is never a stop that says actually that's not a priority for the NHS or the opportunity cost of that is too high, then the acute sector of the NHS will spend more and more money. So what has happened is where we have saved money in some areas, they will have been reinvested in other areas. I think that just a headline, we're probably spending £30 or £40 million more on drugs on prescribing both in the acute sector and primary care in this financial year than last. That is not covered by the inflation uplift that we've had. So it comes back to this issue about choices. Do we want to have really, really good community services where people are looked after at home or in more community settings? Or do you want to spend more money on the acute sector? That choice with the HSCPs now being in place becomes much more explicit, but the more money you spend on acute, the less you spend on other things. The risk has always been for NHS services like drug and alcohol services, services for mental health, services for child and adolescent mental health are Cinderella's because they don't have a public profile. Services about new drugs, new cancer treatments, new pieces of equipment create a public mood that wants to see those provided by the NHS. That's an intensely difficult debate because there is not enough money for everything. So just picking up on that, recently the drug and alcohol budget was cut quite significantly and you guys were told to replace that money. Where do you magic that money from? I think that on that specific, we didn't reduce the drug and alcohol budgets that we allocated to the HSCPs by the same amount that had been reduced nationally. That amount of difference between that national allocation and what we passed on, the gap between that has become part of our financial problem. Our board doesn't, at this time, have a balanced budget. We're still looking for savings for £1617 and our acute sector is overspending. We are, as a number of health boards around Scotland are, in a position where the books at the moment don't balance and difficult choices need to be made. Now, if you get those choices wrong, you undermine the kind of delivery of care that we're talking about here. If you take money out of community services or mental health services, you end up with more people in hospital. It's only despite the fact that there are a number of statutory bodies involved in the provision of those services. They're one system for patients. If we don't have that balance right and we change services in an unplanned way, we will go back to the 109,000 delayed discharges. We will go back to a system that is completely out of balance. That's why there are some hard choices to make about how the NHS spends money and what the priorities are. One of the issues that were repeatedly raised during our inquiry by other health and social care partnerships, including Glasgow, was the length of the process that was associated with adolescent capacity. You have identified that it has cost Glasgow City £1 million in delayed discharges. Can you explain to the committee why the process takes so long and what Glasgow City is doing to mitigate that length of time or how you are trying to remedy that? I'm happy to have a go in in the council care. It's complex because each individual case is different. One of the things that we have tried to do in Glasgow is apply 13zA for individuals that are lacking capacity where it's in their best interest to move without seeking... What 13zA is? That's what you're asking me. It lets you move a patient from an acute hospital to a care home in their best interest. I have to say that, objectively, our consultants will always say that if somebody is ready to leave hospital, it's in their best interest to be in a more homely environment. Sometimes it's not possible because someone already has powers, so they have a power of attorney or a guardian or someone is seeking powers and so on, so every individual case is different. That's part of the complexity of the issues for the health and care system, in that we are not completely in control of what happens because it's a legal process. Court time has come under pressure, for example, in Glasgow. We've seen increasing court time set aside for consideration of guardianship applications and then there was a change to that and a reduction in court time because courts are under pressure. That leads to a delay in powers being in place and less powers are in place. You can't move someone from the care of a consultant into a social care environment, for example, which would be the normal route for people. The court process is certainly part of it. There are issues sometimes around how a solicitor might be—very often it's a private solicitor that's acting on behalf of a family member or relative that's seeking guardianship powers. We have heard of cases of people going off long-term sick or going on holiday and so on, and that just prolongs the time before guardianship is in place. What we are trying to do, apart from the application 13A, is to perform and manage the process. We have a policy position now where the partnership will seek to intervene through the courts if we think that a private application isn't being pursued as a seducerly as it should be and we can seek power to intervene in that case. It's a complex managerial process, because those cases are held by countless care managers, social workers across our system, so trying to manage all that is an undertaking, but it's certainly a priority for us to do that. The other thing that we have done initiating Glasgow at a more strategic level was the power of attorney campaign to try to educate the public about that issue and the risk that a loved one or you yourself would end up in a situation where you're in limbo effectively because of the guardianship process and about bearing your best interests so that someone can move you, someone you trust can hold power of attorney and make decisions on your behalf if those circumstances arose. That was an investment that started in Glasgow a couple of years ago and has certainly developed and we've now got a number of health boards and HSEPs that have been investing in that campaign and it's been very successful in generating applications to the extent that the office of public garden sometimes struggles with the demand that comes through, so it's always an unintended consequence, but that will be a long-term benefit I think. We would expect to see the benefit not right away because many people taking the powers of attorney may not have to use them for many years and you would get the benefit further down line, so we're coming at it from a number of different ways but it's always been a major issue and a major stress to the acute system. The other thing that we have done strategically in the last couple of years is to commission beds and care homes in the city, a couple of care homes in particular. These people remain NHS patients under the care of a consultant but they aren't in acute bed, they are in a place of sight which has relieved some of the pressure on the acute system in the city, so we're trying to come at this from a number of different ways to manage it. Could you just add one more thing? Apart from the power of attorney campaign, another part on the front end of that system is that we have a very successful support network in place for carers in the city and we've got a great team working on that. One of the things that they do is that we identify carers and we get carers assessments done. That idea of the power of attorney on the possibility of it is one of the discussions that can be thrown into that mix, as appropriate, obviously. We try not to miss an opportunity to have that discussion with somebody as early as possible in the process, but the big snag seems to be, as we've had that lump, if you like, going through the system, that the system's going to go into a halt a little bit in some places. The short term thing is key, that we've got these interim beds which are not the same as intermediate, just to confuse everybody, where our consultants are still clinically responsible for the patients, but they're not on acute sites, so we're doing what's in the best interest of the patients, but we're not following the final of the law because we keep NHS responsibility for those patients, but they're not sitting in an acute hospital taking up beds or being in the raw environment for them. Richard? I've sat and listened intently and I've complimented you on what you've done, but can I get a handle on this? You say you've reduced and delayed this charge in the city by 70%. So that's money saved. The government, when they brought out the public bodies bill, said that it would save between £150 million over Scotland. So the money you saved because people are not in those beds, are you now spending that in acute services? Are you now, and you moved into, you said a minute ago, your, you know, about drugs and things, so basically can I ask the money we're saving because people now no longer are sitting in the hospital at the cost of their bed, now is getting spent in other places and really we're not saving, we're not going to save any money, you might be over spent. Is that what we're saying? I think you have and you will save money around the costs of delayed discharging acute services, but every year when we reset our budget there will be another series of funding demands that will then, so there'll be a saving comes in, if you like, as a source of funding in terms of the pressures around delays, but then there'll be 30 or 40 other applications of funding that come in every year which we were expected to fund, and if you looked at the budget for 1617 there was, the NHS uplift included a half a billion pounds that was taken out of the NHS uplift and given immediately to local authorities, so although in our board's headline figure there was, I think, 150 million, but I'm probably exaggerating, I haven't got the numbers in front of me, but there was a multimillion amount of money that we passed straight to the health and social care partnerships, so when health service uplifts are shown at a kind of headline level as very large sums of money, certainly a large chunk of that in 1617 was given quite rightly to the health and social care partnerships to finance the development of social care, but the concept of a kind of a spare sum of money in the health service that's just waiting for somebody to spend, it isn't one that I would ever have recognised. What I've also got is some of the boards now, the joint boards are saying that they don't have enough money, that they didn't get enough money, that also was a council many years ago, and you get your budget, so you have your budget, you have your budget, you have the headline figures, have we ensured that we've put all the money that we should have put in to set up the joint boards, have we ensured that that's been done, or have, with the greatest regret when I say this, some of the joint boards being shortchanged? One of the problems of the construct of the HSCPs is the health board allocates their money, so we're allocating across acute and the HSCPs, so when there is a pressure on the boards overall budgets, we have to distribute that between the acute sector and the HSCPs, so certainly in our case we started with the ambition to fully fund the HSCPs and try to limit the level of savings that they had to achieve compared to the acute division, but there is a savings target for our HSCPs, and we have not yet identified across the services how those savings will be delivered, and we are, as I've said, also overspending on our acute care, so there is a financial problem right across the system, but I suppose what I would say in Glasgow and Matt is obviously a board member of the NHS board as well, which he's concealing from me at the moment, is that it was a very difficult budgeting process for us, and we're still not in balance on those very difficult choices about what we can't afford to do, because that's the reality. The opportunity cost of certain things means we can't afford to do them, is a challenging debate every year, and I think that this has certainly been the most difficult financial year we've had as a health board. We've got that in common, at least. It's the most difficult financial year that I've known as a councillor anyway. I don't think that I'll be alone in that across Scotland. In terms of being shortchanged, as a board member, I've got to be quite careful, but I think that the board has put in what it should in terms of its input into it, and I think that the council has to. As I said earlier, a third of the council's budget goes into social care in Glasgow, and we took the decision for very sound service reasons, apart from anything else, to put just about everything in to that partnership. There is no question that, in my view, there is a commitment financially from the councillor on that. I'm trying not to be too party political here, and I'm not going to do it, but there is a point here about how local authorities have been funded in the long term. I've been a councillor now for nine years. My local authority has been cut every year for nine years. A third of our spending goes into social care. You can't take that amount of money out of local government and not expect it to have an effect on social care, especially when a third of your spend is on it. It's going to have an effect. You do your best, and we work with everyone that we can to try and mitigate those effects, but at the end of the day it will increase the pressure. It brings situations like delayed discharge to head. We, through hard work in terms of integration, have managed to get ourselves what we have now, and I'm really proud of all the staff that have worked so hard to achieve that. However, I think that there is a wider issue in terms of the funding of the entire system that needs to get looked at. Catherine has mentioned that the NHS is always running to stand still in terms of funding, and it was always thus going back to Bevan. You set a budget that will be spent, but it's the same in social care, especially in a city like Glasgow where need is huge. We are not the only people in that boy. I understand that across the country. However, you have a situation that's not really being addressed. At some point in the political class, in the widest possible sense across all the parties, we need to level with the public about this system right now. I'm proud that I'm here talking about how we've done well in Glasgow in terms of our delayed discharges, but I really worry that that kind of progress isn't permanent and isn't sustainable unless we have a genuine discussion with the public about how our care services are funded in the long term. With the greatest respect, you reduced your delayed discharges by 70 per cent, so where's that 70 per cent of that money went to? It will have been part of the budget planning process at the end of each year. We'll be in total what new pressures have we got and how we're going to finance that. I have to say that there is definitely new investment in community-based services in the HSCPs compared to where you were three or four years ago, so there is a greater range of community services and greater spending on them, but that hasn't closed the whole financial gap. It is an extremely worrying position to be in that we still have savings targets to meet in this year, and inevitably, when you're making short-term savings, they're not necessarily the most sensible things to do. The core issue is going to be what size of acute sector is deliverable and affordable, what size of acute workforce, because there's a series of workforce challenges around acute as well. It's hard, for example, to recruit consultant geriatricians. Some of those difficult issues need to be out in the open for debate. The acute sector will consume as much money as taxpayers want to give it, but you won't then get community services, social care when you want it, home care when you want it, palliative care to die at home. Doing all of that is not possible. Sorry, just a very quick word on this. The important point to stress here is that this isn't a steady state, but dealing with new demand and a tidal wave of demand. Every time you take an efficiency, there's a demand coming through to consume it, and that's really what we're experiencing in Glasgow. Okay, thank you very much for your evidence this morning, and we will be watching the progress that you make with real interest. Can we suspend for a few minutes to change the witnesses, please? Okay, our second panel today is from South Ayrshire. We are not expecting any opening statements, so we'll move to questions. We have with us Tim Eltrion, director of South Ayrshire Health and Social Care Partnership, councillor Rita Miller, chair of South Ayrshire Integrated Joint Board, and Liz Moor, director of acute services NHS Ayrshire and Arran. Again, if I could ask people to be brief with questions and answers, that would be helpful. Alison, do you want to begin? Thank you, convener. Thank you. I believe you were listening to the previous evidence session, and it seemed that Glasgow weren't focusing so much on a lack of funding or even care home places, but they were speaking about various cultural barriers they had to overcome, as well as those resources. You've been quite clear in your very detailed response, for which I'm very grateful, that there is insufficient funding to enable the placement of people requiring care home support to leave hospital. Are there enough places, if there was sufficient funding? It's interesting. If you review the figures that we sent to you earlier last year, we were struggling in terms of placement identification, and that was the most significant issue for us. This year, in the past few weeks, we have been able to release some resources to make placements. I think that we have found a number of people for whom it's been difficult to make those placements in care homes. The evidence that we submitted demonstrates that, around about 14-15 months ago, we had a very significant rise in terms of the numbers of people requiring care home places, and that does put pressure on the overall numbers. Clearly, some care homes are more popular than others, and while there may be vacancies in some, obviously family and older people themselves, quite often express preferences for those that are the most popular, and that can, therefore, sometimes make it appear that there aren't sufficient places altogether. What sort of unmet demand do you have? I think that we haven't tested that to destruction yet. We are, I think, at this stage confident that the numbers of people that we're looking at who are delays, which are still something between, I think, 20 and 30, all together. We've placed or arranged funding for around about 30 over the past four or five weeks. Whether, at the end of the day, we'll be able to accommodate all of those in the homes of their choice remains to be seen. Clearly, placement in care home and the arrangements and funding and so on are a balance between new people turning up and, in fact, attrition. Obviously, people dying and places becoming available. For us, what we felt over recent years and probably over the last two or three years is that there's something in our local system that is perhaps propelling people into care homes a little earlier than we would hope, and so the length of stay is a little longer than we would hope. That, therefore, is if you like, using up that capacity more than we think would be sensible. Later on, if the committee feels it helpful, we could talk a little bit about how we're trying to reduce the numbers of people overall for whom the assessment is the requirement to go to care home. Eiers was one of the few responses that we had that was able, that had isolated the expenditure specifically relating to delayed discharges, which is obviously helpful when it comes to measuring progress. But another way of progressing this issue seems to be around culture and you speak in your response of hospital staff perhaps having a lack of confidence in the ability of community services to support someone. Is this an issue? Obviously, it's about education, raising awareness amongst acute staff and others of what is available. Is that happening? I think our response will be very similar to the one from colleagues from Glasgow. Very often, I think, it's very much on a sort of knife edge. People will, you know, within a multidisciplinary team, some will be more risk averse and some will be more risk enabling, if you like. There needs to be a confidence once somebody's in hospital amongst the team who are responsible for the discharge that that will be a safe and appropriate discharge. I think that I absolutely understand that as one who's worked, well, wholly in my career in the community. Your point is that we need to do everything that we can, I think, reasonably to support that decision making amongst our acute colleagues. Maybe, Liz, I don't know whether you wish to respond to that. I can corroborate what Tim is saying. I think that in terms of acute services, acute teams require great confidence in terms of the services that they're discharging their patients home to. We're doing a range of work just now to build that confidence with community teams and that we bring community teams into acute hospitals now to work with our consultants and our ward staff, just to demonstrate the types of services and the range of services that are available for older people. However, there is a general risk aversion in terms of older people going home where they maybe don't have full family supports, et cetera, but that's work that will continue to be on-going in terms of building the confidence around services, as services change, because we heard from Katrina that there's a whole range of services now available in the community for families, communities and older people, and often acute services don't know that range of services. They're not familiar with everything that can happen in communities, and unless someone can explain them in great detail that a patient will be safe and someone will be there to visit them at a certain time, they worry about sending patients home. They look for that information, they look for that piece of information. It's again around education with acute services to advise them of those services and build that confidence through those services, integrating with acute hospitals, and that's what we're doing now. I say that there's also the family influence in it, because we have already developed our model, as it were, and we're trying to change it. It's about families understanding that the community is actually better, in most cases, for people to be discharged, but they have to feel that their relative is not at any real risk, and the risks have been taken into account. It's about describing what this different world is for two families, so that they'll be confident and not be contacting MSPs and other politicians to say, wait a minute, there's a wrong assessment here, I think that it should be that. There's this lack of confidence there in some families. I would say that others will say, best thing that's ever happened. We didn't want that to happen anyway, so it is about getting the local confidence, if you like, built up, not just the professional, but the community confidence built up. A further element of this is, in circumstances where somebody has cognitive impairment, one way or another, either as a consequence of dementia or a long-term limiting condition, or what's quite often described as delirium, I'm not a medical person, but essentially as a consequence perhaps of a urinary tract infection and so on that might be short lived, I think in those circumstances where there is that cognitive impairment, colleagues, I think collectively across the health and social care system are obviously more anxious because people's ability to look after themselves is less robust. I think we recognise locally and one of the developments that we're keen to progress is a much closer relationship between our colleagues at the front end of the hospital or at the medical receiving wards and older adult psychiatric services. We're looking to strengthen those arrangements to give clinicians for whom the cognitive impairment is not their area of expertise, a degree of confidence that a discharge can be made safely. Thank you. Richard. Thank you, Cynunia. You would hear my question earlier about the concern I have, there's a lot of the joint boards are now suggesting that they don't have enough money. Can I say your submission is excellent? Can I double check your total budget for the HSCP 2015-16 health board put in £94.6 million, local authority £66.6 million? What has set aside budget, £21.6 million? The integration joint board, the public bodies act, recognises that without the integration joint board being able to have an influence on the spend in relation unscheduled care, it's unlikely that we will make progress with many of the issues that you explored with colleagues from Glasgow in terms of trying to manage that shift, trying to look at unscheduled care in the round. It's as important what happens in somebody's own home, in a GP practice, in accident emergency, in the receiving ward, downstream wards and so on. So we need to look at all of that resource in the round. What the set aside budget is, an attempt at this stage, probably a little crude if I'm honest, for the integration joint board to understand how much resource in Liz's facilities, in the acute hospital air in particular, is consumed by the people of South Asia. The integration joint board is charged with overseeing how that resource will be managed in due course. So the integration joint board is responsible for a number of delegated services and the provision of those services through me. The set aside budget, the unscheduled care, will continue to be managed by the director of acute services and the health board directly, but the integration joint board has a say in terms of how that resource should be spent. Is that money comfortable? That money is essentially health board money. Health board money, okay. And regard, go back to the question that I asked to Glasgow, you're basically saying, in code nine delays, you lower 3196 loss bed days due to code nine in 2015. A cost per night is estimated at £170. The annual cost was £665,000, but now you're saying that the estimated cost 2016-17-17-18 will be £489,489 per year, which you'll save about £176,000. Your detail is fantastic, right? I wish we could have got that from the previous. But basically, the number of my question is, are you going to say you're going to save money? Are you going to say you're going to be overspent? Are you going to say you've been short changed? Okay. My answer perhaps is similar to the colleagues from Glasgow. We can apply a notional cost in relation to code nines, and the committee will be aware that we've worked hard on code nines similarly to Glasgow and are keen to identify people early for whom adults within capacity act issues emerge. It's a notional cost. The ward that those people are inhabiting, whether there are two, three, four or ten, is still staffed in terms of the capacity that's required there. Again, Katrina Renfrew from Glasgow and Liz would be able to say, probably the same things, and I'm sure she will in a moment, the demand on the acute service is beyond what anybody I think had modelled in terms of the numbers of people emerging at Accent and Emergency, the numbers of people who require to have treatment in hospital, and therefore the numbers of beds that the system needs at the moment are huge. Trying to identify small pockets of money that are saving actually is really very difficult, and I think you're asking whether we've been short changed. I think in terms of the rules of engagement, I think both the NHS and the local authority have to be careful what I say in relation to this, but I think they've both played by the rules, and the arrangements particularly this year that were more complicated I think than in previous years have been reviewed and stand up to scrutiny. Have we got enough money? Same answer to our colleagues from Glasgow where I could spend it two and three times over. I think there are particular pressures this financial year for health and social care partnerships, particularly in relation to the payment of the national living wage, the UK government living wage, the arrangements that we've had to put in place to fund sleepovers, for instance, for people who have 24-hour care, where European legislation is essentially means that we need to pay almost twice as much for a night's care. For South Ayrshire, that's £1.2 million extra that I'm having to pay. No extra care provided. Quite appropriately, people are within the law receiving the payment that's due to them, but in terms of pressure on the service and pressure on the budget, that has been probably the single most significant issue. I don't know where they want to say a bit about acute services and demand. Probably just to put the numbers into context. Over the last three years, we've seen an increase in demand and services in terms of patients presenting to our emergency departments. It's been more significant since the winter of this year and it's continued over the summer, which is quite a different pattern from what we've seen in previous years. If I look specifically at the over 65 population, because the over 65 population has a higher tendency to be admitted, so any over 65-year-old person who comes to an EDE with an unscheduled care presentation, 60 per cent of those people will be admitted where the general population is much smaller. It can be in the mid-twenties. In the last three years, three years ago, we were admitting on average 16 over 65-year-old patients into the air hospital, and it's the hospital that we're talking about today. That's 20 now. If you take the length of stay on top of every other age group, which is increasing, that's a significant amount of beds. It appears that that could be around 20 beds that we would require now in terms of the increase in the numbers of patients that's come into the system in the last two to three years. Obviously, you don't want to hear us saying, we need more beds, we're going to build more beds, so that's the sheer demand in the system. As said, when we're talking to our Glasgow colleagues, we're looking at a number of ways to try and reduce that impact on acute services, because it doesn't help older people to be in acute hospital longer than the time they need to be to receive a very specialist acute period of care. I'm working particularly with our partnership directors. We work, we've got three partnerships in Ayrshire, and we work together across Ayrshire, because patients do move across Ayrshire. South Ayrshire patients don't always remain in their hospital, they go to other hospitals across Ayrshire. In terms of our older people services strategy, our aim is to reduce admissions where that's possible, and that's right up to the front door, where we're looking at teams being in ED to try and prevent older people from being admitted where they don't need to be by putting in some care and support. In the acute hospital, we're looking at processes to ensure that patients don't stay any longer than they need to in terms of our assessment, treatment and diagnosis stages, and then trying to reduce any delay in discharge. So these are all the processes that we're putting in place, but there is a demand issue in the NHS, as we heard from Glasgow. It is increasing, and we work tirelessly day in, day out to develop the services that we need to develop going forward, to be able to meet the demands that they're facing, really, in the NHS and in social care services over time. I'll pick up on something on the back, Richard. There seems to be a bit of dubiety about what the figure is for a hospital bed per day. You're saying £170. I've heard when Alex Neil was Cabinet Secretary, he regularly used a figure of £3,000 to £4,000 a week. Audit Scotland is saying £214 a week. Why are we all over the place on this? We probably both know the answer to that. It depends on how you cost that bed, and different boards will cost that based on the bed that the patient is actually in. If a patient is in an intensive care bed, it's a figure. If a patient is in an interim placement and we use an interim placement different in Ayrshire, where we use a community hospital rather than a care home, that's the cost, £160, so that's the cost that you've got in the papers, because we ordinarily don't keep patients in an acute bed where they are waiting for assessment, or if they're waiting to go to a care home, we would transfer that patient to a community hospital bed where possible, and that's the cost of a community hospital bed, as opposed to an acute bed, which can be anything around £260, £350 and upwards. It just depends on the detail around what that actual bed offers in terms of clinical care. I'm interested in some of the barriers that you're highlighting in your written submission on tackling delayed discharge. In particular, what you describe as workforce pressures, to what extent is recruitment and retention of staff at a real issue when it comes to tackling delayed discharge, particularly, I suppose, in a rural area like South Ayrshire? I'll start, and I think that Liz will probably be best to talk about the hospital service. I wouldn't want to overstate the issue. I think that what we tried to do was to include examples of the sorts of things that are, at times, likely to be problematic. Again, you heard from Glasgow that, certainly in their experience, they manage in relation to care-at-home staff, for example. I think that for us in South Ayrshire that goes probably in peaks and troughs. Sometimes it's more straightforward for us to get staff. We have a very significant, unlike the Glasgow model, which is an arms-length provision of service for care at home through Cordia. We have a mixed economy, probably about 30 per cent in-house service and 70 per cent externally purchased, as it happens. I think, obviously, the in-house service tends to pay slightly more in terms of the externally purchased provision. This is just a very hot-off-the-press example. We advertised recently for around about 25 staff internally. We've got 11 or 12 applicants, and about 10 of those are people who are suitable to take on. We'll go back out to advert again. Sometimes that could just be because it was the summer holidays and so on. I think that private providers are having difficulty with recruitment and retention. That's what they report to us. I think that some of the uncertainty that there is currently in relation to the rates that local authorities and partnerships are able to pay providers is creating a difficulty for them at this stage, both in relation to the national living wage and the living wage from October—the Scottish living wage, if you like. I think that in our professional services, if you like—for instance, social workers, district nurses and so on—again, we do, at times, struggle for staff, particularly as the question implied. Once you get further down in the county towards Gerovan and other places further down south, further away from the main conurbations, it does become difficult to attract staff. I think that probably the most significant issue for us generally is in relation to hospital doctors and so on. Liz is probably the best place to answer that. In terms of delayed discharges, I wouldn't say that there are delays in the system specifically around the lack of doctors or nurses within the acute environments. We have, however, got challenges around our medical staffing in Asia because we are further away from the central belt. We have a number of vacancies in our medical professions, particularly in our surgical specialties. That is not just such a significant issue, but in medicine, which means that, when we are referred back to having the best processes in place to ensure that we care for older people in the best way possible, we can have delays if we do not have medical doctors on-site to the number that we require off with the skills and the expertise, but it is not impacting on delayed discharges, but it does impact on the day-to-day management of a hospital when it comes to increasing demands. We have done lots of different things to improve our recruitment and retention in Asia, including international recruitment, but we have, in general, around 30 consultant vacancies in Asia. That is significant in terms of the number when it is around 230 consultants, so that does impact on current services. In terms of nursing, across Scotland, we are now starting to see some pressure in nursing because she will be aware that there has been increased agency spending in nursing, which has not been a feature in the past. That is because of expansion of services. As we expand services beat in the communities or in hospital, we require nurses in a number of different areas because nurses and allied health professionals are tending to provide the majority of that care, along with carers and voluntary organisation staff. Going forward, we have to be careful around the projections of nurses that we train in Scotland to ensure that we have enough staff because we are investing in services rapidly to meet the demands in the health service. What comes with that is the requirement to invest in clinical staff. We are running a wee bit behind in terms of being able to produce the numbers of staff that are required in Scotland to be able to deliver those high-quality services, both in health and in social care. Care homes, which is a new phenomenon, is starting to see that because patients in care homes now are more complex than what they might have been five years ago. Care homes would have at least registered staff on a shift than what they require now. We know now that care homes are now struggling to recruit the number of registered nursing staff that they need to deliver that nursing care that they would in the past. We are competing together. If there is a job in an acute hospital or a job in a care home, the chances are that a nurse who does not have a job will apply for the acute hospital post. It is again trying to keep up with the demand in service. We need to keep up with the demand in terms of the numbers of staff that we require. Going back to the latest charges, it is not having a direct impact, but it does have an impact on our caring services in health and social care. Can I say something about the contractors for the nursing home care? At the current point in time, COSLA is doing an exercise for some of the local authorities in terms of getting costings for the cost of care, because the national care home contract is being renegotiated. That is the availability of highly qualified nursing staff and what they feel they will have to pay them that is being put forward by them as one of their additional costs and their concerns in general, that they will not be able to recruit the quality of staff that they will require. As Liz rightly says, as we are making sure that more people stay in their homes as long as possible, it is a more frailer group of people that go to the care homes and therefore need more intensive care, so that they require a different balance of staff, so that they will need more and better qualified staff in order to fulfil their duties to their patients. It is a very complex situation that we are in. I will make no mistake about that. I was saying to your chair as I came in that we have been able to come here to tell you about that, because it is so important that we get it right and that we make sure that we do not think that we are always saying that we need more money. What we are trying to do is use the resource of Scotland better, because we know that we have got these challenges coming up in us, but no one is going to take a pocket of money away in their pocket for this, but it is an interesting exercise. I think that workforce project is important. Again, with our system in Ayrshire, we are projecting better into the future about what we require to be able to deliver services in communities as much as in acute environments, because that is where the delays occur if something is not able to be delivered across the system. We are doing that as one. I thank you very much for coming along. I take it back just to look at the delayed discharge picture and correct me if I have got that wrong, but I cannot have a reducing trend over a period of time. If you look at the graph for the last number of months, you have basically had a situation where, if I am reading the colours on this chart here correctly, the vast majority of it is because of what you talked to earlier, lack of funding to access care home places. The cos 9s are actually very small, and if you did not have that issue of care home places, your graph would probably still be on a downward trend. We have talked about the financials, and I get that because you have a variable cost going out of the care home on your paper day, whereas on the acute, unless you restructure the take-out cost, you have a big fixed cost, etc. It is probably harder for you than it is for someone like Glasgow because you have less scope to being a smaller board, etc. I get that. If that was simply the case, and it is costing whatever is £100 a night to be in the care home versus £200 or £300 a night to be in the hospital, and you did not have all this other demand coming in, would you have the scope to restructure to realise those savings? That is the first question. The second question is to look at the broader pipeline, and you talked about A and E driving utilisation of acute beds, etc. You mentioned about what you are doing there. One of the things we talked about at our weekend session with the GPs, and they basically put a graph up that says, the reason why A and E is going up is because funding for GPs is not going up or is going down in real terms. Do you want to comment on that? Is there an issue there with the gatekeeper when you are getting extra demand on A and E that is spilling over an acute that is causing that kind of problem further down the line? All of the number of points within that question, I think that the first point is around restructuring and looking at our bed models and so on. I guess implicit in the interim report that is now in the public domain but was not before publication for this committee in terms of the modernisation process that we are undertaking across A and E, and clearly there are discussions about whether we have got the bed model right in a number of areas, particularly in terms of community hospitals and so on and so forth. Obviously there are a number of sensitivities associated with that but we do recognise that there are probably better ways of managing the resource moving forward. In relation to the issue in respect of GPs, colleagues from Glasgow reflected again the pressure that there is on general practice, particularly in rural areas, that there are particular pressures. I think that there are opportunities for us to work much more collaboratively with GP practice and I think that we are having a pretty good go at that in A and E. One of the particular initiatives that I referenced in the papers was anticipatory care planning. In some ways there is nothing new under the sun 25 years ago. Regularly I think I have had circumstances in which district nurses, social workers and others were meeting within the GP practice to talk about patients if you like at particular risk and having a conversation about how to maximise the care for that person, what happens if it goes wrong and so on and so forth. I think our GPs in South Asia in particular following a pilot that or a test of change that our clinical director pursued within his own practice are meeting indeed today with 14 of the other practises within South Asia with a view to rolling out that methodology. It is a very simple proposition but the key to a lot of this both at the front end of the hospital in general practice is multidisciplinary work and multidisciplinary decision making and those are the things that I think we feel are likely to have the greatest impact moving forward in terms of maintaining people within their own homes rather than perhaps propelling them through a system where care home becomes the default position at the end of the process but the other part of your question is about acute services I think or have I answered it all? I am not sure if I know. If you have to be able to get to the scenario where in theory you move people to care homes at a lower per day cost and assume you do not have as wave of stuff coming through would you be able to restructure to take that money out which is kind of where it holds? I think there are elements where we could use the money more productively. Whether at the end of the day that will provide the whole solution I think remains to be seen. I think one of the things that we feel is significant is once it is back to that question that was asked of both us and colleagues in Glasgow is the risk management issue. Once somebody gets to hospital you are in some difficulty in terms of getting a discharge for a variety of reasons particularly a much older person with a degree of complexity and if our system is not slick enough to manage expectation with the family and the older person themselves and everybody else that a quick discharge back home get the issue fixed go back home. I do not think our arrangements in air at the moment are sufficiently robust and we are at the beginning of trying to improve that. I think if we do not get that right then we will continue to see that pattern of very very high demand. I think what we are trying to do or what we will successively do is to manage an early discharge and rehabilitation at home and I think that has to be the way forward. Just to add to that we have been bed-modelling in Asia for some time and in South Asia in particular you will be aware we have just built a new emergency department and we are now in a second phase of building a combined assessment unit. That combined assessment unit was modelled on the prevention of admissions where admissions is not the right thing in that this unit will be is being built alongside the emergency department all open next spring and any patient who is referred from their general practitioner will go direct to that unit they will not go to the emergency department or any patient who has come in an unschedule basis through a 999 ambulance or being brought in by a carer or a self presenter will go to ED but then will be streamed into the combined assessment unit. That unit will allow the multidisciplinary team to carry out that assessment where we do not have that facility near to do that just now because we are still working with the traditional model of hospital care because of the facilities we have got so that will allow us to build the teams and that was built into our model of care so the time is opportun now as we have moved forward with our health and social care partnerships to build those teams both in the community but both at the front door of an acute service where we can avoid admissions where we can and where we can pick up patients or people where we can then help patients back to community help families understand about care requirements and do the best that we can prior to admitting someone to an acute hospital bed if that is not required so that comes in streaming spring which will give us another avenue to be able to care for patients in a better way. In the combined assessment unit it's a much camera atmosphere in there so as our consultants in A&E they say A&E is not the right place to take anybody in if they are in any way agitated or anything like that it's very very difficult for them and the older and frailer people get the worst that experience is for them. The other way to look at it is if people have very robust packages of care at home if you think of the thing that needs the you know the the extra medical care as a blip in that rather than as you know the the full satamonte situation then if you if you keep them within their package of care it saves all the bother of reassessing rejigging you know you're putting a whole lot of stress into the system by taking them into hospital for a few days and then they're in the kind of delayed discharge all that you know reassessment they're in another route as it were so if we can just hold people in a safe and secure way within their own home and only take people out when it's absolutely essential to take them out when they really need you know the heavy duty care but getting them back then for the actual individual and the family it's far better you know so it's not that we're going to give in the secondary service we would want to do it that way you know we don't we actually don't want to put people into care homes either see we want to keep people out of care homes as long as possible so that those who have to go into a care home spend as little time there and then they they get the right situation in which to die you know with comfort and with their family so we don't we don't want that old pattern we want to keep that bit to the minimum lessons I took from greater Glasgow and Clyde when they were in before you was they'd really looked at how they do early hospital commissioning for patients and also how they transition patients and then from what you've said today what I thought was quite clear and looking at the set of details of number of beds is actually Ayrshire and Arran have one of the lowest number of NHS and local sector hospital care home places available I think you from a pq I had in July it says you've got 94 beds available compared to a similar size health board by NHS Tyside which has 328 to what extent are you reforming that transitional services so that people are moved out of acute care to be able to then find a by the go home or have a care home place either in voluntary or the private sector I'm not sure that I understand your question in terms of the beds which beds are we talking about this was in terms of local authority and NHS sector beds there's 94 care home places available registered care home beds in that sector and obviously in looking at other health boards who have much larger numbers of beds available for transition in patients potentially to a voluntary or a or a private sector bed do you think that the fact you don't have that capacity is having any impact okay I hope I hope this will be helpful I'm not quite sure that I'm understanding fully what the what the issue is here so in terms in terms of care home beds for long term care we're resourcing about 900 and you know that's and we've obviously had previous discussion about are there vacancies and so on in terms of interim beds which I think is what the issue is we're not we obviously not funding those in the way that Glasgow have chosen to they don't have any community hospitals in the same way that that Ayrshire and Arran have in south Ayrshire the from our perspective the hospital that predominantly provides if you like interim care a combination of complex care for for for some people what might have been previously called continuing care end of life care and significant amount of rehabilitation support there are 113 beds at the bigot hospital and a number at Gervan that there are 20 at Gervan but it's again a slightly different model do we think that we need more I think that's actually unlikely that we need more of the 113 beds that there are at bigot for reasons that we've already explored and referenced in the paperwork we were consuming probably two fifths of those for a period as delayed discharges and that's essentially a dead weight that we're not using those beds productively to rehab people obviously we've made a little progress in in recent weeks to begin to address that but I think while you've got those beds with delayed discharges in you're not really using the facility in an interim way in which would give us best value in terms of real focus on rehabilitation or where necessary end of life care for example so I think what we what we are expecting as part of the modernisation work that's referenced in the papers the opportunity presented by being able to tackle significantly the delayed discharges issue in terms of care home is then I guess get a better handle on what the real demand for interim placements would be your question though is is it enough and I don't think we know the answer to that in fairness you can learn from great Glasgow and Clyde then in terms of how they've put in reforms and how you could maybe pick up some of these I think I think I think funny enough I happen to work in greater Glasgow and Clyde and worked in East Renfrewshire and I was pleased to see that the legacy has been good in East Renfrewshire where it worked previously so so so much of the learning obviously is is is known to people around the system in terms of what's what's likely to work and what's likely to take us in the wrong direction I think really for us and and as the figures suggest while in no way would we be complacent I think if it hadn't simply been for the resourcing issue I think we would be continuing to use some of the the sorts of initiatives that that Glasgow and other partnerships have adopted the integrated care fund the resources available through the delayed discharges money I think have allowed us to look at a range of innovations but particularly the the sorts of things that are referenced anticipatory care planning significant investment in further rehabilitation capacity enabling us to focus on modernising our care at home service that needed modernisation a reablement service so at the front end of the home care service rather than people simply being assessed and getting a service for every day process at the beginning is very much focused on well you know rehabilitation using the the the the capacity and ability that somebody has to maximise the ability of them to undertake activities of daily living themselves rather than us doing it so again a number of a number of pieces of the jig so very similar to those that Glasgow and the neighbouring authorities in Greta Glasgow and Clyde will have done and I think it is it has for us in that that period hopefully that we're getting past now been a resourcing issue help to just explain the impact nature which is different in Glasgow so Glasgow explained that patients who were transferring to a care home there was there were very little other options in there it was acute hospital to care homes they were using interim placements but purchasing a care home place to allow assessment to be carried out or a period where the the patient can't move on because of other reasons in Ayrshire and we always stepped down from acute hospital to a community hospital and that's been our model for many years and we aspire to to retain that model in in that the impact in Ayrshire where there has been delays in recent times which hasn't been in the past as Tim's explained is that patients who would routinely step down to community hospital for rehabilitation those beds are not available or haven't been available over recent months because those patients are waiting to move to a care home so it's the community hospitals that have got delays not the acute hospital but it backs up in that the acute hospital patients can't move as quickly as which as quickly as we prefer to a rehabilitation bed so what we're having to do just now is try and bring in some rehabilitation support in this interim period into acute hospital to try and prevent patients from not benefiting from the rehabilitation if they don't get it and that that has been some of the the challenges that we've had to be able to get staff to do that and that's what we're working on just now while we work through this period where we've had a particular problem really since the beginning of the year but we always would step down to community hospital bed so that a patient has got the opportunity to I suppose rehabilitate to a point that they may be able to go home with a care package as opposed to going to a care home and so so that's why we've avoided using the care home approach and that's been working well until recent times until we've had this particular problem We've got quite a few people still with us so if we can be as brief as possible. I'll ask two quick fire questions then. First of all question seven your response was saying that you had reduced your number of code 9s to lead discharges I'd be interested to hear briefly how you've done that and if there's learning from other health boards and another going off another tangent we've been very driven by money process and structure but the number of this is a patient a person who is not getting to where they need to get to in a timuous way what are you doing as a as a hscp to support them and their family? In terms of the code 9 issue I think it's simply been focusing on that driving the process Stephen from Glasgow described management oversight and there has been management oversight of that I think identification of patients as early as possible or service users as early as possible who may have capacity issues I think allows you to set in place processes more quickly and obviously we're pleased that those numbers have come down clearly implied in the second question is we recognize that people aren't in the most appropriate place to get care and that's a frustration I think for us as a senior management team certainly for families and particularly nursing and ward staff at the bigger hospital that we were referring to I think we've tried to keep people as informed as possible in terms of the state of play but I think we can't escape from the fact that it does create tension and anxiety and frustration for families and staff at the front line Richard Cunzina I'll try and be brief can I firstly compliment councillor Rita Miller and our officials on the level of detail that we've got from you from you and can I also touch on a sensitive subject Rita that you actually touched on a minute ago was death I noticed that 4,643 deaths in yesterday and a very sensitive subject and I do apologise if I offend anyone national survey the audit office found that 40% of people who died in hospitals in your area did not have the medical needs that required them to be there nearly a quarter of them had been taken in hospital for a month 50% of residents admitted to hospital who died could have been cared in a care home or in their own home I had a situation where a friend of mine wanted out of hospital and sadly didn't get out of hospital she wanted the dignity of dying in their own home do you think we should do more to give people that dignity We attempt to ensure that patients can go home to die that can often be a complex situation in that often it can be families who are scared to take a relative home who may be in the last stages of life and again it comes back to the confidence I've been able to put in the care and support that that family requires along with aid and adaptations and we know that sometimes that that can take a significant amount of time if patients don't have beds downstairs etc and it can often be quite difficult to approach that other than that it comes down to community based services and whether those services are I suppose have got enough in terms of being able to respond if something goes wrong for families and again giving them the confidence but on all occasions we attempt to get a dying patient home it's the first conversation we'll have and it tends to be around being able to put those support mechanisms in the home as opposed to not allowing a patient to go home from a medical perspective we do have multidiscipline teams on a regular basis we're getting better at it and we're also trying to identify now their health and social care partnerships and again a possible transfer from acute environment because hospice doesn't have many beds it's you know it's quite a strict criteria in terms of hospice care it's not about longer periods of care so we're looking again at our community hospitals to try and ensure that we do have appropriate capacity in each of those hospitals to either transfer a patient from acute hospital if families would prefer that where families can be with their dying relative and it means that we're not having to work to put in aids and adaptations and all the other things I've mentioned or it means that a general practitioner who's maybe having that discussion with a family and often the general practitioner gets the point where they're saying well you know pose we have to admit your relative if we don't if you know if we can't keep your relative at home it means a family can then work with a GP to be admitted to to a care home one further sentence I promise complicated as you can imagine but we we are attempting to ensure that dying patients can die at home where possible the only other thing that I would add to that is the use of technology enabled care in order to do that and could pursue that another time and cheer the other pilot is the hospice are piloting at the moment having a little unit so they they did try an apartment that didn't work very well they've got a little bungalow in the grounds which families get the use of and that does seem to be quite a successful approach at the moment and it does strike me that we might have something we have the midwife's unit at the maternity hospital where people have a little unit that they have privacy in and the midwife's coming in out there might be something like that that we could develop that would give a family a lot of privacy but still have the hospital stuff around it as it were for an emergency and might reassure the family I think that would be a much better way to deal with things so I do think we need to look at this and new approaches are required and we we need to to look further into how we can do that yeah thank you very quickly I'm just interested in how you manage when you have a deficiency of beds for for patients to go into or after discharge and do you what use of out of out of authority placements do you make and is that linked to this term hosted services which I don't quite understand in the budget line perhaps you can explain that I'll deal with the last the last issue first hosted services essentially the three partnerships in in Ayrshire and Arran recognised that there were some areas of service that it made sense to manage on a pan Ayrshire basis across the three partnerships so for example mental health services particularly the hospital inpatient services are managed by North Ayrshire they happen to be located within North Ayrshire but are available to us all in South Ayrshire we manage and oversee the old health health professionals and in East Ayrshire they have responsibility for the hosted service in relation to primary care and those so that's that's it's simply a managerial or a governance construct in relation to in relation to bed you have forgotten a little bit of the question now beds out of area beds I mean I don't think from our perspective that we would have a difficulty with that I mean clearly most people wish to be cared for within their own locality are we referring to NHS beds perhaps I think it goes back to if if we have got delays in our community hospitals where I said that obviously those delays back can back up into the acute hospital we create additional capacity in acute services so that's the impact and we have done that over recent months in the hospital to enable you know good patient flow through the hospital we've had to create extra capacity when we talk about the community hospitals being the provider of the interim just to be clear is are they out out of the delayed discharge figures then is that does that count as a discharge or do they still come within they're still part of the delayed discharges figures so there are a hundred and a hundred and thirteen beds in the bigot hospital at any one time we've had 45 that are delayed discharges in there and they're reported as part of the the figures that are in the paper so until the discharge from the community hospital they remain yes so we're resourcing it differently to Glasgow so in other circumstances they might appear as a delayed discharge in another area yeah that that was that prevents me asking my next question which was the extent was that a shifting of from one hospital to another but it's still within the system yeah okay thank you thanks give me just a final point says within the submission that the graph that you provided on placements the downward curve in the graph from 20 October 2015 reflects a decision by the to reduce care home placements to contain costs within the available the budget available that to me would suggest that decisions are being made that are not in the interest of the patient but in the interest of the being counter and the accountant who's saying we just need to cut this we just need to cut this whereas and you're then having to make a decision that says well mrs smith actually should be going to a care home but well i mean it was a decision that the that the board took and it was we knew the decision we were taking everybody on the board knew that and we did it with well very reluctantly of course but we we had to live within our means and we have to do that we we did ask a lot of questions about how the situation would be dealt with in reality as you say but and that no one was put at risk and so on so those are during our discussion of what was the least worst option you know basically was what we were looking for because we simply had to we we did not have anybody bailing us out in terms of you know giving us some more money i mean could i say i know because i've asked my colleagues and that were at coslan friday with me how did you deal with the situation you had because they were in a similar situation and in some cases to a certain extent they've painted over the cracks because they've actually had a subsidy from both their parent bodies as it were to just let them go ahead now well that's fine and that digs them out the hole this time round but we also felt we had to make sure we get all the the which we say it's a it's a whole system we need to change and not just speed up the process and put more people into care homes you know i mean that's not solving the problem it's not sustainable in the long term it just isn't so we have to change the model and therefore we have to get you know more provision put into the community so it's i mean you're right it's hobson's choice you know not a good choice but we did we did discuss it and you know we were we were concerned about exactly what you were saying and we were reassured that no person would be at any risk but it's still not the best situation to be in i mean people were in community hospitals the rehabilitation wouldn't be as active as we might have wanted all that's true yes and we wouldn't want to do it okay thanks very much really appreciate your evidence this morning it's been very helpful to all of us and thank you very much and we will now go into private session