 Good morning and welcome to the fifth meeting in 2019 of the Health and Sport Committee. Please ask everyone in the room to ensure that mobile phones are off or on silent and that they are not used for photography or recording proceedings. We have received apologies this morning from David Torrance. The first item on the agenda is subordinate legislation, consideration of an affirmative instrument. As is usual in these matters, we will hear first from the cabinet secretary and her officials on the instrument. Once all questions raised by members have been answered, we will then move to a formal debate on the motion. The instrument that we are looking at today is the Community Care, Personal Care and Nursing Care Scotland amendment regulations 2019 in draft. I welcome to the committee Gene Freeman, cabinet secretary for health and sport, Mike Liddle from the adult social care policy unit and Matthew Liddle from the legal directorate of the Scottish Government. Cabinet secretary, I believe that you would offer us a brief opening statement. Thank you very much, convener, and good morning to you and members. I am grateful to you for the opportunity to speak briefly about these amending regulations. The draft affirmative order before the committee reflects our continued intention to increase free personal and nursing care payments in line with inflation. The order, if approved, will continue to benefit self-funding adults, resident and care homes. The rates are calculated using the GDP deflator inflation tool, which this year produces an increase of 1.57%. That would mean that the weekly payment for personal care will rise from £174 to £177, and the nursing care component will rise from £79 to £80 per week. The committee will be aware that, from 1 April, our policy of free personal care will extend to under 65s, and the weekly payment rates will be the same for both over and under 65-year-olds. It is estimated that the rise will cost £1.9 million, and that includes the estimated cost for self-funders under the age of 65 following the extension of free personal care. As part of our 2019-2020 draft budget, £160 million will be transferred from the health portfolio to local authorities, in-year investment for investment in integration, including delivery of the living wage, operating free personal care and extending it to under 65s and school counselling services. I'm happy, convener, to take any questions on the regulations. Thank you very much, cabinet secretary. David Stewart. Thank you, convener. Good morning, cabinet secretary and officials. Can I ask a technical question? I generally don't know the answer to this. Measures of inflation are really very important. Obviously, I'm aware of the GDP inflator, which, as you say, is 1.57%. I was just wondering what room for manoeuvre you had, cabinet secretary, on this. If you jump to the next piece of legislation, you'll see that there are other measures of inflation. The consumer price index is 2.4. If you look at the average earnings, it's 2.7. Basically, inflation depends on the measure that you decide that you're measuring. I know from my work on pension committee, for example, that there's a big issue in the long term according to the measure of inflation that you determine. Did you have any room for manoeuvre on whether you used the GDP deflator or could you have used some other measure of inflation? The GDP deflator is still the standard measure used for inflation in the Scottish Government and is used for creating real-time comparisons. If you look, for example, at the carers allowance, using CPI to operate free personal and nursing care would increase the £174 payment to £178, but it would increase the £79 to £81 for nursing care. There are variations, but in terms of the overall standard usage in the Scottish Government, it is the GDP deflator. The final decision about what we will use sits with the finance secretary. Obviously, we're not the next item yet, convener, but obviously, in the next item, you're looking at a different measure. You're looking at CPI and then average earnings, which give you different results. Yes, sir. Thank you very much. Are there any other questions from members? If not, we will move to agenda item 2, which is the formal debate on the affirmative instrument on which we have just heard from the cabinet secretary. I remind colleagues that members should not put questions to the minister during the formal debate, nor in particular to officials. I would invite the minister to move the motion S5M-15752. Thank you very much, cabinet secretary. Are there any contributions to the debate from colleagues? If there are none, I would therefore invite the cabinet secretary if there's anything that you wish to say before we move to a decision on the matter. The only thing to say, convener, is that all of this is dependent on Parliament approving the 2019-20 budget later this week. The question is that the motion S5M-15752 be approved. Are we all agreed? That is agreed. Thank you very much. We now move on to consideration of two negative instruments. The first is the national assistance assessment of resources amendment Scotland regulations 2019. There has been no motion to annul and the delegated powers and law reform committee has not made any comments on this instrument. Are there any comments from members? If there are none, is the committee agreed to make no recommendations? That is agreed. Thank you very much. The second negative instrument is the national assistance sums for personal requirements Scotland regulations 2019. Again, there has been no motion to annul and the delegated powers and law reform committee has not made any comments on this instrument. Are there any comments from members? If there are none, is the committee agreed to make no recommendations? That is agreed. Thank you very much. We will suspend briefly to allow a change of officials at the table. We will now resume. The next item on the agenda is an evidence session on the ministerial strategic group for health and community care report. This session will inform the committee's on-going interests and focus on the delivery of integration. Can I welcome again to the committee, Jeane Freeman, the Cabinet Secretary for Health and Sport? Can I welcome Malcolm Wright, director general of health and social care and chief executive of NHS Scotland, having worked with Malcolm in other roles and congratulating him on his appointment? I will welcome him to his first meeting of the committee in his new role. I welcome Councillor Stuart Currie, spokesperson for health and social care with COSLA, John Wood, the chief officer for health and social care with COSLA and Alison Taylor, head of integration division in the Scottish Government. I invite the cabinet secretary to make a short introductory statement on behalf of the ministerial strategic group. I am grateful to you for inviting Councillor Currie and me to give evidence today on behalf of the ministerial strategic group on health and community care about the review of progress with integration. The fact that we are here together today is, I believe, an excellent demonstration of the partnership between Scottish Government, local government and the national health service, all of which underpins integration. The wider membership of the MSG, which we chair jointly, demonstrates the importance of sectors and professions across health and social care jointly committing to integration success. This work belongs to all members of the MSG, the statutory partners, the third and independent sectors, the professional bodies and the royal colleges who make up its membership. One of integration's defining characteristics is that we all agree that it is vitally important. It is a necessary change to ensure that our health and social care services keep pace with the evolving needs of Scotland's people. I will not rehearse our reasons for integrating now, and I know that members are very familiar with those. When I became cabinet secretary for health and sport last year, I set out my top priorities of which integration is one. I said then that my focus was increasing the pace and the effectiveness of change. We now have evidence from the Audit Scotland report published in November that integration is beginning to work well in some local systems and having a real impact on people's experience of care, along with its quality and sustainability. The review of progress, jointly led by the Scottish Government and COSLA, provides us with an excellent vantage point for setting out our priorities for the next year or so. We know that challenges remain with properly and fully implementing integration. The review has sought particularly to identify barriers and to address them in its proposals. It is not a review that sets out high-level principles. All of that work has already been done for integration when we legislated and set up integration authorities. The review is deliberately focused on practicalities. It includes some challenging timescales. To ensure its success, we will be drawing together and building upon existing work streams across health and social care and, in some instances, undertaking new work to reinforce progress. COSLA Corry and I, through the MSG, will be holding to account all the contributors to progress, and we are pleased to take this opportunity to restate our shared commitment to making integration work. I am very happy with that, convener, on our joint behalf to answer any questions that members have. Thank you very much, cabinet secretary. It does indeed seem that the report indicates a recognition of the need for perhaps increased pace and effectiveness in going forward. Can I ask 1st Jane Freeman and 2nd Mr Corry what, respectively, the Scottish Government and COSLA see as your role in ensuring the implementation of the recommendations? You will see, convener, from the review report that we are very clear in setting out what requires to happen and the timescales within which it happens, but also in setting out very clearly what we, that is jointly COSLA and Scottish Government, intend to do in order to provide that very visible joint leadership. The group that was charged with undertaking the review has been commissioned by us to continue, as an oversight group, to lead the implementation. The review itself was published on 4 April. From memory, the group met on 11 February and has drafted an implementation plan that sets out very clearly what are the practical steps that need to be done. One of the things that COSLA and I have discussed and we will undertake to do, there are three elements to it. First of all, to look at embedding that partnership approach by bringing into Scottish Government to assist our joint work direct experience from a chief officer and by providing to COSLA an additional resource from Scottish Government to support their work in this area. The other element is to make good use of the considerable expertise that exists in the health directorate of Scottish Government, but also in joint work with COSLA of the quality improvement methodology. Members will recall that as a significant methodological and practical approach that has produced our Scottish patient safety programme, a Scottish-wide systemic improvement in patient safety sustained over 10 years now and is an approach that has contributed to the children and young people's collaborative work with local authorities to use that resource to help our integration authorities to systematically and systemically improve their practice so that we share that good practice. Members will be familiar with me saying more on one occasion that I am really not interested in learning from good practice, I am interested in implementing good practice, but we need to give our integration authorities some of the tools and the expertise that exists between COSLA and ourselves so that they can do that in a very practical way. You mentioned an implementation plan, which you said had been drafted last week or possibly agreed. Is that a plan that can be shared with the committee? It can be shared with the committee once the ministerial strategic group has itself seen it. At this point, it is in draft stage and there will be some more work to be done by that oversight group to fill in some of the areas that are not yet completed. That will then come to the MSG and, as soon as the MSG has approved it, I am very happy to share it with the committee. I think that what is important is that we show that leadership that is required at a national level. That can be done jointly. It is about working with our partners in the third and voluntary sector to ensure that we all understand why it is so important that we work together to deliver. It is also about increasing that pace of integration. There have been a lot of discussions and a lot of reports over the past few years. I think that there is an expectation rightly so about delivery. It is important that, when you look at the timescales that are contained in the MSG leadership report, those timescales are challenging. I do not think that they pull any punches. I think that it goes straight to the number of many of the issues. Those timescales are challenging, but it is important that we hold to account to ensure that those challenges are met. To do anything other than that would be to not succeed, as we would all want, but also in terms of best practice. It is important that, where we have evidence, and there is evidence out there of best practice where things are working really well, it is identifying those and making sure that we can see how we can use those examples of best practice elsewhere. If something cannot work somewhere else, we should know why that is the case, but if something can work somewhere else, we should look at that too. It is about learning best practice and making sure that we have that in a wider area. I emphasise the point that I think that there has been a lot of discussion and there has been the Audit Scotland report and there has been this report. I think that there is a real expectation rightly so about delivery, and that is why those timescales, challenging as they are, must absolutely be met to ensure that we make progress. That is good to hear from both the Government and COSLA. Can I ask again both of you in terms of measuring the success of the proposals that are agreed in this report and also measuring the success of IAs in implementing this report in terms of outcomes? I wonder if you would like to comment both on how the success will be measured and how delivery against outcomes will be measured in going forward. Thank you, convener. If I could start with that, just for the benefit of the record, I should correct the oversight group that met on 12 February, not the 11th, and I have agreed to meet every six weeks, which I think is important to indicate to the committee the seriousness with which we are taking both the work that needs to be done, but as Councillor Corry said, the challenge of the timescales in that we are determined that we will meet those timescales. In terms of measuring whether or not we are progressing as we require to progress, that will be included in the draft implementation plan. My colleagues, either from the Scottish Government or indeed from COSLA, Mr Wood, might want to talk a little bit about the data that is already collected and how we might triangulate that data a bit better in order to be able to measure across the whole system how well integration is working. Of course, it may not just have questions later on about the impact of successful integration on, for example, delayed discharge, so you cannot measure the success of integrated health and social care as a kind of standalone without looking at what are the comparable measurements that feed into that from, for example, performance in health, as well as performance elsewhere in local authority services. However, we have had, Councillor Corry and I, productive discussions about what those successful milestones and measurements might be without requiring significant additional data collection on the part of integration authorities. We need them to get on and deliver the services and not have an additional unnecessary element of data collection. The work of the oversight group and the officials working to that from both COSLA and the Scottish Government will be looking at the data that we currently have and how that can be triangulated, as I said, most effectively to demonstrate progress or not. Of course, Councillor Corry and I are keen to know in a very timious way how progress is being delivered, because if it is not, then we need to look at what further interventions we might jointly want to take to ensure that progress is being met against those timescales. However, I do not know if you want to add in. I will briefly ask Mr Wood just to comment some of the data areas, but I think that it is important that, where there are concerns or where there are issues or where things might be on working as has been envisaged, we do not just wait or no one waits for a report to come out some period in the future to tell us what we potentially already know and we can help with that. The other thing is about providing support and knowledge and support and leadership skills and practice across the board. It is not just about saying that we know everything at the centre, but I do think that where there are areas where we can assist in terms of resource or discussions or bringing people together to discuss those matters, that seems to be a helpful way forward. However, I might ask Mr Wood just to comment some of the areas around data and how we measure. Thank you yet. In terms of answering the question of how we are going to measure success from this, I suppose that it works at a national level and at a local level as well. National data is received by the MSG. We have agreed six outcomes, sorry, indicators, that the MSG receives regular reports on them. As Ms Freeman says, that data will be triangulated against the success that we hope to achieve. There are also the 23 integration indicators that IJBs report against. All that information will give us a picture, but there is a certain time lag to that. With regard to measuring success against the implementation plan that we are setting out as a result of the review of progress, integration joint boards will also be taking that report and benchmarking their own progress and activity against some of the actions and some of the asks that are contained within that. We expect that to be reported into the leadership group on a regular basis, but most importantly it will be picked up in the annual reports that the IJBs produce. Thank you very much. I was very interested in the third and voluntary sector, which is very important. One of the areas that I wanted to raise was the alcohol and drug initiatives, regarding the implementation plan and, as Mr Woods said, getting the outcomes and information having visited, as most of the committee has done, all the partnerships in the area to do with alcohol and drug abuse. Will that be fed into the implementation plan? Will that be fed through the IJBs and into the implementation plan? Those measures, we would expect to form part of the local plans for improvement. Mr Woods described that we take a small number of really key indicators to the ministerial group. The thing here is to ensure that we interleave that which is important in the local system into what we look at across the piece. Alcohol and drug interventions are of considerable importance and it would obviously be for the chairs of the ministerial group to decide if they wish to take a particular look at a specific subject at any meeting. I am interested in the issues around collaborative leadership and building relationships. You talked about achieving best practice. I know that health and social care integration requires lots of people working together to develop teams and then share good practice across boards and regions. I know that some of the processes can take a while to achieve, but I am interested in some of the issues around leadership and how the Scottish Government and COSLA can ensure that there is appropriate leadership in place to deliver continuity and then support the services and delivery and ultimately integration. It is an important point. The ministerial group that looked at and approved the final report from the review, there was quite a lot of discussion around leadership and one of the things that was noticeable about that discussion was that each of the different partners, if you like, to integration undertook their own leadership programmes and what was evident from the discussion was that what we needed to have was almost a single leadership programme that brought all those parties together, whether that was at chief officer level with partners in health boards and local authorities or finance officers or so on. Part of what is proposed is that all leadership development will be focused on shared and collaborative practice, whether that is leadership development inside the health service for clinicians or others, whether that is leadership development inside local authorities or whether that is joint in terms of the integration work. It was one of those moments when all of us realised that there were parts of our own practice that were not sufficiently integrated when it is essential to underpin the overall drive for integration, but I am going to ask Mr Wright to pick up on some of that too. I think that the whole leadership piece is absolutely pivotal. If we get the leadership work right, a lot of the other actions within the action plan delivery plan will fall into place. It seems to me that we need to tackle this at different levels. There is a range of some of the national programmes that are currently under way, be it in the health service, be it in the improvement service. How can we bring some of those programmes together? We are looking at some of the NHS national bodies and how they work with the improvement service. How can we pull that together? Critically, most local systems have leadership programmes of one form or another running. It will be important to see whether we can bring those together at a local level. For me, it is about how we support the chairs and vice chairs of the IJBs, how we support the chief officers, the chief financial officers, how we support the senior teams and, pivotally, how we support practitioners working together on the ground, delivering care to people's communities and to people's homes. That is the most important thing. The second thing that I would add would be the importance of working relationships at the most senior level. My experience in the health service is working in different boards. When those relationships between the health board chief executive, the local authority chief executive and the IJB chief officer are working well, a lot of those improvements can flow. If those relationships are not working well, that is why we tend to see some of the challenges. How those relationships are working well and how the chair of the health board, the non-executives on the health board, are working collaboratively with the conveners and leaders of the council. There is a big bit of work to do to make sure that we are covering that at all of the different levels. My sense of reading the draft plan, and I can talk a little bit about how the meeting went and some of the areas that we covered in that, there is a strong sense that when we get into some of the more technical but important issues like set-aside budgets, if we get the quality of relationships and leadership right at the most senior level, those are technical issues that we can help to happen and make sure that we get those shifts in not only in resource but in terms of where people are cared for much more towards their homes and within their local communities. I hope that that helps convener in terms of the importance of leadership and what we intend to do about that. I think that what is crucial is about that mutual understanding of where everybody comes from. Obviously, there has been too a huge shift in terms of integration from health service and local government coming together. It is really important that people work together. I think that the importance of a joint approach to things like leadership and leadership work is to ensure that integration does not just stop when the meeting finishes. Integration is just part of the day-to-day activities. It is no different when you walk down a corridor in the building, you are speaking to someone and you should not know whether someone was formerly from the health service or from local government. You should have different lanyards. You should not have this thing where people can spot that that is a health service person or local government. It should be clear that you are dealing with integration of health and social care. That is the point of it. Leadership is important when people meet outwith formal meetings. They are talking about integration, they are discussing integration and they are gossiping about integration. Integration is the sole focus of the work that goes on. That is really important. One of the major recommendations is not just about leadership but about building relationships. That goes beyond the confines of a council or an NHS building. It is with the third sector and the voluntary sector because the whole system approach is crucial. I do not think that any one part of the former system can deliver on its own. I think that only those different systems coming together that whole system approach will deliver health and social care integration, as we all want it to work. However, it is absolutely crucial that when people are discussing matters that we understand, it is about integration, not just at formal meetings but throughout everything that we do. If we do that, there will still be the challenges and the issues that people have concerns. Nevertheless, I think that we will be in a far better place to meet those challenges and concerns as we go forward. One additional thing, if I may convene it. I think that it is only fair for us to recognise that, as both Councillor Currie and Mr Wright have said, that what we are doing here is bringing together different cultures over decades and consequently different operating styles and expectations. There are a lot of similarities but there are significant differences. The real challenge is to both our NHS and our local authorities to recognise that a different cultural approach is required. We have experience of helping people to fear that less than they might otherwise do and see the gains. The real trick in the review report will be to jointly, at the same time, produce tangible improvements in service delivery in a consistent way across the country in order to back up the requirement that we have together on those cultures to make changes to those relationships. Audit Scotland set out very clearly that it was about relationships. We did not need to alter legislation and there were no issues in terms of the clarity of governance. There may be some issues and there are stems from different cultures around the understanding of that clarity. Part of what we have to do—it will be a significant role for both Councillor Currie and myself—is to help to ensure that we lead this in such a way that that is really clear. It is clear in the letter of the law and it is clear in guidance but it is not necessarily clear in people's minds. Just to pick up the point about culture and different people, we have allied health professionals, multidisciplinary teams across health and social care. I am a former NHS employee myself and I have witnessed that change can take an awfully long time. One thing that was raised with me was the different language that is used between local authorities and then healthcare in that we need to speak a national common language for health and social care integration. Leadership collaboration would focus on that and support that. My final question would be, how do we expect integration authorities to ensure that the multidisciplinary team, the social workers, the allied health professionals are all part of that discussion using the same language? I think that there are limitations to using the same language, if I am honest, but I think that what is really important is that people understand what each other means. The way that you do that is through joint leadership and collaboration so that you understand better the particular requirements and pressures of a colleague's job compared to yours and their years and therefore you can work better together. One of the things that is noticeable at the moment in terms of integration is that at a delivery team level, oftentimes people are just getting on with it, it makes perfect sense to them that they are delivering healthcare alongside allied professionals, alongside social work and social care. That makes perfect sense because they are closest to the individual who requires and is receiving that care and it makes sense to them that it should come from more than one place. We need to ensure that that sensible understanding of what is needed is understood at all the other levels in terms of integration, inside boards, local authorities and at the IJB level. One of the specific recommendations in the review is about how we will assist integration authorities to engage better with their local communities and with those who represent local communities. We are part of the delivery plan to look at how we might do that. That has, as we have discussed in the committee before, a resonance with how well or otherwise our health boards engage with their local communities in terms of persistent and consistent engagement, and not just when something big is about to happen. Alex Cole-Hamilton Ben i'n gweithio, Cabinet. It's actually a good morning to your colleagues as well. I'd like to expand this issue around leadership. One of the things that we picked up is the slightly worrying churn in the higher end of the leadership within IJBs. Some 57 per cent of senior managers have changed since the project started. Indeed, that happened in Edinburgh. We had a change of chief officer quite early on in my terms and MSP. I work closely with the chief officers of IJBs, as I'm sure that all parliamentarians do, because we have cases that come into that universe, and I've always been struck with the high calibre that we attract in those roles. If they are talented individuals and they've got the right skill set, why are they leaving? Is this because the project is ungovernable or because the expectations are too high? What is the reason for that, chair? I'll give you my view. I haven't conducted a survey about it, but my view is that integration is relatively young and new, and that for some individuals it may not have been the experience that they expected it to be. In those circumstances, it is entirely insensible for them as individuals and indeed for the wider project of integration for people to seek roles elsewhere. If the job is not the right job for you, then if it's a tall possible, the best thing to do is to go elsewhere to a job in an environment that works for you. My own view would be that that is in part at least what has happened, and I don't see anything troublesome about that or to be worried about that. I think that we have a very good overall, very good group of chief officers, just as I believe that we have a talented and able group of senior officers in local authorities and in the health service, but people need to move into what is this new world of integration and to do that in their heads as well as in their practice, which is part of what Mr Wright is referring to and other colleagues about the importance of leadership and shared and collaborative leadership support and training so that people can be helped to do that. Too often, when change comes our way, we are understandably fearful of that, but with the right support, we can discover that our role is much enhanced in that different environment than it was before and much more rewarding than it was before. I think that what we are seeing is almost the inevitable flow as a new idea creates itself, embeds itself and now needs to move on and deliver much more systematically and sustainably, but I do not know whether Mr Wright or Councillor Cary may want to say anything about that. I am not certain that the turnover is necessarily massively different from what we have experienced in the past. Before we had integration, I certainly remember as a councillor a number of senior people in health and local government moved on. When something is new and relatively new, there is a point and there is a period in which people make a decision whether it is right for them to go forward and, if it is not, sometimes people move on. However, I do know that when roles are advertised, I am not aware that there is a shortage of people coming forward. That is good in terms of that kind of competitive recruitment. People see it as the opportunity to do something new, something that is quite exciting and to deliver better outcomes for the people that they seek to serve. That is encouraging. Obviously, time will tell, but I think that in any organisation when there is bringing together of two huge organisations in health and social care, there are going to be people who will decide that it is not for them. That is absolutely fine, that happens all the time, but it is important that, when recruitment is undertaken for chief officers and a whole range of other officers, we ensure that we get the best possible people in there to do the job and people who know what the challenges are and are excited about those challenges and want to meet them. It is also important to recognise that those jobs are changing and have changed. When integration was first established, chief officers were appointed. There was a lot of work in getting the integration authorities established in law, setting up the statutory body and starting to make rapid improvements as a new body on what is already a complex landscape. The report that has been published signals a step change in the pace of integration. My sense of working with the chief officers is that, as the cabinet secretary said, we have a good group of chief officers in Scotland. My sense is that they are up for this challenging change and there are lots of challenges in it. Between Scottish Government and local authorities and the IGB boards themselves, how we support the chief officers to deliver it in that very demanding landscape and, certainly, the leadership group that supports the ministerial group that is co-chaired by myself and Sally Loudon, that is also a very important signal that Scottish Government and COSLA, health and local authorities, are going to work together to support the chief officers in what are hugely challenging positions. I think that, as I said before, this report signals a step change in how we want to drive the pace and the scale of integration. The role of the chief officers and, of course, the report also mentions the section 95 officers, the chairs and the vice chairs of the IGB. We really need to get behind our folks and really support them. As the cabinet secretary said, there will inevitably be a turnover of chief officers as the job evolves, and I am not seeing a shortage of people who are keen to take on those challenges. I think that we get four square behind our chief officers. I am grateful for that response. It is encouraging to hear that we still have healthy competition for those roles. The cabinet secretary described the integration as a new world, and I share that vision. I think that that speaks to a shared ambition to move from that more siloed culture, where we are thinking about acute care and then social care, and the community has two separate complete entities, and people are very protective of budgets and things like that, to something where there is a lot more fluidity and flow, as you described by cabinet secretary. My concern is that there is still a disconnect there, that we are still failing in that regard. I often raised the example of my constituent, who spent 150 nights in the Liberton hospital after the point at which he was declared fit to go home, because of a minor addition that he needed to a care package that nobody could find provision for. He was spending, let's say, £400 a night in the Liberton hospital, whereas a £80 a night care package would have seen him home. Why is that still happening? The two things to say at the outset. First of all, I would share your view that that should not happen and that that would be our intention that that would not continue to happen. Secondly, I need to say that bed days lost and delays continue to decline, albeit not at the pace that any of us in this room wish. What we see is, across our integration authorities, a mixed picture of some who are managing successfully to significantly reduce the volume of delayed discharge in their respective boards, with care at home and with packages and so on, and others who are being significantly less successful for differing reasons. You are sitting beside Mr Briggs and you will know yourself, you have both raised this with me, the particular issues in and around the city of Edinburgh that are in part, I wouldn't accept totally, but are in part a product of the local economy here and the competitiveness of employment and wage rates and so on and so forth. As you both know, both the local authority and the health board have contributed additional funds to try and address at least some of that. I think that we have seen some improvement in that situation. Part of what we are trying to address in this report with those tight time scales and with that delivery plan and that six-weekly meeting of the oversight group reporting to Councillor Corry and I, and I hope that we are continuing to assure you of our absolute shared personal commitment to delivering on these actions, is moving towards a position where we see fewer and fewer of those situations like your constituent and that disparity across the country between different integration authorities in terms of what they are successfully achieving is significantly reduced over the coming year. That is the intent. That is what we mean when we talk about implementing good practice. Not every bit of good practice in those integration authorities that are doing well in this area is applicable directly over to those who are more challenged by it, but there undoubtedly will be elements that are applicable. If you recognise that and you take the quality improvement methodology—it is a very practical set of tools—then you give people the tools to lift the relevant good practice and apply it without having to reinvent the wheel. There is more than one strand here, all of which is aimed at combining to get those exactly the kind of results that you are referring to. You mentioned Cabinet Secretary about the new world. Is it not the case when you are talking about leadership and the culture that we are having to deal with in local government and in various other bodies? That is a major step. It needs to be part of that vision and to be involved in it. I am a former councillor myself. I have seen it from both sides. Not to be necessarily negative, sometimes there can be some people in that cog that will be quite difficult not to grab on to it and start thinking about their own traditional ways of working, as opposed to looking at that new vision and idea or trying to deliver for the people that they serve. Is it not the case that we need to make sure that senior staff are in a place where they can actually work together in that way? That is quite difficult. You are talking about chief executives that have been so used to making their own decisions and moving forward. How do you get those personalities to all work together on one joint board? It is a very good question. I think that sometimes, most of us, I certainly know that I would fit into that category. Mistakes control over a number of things as equating to levels of authority and to your leadership skills. Good leadership skills very often are demonstrated by how much you devolve the decision-making to others and do not hold it all to yourself. That is a big ask for folks sometimes or it can feel like a big ask if that has not been, as you have said, the way that they have traditionally held those positions or if that has not been the culture of the organisation that they have risen in. As we know, leadership from the top can dictate in large measure behaviours at various stages down an organisation. If you see a leader at the top and you want that role eventually and their way of doing it is to hold everything to themselves, you understandably think that that is the way that you will get promoted to. There are big changes here and big asks that we are making of people, but we have, I believe, inside our local authorities, inside our health boards and in our chief officers, individuals who are demonstrating a different approach to leadership that is producing results in terms of the improvement in care and service to those that they are seeking to work with, as well as an environment that people want to work in. I think that you get to a tipping point where that becomes the norm. We are not at the tipping point yet, but part of the very practical propositions in here are all about leading us to that place where not working and leading that kind of culture becomes the outlier. At that point, you take personal decisions, do not you? You either want to be on the bus or you think that that is not for me and I need to go somewhere else, but we are not there at this point yet. We need to move through the leadership, through some of the practical propositions that are in this review report, through some of that quality improvement support that we are talking about, so that we get a body of leaders in all three partners. In the independent sector and the third sector, where some of the leadership skills that we are seeking to emulate, we will find. We are making sure that they are at the table alongside everybody else. Ms White mentioned the third sector, but the independent sector is an important part to play in that as well. Already, they are moving to looking at learning some lessons and ideas from the health service, for example. I am sure that you have heard in other committee sessions some of our smaller independent care providers looking at working in clusters in order to share some of their additional professional skills that they might need between a number of smaller care providers that individually they would not be able to deliver for themselves. All of that shared learning and leadership will, I am convinced, take us to where we need to be. The most important thing to be aware of is that integration is here to stay. I often think that when there is a huge amount of change, people who are not convinced about the need for change often say, I will wait a couple of years and we will all go back to where we were. That would be fanciful. Integration is absolutely here to stay. There is a reason for that, of course, because it makes sense. I think that members of Mr Koham and others have referred to people discussing things in wards with social work. I think that people have been doing integration in an informal way for a number of years. I think that what we are saying is that when it works, it works. It is really important that people realise that there is not a door marked option B. Integration is it. In terms of the delivery and successful outcomes for the people that we all seek to serve, integration in health and social care is crucial. Shifting that balance of care is absolutely crucial because it will work. It has worked in the past and it can work in the future. The other thing is that, in terms of leadership and everybody ensuring that they understand what leadership is required, we should not think that any one area of all our stakeholders has a monopoly on wisdom, be it the third sector, the voluntary sector, the independent sector, health, local government. Wherever those good ideas—we should not be too—a good idea is a good idea. If that delivers a better outcome for individuals, it must be the way to go. I just stress that integration is absolutely the way—people need to understand that. We are not going backwards, we are going forwards. Indeed, that is why this report has these challenging timescales, because it just sends out that strong signal between COSLA and Government. It is not only here to stay, but we are going to deliver those changes that are absolutely required in short order. Just in terms of our response to the question about how we get senior staff to work together to points that I had added, I guess that Councillor Corry and Cabinet Secretary have demonstrated a bit of that today. However, the political leadership is also really important in getting senior staff to work in the collaborative way that we want them to. That again operates at a national and at a local level. The joint statement that was issued on 26 September last year reiterating the commitment to integration was really useful. Leadership is not just about an instruction, it is about constant reminders to a system that is a direction that we are travelling in and a way in which we want to work. That constant leadership at a national political level and at a local level in terms of the integration boards that are taking on their identity as IGB members further is something that will really help. The second point is just around the development of staff. I think that Mr Cole-Hamilton was absolutely right to say earlier that it is not about the calibre of staff, but there is a side benefit to bringing senior staff together through the ranks so that, when they reach those senior positions, the clash of cultures perhaps does not feel so strongly. Again, we are reminding ourselves that that is not just about local government and not just about the health service but also senior managers in the third sector who we would hope to attract into senior public sector roles as well. Thank you very much. Good morning, Cabinet Secretary. Good morning to the panel. I think that we would agree that consistency of commitment towards delivery of integration is going to be key here in its ultimate success. Some of the evidence that we have taken in here has shown a disparity between IGBs and where they are along that process and also some of their understanding of what that commitment is. I wonder how the Scottish Government is taking a lead here, perhaps, in ensuring that consistency of commitment across Government departments and in health and social care policies and legislation. There have been quite a number of policies and ministerial statements in the health area. I am always struck by the fact that there seems to be quite light in mentioning integration. I wonder where the Scottish Government can be encouraged to take a lead here. Thank you, Mr Hodge. That is a very good point. If I can add one thing to what was said previously, one of the things that I think, in addition to what Mr Wood said about the shared political commitment between COSLA and Government on that, I think that people are beginning to appreciate that across this Parliament there is, regardless of political party, a shared commitment to the integration of health and social care. We will undoubtedly have disagreements from time to time about how quickly we are moving or how successfully we are moving, but it is striking that all political parties agree that this is the right thing to do. The more that that message is received in all the various organisations charged with making a success of integration, the better. As Councillor Cary said, there is no point in waiting on something else to come, because it is just not going to happen. Back to your point, I think that it is a very good point. I think that, marginally in my defence, I might say that if you gave me longer to speak, I would get all those other things in as well, but the Presiding Officer might have a view on that. I think that he thinks that I speak too long as it is. I do not have anything else to say. I think that you have raised a really good point and one that I will reflect on as I talk in future occasions about issues that are focused inside our national health service in terms of how I think whatever it is that we are doing or dealing with will or will not contribute to this bigger piece of work, which is the integration of health and social care. I think that that is a very important point. I should say, and Mr Wright might want to add something to that, that what we have said inside the health directorate is that every aspect of the health directorate now has a role in assisting in the delivery of our part of the review and the recommendations in that. We are looking actively at how we work inside the Government in terms of, first of all, the health directorate, but then reaching out to my colleagues in other portfolios where there are clearly connections in terms of some of the work elsewhere, undertaken elsewhere by other cabinet secretaries. However, as I think about some of the specific measures that we are taking in terms of NHS in Scotland—the waiting times plan and so on—we will reflect absolutely on the point that you are raising. I do not know if Mr Wright wants to say something about that. I think that one of my roles in the leadership of the health directorate is to make integration front and centre. The cabinet secretary has spoken a lot about integration, about the importance of mental health, about the importance of the waiting times improvement programme. All of those things are linked, and it seems to be that getting integration right and bringing together health and social care, having more people cared for at home or in community settings, getting teams of people working on the ground in people's communities and in people's homes is to create some of the space within the hospital environment in order to get the waiting times improvement plan driven through. Of course, all of those things, if we take mental health, are aspects not just for the health service but for local authorities and third and independent sector providers. If we look at the public health reforms, if we look at the GP contract, all of those things are interlinked, and integration is central to all of that. In my conversations with the health directorate and board chief executives, I am putting integration right there and saying that this is all of our responsibility to make this work. Coming back to the delivery plan that we are preparing, I want to make the front and centre of a number of the conversations that I am having with my board chief executive colleagues as well as colleagues within the Scottish Government. I am sorry, convener. I have just touched on the new GP contract. Of course, all the work on primary care reform is central to effective integration, because that is where the health service provides a more integrated primary care service. Before we came down, Mr Wright and I were discussing what better use or increased use we could make of the new paramedic provision, which looks to deliver not acute care, but care that can be delivered at home and a response that can be delivered at home that is already proving to reduce the number of admittances to A&E, and then from A&E through into a hospital bed. That is not always clinically appropriate, but those paramedics are trained to a level where they can make those decisions, they can prescribe and they can deliver that care to an individual at home. The more we can make effective use of their skills and their numbers—and, of course, we are increasing their number to 1,000 additional paramedics—the more effective what the health service is providing to integrated health and social care is in getting that shift in the balance of care that Councillor Cary mentioned. If I could take it on to a more practical area, one of the key elements probably to underpin or definitely to underpin the success of the delivery of that sort of integration will be an IT system that speaks to everything. As we heard evidence in the Health and Sport Committee, the IT systems do not speak to the health board, as it currently stands. In fact, in certain health boards, the IT systems, that collaboration is problematic. We are layering a local authority on top of that. What work is being done to ensure that the operational plans are being properly integrated within an IT system that will speak nationally? I will start on that. It seems to me that the Scottish Government's digital strategy and the importance of that is another one of the building blocks that we absolutely need to improve the digital infrastructure that allows local authorities and health boards to share data in a way that meets all the requirements of the data protection act and patient confidentiality and all that. The health service is working nationally to see if we can drive through those new digital platforms. The information sharing with local authorities is of pivotal importance in doing that in a confidential way that meets the requirements of the law. I will listen to what you might want to say more about that. The digital strategy is obviously the main vehicle for addressing that. It is hugely important that when I am out and about, people mention it to me all the time, as well as people who are dealing with patients and service users, the importance of being able to access the right information readily on the ground. I guess that it covers three points. Malcolm has mentioned them broadly. Interoperability between systems, making sure that the equipment itself is up to date and appropriate, and the critical issue of information sharing. We have made great strides on that last point in the past few years. The other thing that is pleasing from an integrations perspective, if you like, about the work on the digital strategy is that the governance is shared with the NHS central government and local government. There is an integrated approach to overseeing the work, which probably gives it a very good grounding from which to make progress. We have a strategy here to integrate an IT system that allows for the integration within the IJBs. Is that costed out? Do we have an end product with a cost element to that? My understanding, and my colleagues will correct me if I am wrong on that, is that what we have is that we have a piece of work under way that is looking in terms of NHS Scotland, how well its systems are integrated with each other and the information can be exchanged. Alongside that is running in partnership with it, a piece of work that looks at how we can make that work for integration so that information is exchanged. That does not necessarily mean that what we are going to do is create a brand-new IT system that everybody plays into. We need to make sure that the existing IT systems can talk to each other in the areas where we need them to talk to each other. I am glad that I got that bit right. There will be elements of cost, so we can go and have a look at that and make sure that we have that information in terms of our bit of the Government's digital strategy and the work that we are doing with COSLAW. I do not know whether Mr Wood or Council Cary will want to add to that. The only thing to add is that there is the digital health and care strategic portfolio board, which is a group of senior officers overseeing the implementation of the digital health and care strategy, which is co-signed by COSLAW. That is a focus for a lot of the activity there. From the local government side, we have a local government digital office situated within the improvement service, which is the interface with the NHS on building a single platform. It is one of the tasks that it is exploring at the moment, so that there is work under way, but it is another area of work where we need to continue to encourage pace. David Stewart on information sharing, and then we will come back to Thunderfight on other planning. Thank you very much, convener. I focus specifically on data sharing. Like many members, I have shared a number of conferences recently on that very subject. As one wit in the audience said, data sharing is a bit like world peace. We all want it, but it does not always happen in practice. Could I ask specifically about what steps the Scottish Government and COSLAW have taken to look at national solutions, as recommended by Audit Scotland? It is part of the implementation plan, and it is certainly something that the leadership group will be looking at and will be taking reports on. When we talk about information sharing, it is not just necessarily within the integration space. It is important that there are separate bits of work in community justice across public health, where the conversation about data sharing comes up, and it is important to look across all those bits of work to ensure that when we talk about data sharing it is not in a siloed manner. Alison Taylor. The delivery plan, as Mr Wood says, touches upon the Audit Scotland recommendations for information sharing. I think that there are several things that come into this. There is the actual sharing of data between health boards, local authorities and IJBs, which allows us to build up the resource of data that then supports effective forward planning for services. There are information sharing protocols in place now around the country to enable that to happen, which allows support from national services Scotland to all of that effort of planning work. That is one important part of it. Another aspect of it, which has been touched upon already several times today, is that effectiveness varies around the country. One of the things that the chief officers have agreed to do with us is to make sure that the effectiveness of information sharing within a partnership area is something on which the exchange could practice and understand from one another why some of them are able to do it much more effectively than others. That also leads into the question about making sure that we effectively share good practice in a broader sense and have a broader understanding of what good looks like on the ground. It touches on several points. You made a good point earlier when you said that it is important that there is a consistency in education authorities data, so that you can make comparisons across Scotland. Is that something that you have pushed quite strongly from the centre to make sure that that message is going out? Yes, it is. We have asked the oversight group to look at the implementation plan to do and to identify what they believe would be the appropriate measures to measure success. We will then look at that. The ministerial steering group will sign that off once they have come back, but it is partly what I said earlier in another answer. We collect a lot of data between us. That may be all that we need. We simply need to triangulate it better. Or, indeed, there may be some of it that we do not need to collect, but there are other measures that we should or other areas of data that we should collect. We have done it by asking the group that is charged with the implementation plan to identify what would be fair measures by which we would be able to look at how each of our integration authorities are doing and how we are doing overall. We will then be able to report to ourselves and to others. On 12 February, which was chaired by Sally Loudon and she and I are co-chairs of this group, we went through each of the items on the delivery plan and we had a discussion about what is the outcome. What are we going to see differently as a result of all this? The next iteration of the delivery plan will have that much more clearly. How do we know that it is happening? What is the data that we can report through to the MSG to demonstrate that those changes are happening? How do we pull together that sort of data pack that we can demonstrate that we are making these improvements? A lot of that data is already there, but we need to pull it together. Secondly, the point about how we use data locally for improvement—back to what the cabinet secretary was saying about improvement methodology being really important here—and about the sharing of data for individual people in individual communities so that GPs, social workers and nurses are working together and able to share information in a confidential and legal manner. There are a number of different levels to that. Thank you very much. David Stewart. My next area of interest, perhaps more from Mr Cary and Mr Wood, is should integration authorities make their data publicly available? Mr Cary? Mr Wood will deal with this first. Fair enough. John Wood? I think that performance data is publicly available and rightly so for the purposes of local accountability so that communities and partners at a local level can understand what progress their integration authorities are making. That is a fundamental benefit and principle of health and social care integration. It is that element of local accountability and local transparency in terms of performance and improvements in performance that can be reported through the annual report at a local level, so I think that it happens. Perhaps not now, you can plan rights to the committee. Have you any examples where integration authorities have made their data publicly available? I can see Alison nodding to my left ear, but yes, absolutely. I think that some of that was contained in the Audit Scotland report, and if you want us probably together with the Scottish Government, we can provide a little bit more on that. That would be helpful. Stewart Kerr. I think that in terms of the data that has been made publicly available, if you are driving forward improvement, first of all, the data needs to be at the right level to ensure that people can understand that it makes a difference. If the data points to improvement, genuine improvement, the public in a local area should see that. There shouldn't be data that says things are going really well, but the experience isn't chiming with that. If that is the case, that would be a concern. In terms of accountability, it is really important. We talked in the report about engagement. It is really important that engagement is not a one-trick pony. When something is going to close, there is going to be a major change in that engagement. That engagement needs to be an on-going discussion with the public in terms of the services that they are receiving from integration joint boards. Of course, with that comes the data to ensure that we can say that there is the difference that is being made. Frankly, there needs to be a base point by which we can say that things have got better. We can't just say that we think that it has got better. We should be able to demonstrate not just to the public but to ourselves and many others that things have got better, and here is why we can demonstrate it. Presumably, when you say that if the data shows improvement, that should be shared. You don't mean to imply that the data shows no improvement, but that should not be shared? No, indeed, I don't. The reason for that is that accountability and being held to account is not just for when things are going well, but when things are going less well, because then the responsibility is on everyone to ensure that measures are put in place to improve. You can measure against that whether that improvement has been delivered or not. My final point perhaps to the cabinet secretary, but I welcome contributions from any of the panel, is Audis Scotland, which is obviously independent, had quite a killer line that she should be aware of in the recent report that said, and I quote, an inability or unwillingness to share information is slowing the pace of integration. One example that she gave was the inability of many cases of GP practices, agreeing data sharing arrangements with their integrated integration authorities. Do you have any comments on that, cabinet secretary? As you will know, GP practices are for the most part the overwhelming majority of our independent businesses. Part of the work in primary care reform around the GP clusters and the additional investment that we are putting into primary care alongside the GP contract is to help our GP practitioners to see the gains for proper data sharing to their practice, as well as to their partners locally. That work is under way. Many GP practices do not have that concern around information sharing, but others do. It is not dissimilar to other areas of health and social care integration in which we have examples of where it is working well and other examples of where it is working less well. What we need to do is use the good examples to help the others to overcome some of the concerns that they might have. The GP clusters are one practical way that allows us to be able to do that. Just in summary, the new GP contract is an important tool in terms of data sharing. The new GP contract is an important tool for a large number of improvements that we and the BMA and the GP themselves wanted to see in primary care, partly in the investment that we make to it. The announcement that I made last week about the loan scheme that helps to de-risk GP practices is designed to encourage more particularly younger GPs, often women GPs, to come into general practice without the burden as they see it of signing up to a partnership approach and the financial concerns that that brings them. There is a whole range of areas in which the GP contract contributes positively to primary care reform, which is absolutely essential to the effect of health and social care integration. Thank you, convener, and good morning to the panel. I welcome Malcolm Wright to his position today. I wanted to ask some questions about financial planning and reforms around that. I think that if the experience of integration has been anything, often the problems have come down to the person who pays the piper in delivering the reforms. I wanted to ask in terms of Audit Scotland's key messages. One of the messages was the fact that financial planning is not integrated long-term or focused on providing the best outcomes for people who need support. I wonder if the panel could outline, as things stand today, what level of debt to all the IJBs collectively have. I do not have the detail for each of the IJBs. I am quite happy to provide it. I cannot tell you what their reserves are looking like. As you will know, we have a number of IJBs with significant reserves, around 23 million of which is not earmarked for anything. In the discussions around the budget, the draft budget, where 160 million is moving from the health budget to local government to provide additional investment in integrated health and social care, what councillor Currie and I have also discussed are the reserves, the position around reserves and what would be a fair position to expect IJBs to have in terms of our overall percentage. What is our expectation on the level of reserves that are above that and how they might be using those to improve services? Equally, our position on what is known as set-aside money. Essentially, what we are looking to achieve is a fairer balance in terms of financial decision making. Of course, the legislation is really clear and Audit Scotland's report was really clear. That is where an IJB has delegated authority to deliver a service, the decision around planning and commissioning of that service and, consequently, the financial planning for that service sits with the IJB. That is the bit of governance that is crystal clear. The delivery of the service that is then commissioned of course, the accountability for that, sits with whoever is delivering that service, whether that is a health board, whether it is independent sector, third sector, local authority, whoever it might be. That financial planning should be integrated into the overall planning and commissioning that the IJB has responsibility for. What we have asked and either Mr Wood or Mr Wright will be able to give some detail in terms of what the implementation plan says is what we expect to see before the start of the next financial year by way of individual IJB budgets and their planned use of those, which will also allow councillor Curry and I to look and be sure that, where additional resources have been given, those additional resources are being passed over to the IJB and used for what we need it to be used for. I do not know. It seems to me that the report actually takes us forward with a number of fundamental things that need to happen in every integration authority across Scotland working with the health board and with the local authority. Certainly, my experience in working in health boards has shown me that there are variable levels of safe financial transparency and one of the pieces of work that I was able to do in my time in Tayside was to work with the local authority chief executives, health board chief executive, the chief officers just to get on the table what the financial position was in each of the IJBs, what the contributions were from each of the local authorities and what the contribution was from the health board. There is actually transparency in that and certainly in my experience in working in NHS Grampian that was something that the four chief executives of that system were able to put in place. That piece about having a joint understanding of each other's financial positions, because we all know that public service finances are under challenge right now, so having that transparency is really, really important. Secondly, about agreeing the budgets and trying to get better consistency that each of the integration authority's budgets will be agreed by a particular point in the year and certainly before the start of the new financial year. I think that that is an important principle and I think that if NHS and local authorities are agreed as we are in the plan then that is important. That helps us to, if you put in place the leadership arrangements that we talked about and the relational issues, we put in place the delegation of the budgets on time, we put in place a joint understanding of everyone's financial position, then actually with the strategic planning commissioning arrangements that enables the set-aside arrangements to be implemented as per the legislation. Finally, it is really important that there is that not only transparency about the range of reserves that we have and we can see where the reserves sit. As the cabinet secretary has said, what is designated, what is not designated, but actually each of the integration authorities have a policy about the use of those reserves and that policy is open and transparent and known by all. My sense is that if we can really focus on the leadership and the relational things then I think that all of those recommendations deliver what Audit Scotland has been saying in their report and I think that this is a really important bunch of recommendations that we need to take forward and implement and we've now got work going on on each of those recommendations to make sure that we put them into practice. Gareth Stewart-Cuddy. In terms of longer-term financial planning, what is crucial is that budgets in the past have been set at different timescales. For example, I think that it's been unhelpful. We have local authorities setting their budgets sometimes a few months before the health board, so you have different offers coming in from different partners at different points and actually the report is very strong on that. It talks about saying that there should be no reason and indeed, with the medium-term financial framework, there should be no reason why they can't converge. That has to happen because for an IGB to successfully plan ahead, not just for one year but multi-years, it has to be clear that here's the offer and we can use that in this way. Obviously, the report also talks about giving sufficient support to finance and section 95 officers who are involved directly in the integrated joint boards because that's quite important as well. It can't just be something that you do as part of another job. It has to be clear that you have a crucial role to play there, as you would with a local authority or any other part of the public sector, so I think that that's really important. In terms of reserves, what's important is that the report is not about saying here's what the reserve should be or setting limits, what it says is that it should be appropriate. That's about making sure that some IGBs that you'll see from now that the Scotland report have no reserves. Some do have reserves, but it's about making sure that they're not being built up for no reason. Obviously, the first question that I'm sure might mean that you look at a bar chart or a flow chart or whatever it is, you look at a chart and you say, well, how come if that IGB has X amount of reserves, why is there issues around finances? That's one of the questions that's there, but that is discussions and work that's on-going and actually important. The longer-term financial planning should be possible, and I think that it has to be possible, because in terms of some of the services, some services and some change in services don't happen in a fortnight or a month or six months or even a year. They can take some years to roll out and get that full effect of the benefits for individuals, so it's important that people are able to plan ahead not just six months or a year, but beyond that wherever possible. I think that that's useful what you said, and it would be useful for the committee to also have sight of some of this data as well, which we've not in the past. One of the things that I think we need to really look at is what this means on the ground. The cabinet secretary mentioned here in Edinburgh that they've been using their reserves, that they've been looking at actually diving into set-aside budgets. This week, they'll be looking to make £19.4 million of cuts. In terms of that IJB, I know from members who sit on it, that they're seeing that this is actually undermining some of the integration work they've done in the past. How we make that sustainable, and currently we're all agreeing, this is important to actually make it work, but it's how we move towards what will actually make proper financial management and sustainability for our IJBs. I think one of the things that I've raised with the former cabinet secretary was single budgeting, like they've looked to move towards in Northern Ireland, and actually regional planning as well of some of the integration, which doesn't seem to have happened, in which order Scotland have looked towards trying to suggest needs to happen. I was wondering in terms of the leadership teams and what we've heard today, how that actually is going to be taken forward. All of that, or any particular bit of it? I think that in terms of financing, it's absolutely key. In terms of IJBs, if they're going to be asked to actually make those changes in the future, the Audit Scotland report suggests £222 million worth of cuts, which collectively they're currently looking at making. That's impacting on how they deliver integration today. Of course, Audit Scotland wrote that report before our draft budget commits an additional £160 million to integration. We're very clear that that £160 million is additional, it's not substitutional in any respect. Of course, the decisions that a local authority then choose to make are for that local authority and not decisions that I can directly intervene in. What we can do, partly because we have the advantage of being a relatively small country, and a very strong shared political commitment between COSLA and this Government to make integration work, is look at individual integration authorities and have the discussions with them, and with their key partners that form that integration authority to try and understand why they feel that they have to take the steps that they feel that they have to take. At this point, I am unconvinced that Edinburgh needs to take the steps that it believes it needs to take, either as a local authority or, consequently, the knock-on effect to the integration authority, so we will pursue that. Councillor Currie is absolutely right. The point about the medium-term financial framework was precisely to allow, among many other things that it successfully did, to allow that longer-term financial planning. Like you, I am interested primarily in how all of that then delivers on the ground to folks, but the review and its proposals are really clear on the integrated finances and financial planning in terms of all the steps that Mr Wright set out in what is required. That is picked up in the implementation report, and in that implementation work, of course, we are looking for Audit Scotland's involvement—I believe that they already are providing us with some assistance in that—and with SIPFA in terms of, for example, what would be a prudent reserves policy for a body to have. All of that work is under way. My point about the additional money that is currently in the draft budget stands, I think. In terms of a regional approach on health and social care integration, it would be a useful approach to look at taking for a number of different areas of the service. My own view at this point is that we need to get all our different health and social care partnerships operating in a more consistent, outcomes-focused way and some of the core measures that we would look to see them delivering on and then look at whether or not there is room for additional regional working. The reason for that is simple. I do not want folks' eye off the ball on the first of what we require and what the review requires while they go away and think about how they might work regionally. We need them to work well locally and deliver well locally to the review's recommendations, and then there is absolutely, as there is in the health service, fairly consistent and effective regional planning, for example, for some important services. You could see some of that developing in time for health and social care. Before I bring Miles Briggs back in, you mentioned the additional £160 million. My understanding of the budget stage one provision is that it gives local authorities the flexibility to offset their own adult social care provision by up to 2.2 per cent of 2018-19 figures or up to £50 million across all authorities. Does that mean that potentially that £160 million in practice could look more like £110 million or somewhere between those two sums? That is entirely a decision for local authorities. As far as I am concerned, £160 million is going from my budget in health to local authorities for additional provision in health and social integration. How local authorities make their decisions is a bit like the car parking tax. It is entirely for them to decide whether they wish to use that flexibility. Stuart Curry, if you can cast any light on that at this stage. Two issues. First, in terms of set-aside, I should say that the report is very strong that, in order for integration to work successfully and fully as we go forward, it is really important that the arrangements around set-aside are implemented. It does not require legislation, the legislation is there. Helpfully, it is very clear, but it just needs to be implemented on that basis. In terms of longer-term financial planning, IGB is having the ability, as they should do, to look ahead about how the use of that set-aside in order to transform funds. I mean, set-asides are a strange definition of what it is. It is a transformational fund that is not a forever fund. It is about shifting that balance of care, that 50 per cent shifting that balance of care from the community into the communities. In order for that to happen, there must be planning. It cannot just happen overnight or even in one year. That is why another aspect is that, to say to IGBs, for example, potentially, you have to look at using your day-to-day funding to try and transform services. That is not going to happen, because that would result in either robbing Peter to pay Paul or overspends. However, set-aside is there to help resource those sort of changes that are required. The benefit of those changes may take one or two years for the stagger to unwind, but it is crucial that set-aside works in that way to ensure that transformation can happen and the resource is there. The important thing about flexibility is about making decisions for better and the best outcomes. Children's services, for example, probably in all, if not most of the IGBs, is not a delegated function. It is not a function that sits within the IGB from a local government point of view. However, the investment in children's services can make a huge difference in social care and related activities that are part of the IGBs' power of view. That is really important. I have spoken to colleagues in local government, and that is what they are looking at in relation to the potential around flexibility. Some people are saying that they are going to leave the potential flexibility where it is, but some are saying that we can invest in areas that are aligned very closely with the IGB services. That is important, and it is further down the line to make them sustainable. To come back on that point, one of the key aspects of integration finance that showed at Scotland was to commit for the Scottish Government to continue additional pump priming funds to facilitate local priorities and new ways of working, which will progress integration. The cabinet secretary does not have a figure of debt today, and we will provide the committee with that. However, in terms of how we have seen health boards find themselves in difficulty, and the Scottish Government has written off £150 million of health board debt, are we not in a concerning position where some IGBs, and I know from my own here in Edinburgh, find and feel like they are sinking because they are constantly trying to make cuts or not be able to manage their overspends? The vision that we have and all support of actually moving is not happening in some areas. There are some IGBs, and Murray was one that was highlighted to us, which are managing that. However, in the future, I do not want to see—I do not think that anyone right in this table wants to see—a situation where some IGBs are like some of the health boards with huge debt attached to them. I wondered what your view as a panel was on that, and what the picture—we obviously do not have the figures today—is like, but what works preventing that occurring in the future? In answer to the second part of your question, all of the work that my colleagues and I have described is the work that is under way to ensure, under the medium-term financial framework—we should not lose sight of these things. Mr Wistel talked earlier about a very important question about how we present all of this within the frame of integration. It is incumbent on all of us to join the dots on some of this stuff, and so the medium-term financial framework is a pretty important part of what underpins our approach on the integration of health and social care, along with all the other elements that we talked about, and the work that is going on in order to get as clear a picture as we possibly can about the financial position and the forward look of that financial position. That answers the second part of your question. We are not complacent on this. Health and social care integration will, of course, face all the challenges that public services in Scotland face anyway, and we need to look and see what we can do that is best for all of that. However, one of the questions that always comes to my mind when I see an integration authority doing well, for example, on delayed discharge and another not, doing well in managing its finances and another not, is what is that one doing that this one is not doing? The share by which the funding is allocated and the requirements that are made are comparable—I do not accept that individuals at the length and breadth of the country are so different in their health and social care needs so that it would account for significant differences. That is why I said that one of the things that we are fortunate in being able to do but absolutely determined to do is where we have integration authorities and, indeed, in some instances, health boards—and let's not overstate matters—where they appear to believe that they are facing financial difficulties is to go and have that conversation with them about exactly what is producing that financial difficulty, how are you using your resources, is the support that is coming from health or from local authority, what we would expect it to be, and if it is not, then it is Councillor Curry and my job to go and speak and see if we can improve that position. That is quite simply the approach that we will take. The implementation plan so that members are really clear. Although it is the oversight leadership group that is working on that and will continue on that six-weekly basis to work on that, that work at the end of the day sits with Councillor Curry and I and where we see difficulties for whatever reason, then we have a shared and agreed responsibility to act together to see if we can resolve those. I should say, convener, that when you look at the report and everything that we have talked about this morning, it is about making sure that services are not just deliverable but sustainable. When you look at the demographic challenges, if you looked at nothing else, everybody knows the demographic challenges that we face across Scotland and it is absolutely crucial to put in place those measures now. We have talked about set aside exactly why it is such an important issue to transform our services to ensure that we can sustain the level of services that, frankly, people have every right to expect in terms of health and social care. In terms of the local government budget settlement, £160 million is welcome, it is additional funding. There are many, many challenges and there are many areas where coslin government take a different view, but in health and social care the additional funding is not just welcome, it is crucial in terms of delivery. It is about things like, for example, school councillors ensuring that we can deliver the living wage in the independent and third sector. That builds capacity in terms of making it a good wage for a day's work. As you will know, Mr Big has extended free personal care to under 65s. It is possible because of the additional funding in the draft budget in terms of health and social care. We just feel that that is to be welcomed and we should say that. Whether there are things that we do not welcome, I am sure, because there will not be shine coming forward and saying that we do not welcome, but the additional funding will make a huge difference across Scotland and your constituents and the people that we serve. Can I go back to the point that the cabinet secretary was making about the funding formula and how Scotland is not that different? I accept the generality of the points that the cabinet secretary is making. Clearly, the strength of management must be a factor and I do understand that. Can I perhaps do a hands and hands point as you expect me to raise? As you well know, one of the reasons that authorities like Highland Health Board and Shetland, for example, have had real problems in requiring brokerage has been the whole issue of staff retention. You will know from studies that retention is much stronger in your teaching hospitals in Glasgow and in Edinburgh. If I recall correctly, I was speaking to Shetland not so long ago for the first time ever that they require brokerage, purely because of the costs of local staff. I think that the Highland example that I have given you before was local consultants of £400,000 a year. Clearly, you can be the best manager in the world and if you are paying out £400,000 if you are local, you are going to have real problems on the management. Would you accept that staff retention and recruitment, particularly for key occupations such as doctors and consultants, is a real issue in rural areas? Do you like to answer that question in the context of integration authorities and their requirements? Yes, I will. I do. That is an area that we consistently look at. For example, it is one of the reasons why we have the specific relocation package for GPs to try and encourage recruitment and retention in GP practices in rural areas alongside a number of other measures. I do not disagree with the point that you are making. I think that it has to be something that we are consistently looking to see what more we might be able to do to help in those areas where retention and, therefore, increased recruitment costs or increased locum costs are an issue significantly more than it might be, for example, in the central belt. That plays to health and social care integration, although what I have to say is that our biggest retention issue in social care workers is the prospect of leaving the European Union, where Scottish care has made it very clear that, although we know that, overall, across our social care workforce, about 5.5, 5.6 per cent are EU nationals, we have particular hotspots in health, but particularly in social care, where that number can rise to much closer to 30 per cent. Of course, the prospect of losing those individuals in the short time scale of Brexit, which is not that far away, is of considerable concern. There is a limited degree to which we can mitigate against that. Obviously, paying the real living wage is a help, some of the other work that we are looking at jointly ourselves and COSLA and Scottish Care and others in terms of social care as a career option with additional training and support, the prospects of moving inside social care to other more enhanced roles and so on, and some of the work that is under way on that will assist anyway in terms of social care, but the real workforce challenge for us in social care is Brexit and the prospect of losing those valuable EU workers. Indeed, I understood that. In that context, cabinet secretary, I wonder if you can provide us with an update on when you anticipate the integrated health and social care workforce plan may be published? That is still a discussion between ourselves and our partners. We have tried to take a little bit more time in order to build in what we anticipate might be the difficulties in Brexit. That is not to make a political point, it is simply a sensible point if you are planning a workforce and you anticipate losing—it is a realistic prospect—to lose some of that workforce or, in the case of nursing, to see something like an 80 per cent reduction across the UK in the number of EU nationals registering to come and nurse in the UK, then you should sensibly take account of that. Of course, again, it is just a statement of fact that the position on Brexit remains remarkably fluid, so I would hope to be able to publish that workforce plan in the coming weeks. I have a final question in the area of governance, I think, for both councillor Cury and the cabinet secretary. That is the ministerial steering group recommends that clear directions must be provided by IJBs to both health boards and local authorities. My question is simply what implications the greater use of directions by integration authorities will have for the governance and accountability of both local authorities and health boards? One of the important things to say is that those are not directions in the sense that a minister gets to make directions, but they are about providing clarity about where decisions are taken. We had a very useful discussion in the last ministerial steering group around the report in draft form. Where functions have been delegated to the IJB, that is the place where the decisions are taken on planning and commissioning, for example, around various areas of service. However, if I just talk about the health service, the delivery of a primary care service, for example, the accountability for the delivery of that service to proper clinical and other standards, sits with the health board. There is no confusion on where accountability lies. Another example would be nursing care provision in a care setting. The care provider is accountable for the quality of the service that they provide in return for the contract that they have undertaken. However, that individual nurse professional has an accountability to her professional and regulatory body for the work that she undertakes, as well as accountability for who is employing her to do that job. Those dual accountabilities, if you like, in health have always been successfully managed and understood. We simply need to be clear about what the IJB's role is in making decisions and then the follow-through of who is the provider of those services and their accountabilities. I think that the discussion that we had and what the report says is very helpful in that regard. Thank you very much, councillor Cary. I think that, like everything else, it is important that we are clear about governance and who has the responsibility not only to make decisions but who equally is accountable for ensuring that those decisions are delivered at the various levels. Just one example has come as a shock to many councillors that what we used to be called section 10 grants are no longer a decision of the local authority. It is something that has been delegated to the integrated joint boards and they make decisions based on a whole range of factors, not just from a local authority point of view but from a joint health and social care point of view. However, there still is that issue where a lunch club, for example, funding may end for that lunch club. In the past, local councillors would be, well, we can just sort that out, but it is a decision and we have to recognise us as a decision for the integrated joint board. However, of course, making that decision in terms of the governance about that accountability is making sure that it can evidence why, if there is either investment or disinvestment, why that is the case and how it will deliver a better outcome. I think that that is the key issue around governance accountability. You do not just make a decision because you can, you make a decision because it will deliver absolutely better outcomes for individuals, for families, carers and communities. If that is not the outcome that we think is going to be arrived at, then it probably was not the best decision to make and it is probably the wrong conversation. It seems to me that we have to be crystal clear. That is a learning process and people sometimes get upset if they think that it is their decision but it is no longer their decision. However, the world has changed at the point that I was saying earlier. Integration is here and it is here to stay. It is here for a purpose and that means that people who had decision-making responsibilities in the past have gone and it is now a joint responsibility. However, with that comes accountability to deliver those better outcomes. Thank you very much and I think that that emphasis on outcomes is a positive note in which to conclude this evidence session. I thank the witnesses for their attendance and for their evidence this morning. We will now suspend for five minutes and resume in public session in five minutes time. Thank you colleagues. We will resume again the next item on our agenda is item 5, which is consideration of two petitions. The first petition is PE 1611 in the name of Angela Hamilton on mental health services in Scotland. This petition was lodged on 27 July 2016. As detailed in today's public papers, members are aware of the previous work that was carried out by the committee on this petition. We agreed to consider it as part of our previous work on mental health. We wrote to Sir Harry Burns in his role as chair of the review of targets and indicators to make him aware of the petition and its request to reduce mental health weight and times. Members will also be aware of the recent commitment from the Scottish Government in its proposed budget. In a letter to the committee on 23 January, the cabinet secretary stated that overall funding for mental health services will amount to £1.1 billion in 2019-20. Of course, colleagues will note that we are to undertake an inquiry into primary care this year, which will include consideration of mental health. In the light of those points and in the light of the fact that the petition is now some two and a half years old, I wonder if members have comments to make on this petition, and in particular on whether it would be appropriate at this stage to close the petition in order to focus on other aspects of the mental health agenda going forward. Can I write any comments from colleagues? Thank you very much, chair, and I appreciate the amount of work that went into the petition and through the petition's committee having sat on the petition's committee previously many years ago, I think that it would be. In light of what you have mentioned in regard to the Scottish Government and the commitment to extra resources, the age difference now in CAMHS, which is one that is very important, but one of the most important things is the fact that we are looking into primary care inquiry. As this petition is three years old, I do not think that it gets to that level of the inquiry that we would be looking to, so I would be minded to close the petition as it is, but also obviously to include evidence from that petition into our inquiry, if that was acceptable to the committee. Thank you very much. Are there other colleagues? Brian Whittle? I think that I am sitting in the petition's committee and there is an increasing volume of petitions coming in that are very pertinent to this petition in terms of the mental health element of them. I am quite concerned, I have to say, and we are in the petition's committee looking at how we can gather those separate petitions together into a wider piece of work. I am just wondering whether, if you close this petition and put it to the side, there is a very good chance that quite a lot of those petitions will come to this committee. You will just be going over that over the ground again. I do not know whether we can suspend it or whether we have to do that, but there is a lot of work coming down the line in that area that the petition is still pertinent to. Are there other comments? If I may respond to that clearly, you are right that there will be an increasing volume of attention paid to those issues going forward. As you say, future petitions can be expected. The question then is whether our scrutiny of policy in those areas should be based on those current and contemporary petitions, as opposed to the one that was submitted some time ago. I will just break it and then I will respond. I am not aware of the numbers that Brian is suggesting in terms of mental health petitions, but if there is a chance for a petitions committee to group those and the issues that they are arising, and for us to consider that, that would be useful instead of an act. That is exactly the work that we are doing just now. We are trying to get together the commonality between a lot of the different petitions and bring them together as a much bigger piece of work. I think that, in inevitability, that work will land on this committee. I endorse what Miles Briggs has just said. It is important to recognise that we are in a very dynamic landscape in terms of mental health, and it is not necessarily an improving landscape. The fact that the petition has been in front of the committee for two and a half years, is that right? That concerns me slightly, because I think that the debate has moved on. Again, I think that we are backsliding in some areas on mental health around it, but I would uphold the fact that, if we were to close this petition, it is not a reflection of the fact that we think that this issue is sorted but far from it, but recognise that there are developments in that area in which we are going to receive representation from the Petitions Committee, which we should devote our attention to. I take on board the comments, especially what Brian Whittle says about lots of petitions coming forward that are mental health related. I think that I would be interested in a collaborative approach looking at the evidence. I know that we have a mental health minister that has made announcements and commitments for spending money, especially for young people and children at school. I would be interested in a broader approach as we go forward to look at where we are when we scrutinise what has been announced and what will be delivered, because there is a wide-ranging approach. Mental health is really high on everyone's agenda right now. I therefore suggest that we agree to close this petition, but we also draw that decision to the attention of the Petitions Committee, which will consider how best to group petitions that are currently in front of them and may wish to take that into account. We will move on to the second petition before us today, which is PE1568, in the name of Catherine Hughes, on funding, access and promotion of the NHS Centre for Integrative Care. The petition was lodged on 12 May 2015. As detailed in today's public papers, members will be aware that we agreed—or the committee agreed—at its meeting on 15 November 2016 to invite the Scottish Health Council to give oral evidence on their general input and approach to consultations of the type being run in this case, as well as their involvement in classification of major service changes. More immediately, I wrote to the chief executive of NHS Greater Glasgow and Clyde on 28 November 2018 to request an update on the current position of the integration centre and whether any further changes to the service were anticipated. Members will have seen the response from NHS Greater Glasgow and Clyde as part of today's paper, and in addition, a number of letters that have been received in support of the original petition, including from Elaine Smith MSP, from the British Homeopathic Association and from other concerned parties. I invite, including of course the petitioner herself, to make any comments from our colleagues about the matter. Thank you, convener. I start by thanking the petitioners and the campaigners. You have already outlined the correspondence that we have received. Catherine Hughes and her mother are here today. I know that they have not been well over winter, so it is good to see them here. I think that there is a lot of important work that we still need to try to take forward around this. I am co-chair of the cross-party group on chronic pain. In terms of Elaine Smith's correspondence, there are a number of issues that are on-going with regard to the variation of treatment available across Scotland. It is important, as the friends have outlined, the friends of the Centre for Integrative Care have outlined, that keeping the petition open would allow time for continuing correspondence and some investigations to take place. I would be reluctant to close the petition and look towards how, as a cross-party group, the work that we are undertaking, but also any work that the Health Committee could look at in this regard. Thank you very much, Brian Whittle. I am co-chair of the cross-party group on MSK and arthritis. We do quite a lot of work with the chronic pain cross-party group. Again, it is all the same time that there is a bigger piece of work to be done here. I think that there is a much bigger outcome possible here. It is how we fit that in and whether that is a cross-party group way in which we are dealing with or whether that is a health and sport committee group. Without question, there is a much bigger bit of work here that we could do for sure. I will scroll on. I will go on to Brian Whittle's remarks. Unlike the last petition convener, that is not being followed through the Petitions Committee by a glut of other petitions of a similar nature. That is a standalone issue. I am anxious about closing it now because it suggests that the issue is resolved. I am not sure that we are there or anywhere near there at the moment. I would just endorse Miles Briggs's recommendation that we retain it and keep it up. Thank you very much, convener. As I reiterated earlier on, being involved in this particular area for the last, I think, 10 years along with others as well, it really concerns me that 2015 this petition was put in and it is just coming to the health committee now. That is a concern for me alone, four years down the line. There are so many issues that need to be raised throughout this. One says that the patient is still open and somebody else says that it is closed. We need evidence of exactly what is happening in the area. Brian Whittle is something that we are talking about health and social integration. Heardly we are all in the evidence session. It is something that should be part of that. It is a much bigger issue. I do not know how we can move on with it, but Miles Briggs said that he had that cross-party group. I want to know about it, and Dorothy Gray said that she had been involved in it also. Perhaps it can be discussed there. I am pretty close to closing the petition at this moment in time, but I do not know where we can go forward with it. It is not just about this centre at Gartnavel. It is about a much bigger integration. It talks about counselling and dietary service. That should be provided in every health authority. It is a much bigger thing than that. For clarity, the petition was lodged in 2015. It was referred to this committee and evidence was taken by this committee in 2016. We pursued it last year as well. It is not only arriving here for the first time, but we have a decision to take as to whether there is anything further that this committee can add to the consideration of this specific matter or not. Thank you, convener. It is just a quick point that, over the last couple of years, as an MSP, I have attended many events, whether in constituency or in Parliament, related to pain management, myalgic, encephalitis, fibromyalgia and different aspects, which are related to the petition. My main focus is evidence-based approaches to delivery of best care, whether it is in the community or in health service settings. I am reluctant to just close the position without seeing that there is a resolution, but I am interested in a way to make sure that we have a wider ability to look at all the other issues that are coming forward in the past couple of years. Thank you, convener. Like many, I served in the petition's committee for a number of years, and I praised the work that Catherine Hughes has done in the petition. I could also just endorse to members the very third letter that Elaine Smith has put out, albeit that it was fairly 11th hour. I think that she made a very strong point about this vital that the petition remains open so that we can be patient first. She also stressed that it is a Scottish-wide problem, not just about a local area. I would share the comments that were made by my other colleagues. Thank you very much, Brian Whittle. Given the amount of work that has been done by various groups around this particular topic, there must be some way to pull that work together into something a little bit more cohesive, because there is an almost point repeating some of the work that has already been done. I would look from this committee up not necessarily to do a great bit of investigation, but perhaps to be a catalyst to pull together a lot of the work that has been done out there into something that is a bit more solid and cohesive. In terms of Scottish Government, it has outlined an advisory group who are meant to be undertaking work to look at some of the postcode lottery issues. I think that there is an opportunity to use what the petition was looking at to ask the Scottish Government what they are doing around this coming out of that advisory group, because it is important for the petition's outcome to find out where the Centre for Integrated Care future sits. That would be useful for the petition. I would be very brief. I am reminded that I attended an event last week about migraine, not last week before. There is a postcode lottery attached to how we support people with migraine, so it is along the same lines of a whole integrated approach that supports people across the whole of Scotland. I think that it is quite clear that we do not wish us a committee to close this petition, but we wish to maintain it. However, it is important that, rather than simply coming back to it again in a year's time and going, what has happened in the past 12 months, we should at least two cross-party groups with an interest in this matter have been mentioned. I would suggest that we write to those cross-party groups and say that the Health and Sport Committee is keen to understand what it can do to advance the issues raised here, report back to us and then we can make a judgment on receipt of those replies as to what usefully we can add going forward. Is that agreed? If that is agreed, thank you very much colleagues. We will now move into private session.