 Yn oedden nhw gyda'r 25 eich gweithio ar y Comitul Hesbeth Cymru 2020. Felly mae cyntaf i'r cyfieithio'r ddeg? Mae'r ysgolwch ymwyllt iawn yn y gyfieithio'r gweithio 2021-22. Mae cyfieithio'r gweithio'r gweithio'r gweithio yn ddechrau'r gweithio'r cyffredinol review group, and entails addressing budget implications throughout the year to bring together to inform a pre-budget report for consideration. This year, we are also considering the impact on health and social care of Covid-19 in the current financial year, and we are taking evidence from a number of relevant bodies before hearing from the Cabinet Secretary. This is the third of the series of meetings, and today we are hearing from chief officers of IJBs, and I welcome to the committee a Judith Proctor, chief officer of Edinburgh Health and Social Care Partnership, Vicky Irons, chief officer of Dundee Health and Social Care Partnership and any phraser, chief officer of East Ayrshire Health and Social Care Partnership. We will take questions in a prearranged order. I will start with the first questions and then ask each member in turn to ask their questions. As ever, it will be helpful if members could indicate when they have reached the last of their questions in order to assess broadcast and comics to move on. Likewise, if witnesses wish to come in and answer the question, in addition to a question, and answer those that have been given, please indicate through the chat function. Can I start? Clearly, Covid-19 has changed many things in the way that we all work, and not least in the areas for which health and social care partnerships are responsible. Can I start with a general question and ask our witnesses whether the existence of your organisations of the health and social care partnership did the existence of IJBs assist with the response to the pandemic, and if so, in what ways? I wonder if I could start with you. Yes, good morning, convener. Good morning, committee, and thank you for hearing from us today. I think that my answer to that would be a resounding yes. I think that the whole approach to integration, having integrated teams, being able to mobilise across our whole system with our partners, was a significant contributor to our ability to mobilise across our city and across Scotland. I think that some of the barriers in terms of inter-organisational barriers disappear, and we were able to move our staff across areas. We were able to support areas where we knew we were going to have significant pressures, and we were able to take a really holistic approach to how we supported people at home in care homes. The way that we worked with secondary care and acute care demonstrates our ability to move swiftly, so I would say absolutely yes. Thank you very much. Good morning, and thank you for the opportunity to comment. I would also endorse the comments that Judith Proctor has made about the initial response. I think that the thing that has certainly benefited both Dundee City and the rest of Scotland is already the foundation of partnership that exists across the city. Particularly at the outset of this pandemic, we saw Covid presenting in communities, and not necessarily in the way that we predicted in terms of a huge surge for hospital-based activity. We have really depended on the full support of our local authority colleagues in being able to bring together new services that needed to be configured very, very quickly, but also the wider partnerships that are engaged in our IGBs, such as the voluntary sector, to ensure that we provided essential services, particularly for those who were shielding, and those with very complex needs. Without a doubt, we have seen a very large transformation of the type of care that we can now provide in community settings as a result of that. If we had not had the foundation of those partnerships in place in Scotland, our response would have been very different. Thank you, and good morning, convener and committee. Obviously, building on what my colleagues have said, some of the areas in particular that we think about it, and if I use that example that Vicki gave about shielding, so I led for both the council and for the NHS Yershanaron in terms of shielding. We were able to join things up and make sure very quickly that people who were shielded got the essential practical supports, like shopping, like support with prescriptions, that there was no differentiation between that. In other areas, we were able to build in long-standing work. For instance, we had already weekly meetings with care homes, and that was very quickly able to bring in public health in a range of other professionals when that was required. Therefore, the relationship in terms of going forward has been built stronger rather than being fractured through this. One of the other areas that I would reflect on is that if we weren't sitting in an integrated environment, there would have been a real risk of bickering over budgets and who was paying for what. Essentially, in local communities, it didn't matter, because the chief officers were responsible across the health and the care budgets, and therefore we were able to take decisions and act under the auspices of the IGIB. I think right across the whole system that sitting there is an interface between the NHS and councils, but also, importantly, with the third sector and the independent sector, the role of IGIBs has been essential in that. Can I ask Judith Proctor what the key challenges have been for integration authorities and whether the experience of the pandemic has changed your perspective on what the challenges are for the integration authorities in general? Judith Proctor? I think over this, some of the key challenges that we saw for the integration authority in a way disappeared. If we are talking about the IGIB itself, we worked very early on to ensure that we had good and appropriate governance within the IGIB so that it could undertake its strategic decision making. In large part, the responses that we put in place were operational through the health and social care partnership. I think that we need to make a distinction between those two things. Our IGIB enabled emergency decision making to be undertaken by myself in partnership with the chair and vice chair of the IGIB, and, of course, we, as chief officers, as Eddie has said, are responsible both through the NHS and the local authority, so we are working very closely with the incident management teams, the gold command and both those organisations so that we can make decisions really swiftly. Quick decision making and appropriate decision making was really of the essence at the height of Covid. I think that some of those things sometimes can be challenging in terms of the speed at which we make decisions. They disappeared through Covid and, again, we have touched on that with mobilisation plans and the funding. I think that some of the issues in relation to funding being able to make decisions, knowing that the funding would be made available for us to ensure that those services and responses could be put in place. That also ensured that some of the usual challenges that we face were not in place over Covid. I am not sure if that addresses the question that you were answering, but I would be happy to follow up on that if there is a follow-up. I think that it does. Thank you. Vicky Irins, you have heard from both, due to what you have already said, about working between integration partners within the Thorgas. Is it also your experience that there has been effective joint working among health boards to look with Thorgas and IJBs to ensure contaction? Is it your experience and that of others that the partners have been represented equally in decision making through the pandemic? Thank you. Certainly from my experience and to reflect also, due to its comments, moving into our pandemic response and emergency measures has, in some ways, liberated the system, I think, just to be able to get on and do the right thing. I think that is an expression used by one of our colleagues recently. We have definitely witnessed a level of integration that maybe was not present prior to the pandemic response or certainly not present at the pace at which change was enabled during the early weeks of the pandemic response. We have, as Judith has also highlighted, very robust processes in place in terms of our command centres, both within the IJBs, and we also pay a participative role in the NHS Board arrangements and the local authority arrangements. As a collection of IJBs, we are also in regular contact with Scottish Government officials and other key agencies such as Public Health Scotland throughout the process. For me, that has absolutely cemented some of those relationships and enabled the system really to develop one response that was entirely necessary under the circumstances. Thank you very much. Can I ask Eddie Fraser whether the experience of the pandemic has highlighted the areas for improvement in the structures in place for decision making and in the allocation of resources? Eddie Fraser? In terms of the allocation of resources, some of the things that were reflected by the others are also down to the relationships between the organisations. If the relationships between the health board, the council and the IJB are strong, some of the things that can be idly, because there is trust between the organisations, you just go ahead and do the right thing. Sometimes, if you need to do things, you go ahead and do it. One of the areas that I certainly felt at the start, particularly, was a miscommunication with people. A miscommunication with the wider actual members of the IJB until we got all these different video conferences and something running. I think that that was difficult. The work that we do is visible leaders out there, whether that is in care homes or people learning disabilities or care experience young people. Not being able to see and hear for them easily to start with is difficult. There are bits at the start of it that I think that we had to learn from and how to communicate differently with people. I dare say that that is something that we are going to have to continue to learn with. Clearly, the worry is that those who have most difficulty accessing us because of our arrangements are the ones that we are not able to speak to enough. I think that that is some of the things that we are having to learn differently as we communicate and make sure that we continue to be inclusive. It is very necessary for us to go into a command and control model in the middle of a crisis, but it is also very necessary for us as we go forward to make sure that everything that we do is informed by our communities and is for our communities. Thank you very much. We heard from Vicky Irons about co-ordination with the Scottish Government. What is being done to ensure that positive lessons are retained once the pandemic is over and how are experiences being shared across the country? Perhaps the committee will be aware of the several pieces of work that we have done in partnership with other organisations. A lessons-learned process was undertaken with colleagues in the Scottish Government in around July or August. That has been shared with the committee from Eleanor Mitchell's letter to you last week. I think that that was a valuable piece of work and positive focus done in the front of it about lessons learned in relation to the lead discharges. I think that it looked across the broader spectrum of our experience in health and social care partnerships over the pandemic, what worked well and what we were able to mobilise quickly, what some of the issues were and how we would retain those into the future. We also, as a group of chief officers in health and social care Scotland, partnered with the BMA and some work was done in relation to lessons learned around primary care. Primary care is a significant response early on through Covid centres, the way that they have retained services, different modalities working through things like Near Me. That has been a really valuable piece of work that we have shared across our network. I think that we are all individually doing a lessons learned to capture. We certainly started that quite early on in Edinburgh from around about April, started capturing the lessons that we were learning. That has been pulled together. We are disseminating that throughout our partnership. Health and Social Care Scotland and the chief officers groups are very strong, very supportive collective of chief officers. That focus on sharing what we are learning as we go has really been a future of the network from the get-go and has really been enhanced and accelerated through Covid. We met daily with Scottish Government throughout the early part of the Covid and a teleconference and we are shaping our future agenda based on what are the lessons that we take from Covid that we implement across Scotland. I think that there has been quite a lot in that area. We are also, as a network, doing some work with the Kings Fund in relation to our personal experiences of leading through that. That work is on going at the moment. Thank you very much. Finally, can I ask Vicky Irons how to cast your mind back and tell us how early you and others were able to begin preparing for lockdown? Was it a matter of days or weeks that you had to be ready for that and what planning took place for that? Vicky Irons? I think that we have benefited largely from not necessarily having been able to predict the scale and the length of this pandemic, but we have benefited from having previously exercised plans for other pandemics such as bird flu and other occasions. We are already in a position where we had, if you like, a sequence of events in terms of how services may change and in the event of lockdown or in the event, for instance, of large absences from staff available at work, how we would prepare for that. I think that, in essence, we had a fair level of warning in terms of being able to prepare certainly our care and our service provision for the eventuality of lockdown. I think that some of the elements of that, such as the shielding and the provision of care and supplies and medicine supplies and lots of other very practical things, we had just a number of days, if potentially a week's notice to get those arrangements into place. But again, being in the position that we are in, particularly where the expertise we have with local authority colleagues around the table with all of their logistical expertise, we were able to respond to that very quickly. We had already prepared, for instance, about how we would provide care if buildings were closed and how we would provide medicines and other essential supplies for those who are most vulnerable. Most of those elements fell into place quite quickly. I would like to follow on from the convener's questions on additional funding for health and social care. We know that the Scottish Government had committed £100 million to that. The first tranche was £50 million funding and then followed up by another £50 million. Judith, in your comments to the convener, you mentioned that funding would be made available and that it was a positive aspect. However, we have some concerns raised in regard to the submission from Edinburgh regarding the funding received that is not sufficient to meet the full cost of paying the living wage uplift and, as others have mentioned, lessons learned report, where some concerns have been raised. In a number of questions, are you confident—not just yourself, Judith, but others, given the witnesses—that resources will be made available to meet the additional costs that are identified in respect of health services, which the IGB has responsibility and has been mentioned in social care services, which the IGB has responsibility also? We have worked very closely with Scottish Government colleagues over this in relation to—and with our health colleagues and with our local authority colleagues—in relation to the costs that are additional to our core costs as a result of Covid. We are capturing those as we go. We have resolved the issue in Edinburgh in relation to the living wage, and we are working on being able to provide that with our partners. The IGB agreed that on 24 August, and it has been agreed by the Finance and Resources Committee in the City of Edinburgh Council and is now going to the full council to be discussed and one anticipates agreed there as well. The living wage aspect of that has been addressed in Edinburgh, and we are looking forward to being able to pay that to staff. I think that the challenge of sustaining the Covid costs is going to be a very real one. I think that our job here as health and social care partnerships is to be really, really clear about where our additional costs are being incurred and making sure that in partnership with the councils and with the NHS that we are capturing that and discussing those with Scottish Government. I think that in relation to some of the challenges around their sufficiency, I think that that probably relates to the unknowns in Covid. We do not know how long this is going to go on for. We are seeing some increases of the incident of the virus in some communities. There is an issue of the length of time that we are going to be working in in this period. I think that some of the issues in relation to its sufficiency are very much related to the unknowable aspects of living with Covid and moving through the route map. Sandra White Thank you very much, convener. I just wonder if any other witnesses have any comments to make on that particular aspect of health services responsibility. No one else wants to come in on that particular one. If not, I will move on to my statement. Michael Russell I think that Vicky is suggesting perhaps that any traceer should respond in addition to that question. Vicky MacKinnon Thank you, convener. I think that there are a number of issues around the funding. We are an IGIB in total. I anticipate that there will be a £9 million extra cost to us this year in terms of funding. Just now, that is sitting at a net cost of about £6 million to us. That is not all direct IGIB, because we also run many panierser services, so the Covid hub, etc., was all included in that. Those costs are all included in the mobilisation plans that have been put to the Scottish Government. Indeed, later this afternoon, we have a feedback session in the Scottish Government around that. However, there are also a number of other things that we need to consider that are really required. To sustainability payments to our social care partners, we need to make sure that they are able to be sustained, because if they are not sustained, it will just end up with, first of all, poorer care for people who receive their services, and secondly, it will be at greater cost with public services having to pick that up. How we work together to do that is going to be one of the issues for us. One of the other issues that is again one of the unknowns that Judith spoke about is what it will mean for how long it takes to do each individual's social care visit in terms of putting on PPE and taking it off and still providing people with that level of care, the same with our community nursing services. The same intervention has taken longer to deliver in those cases, and we need to work out what that will mean for us. The other areas that are important for us are changes in ways of services. Just now, if our day services are limited for both adults and for older people, we are having to change that to care at home services, and often that is a much more expensive model to deliver and make sure that people get that. It is also not the same, because people are not getting the same social interaction, so we are going forward. How we deliver social interaction for some people who have been getting that in a different way are going to be some of the costs to us. There are, as we know, the known knowns, and we are all working through that by mobilisation plans, but there are also a number of unknowns for us at present, and I think that there are some of the biggest concerns for us just now. Thank you, convener. Just to build on comments from both Eric Fraser and Judith Proctor, the issue for us moving forward and certainly the cost of pre-mobilisation has had extensive work undertaken in connection with that, and certainly the cost for Dundee City is sitting at around just over £16 million of the national funding. I think that we have had about 1.5 released so far, so we are entirely dependent on some of the assurances given at the outset about being able to respond to that level of financial risk. We do incidentally have a series of papers that have clearly been put forward in our local systems, outlining the detail of that if that is of interest to anybody. The essential added issue that I would like to highlight is really about the next period of the Covid response and balancing that with demand that we will see naturally through the winter season, particularly with the increasing flu immunisation programme and other immunisations that will hopefully come on stream. More than that, it is about a sea change in those people who are now requiring capacity for community based care. That has absolutely changed throughout the period of this pandemic. People are confident and people are asking for their care to be provided wherever possible in their own homes or in community settings, so we as an entire system need to be able to respond to that level of demand and we need to retain some of the new developments that have emerged throughout the process to enable us to do that. Beyond that, I think that we are now all seeing signs of a significant increase in demand for support from mental health issues and a huge level of anxiety across the population. This will undoubtedly have an impact not just in terms of mental health but in terms of physical health in the years to come. We need to prepare ourselves adequately to respond to that and inevitably there will be a resource implication of that level of demand for us all. We need to understand those risks now and, to a certain extent, we need to undertake a fresh GTG needs assessment so that we can plan for that accordingly. I thank you very much for the hard work that has been put in there and thank you all for the work that you are doing. We are talking about responses. What is the mechanism for passing on resources for your cells and for social care? You mentioned the fact that you have had Zoom meetings, etc. When you are speaking to the Scottish Government, whoever has given you the money, do you have the responses that are being allocated and being quick enough to cover what you are asking for? I know that one of the challenges that has certainly been raised by our colleagues in the third and independent sector has been about the speed at which the sustainability payments have been able to be made. Obviously, those have come into our organisations. They were passed on through NHS into local authorities. Our colleagues, the chief finance officers, had undertaken some work, so, as far as possible, we were able to make a similar process in all 31 health and social care partnerships, bearing in mind that a lot of providers work across multiple partnerships. We wanted something that, as far as we were able to make it, was familiar in different areas, because there are different circumstances in different authorities, different IJB areas. We developed a process. Obviously, we have to be mindful of our due diligence and our responsibilities for the public pound. We did try, in that process, to make something that was as light-touch as we could make it in relation to the release of the funding. We asked providers to inform us what the funding was for and to give us some evidence of their expenditure and the use of that funding. We are certainly now, in my partnership, releasing increasing amounts of the funding that is due to our providers. However, I know that it was certainly a concern from providers and provider organisations early on that it just wasn't coming out. I think that they did feel that it was unfair that they were being asked to undertake some processes of evidence that they maybe felt that we weren't subject to. I think that we have, indeed, had to demonstrate and justify the additional funding that we are using as well. Certainly, speaking for Edinburgh, we are releasing the funding now. Thank you, and briefly also from Eddie Fraser. Just to say that funding and support has come in a number of different ways, one of the ways in which the Government has been really welcome is with NHS support around PPE, so that direct delivery down through our local PPE hubs. It has really been funded centrally and can be right out through the whole system. That has been really welcome in terms of what we are doing. At the same time, there have been other areas so locally when we have been buying PPE through the council. This is all a matter of trust, so we have spent £2 million in buying PPE directly through the council on the trust that that will eventually feed back through, but we have still went ahead and done it. There are two things there. First of all, about the trust in terms of going ahead and doing it when it needs to be done. Secondly, there has been other funding mechanisms as well in terms of support to the social care sector, in particular, through PPE that has been really welcomed. Thank you very much, convener. I know that time is short, and perhaps I could just give a written question, but for clarification, exactly what process you go through—I mean, I have had the NHS mentioned, then I have had the IGBs and the local groups—I just wonder what hoops has got to be put through before the funding actually gets to the people who are asking for it, and that is what I was looking for. I know that time is short, but perhaps you should write in and let us know. Is it the same for all IGBs? Maybe just briefly, Judith, if you could indicate whether financial report requirements have changed and whether any of those changes might become permanent. In terms of the question about the process, I am sure that we and our SCFO colleagues could provide an update on the process and the mechanism by which providers are asked to complete a form. Tell us what the additional funding is for and be able to demonstrate that when we release the funding. That is the process for that. That is obviously the additional funding for Covid costs. I am sure that we would be happy to just admit that separately for your information. That would be great. My final question, convener, if that is all right. Integration authorities are really, really important that you have mentioned. You mentioned earlier about working closely with NHS boards. Has it worked very well for you in developing the remobilisation plans? Have you had any problems in that respect? I think that our experience around the remobilisation plans has mirrored much of the earlier work with the original mobilisation plans to some extent. All of that work has been done essentially as one system. I think that the drafts have been submitted to the Scottish Government. Each of the IGBs have also referred back to my previous comments made around that kind of fuller strategic needs assessment that has undertaken a really thorough exercise in terms of remobilisation, really in terms of being able to point towards the future, in terms of service redesign, but also with on-going requirements and accountabilities around the on-going response to the pandemic. As Judith mentioned earlier, we still do not have the end insight in relation to that response. I think that, certainly from my own personal experience in my system in Tayside, the relationship is being positive and the outcome is being positive. I think that some of the gains that I mentioned earlier, particularly around lots of people practising for the community focus, lots of specialist clinicians now providing care in people's own homes in collaboration with general practice, we want to retain all of those elements with the remobilisation plans. If there is anything good to come from this, those are the aspects that we really want to hold on to. I know that my colleague Eddie Frazer has also had a very integrated approach in AERSHA, so I do not know if he would like to add any comments. Eddie Frazer, briefly. Thanks, convener. As Vicky said, it has been a very integrated approach to the point that community and primary end, we wrote that end, we jointly with our acute colleges, done the unscheduled care part, a colleague in North Ayrshire who leads in mental health wrote that part of it, so we have been fully integrated in terms of how we do that and put that together. Indeed, it has been one of the things that we are putting together that we are not only looking at immediate response but also looking at how we go forward in terms of that, because some of the things that we have learned here have to be things that we learn for the future. There has been lots of care being able to be provided in the community. One of my GP colleagues called it that she was able to do today's work today. What she meant by that is that she could speak to her patients, she could then phone up a specialist clinician and get advice back from there because there was space in the system to do that, and it saved big long waits for patients and things, so there is real learning that can go on from here. There are some of the things that we have tried to reflect in the mobilisation plan. How do we maintain the good things that we did? I think that throughout our reviews on that has to be one of our big focus. Brian Whittle Thank you. Good morning to the panel. I will talk about financial empowerment. In previous committee work, looking at the integration of IGBs, a repeated theme has been the lack of progress towards that financial empowerment of the IGBs. In fact, the MSG has set out the concerns in this area as well, and I think that one of the things that I noted there was focused should be on outcomes, not on which public body put the pound in in the first place. Therefore, what progress has been made in achieving financial empowerment for the IGBs, or do individual parts continue to be influenced by where the money came from in the first instance? Michael Matheson I wonder if I can ask Judith Proctor to ask a third question. I think that we have made real progress in this. I was thinking when the question was being asked, good examples of just that financial empowerment. I think that financial empowerment comes at the end of the role of the IGB as the strategic planner in setting its direction and setting its ambitions out. If I give an example of that, not necessarily a coded example of that, some of the work that we have done in Edinburgh in shifting the balance of care so that we are able to provide more services in the community, the IGB set a direction to deliver a home first approach, where we were very much focusing on supporting people in their own homes initially, or if they were in hospital for a period of treatment, being able to get them home or to a homely setting as quickly as possible, so that we were able to reduce our delays, but more importantly, supporting care for people in the right place the first time. The board set that direction, set its ambition and, through that, we were able to decommission acute care beds within the Western General Hospital in Edinburgh and take that investment, take that funding and increase our hospital-at-home service and our home first capability. That came from the IGB's strategic planning independence, its role as a public body, and then our role as officers within the health and social care partnership, working very closely with colleagues in NHS Lothian to make that a reality and make sure that we had the right pathways in place, so that individuals could go home and that we had the services there to respond to that. I think that financial capability comes from having a good strategic plan, an agreed direction and then the good relationships and the way that we work with our partners in delivering that. Ultimately, we have delivered a better outcome through that. We have enabled better capacity with an acute. They can now use those beds for other necessary acute services. We have built capacity in the community and, as a result, we have improved outcomes for people and we have improved our performance. Brian Whittle Thank you, convener. I would be quite interested to see, quite frankly, if there is any other response from across the other IGBs, if that is the feeling that they have as well. If I could ask the next question that I have here, which is related to that question, on whether the IGBs consider that they have full control of the resources that are available to them or, as I said previously, which partner provided the funding to dictate to some extent where the money flows back to health and social care? Michael Russell You know the ability to flex money across the system. Obviously, when money comes to us, there are big parts of the system that are quite fixed, if I can say that. There are parts of the system. In my budget, I spend about £15 million a year in care homes, I spend about £20 on care at home, etc. Large parts of that are going to roll over year after year. The same is the large parts of the budget within my health budget that will roll over my community nursing, my health visitors, year after year. Where we are seeing an ability is we have been able to do things a bit differently and therefore free up money. When we have been able to free up money, that is when we have been able to move it around. We have been able to move more money irrespective of where it came from across to intermediate care. We have been able to move some more money towards the front door of our social care services, which means that we spend less there. Some of that money has been health money, so we are bringing allied health professions across to the front door services. Where we show real successes is that the interface between the health and the care services. There are still large core services that work out there that are big parts of the budget. We cannot move and likely should not move because they are really good services. However, how we do things differently is the area that I am starting to see that works really well. The areas that are more difficult is that we work in a system in Ayrshire and Arran where there is an underlying deficit budget. It is hard at times to move other than very clear business cases that show that how do you move money that actually costs less for a better outcome for patients? That is some of the work that we continue to look at and do. Thank you very much. Brian Whittle. Thank you. I was just looking at the financial data for 2019-20. I could go to speak to Eddie again here. I notice the unusual words here of underspend for East Ayrshire of £2.4 million. I wonder if you can maybe comment on underspend, Eddie, and where you see that being allocated. Eddie Frazier. Some of the underspend is a few years ago because we had an overspending in our children's services. The council gave us a loan at that time, so we are repaying some of the loan back to the council. That is again within the integration scheme of how that should work. We are also then investing money as we go forward in our care at home services and our intermediate care services. The areas that I said that is what we are freed up to do, the areas that we can do that. One of the other real areas of focus and areas of challenge for us is around our understanding of the challenges around mental health and addiction. Therefore, what we are able to do is that we have created another service around mental health and recovery, and to make sure that we focus on that. That is a real issue for us, and that is an ability of an IJB to work together to focus on that. It is about how we take our money and invest it towards the areas that we know that are challenges for us. The evidence session 11 of August 2020 was highlighted to commit to the issues around inbra health and social care partners' financial stability. When the Scottish Government responded, it said that it would continue to work closely with the inbra IJB to understand their financial position and provide necessary support where it is needed. Can I ask, then, what on-going support is being provided by the Scottish Government in respect of achieving financial stability in Edinburgh? How will that financial balance be achieved in 2019-20? We achieved balance last year. We set out a significant savings programme, which we delivered. In fact, we over-delivered the savings programme that we set out last year, but we had to achieve balance in the year using some reserves and one-offs within the health and social care partnership. I would add that that is the first time that the IJB in Edinburgh has achieved balance in its budget under its own steam, with the funding allocated to it in previous years. In fact, in every previous year, before then, there has been additional funding coming in at the year-end from our partners. That was progress. We are very cognisant and aware of the challenges of our financial position. Our opening position this year was a £23 million gap, and we have agreed a savings programme that addresses that over the short, medium and longer term. We recognise that the true financial sustainability comes not from year-on-year savings plans, but from setting out a strategic change programme and a strategic plan that creates a right-size organisation that delivers services in a sustainable way. That is the approach that we are taking with the board. We are in the process with our board of developing that longer-term financial strategy. We go into this year with an agreed budget, with an agreed savings programme, which, when achieved, will again deliver a balanced position towards the end of this year. It is going to be a significant challenge to do, but we have got our plans in place and we have got the governance around that. In relation to the support from the Scottish Government, we worked with them over Covid. They supported through the work with PWC some work with us on provider sustainability. We have a large number of providers that we work with in Care at Home in the city, and we really wanted to work on how best we co-ordinate that and how best we spend our commissioning funding as a partnership in part to help us to achieve better outcomes for people, but also that financial sustainability over a large part of our budget, which is the services that we purchase for individuals for packages of care. That piece of work with the Scottish Government has come to an end, and the support that we work with with the Scottish Government is just ensuring that we are in close contact with them on our position. In terms of financial and practical input, that has come to an end with the work that we did with PWC. Finally, if I could ask Dundee, he had an overspend in 2019-20 of £5.3 million. I wonder whether, in the next upcoming financial year, the budget might be balanced. Thank you, convener. We are certainly making progress this year in terms of the financial balance of the IGB and putting in lots of plans in terms of developing more sustainable responses across all service areas. The major pressures for last year came largely in responding to demand for social care. Clearly, the additional resources that I mentioned earlier that have been required in response to Covid will exacerbate some of those pressures, particularly in responding to some of the issues that Eddie also highlighted in terms of mental health services, but responding to some of the key service changes that we need to make as a result of the Dundee Drugs Commission will be really key within the city. However, we are certainly making progress in terms of our financial position and working with evidence from lots of other areas in terms of which aspects of service need to go through a level of reform to be able to get us into a more sustainable position. I recently joined Dundee Health and Social Care Partnership in February as previously the chief officer for Angus. It is very clear to me that the demands certainly in a city environment in Dundee are very different from the previous area that I had accountability for. It needs some time to be able to work through the responses and to work through the financial settlement that we need to agree with both the local authority and the NHS board to be able to respond to the pattern of demand that we are now seeing. David Thomas Thank you convener and good morning to the panel. Has it been an estimate of a cost to clear the backlog and return to pre-Covid levels of activity and performance? What estimates have been included in your plans? Who would like to have a go at that one? Eddie Fraser When I earlier indicated that I thought that it would cost us an additional £9 million in terms of Covid, that is us projecting for the whole year in terms of the immediate costs and the pressures. It does net off because there have been savings in other places to about £6 million, but much of that is dependent on our model going forward. The public have reacted a bit differently than maybe we would have anticipated. Some of the public who are getting some of our lower-level services are essential preventative services. They have been quite frightened to take some of those services and they have backed off some services. One of the things that we need to look at is to make sure that we do not only take into account the health part of the support that we give, but also the social part of the support that we give. I think that that is essential and that is where we are working jointly with councils that will not just be about funding in relation to IJBs, it is about how that funding then flows through to some of our social care in our community services and their relationships. How do we get back to lunch clubs? How do we get back to people actually engaging together in the type of social settings that is a massive preventative service? I cannot give you an exact answer for that, because this is about how we change what we do. I think that we could go forward and we could provide, likely separate from Covid within a budget, a clinical service, but it is not the social care service that I know this committee is also looking at in a separate thing, about what is the meaning of social care services and the value of the social care services as well. I think that that is where we need to get the balance of understanding what we can provide and what is that preventative inclusive provision that we want to provide. The cost of things depends on what our ambition is and we are very ambitious to be able to do that, so we spend more money on that preventative social inclusion end and people live the healthier lives and do not need as much of the clinical side of it for us. Thank you. I guess that it is important to distinguish, in terms of the use of the word backlog, that most of the activity that is delegated to the authority of the IGBs has continued throughout the pandemic, with a few small exceptions, and I can come on to that. We have not in the same way potentially that the acute sector has posed some of the elective activity, got a huge backlog in terms of responding to people's care needs. What we have done is responded to people's care needs, but certainly in some circumstances provided that in a different way. There is one area in particular that there is a cause of concern at the moment, and that is the additional demands that have been placed on carers, particularly carers who were looking after people with very complex conditions and were initially in the shielding category. Some of those did choose to pause some of their packages of care to prevent additional people from coming into their home and exposing the members of their family to additional risk. Again, at that point, we did not really know what length of time we were all dealing with, so we are now in a position where we are going to have to look at all of those needs individually and assess how we can safely start to re-provide some of that level of support. Indeed, that is already happening. The other unknown entity here is what we call the bubble, if you like, of post-COVID activity. We are starting to see a lot of additional demand on our services now that it is not Covid-related. Some people describe it as deferred activity, but those are people who are now presenting in the system who need our care assessment treatment and support but have been delaying that for fear of exposing themselves to risk by entering into our health and social care systems. Again, we do not have a figure on that yet, but many of the cases that we are now seeing are more complex and will therefore result in an increase in costs. However, just to reiterate Eddie's point, in terms of remobilisation, we do have—each of the partnerships has a figure in terms of what that will cost, and we can provide that level of detail if it is of interest. Thank you very much. I am sure that it will be indeed of interest. Yes, it was very brief. I am aware of committee's time to endorse my colleagues' comments and add that one of the other elements in this that I think we are all very aware of is about the increase in the burden of poor mental health resulting from Covid lockdown, anxiety and so on. We are beginning to see some of that, and again that is in the unknown categories from our mobilisation and remobilisation plans, but we are anticipating those increasing demands on our services. Thank you very much. David Trotl. I have my final question, convener. I probably know answers from all the panel members, but on balance over a whole financial year, would you expect additional costs from Covid-19 to be offset by reductions in expenditure elsewhere? I think that we have heard from many numbers of £9 million and £6 million. Can I ask Vicky and Judith briefly to comment on that question? Our additional costs do sit at £16 million, so I am afraid that I cannot see that being offset by reductions in expenditure across the public sector elsewhere. We are also in a position where many other parts of the public sector are experiencing loss of income across a range of different service areas, so I cannot see that being entirely offset. Again, we are dependent on the additional support that was outlined at the beginning of the pandemic from the Scottish Government to get us through this point. As a collaborative leadership exercise, the public sector needs to understand beyond the lessons learned reports that have already been commissioned, what it takes to provide a sustainable service post Covid, and to do that, I think that we all need to do an integrated piece and a fresh strategic needs assessment to be able to use the resources that we have to the best of our ability. Thank you very much. Judith Butler. It would be the same. Our Covid costs are estimated at around £32 million for city of Edinburgh, and that will not be offset by a reduction in activity elsewhere. As Vicky said, we are also losing income at the same time, so I do not see that being offset by a reduction in activity. Thank you very much, Michael George. Thank you, convener, and good morning to everyone in the panel. I would like to ask a similar question that I asked of NHS Ayrshire Marn last week. The pandemic and the lockdown that followed appeared to have resulted in a number of innovations in the way that you work. You have already mentioned some of that today as well, but NHS Ayrshire Marn said last week that the pandemic itself quickened us. We have some information from Valkirk IGB, when they replied to the committee's survey. It is acknowledged that Covid-19 presents a unique opportunity to excel at trying to shift the balance of care in light of the available capacity across the health and social care system. I will ask my first question, which would be, in your experience and in your IGB—is this the actual case—has this happened with you guys? It is nice that my colleagues fair share narrative to reflect some of the work that we have done earlier. We were very involved in that interface. We spoke about time before, so that Covid hub that we set up, we did that within a fortnight. At that time, we had a number of GP practices shut, so we were able to bring GPs in. We were able to set up tents for people coming through and really deliver an innovation. The core of that was about setting up the different communications right across the whole system. It is that communication that I said earlier, that we cannot lose. We have been able to take things and to be able to see how we can do things differently and make sure that patients get good access to service, early access to services and other types of things that we need to make sure that we cannot lose. The communication right across the system as we move forward into this winter around the redesign of urgent care will largely be based on the things that we have learned over the last number of months. Again, if we can see that diverse and sizable number of people to a place where they get care quickly, whether that be pharmacy first, whether it be at a GP practice, whether it be advised directly from one of our hubs, but saving people going and waiting for four hours in an emergency department to get seen by someone for 10 minutes. That is not for me to protect in the emergency department. It is for me to make sure that people get the right care in the right place. I think that the other things that we have learned are that we need to take forward and make sure that we continue to build on that. That is the process of redesigning of urgent care that we are looking at just now to do that right across the system. George Adam. Yes, that is quite interesting, Eddie, on what you have said. Earlier on when they came last week to NHS, they more or less said that the pandemic itself had broken down the barriers. It might be a frustration that you feel, Eddie, but my question to them was why did it take a worldwide pandemic to break down those barriers? I suppose that we all get into this thing about chicken and egg, who is going to invest first to save later, and what that did was across. In Ayrshire and Arran, we are essentially working across at least seven public bodies. We have got the three councils, the three IJBs and the health board, and what we were able to do is just sit down and agree. It was under my team that we put together the Covid hub and so on. We just agreed to put ahead of service here and said do it. Some of that was helped by direction from the Scottish Government that freed us up to say that we were able to just do that. It did take that freeing up, if I can call it that, that feeling that that joint purpose, that necessity to drive forward, and that was built again on that level of trust around funding that funding would come to pay for all that. We drove forward, and it has been hugely successful in terms of what we have been able to deliver. We are not only doing that, but we have delivered beside that on testing. We hopefully will deliver beside that as we go forward in flu immunisation. We will deliver on it in terms of Covid immunisation, hopefully. Those things have all been driven together out of that core trust at the start that we can do things right across the whole system. Thank you very much. My final question would be to all of you. It would be basically how these new innovative ways of working, how do you feel that once we move forward and things go back to whatever is the new normal now, how do you feel that you will be able to retain them and keep these relationships going and ensuring that you are still delivering in a very similar manner to what Edith has already said? Well, my view would be that I hope that everybody has learned the value of that level of collective activity and seen the outcomes that are possible when people do work together in an integrated way. So I think it's not a case of let's wait and see whether we're able to retain some of that. I think that it has to be retained. Edith's reflections on just how prepared everybody was to step in and do the right thing has been mirrored across all the communities of Scotland and certainly within Tayside. I think that somebody mentioned the word pace earlier. I was personally quite taken aback at just how quickly new arrangements fell into place, just how quickly all of the barriers that we've experienced before certainly were no longer barriers and everybody was prepared to play a part wherever they could and I think that extends beyond the health and social care family. That extends to our local resilience partners as well who even with very practical issues helped us put the Covid hubs in place literally over the space of a weekend within days of the pandemic being confirmed. So I think surely our collective experience has paved the way for us wanting to retain that level of integrated working. I think there is potentially one risk and the risk is in terms of remobilisation and I guess the pressure that will be put on the individual partners who make up the partnership to resume activity that was in place before the pandemic and that may in an unintended way encourage some partners to revert back to the ways of working that we had in place before but I think we've put so much work into an integrated response particularly through the local resilience partnerships that we're mindful of that risk and hopefully we won't return to recreate some of those barriers that were present. Yeah I would agree. I think we don't wait and see. I think we're intentional about what it is that we're keeping and we put that in place. I think we also need to be mindful on that of the view of people and communities and make sure that we're capturing that so you know the use of near me technology I mean I've been around health and social care for an awful long time and it seems like for an awful lot of that time we've been talking about moving to things like near me video conferencing we did that in a matter of weeks it's been an incredible pace of change and I think we need to know and to be able to demonstrate that for the people that are using that that are experiencing the delivery of their health and social care service through that that it is as good or indeed better so there's that aspect of it too but I think we need to say these things are things that we must keep so therefore let's find ways to do that let's invest in that let's think about how we we we shift our our way of working to do that so I think for me it's that twin process of lessons learned looking at the evidence really understanding that the experience for people and outcomes for people are as good and or indeed better through those new ways of working that we need to to to be mindful of. Thank you very much and now call my colleague Emma Harper. Thank you convener good morning Judith and and Eddie and Vicky thanks very much it's been interesting here the responses so far and just to pick up on George Adam's questions about innovation is interesting and the response about near me I'm interested in kind of looking at where that fits in with shifting the balance of care and set aside budgets and I've asked questions about set aside budgets in the past and how do we move care from acute care and into community because we know that integration authorities are really important to move care into the community from acute care I'm aware that some of the innovative models that have been picked up into Fries and Galloway have been looking at using what's called home teams to go out and and help support people who are in the community and I'm interested to hear from you whether you think that changes from the pandemic and pandemic planning can expect to see a complete long term shift in the balance of care between hospital and community care those that would be a question for you for you all really start with Eddie Fraser so I think you don't look yes because before we spoke about how do we maintain things I think one of the groups of people that are really important in this is the clinicians so for clinicians both acute and primary actually see things can be done differently and better then that helps us with that you know buying in terms of how we change the services so part of what we are doing I can give one example around respiratory care is actually seeing how we can pull a lot of that work down into the community from hospitals so as people get that support in their locality rather than transfer into acute hospitals so I think you know everyone in principle agrees with people getting care as close to home as possible but just now I think what has been evidenced is that that can happen and it's that evidence of that being able to happen is what we need to maintain you know the ability of not only our acute clinicians but also most of our GP practices are now looking at how do people access the GP practice you know how do you do that differently so again you know we've went to you know high levels of telephone contact and people are happy to get that if they're getting it on the day you know but there's still that 30 to 40 percent who need to come in and see the GP and that's fine so we're seeing a real change in how things are happening and it just now certainly in my area we've been able to see some shift of money from hospital to community but that's been around the things that's been within the IGIV's control so it's been around our community hospitals and how I changed that you know to date you know and although we have a programme of caring for air so that is a longer term vision it's been hard up till this time to actually see a shift of any of the acute budget across I think just looking at bed nights as well is a very crude measure that at times when people have used at that it's about the totality of the hospital how do we look at outpatients you know how do we look at you know the ED how do we look at a range of other care in terms of that that shift so there's been success but some of that success to date has been within things that we are in our control rather than being across the whole system for me. I would use again the example that I mentioned earlier we've had some success in relation to you know closing or decommissioning services and acute wards we've closed two wards so far one at the western general one at the royal infirmary and with the investment that sits in the set-aside have invested in community services for people that have enabled us to support people at home in a homely setting so that investment has been around allied health professionals that sort of re-ablement rehabilitation capacity in the community and community teams to do that and one of the rapid developments that we saw over Covid was something that was already in our plans and we've done a couple of test events with home first as an approach which is very much around as I say how do we support people to be at home so hospital at home where we're able to do that to prevent admission to hospital if we can with the clinical wraparound with the care wraparound and then at the other end where an individual has had to be in hospital how do we support them early conversations working to a discharge date not working from a delayed date when people are already delayed in the system and making sure that we've got the flow through from that conversation into to good robust community services so some of those things and we've been able to do some of them as Eddie says are one in our gift because they are our resources but we've worked very hard with NHS Lothian to realise a shift in investment small amounts at this moment in time but you know that they do matter and I think they do signal a possible way ahead and again echoing Eddie's comments they show us as organisations and they show us as professionals and clinicians that it is possible to do that and to do that safely for people and to achieve better outcomes for them and care in their own homes wherever we're able to do it thank you so just to add to both of those series of comments I think when it comes to large hospital set aside even even prior to the pandemic we're starting to see some signs of movement in terms of the level of financial resource that was indicated as part of our financial settlement for this year but I think it really goes beyond large hospital set aside I would agree with comments made by my colleagues about this is essentially about how we do things and it's how our frontline practitioners practice and I think if I can share with you the first principle of our remobilisation plan from Dundee IGV and that is that people will only attend buildings for assessment treatment and care where there is no alternative available and that's purely because we're still in the period of risk that we are about the risks associated with people being in enclosed spaces but really that's an indication of where we should be striving for in terms of our future intent in terms of the provision of care and whereas previously I think we've had really really robust relationships with a bunch of specialties in the acute sector who are aligned to the IGV such as our meds of the elderly consultants and psychiatrists and a range of other respiratory clinicians we are now seeing a growing number clinicians who provide very specialist support now essentially providing particular assessment but assessment and care in a community setting we've mentioned near me but some of the technology isn't always required and lots of consultants are now providing advice doing initial assessments by telephone for instance and have adapted really really well so we must we simply have to retain that and it would be a real shame if we reverted back to a system which is really quite heavily weighted independent on buildings and infrastructure to provide the level of care that we can provide particularly as Eddie's highlighted where we've experienced a difference over the last few months and for many people access has actually been improved it's very different to what they've experienced before but many people are able to get advice on the day not only through their general practice through a range of other community professionals and indeed in some cases right through to the specialist who's who you're usually in quite a long queue to see in the acute sector so we really must retain that and I think rather than use all of our energy trying to negotiate a better set aside deal I think we now need to bank if you like the credit that Eddie's alluded to in terms of the difference that clinicians have seen in practicing in this way and we need to build on that for the future. Thank you for those answers. Previously at committee we heard that set aside budgets was held by the NHS boards or controlled by the boards when actually set aside is supposed to be used for other purposes so and because of the pandemic you're describing things like respiratory pulmonary rehabilitation is now virtual we've done virtually we've got issues with cardiac or cardiovascular rehabilitation which would be done more in the community as well and so I'm interested to hear whether there's going to be an impact on the set aside budget or do we really just need to look at a completely separate way of using that budget and basically directing it completely for community based support programmes to deal with post Covid symptoms like it's been described long Covid so I'm wondering so has there been any impact on the set aside budget and do you think the set aside is working effectively or has coronavirus in the pandemic meant that we need to do something different with it? Just as you know before Covid we had been working very closely with Scottish Government across the partnerships about how we use and use the word yourself there directions so how do we jointly with colleagues get up and say we are going to change something and this is the impact in terms of strategy in terms of service in terms of finance so for instance we have a new pulmonary rehab team and interestingly the funding for that came out the prescribing budget you know we were able to do things so differently there that we made significant savings and some of that went to savings but the rest of it went to fund a pulmonary rehab team and that that use of very deliberate directions you know from IGIBs to both the health board and the council is a way forward and so it's not just around the set aside budget the set aside budget is important but on my total budget the set aside budget is only about 10% of my budget and you know some of that will always require unscheduled care within you know the hospital so the actual free amount of that is even less the important thing for me is that we do these directions that's a clear saying we want to change something this is what we want to change and why here's the service implications and therefore here's the financial implication of that so the examples you give are great examples and they are the things you know around respiratory cardiology diabetes the things that we think can likely be done more in a community setting but not always based on often we base this set aside on bed nights and a lot of this won't be about bed nights it will be about you know how we look at you know our outpatient appointments and the range of other interventions that we have there so I do think Covid has helped us to show that we can do that differently and again it's working with all our clinicians to make sure we deliver that sorry yes I would agree with Eddie I think the focus is on what it is that you want to do and what you want to change and then the budget should follow from that but it's setting out the intention through your strategic direction and an actual direction from the ijb so I absolutely agree with that focus needs to be on what it is that we're trying to do not the budget itself per se yeah just to mirror those comments mirroring those comments I think it's it's fair to see that the original intent of set aside has maybe felt a little bit clunky I can't think of a better way of describing that over the duration of the last five years and I don't think it's the only lever for change that we have it's also only if you like a slice of the acute activity that we want to tackle in a different way and in an integrated way and so I'm far more interested now in having discussions about the total resource I'm not going to use the word total budget because I think you see change through people but if we can have a really up front adult conversation about the total resource where that needs to be how we can genuinely shift that balance of care into community after the experience we've all just lived through then I think that's why we need to focus our attentions rather than trying to increase the figure that is nominally indicated in our set aside budget thank you just a final question convener vicky talked about refocusing for instance instead or re-resourcing so we've seen a lot of redeployment of people working from home and changing the ways of working so we'll have people that were normally based in acute care that are now maybe working in a more community focused way so how has that been able to demonstrate that ultimately that's a saving on bed nights for instance if we're keeping people out of hospital by supporting them in the community and I'm just wondering how adaptable has the workforce been to this relocation of service or refocus of providing service in a community type way so from my experience certainly the answer to the the question around adaptability is is that we've seen huge efforts from those who've been redeployed from an NHS background and also local authority background into new roles in community settings some of those new roles were aligned to new services which we needed to put in place I think colleagues have mentioned earlier on again at pace we had to set up community testing functions and testing facilities which in Tayside and Dundee certainly began with a very small number of people and grew very very rapidly to need quite a lot of the workforce redeployed and to have the skills to testing and to keep up with the level of demand that we had and a whole series of other services have had to be delivered in an entirely different way and in people's own homes that you would expect to see normally in an inpatient setting so lots of the workforce if you like were redeployed to be able to support that I think I think it's fair to say that as we're moving into the recovery phase now lots of people are being if you like called back to this substantive posts because they need to be part of a recovery period for services affected so there is quite a bridge for us that needs to be formed here to ensure that for the new roles that we did commission and bring into the community we need to identify those which we actually need to keep you know that there are new services which have formed throughout the pandemic and there are some of those services will feature in the longer term they're not just an immediate response to demand so we need to understand what those new services are and we then need to have the conversations across the agencies to ensure that we retain those skills and those people in those roles but it's actually quite a significant exercise for a standard take. I think we saw extraordinary flexibility and agility from our workforce and in our own lessons learned capture in Edinburgh the lessons learned piece of work that we did you know from those that that wrote back to us one of the things that many in our workforce really valued was just their ability to be flat flexible and the the different areas of work that they were able to undertake and just the empowerment that came with that and I think that's something that we definitely need to capture you know just being able to to work flexibly with our workforce you know within their terms and conditions and being fair and supporting them and supporting their health and wellbeing but people enjoyed that feeling of flexibility and empowerment in that and just your point in terms of being able to to measure some of the the difference that this has made we certainly saw through through some of the approaches that we took as much as a 63 percent reduction in bed nights lost to delays over this period of time just by us being able to work differently to support people in communities and support them at home. I think we absolutely must capture that hard data as well in terms of the difference that we're making because if it worked in Covid it will work in in winter it will work in a pressure that's that's under that's sorry in a system that's under pressure and so therefore we must do that and it's the right thing to do to be supporting people at home I think Vicky said it earlier on people are really keen now to to experience as much of their care and support as as possible in their community and in their homes so we need to to demonstrate from you know people's experience the hard data as well as what our staff are telling us that that is possible to do and to do well. Thank you very much. David Stewart. Thank you convener and good morning to the panel. I've read a series of questions about delayed discharge in their lessons learned report the scotch government and health and social care scotland and say the causes of delay are in a quote compounded by deep-rooted behaviour issues and bad became the norm. Do you agree? I wonder if I could ask perhaps Judith Broddon to start off. It's quite a statement that isn't that bad became the norm because I don't believe that anybody in our system whichever professional role that you're undertaking comes in to do their job and to not do it well everybody is focused on what they think is the right thing to do for individuals. I think one of the issues that we see with with with delays is that we can just be a little bit too focused on our own lines on that and not really thinking through you know what does the individual here need and what are they capable of. I think there's also something in relation to you know what you know and I think that that that quote from the lessons learned report possibly reflect a view where some partnerships and some of us see the decision being made on where an individual goes post hospital being made by clinicians and professionals who are not familiar with what we deliver in social care and what we deliver in the community and the capability of that. Now I don't know if you would typify that as bad or typify that as you know you can't know what what you don't know and you don't have experience of and our whole approach to home first and it's not unique to Edinburgh they're doing it I mean particularly Tayside Dundee where my colleague Vicky Irons is chief officer you know these are well developed programmes of work where individuals who know the community and know the capability in the community work with the individual in hospital and they pull them from hospital into the community. So I think if my memory serves that's what the the comment in the lessons learned report means and those behaviours in and of themselves are not meant to be bad but I think they do reflect where you stand in the system what you know and your own professional experience and that's the bit that we need to shift we need to make the norm you know it's people at work in the community that work with the individual and their family and their community to help decide how that individual is there then supported in the community. How were additional funds used to reduce delayed discharge in new respective areas? Thank you so our additional funds weren't necessarily targeted to reducing our delayed discharge figures within Dundee we were in a good starting position I think to reflect on my colleague Judith's comments there in terms of our ways of working with the exception of potentially funding some of our more complex care packages so we had a relatively small number of patients in the way at the beginning of the process and each of the assessments in terms of movement of any of those patients was done on an individual basis with our multidisciplinary team and so we weren't required if you like to deploy huge additional resource into that area with the exception of those with some more of the complex care packages and that was really just to ensure that we had the resource available to provide every aspect of care that had already been assessed in terms of the needs of those individuals I think where we have used not sure if this was part of the question but where we have used the additional resource is in increasing demands for care at home those have come quite naturally and we've also deployed a lot of extra resource into rehabilitation services and again that links back to previous comments about still the unknown entity in terms of potential tale of Covid and the recovery of a number of the people who contracted the virus in the early stages. From a very strong place in terms of delayed discharges you know we've not had a delayed discharge breach with any ashramarran for many you know years actually the couple that we've had have been out with the board area and so we have an embedded you know social work team you know within you know the hospital that works very closely with the wards and including mental health officers to draw people out. What we did do was we anticipated that there may be issues about being able to deliver social care in the community you know during Covid and so people who would normally be discharged we thought there might be problems with that so we did commission some extra social care you know like capacity for us to be able to make sure that we drew that down so it was almost about preventing people becoming delayed discharges rather than actually having to deal with delayed discharges as such that the whole you know like hospital at home you know model or intermediate care models of discussion and across these are slightly different things but they are the discussions about how do we make sure that expertise is available in the community and right in the very front page of that lesson learned you know that there's a quote and it's a quote we use all the time this is not about delayed discharge this is about transfer of care people need to be confident that the care of a person has been transferred from a hospital to a different services they are not falling off a cliff you know that it's a safe transfer of care that we should be talking about and I think that you know people the attitudes that were spoken about earlier about you know why people think that somebody you know has to go into a care home when they don't really know what it is we need to make sure that we give confidence that there are good community resources that people can transfer the care to without having to rely on you know getting to a care home if that's not absolutely necessary and sometimes it will be. Thank you my final question and as the panel will know there was a sharp fall in delayed discharge between February and March but the Scottish figures are on the rise again can we sustain the fall and can the problem be eliminated altogether? Thank you yes and we have witnessed an increase certainly over the last fortnight within our local partnership in terms of those numbers so I believe we can sustain our performance in relation to delayed discharges but it may be linked to the journey of the individual prior to admission and I would hope that with all of the additional focus that there is now in a community setting we're reducing the numbers of delayed discharges by also reducing those people who need to attend and be admitted to hospital setting in the first place so we can sustain some of the success so far. I think what we've witnessed particularly in the last couple of weeks is in response to that bubble which I mentioned earlier on and again not necessarily a good description of what's occurring but we are seeing a general increase in demand across the system now for people who are presenting with symptoms unfortunately those people who may have had a deferred level of illness if you like are presenting and they're sicker and potentially more frail and with more complexity of needs so that will have an impact in terms of our ability to discharge people quickly and into the setting of choice but we literally monitor our performance on a daily basis across the partnerships in Scotland so as soon as we get an idea of what some of the key issues are or the key conditions are I guess more than anything else we'll be responding to those to ensure that you know we we do make the most of the gains that we've seen throughout the pandemic in terms of our performance and that we don't if you like snap back into the characteristics that you would have seen pre-covid. Judith Bromberg Like others we have seen an increase and we got to historically low levels of delayed discharge in Edinburgh where we have struggled with this over a number of years and that was down to the mobilisation plan doing things differently also of course because our hospitals were focusing almost entirely on Covid so we saw a significant change in activity and those things together I think certainly addressed the delayed discharge position our numbers are as others going up we would want to sustain them around about where they are now because until we do things very differently at scale I don't think we can eliminate delayed discharge in Edinburgh I think we're working very very hard to make sure that we've got processes in places I say our home first where we have a team that works in our acute hospitals it includes our mental health hospitals as well for those people that are are delayed long term for very complex problems and working together there we also need a sustainable community care service and again the fragility of the market somebody we haven't touched upon but obviously they'll be subject to the independent review that's a real issue for us and we don't know the impact post Covid as providers come through this and sustainability payments are tapered off so there's many many factors that make delayed discharge a complex one to say that we can eliminate it we would certainly be ambitious too because it's the wrong thing for people and people are harmed by being delayed in hospital when they're ready to go home and we really want to be able to get them home as soon as possible so we are keen and working very hard to sustain it at the still historically low levels for Edinburgh and not see a return to some of the the the high numbers that we we've had before but I don't think we can eliminate it before we see those significant large system sustainable changes that we're all trying to do through our strategic plans so yes we would intend to to sustain you know the very low levels you can never totally eliminate when we call it delayed discharges are not you know i'm mean in anyone who's delayed from the point of being able to be discharged I don't mean you know the cut off at the two week period because sometimes it takes time to make arrangements and although we do the best we can to make the arrangements you know look before you know a person's ready for discharge you know this is a bit you know that the human rights aspect of this as well about if a person chooses where they want to go how do we make sure we get them there now we still do that very quickly as I said so it's not about becoming over the two weeks but the numbers of people that will take between three days and you know 14 days there will be some that will be around that you know in terms of that so it's a bit balancing that the rights of people first of all the rights that they do not be harmed by left in a hospital when they don't need to be there but also looking at their wider human rights and making sure that we engage with them and their family about the discharge arrangements so it's not about any of these long delays it's about short delays whenever possible and making sure we get people to the right place at the right gear thank you very much and that concludes our questions to witnesses in relation to pre-budget scrutiny can I thank you with Proctor Vicky Irons and Eddie Fraser for their evidence Vicky Irons mentioned that there were figures in relation to remobilisation that might be of interest to us and we'll certainly look forward to receiving those and no doubt there'll be one or two other items that we will come back to on but can I thank the witnesses very much for your attendance and for your comprehensive answers this morning thank you we now move on the second item on the agenda is subordinate legislation consideration of a made affirmative instrument as in previous weeks these regulations relate to coronavirus and international travel and are laid under section 941 international travel of the public health Scotland act 2008 they are made affirmative instruments that means that they are already enforced but they have to be approved by a resolution of the parliament within 28 days of the date in which they are made and it is for the health and sport committee to consider the instruments and report to parliament accordingly we will hear in a moment from the justice secretary in relation to these instruments and once we have asked all our questions we will have the parliament debate on the motion that he will propose the instrument we're looking at today is the health protection coronavirus international travel scotland amendment number 10 regulations 2020 and I welcome to the committee Whomza Yousaf cabinet secretary for justice who is accompanied by Rachel Sunderland the deputy director for population and migration division Jamie McDougall deputy director of the test and protect portfolio and Anita Popleston head of police complaints and security I will look to colleagues who may have questions and I draw the attention of colleagues to the letter reply from Whomza Yousaf received on the third of September following a previous appearance where he answered a number of questions and I know Emma Harper had raised questions two weeks ago in relation to ferry travel and passengers alive in Scotland and I wonder if Emma Harper would like to follow up on those questions. Thank you convener and good morning cabinet secretary it was just to comment on the response regarding ferries and the detailed response in the letter from the cabinet secretary and also I've checked on one of the websites for one of the ferry companies between Ireland and Cairnryan and they have really detailed information as well so I wanted to just comment and say thank you to the cabinet secretary for his response with the detail in his letter. Thank you very much and I noted in relation to that that the cabinet secretary noted that passenger locator forms are completed by passengers arriving by ferry in Scotland and also presumably in Port Celts where in the United Kingdom for travel onward to Scotland and I wonder cabinet secretary if you can indicate the kind of detailed information which Emma Harper referred to from the ferry operators can also be made available by yourself to the committee. Good morning convener to you and all the committee members forgive me for any of the background noise you may hear as there's a bit of building work going on. I am more than happy of course to provide Emma Harper and the committee with detailed information that we have of passengers arriving by ferry ports into Scotland that information can be made available we can get that from Transport Scotland if you wish we have information around entry into ports at Scotland we can also where possible we can inquire about ports of entry in terms of UK ports of entry I know there might be an interest in for example the ports of Dover and Calais and the number of passengers that travel from there what what I would say is when it comes to those that are arriving in Scotland regardless of whatever way means or method you choose to travel into Scotland if on your passenger locator form your destination is Scotland you end up in the cohort of data that can be and will be sampled by Public Health Scotland so regardless of the way you travel in by air by sea but by any other means if your destination is Scotland then you are very much part of the pool that can be accessed and sampled by Public Health Scotland. Thank you very much cabinet secretary that the instrument that's before us today is of course in relation to the addition of a country to the exempt list and a number of regulations that you brought before us have involved either adding or removing countries from that list now when we spoke to you a couple of weeks ago one of the questions that was asked was the way in which these additions are brought forward to the attention of Parliament and in your response you noted that wherever possible we are trying to align with the other UK nations in relation for example to implementation dates and also to those countries which are on the exception list. However I think it's fair to comment that there remains a misalignment at least on a short-term basis between different countries within the United Kingdom in that regard and I wonder if you can give any indication of the ongoing work that you may be doing to seek to achieve a position where the message to travellers and the travel industry from the four nations of the UK is as far as possible the same message in terms of what the implications of quarantine requirements might be. I think that that is fair comment. I think that there is a degree of alignment of course where we can but clearly there are areas where there is not alignment. I do think that it is important to stress and I saw a good piece by the journalist Peter Smith on ITN around actually why there shouldn't be too much confusion for travellers because we've had obviously as you know can be not only too well over 20 years of the evolution and so therefore the reasons why one part of the United Kingdom, one nation of the United Kingdom might take one decision may well be very understandably different to another part so if I gave you the example of, for example, the removal of Greece that we took last week and I see that other parts of the UK have removed some of the islands in terms of exemptions to Greece. When we made that decision it was very much based on the circumstances in Scotland so the number of positive cases and of course community aware of some of the rise in positive cases, the number of positive cases that were linked to international travel from Greece was giving us concern in a Scottish context. That may not be the same case for Northern Ireland, it may not be the case for Wales, it may not be the case for England and therefore completely understandably one nation in the United Kingdom in this case Scotland, you may well take a very different decision to the others. To answer your question a bit more directly, you may have seen the announcement yesterday from Grant Shaps, Secretary of State for Transport in the United Kingdom Government. He gave me a call just shortly before his statement to say that the JBC, the joint biosecurity centre, will look to now see if they can bring forward data on a more regional approach. I know that the committee has asked me previously whether or not we can look at that regional approach. I have only seen the data for Greece that came in yesterday. My understanding is that the JBC will provide data on a number of islands and we can consider that on a regional basis, which again may help with alignment. We will try that four nations alignment as best we possibly can, but for very understandable reasons there may be occasions when that alignment is just not possible. You did indeed in response to our letter saying that you were continuing to discuss with the UK nations the adoption of a regional approach. Wales has been doing that for some time. The UK Government in relation to England made that announcement yesterday. Do you anticipate a similar announcement in relation to Scotland in the near future? I could not say until I have seen the real detail of the data. Wales only took the regional approach last week and it would be for the Welsh health minister to explain why they took that decision in particular. Even if we have the data on regional variances of the transmission of the virus, what we have to have confidence about—I did not mention that in the previous committee opinions—we have to have real assurance about the travel that happens between the mainland of a country and the islands, because we know that that can be where a lot of the danger lies. However, to answer your question, I will certainly look at the data on where we can have an original approach that is effective. We will look to do that, but clearly you will understand particularly the cases that we have in Scotland. In the rising cases that we have seen in Scotland in the past few weeks, my approach will still be a fairly cautious one. I look to colleagues, but for my own part, I have one more question before we move to the next item of the agenda, which is the debate on the motion before us today. In our previous discussions and in correspondence, you said that you were considering the possibility of publishing on a weekly basis the public health Scotland statistics of those who have recently arrived from abroad, who have developed symptoms or who have tested positive. I wonder if you have yet come to a conclusion on that consideration and what your plans are going forward. The conclusion is that we should publish the statistics. We are just finding a way to do that. That will protect people's privacy, because a number of the positive cases that are linked to international travel are simply one person travelling from a country. Therefore, with a very small number of flights in a week—sometimes even just one flight in a week—there could be issues around identification of that individual. However, they are not insurmountable issues, so we can absolutely work through that. I will give that more or more—I will argue on that consideration, but I will speed up that consideration, because my instinct and my desire is to make sure that that data is published and there should be no obstacle that we can overcome to publishing that. Thank you very much. I look forward to hearing further on that in the day's mix ahead. There are no further questions from colleagues. We now move to agenda item 3, which is the formal debate on the made affirmative SSI in which we have just taken evidence. I remind colleagues that we are no longer in the question-and-answer mode, but in the formal debate mode, and equally officials may not participate at this stage. I invite the cabinet secretary to speak to and move the motion S5M-22521 in his own cabinet secretary. I am happy to wave any rights to speak to the motion. Colleys are there of the detail of it, but I am more than happy, of course, to wish to move the motion S5M-22521 in my name. Thank you very much. If any members wish to contribute to the debate on this motion, if not, that will conclude the debate, and I will therefore put the question. The question is that motion S5M-22521 be approved. Are we all agreed? Thank you very much. A concludes consideration of this motion, and we will report to Parliament accordingly, and we will move in a moment into a private session. I suspend this meeting, and we will resume at 11.50 on a different platform. Thank you very much. I suspend this meeting.