 Good morning, and welcome to the fifth meeting of the Health and Sport Committee in 2018. Can I ask everyone—I'll do it myself as an exemplar—to make sure that their mobile phones are switched to silent, and while you may use devices for the purpose of social media, please don't record our film proceedings, we have our own people who do that for us and they are all publicly available. We start with the first item on our agenda, which is a round-table evidence session on detect cancer early. This session is part of our wider preventive agenda inquiry. I'm Lewis MacDonald, I'm the convener of the committee and an MSP for North East Scotland, and I'll ask everyone please to introduce yourselves around the table starting with Ash Denham. Good morning, I'm Ash Denham, I'm the deputy convener and I'm an SNP MSP for Edinburgh Eastern. Hello, I'm Janice Preston, I'm a head of service for Macmillan cancer sport in Scotland. Good morning, I'm Miles Briggs, I'm a conservative MSP for Lothian and Spokesman for health and sport. Good morning, I'm David Morrison, I'm a consultant in public health medicine and director of the Scottish Cancer Registry. Hello, everyone, I'm Alex Cole-Hamilton, I'm Lib Dem MSP for Edinburgh Western. Good morning, I'm Jenny Goliath. Oh, sorry. You go to get her. Yeah, go. Good morning, I'm Gregor McNeill, I'm the head of external affairs with Cancer Research UK. Good morning, I'm Jenny Gilruth, I'm the constituency MSP for Midfaith England Office. Good morning, I'm Emma Harper, I'm one of the South Scotland MSPs for the region. Alison Johnstone, MSP for Lothian. I'm Bob Steele, I'm co-director of the Scottish Cancer Prevention Network. I also chair the UK National Screening Committee. I'm Annie Anderson and I'm director of the Scottish Cancer Prevention Network. That's at the University of Dundee. Good morning, Ivan McKee, MSP for Glasgow Proven. Good morning, Christine Campbell. I'm a reader in cancer and primary care at the University of Edinburgh. Good morning, I'm Brian Whittle, South of Scotland MSP in Scottish Conservatives, spokesman for health education and lifestyle and sport. Good morning, Sandra White, MSP for Glasgow Kelvin. Good morning, I'm Ewan Paterson, RCGP Scotland and XGP in Govan for 30 years. I'm Dave Stewart, MSP for Highlands and Islands region. Thank you very much and a warm welcome to all of our guests this morning. Can I start the questions by asking about the rationale for the detect cancer early programme, which clearly is, at least in part, in relation to late diagnosis and late presentation in Scotland compared to other countries? Do you ask witnesses for any views regarding what contributes to that late diagnosis? Please just indicate and questions will be through the chair, but just indicate when you're having a bump. I think that there are a number of reasons for this. It's partly due to the fact that many people will delay going to see their GPs with symptoms, but it's also partly due to the fact that in some cancers, symptoms are not good indicators of early disease, which is why we have screening programmes in breast cervical and colorectal or bowel cancer. I think that there are two main issues here. Do you have a view as to why Scotland relatively shows a greater tendency to late presentation and late diagnosis than other comparable countries? There are various issues around levels of deprivation, and we also have to think about the actual causes of cancer. Scotland has traditionally had behaviours that are not conducive to cancer suppression, so there are diet, smoking habits and lack of exercise that have contributed to the large incidence of cancer in Scotland. Excellent. Are there other witnesses who would like to ask a question? I'm still raised around what we describe as the patient interval, so for the time for a patient for spotting symptoms to then presenting a GP. That interval can sometimes be months and even years. Are you asking about Scottish differences in that regard? I think that international evidence will point to UK differences, which are grounded in our relationship with the NHS in the UK. There is a uniquely UK view that we don't want to overburden a system that we all hold in very high regard, and I think that that plays out in a lot of the evidence. If we are looking for more Scottish-specific issues, a lot of public opinion testing will discover a strand of fatalism that exists in deprived areas in particular. There is a healthy level of fear that is required in a population regarding cancer. We want people to hold it in some fear in order that they present, but when it drifts into fatalism, that becomes disabling. We hear concepts such as the big sea and cancer means curtains or even that I'd rather not know. Those sorts of concepts are particularly prevalent in deprived areas in Scotland. I think that DC programmes have made some efforts at challenging those, but there is obviously a long way to go. A general practice perspective working in government for many years, not just the absolute deprivation, but the gulf that exists and is increasing between the haves, people like me and the have nots, a lot of people that I was trying to serve. Not only does that induce fatalism, but there is a loss of purpose, a loss of hope, just what is the point, and that can be extremely frustrating and very difficult to overcome. We could struggle to get people to go back for review who have been diagnosed with cancer. It's that bigger problem, so I think that underlying this, I suspect that a lot of this is global inequalities, and we see that particularly large in countries like the UK and the US. Christine Campbell. My colleagues have said that related to that is the issue of literacy and health literacy, so we deal with the wider context of people's lives where, yes, there is fear and there is fatalism, but when we try to address that through information and awareness campaigns, it is really important that the language that is used is appropriate, and that is where a lot of DCE efforts have gone in, in different ways to try to address giving the messages in a way that people will take on board. Thank you very much. Sandra White. Thank you very much. It's just a small follow-up of someone who was born and given, and we're there and still have relatives there. I know exactly what you mean in that respect in garden fatalism. I just wonder if we should perhaps be putting more effort into the fact that, because you're diagnosed with cancer, certain types of cancer doesn't have to be a death sentence. We should maybe put that forward more rather than, okay, we have the screening, which is great, but the fact of the matter is that, you know, Mick Millen and others, you can actually live with cancer. Do you think that we should be maybe putting more resources into that message, particularly in certain areas? I think that we've got a lot of insight across the UK, in the fact that people in Scotland are more financially stressed. I also think that we've got a bit of insight from Easterhouse, where we did a public health study a few years ago of health improvement, where people said that they didn't trust health messages. So I think that there's something when health messages are made national that doesn't reflect what you see out your window, and there's something about making that real to the people that live there, building that trust and working with communities. Can you take Alex Cole-Hamilton and the others? It's an extension of this wider point about attitudes to health messages, and I think particularly in deprived communities, but actually in all communities, certainly around cancers affecting the bowel and the genitals, I think there's a natural embarrassment about seeking help, and we try and break that down through national messaging campaigns, but we still don't seem to be getting it right. There was a report just last week about uptake of cervical screening based on the fact that women are embarrassed about being examined in that way. How do the panel think that we could be doing better in breaking that embarrassment down? Back to prevention, really, in terms of messaging, because there's a huge gap in terms of raising awareness about preventative action for cancer, and that's not covered by DCE, and it is a huge gap within this country. There isn't a person who's been diagnosed with cancer who doesn't wish it could have been prevented in the first place. So, while your question is very much about after diagnosis, but we must think, Ella, in prevention. I'm sure we'll come back to the prevention. Gregor McNeill, did you want to come back on that previous question? Which was around challenges to presentation where it involves invasive tests. I think technology has a lot of potential solutions around that, so in the cervical screening programme there are pilots going on one in Dumfries and Galloway around home testing rather than having to present a clinic, so that involves you doing it yourself rather than having a nurse do the test for you, which obviously will break down barriers for some. I think the next win on the horizon, if you like, is around the ball screening test and the new fit test, which is on stream now, but that involves taking one sample rather than three, and evidence is showing that that breaks down a lot of barriers for particularly men, particularly those in deprived areas, and we would really impress on the Scottish Government to give that test a real push and make sure that the public are well aware of that change and how much easier it is to do. Janice, I think that you wanted to come back as well. I think that we've got a grown amount of evidence that suggests that the venue in where you have some of the discussions does not need to be within a health setting. I remember a couple of years ago when we launched a service in Renfrewshire in the libraries, people came in and saw the kit and started talking about it, realised it had posted a couple of months before and started to inquire about it. So there's just something about making it more visible and having those conversations, so I think our work with libraries across Scotland now is demonstrating and people have quoted many times to us. It feels like a safe space and where there's barriers may be going into a health environment. Actually, our community spaces are spaces that we need to use more. Alison Johnstone. I have to confess that my question is about prevention. So we'll come back to you. Thank you. I want to add to the previous discussion of a particular relation to embarrassment. That's a huge issue. There is work going on across Scotland. We in Edinburgh do some, but do so to colleagues in Glasgow and many other places. It's really trying to do qualitative interviews, with men and women in different communities to understand some local issues. One of the key things is the power of narrative, the power of stories. If people see someone like themselves either at a health forum or at a local event or in their supermarket talking about having been screened, having done the kit, that's a very useful avenue. I know CRUK's local primary care engagement trying to do a lot of that sort of thing too. Miles, I think that you had a question. Thank you. I wanted to expand the point that Janice just made there in terms of how we could develop that further. Is this something that we need to look at in terms of planning as well to look towards community health hubs so that people have that forum to be able to discuss this and different charities could use that space? In terms of taking messages to people, is there a way potentially for us to link in the bookies, for example, where you might be more likely to have a conversation with someone there? What sort of work is on-going or examples that the panel would know about where we could do that here in Scotland? I think that from a... Is it okay, Van? From our perspective, I think that there's a... there's lots of evidence now to suggest that the improving cancer journey in Glasgow, which we're spreading to Dundee in Fife just now, and other places, and hopefully in partnership with the Government, that actually is engaging with 80 per cent of the people in the most deprived areas, so the people that are taking it up are from those areas. So there's something about that community venue and shared community space that makes that easier for people to access. Once people... 61 per cent of them come from Depcat One, and what we're finding three months on, if you do that needs assessment of all their needs, their financial, their practical, their emotional needs, as well as their clinical. Three months on, they feel able to self-manage and their growth and confidence is enormous. So that point in time, I would say, is when people are receptive, not just them, but their entire family. So I think there's something about building on that teachable moment, that point in time. But I think absolutely those community spaces and how we use them cross-organisational and collectively, I think, would be a huge plus. Sure, supplementary Sandra, point. Just a small and picking up on Janice's point in my constituencies in Glasgow, Kelvin, like the Annex and Partick, et cetera, et cetera, to capture mostly men who don't tend to go to their doctors. It's a drop-in centre, cup of tea, play of dominoes, whatever it may be. They're used to going there, so you think we should use these facilities more because they're not going there to a health centre. They're going there that they would normally do once or twice a week, but they've got the access to testing or whatever that's there. Absolutely, I think men's sheds or places like that are ideal. But we mostly use volunteers, so it's people in the local communities who vote in other people, managed by the libraries, but actually going wherever people are. Mercin, do you have a view on that area? I suppose more from my past experience as a screening co-ordinator, I think one of the challenges is actually we need technology that's better. We all know that the screening tests in all their forms are in various ways embarrassing and uncomfortable. One of the positive things about the new fit test is that it is easier to do and quicker. The real practical challenges that people have to take about motion sample and to do a screening test have been, I think that's one of the reasons that men, and to be honest, people who are less resourceful find it quite a challenge to get everything together. With cervical screening, we can all fully understand just what an embarrassing and sensitive area it is. I think that there's also a challenge in the medical profession to be thinking of developing future screening tests that are just basically more pleasant and easier to do. I will welcome when we find an easier way to do screening tests that just don't impose nearly so many barriers on people. Thank you very much. Andy Anderson. Just coming back to community approaches, I was one of the research team who designed football fans and training, which is a weight loss programme carried out through the Scottish Premier League. I know that various charities have been working, like Balcansard UK, to try and raise awareness through football clubs. There clearly is a huge opportunity there and a door has been opened through football fans and training. In terms of cancer awareness, it would seem an obvious route to go. I know very well from Aberdeen and I know other parts of the country as well. On the impact of detect cancer early, one of the things that was striking was evidence that there was an increase in consultation without necessarily an increase in diagnosis. I think that Ivan McKee had a question on that. Thank you very much, convener, and thanks to everybody for coming along this morning to talk about this very important issue. On that point, if you look at the data over the last number of years, there has been a stage 1 diagnosis. The number has increased very slowly and very limited progress has been made there. For example, if you look at the data on colorectal cancer referrals, you see a significant increase in the referrals but hardly stability in terms of the number of detections. Is there an issue about targeting the wrong people or is there an issue about the way that GPs are dealing with that? What are people's thoughts on that? I think that this is a really challenging issue. The problem, particularly with bowel cancer, is that the symptoms of bowel cancer are symptoms that everybody gets every day. Brechtel bleeding, abdominal pain, change of bowel habit, they are common symptoms. Very rightly, there has been a drive to increase awareness about those symptoms. The problem is that lots more patients go to see their GPs and the GPs are really faced with a situation that is almost impossible. They have a patient with symptoms that could be due to bowel cancer and they don't want to ignore them. There is a drive to use the fit test at a more sensitive level to help GPs to make a decision as to whether or not that individual should go on to invasive testing. The problem is that if too many patients go to have colonoscopy, for example, what it does is it clogs up the waiting list so that people who actually need it are delayed in getting it. I think that what we have to do is be more clever about having tests that will help GPs to make a decision on the patients that they have to deal with when they come to them with symptoms. You're in power. That was part of the nice guideline group that looked to the revision of referral for suspected cancer. Now, okay, that doesn't cover Scotland. That's an England and Wales issue, but I was there through RCGP. One of the things from that is just that even symptoms that you would think are really, really, really serious have a fairly low predictability for actually turning out to be a cancer. Diary on its own is less than one person. The PPV is 0.94. It's a tiny, tiny number. Big things, even bleeding, is not that common the first time around that you see it. I think that it's one of the areas where the term that I think is used well by Mark Marshall is that the GP is the boundary specialist trying to sit across these boundaries and work out exactly what to do with incredibly complex situations. The complexity comes not just from the complicatedness of the symptoms that are presented, but the index of suspicion that arises from the fact that this is somebody who never comes to see you. Therefore, the fact that they have come, all the hackles start when the antenna starts to wave. That is borne out of serial longitudinal encounters and continuity, which in turn, apart from giving that narrative that was talked about earlier, which is so important, also hopefully will engender a degree of trust and start to break down some of the embarrassment things. It's probably easier for an old man to have me examining his bottom than somebody's never met before. That's the reality, if at all. To do that, though, you need an adequately resourced, an adequately staffed general practice workload. I do mean general practitioners, because I still think that the real deal with doctors is that when we were at university, we were trained to make diagnosis and plan treatment. The rest of it is a bit of a bolt-on, but that's the real deal with doctors. Expecting other people to take on that diagnostic role outside of continuity, outside of relationship, I think will present some significant challenges and may adversely impact on detect cancer early. OK. Ivan, do you want to come back? I understand that it's a complex system that the relationship between what you're saying is symptoms and whether or not it is cancer is complex. But a lot of that can be modelled. Is there enough data there in terms of understanding where you need to look and where your best percentage of finding it is based on what you're looking at? I would direct and come on to the cost-benefit question. One of the things that was striking was that a lot of the responses said there isn't much in the cost-benefit analysis going on. Is that something that we might need to be better at, understanding where to put resources to get the maximum effect? Who would like to respond to that? On the point behind putting things together and I suspect that the idea of symptom A, B, C, D and E coming together, the work that the NICE guideline did would suggest an urgent referral for suspected cancer if the overall positive predictive value was above 2. So that would mean that 98 of these people that were referred did not turn out to have cancer. So the hit-rate is pretty small. That's again the reality. The additional danger then is that if you target resources into ensuring that these people are seen timuously, which is incredibly important, but it means that people who've got a PPV of 2.5 wait for an inordinate length of time before they get seen. They're not quite bad enough, but not okay group can get a really raw deal if we're not careful. Did you want to come back? That's right. There has been a huge amount of work done in trying to look at different symptom complexes, but it's not very effective. The most effective tool that we have, as NICE has picked up at the moment, is using a sensitive test for blood and stool. Because if someone does not have blood and stool, the chances of having serious disease are very, very small. So it's just something else in the mix. So when you have a simple blood test for prostate cancer, for example, is the argument that that should be more widely extended or that it should be more targeted? We're talking about the same test that's used for bowel screenings. It's actually looking for blood in stool, except set at a much more sensitive level just to pick up very small traces. So there isn't any peripheral blood test that will be helpful in that context. You said in response to Ivan's first question that we need to get smarter at identifying who we should be targeting. How can that be done in the context of what Ian Patterson has described? A combination of symptom complexes and testing, and at the moment the best test we've got is a test for blood and stool, and I think that sort of combination is probably the way forward. It's about assisting GPs. It's not about telling GPs what to do because, as we've already heard, GPs are professional people, they're doctors, and they make sensible decisions. Gregor, please. We can also look at the context of once referring patients on how we can gain efficiencies within that side of the system, so it always helps me to understand the context that GPs are in when we think that 8 to 10, there's only 8 to 10 cancer cases a year on average out of 68,000 appointments, so that's what they're trying to sift through in terms of cancer. When it comes to referring to secondary care, there may be efficiencies to be had about perhaps offering more direct referral pathways for GPs so that they can themselves refer directly to some diagnostic tests where currently you'd be looking at a model of going to someone in secondary care, then making an assessment, perhaps on a conversation again with the GP, again with the patient, and we hear anecdotally, and there is data behind it, you do get patients to bounce around through the system, so there's probably a value to be had there and building capacity in the system and also improving patient experience in that regard. David Morrison. Just to pick up the question of cost benefit which I know was raised in my understanding of cost benefit is that it's quite a broad thing, you've got a set of costs and you've got different kinds of benefits and you can put costs against those. I think that helps to open up the debate about where our resources might best be put in terms of the primary prevention as Gregor has said, making the systems more efficient to get people through to an early diagnosis and to be treated effectively and what we can do to make the experience of cancer a less onerous one and difficult one. So that cost benefit is actually a big question that is a more tight question about cost effectiveness which is if you've got one effect which is how can you detect cancers as early as possible, what's the cheapest way of doing it. I think that's what we've been rehearsing so far. I think that question and the use of the word cost benefit is quite a useful one because it starts to raise that question about where in all of the experiences of cancer can we put our different resources and we need a distribution of resources because we can't do everything at every point we can't prevent every cancer we can't cure every cancer and we can do something to palliate cancers that we can't cure. I was going to add just a couple of points in relation to the discussion one is that I think we have to think of not a long long term agenda but certainly not a quick fix so it's important to remember that awareness campaigns for example have to be sustained because the people who us who will get cancer at some point we need to have these messages in mind so there's a need for sustained awareness people take time to absorb these and for behaviour to change eventually we trust through time feed into that broader cost benefit issue but can I just pick up on the issue of health systems because it's important to remember there's research going on both in the UK and internationally to look at still keeping a primary care gatekeeper or boundary role but how triage and redesign of the health systems or tweaking the health system or faster referral of the appropriate people just point out two things there's pilots going on in England around fast track there's a redesign of the Danish primary care for cancer symptoms that looks at high suspicion medium suspicion and low suspicion and there's a lot of evaluation going on at the moment of that particular redesign to see what's the optimal pathway for patients ultimately and there's also the international cancer benchmarking partnership that Scotland is part of that's comparing patient pathways and a number of different jurisdictions to try and learn what we can about optimal design a brave supplementary Dave Stewart Thank you convener I was interested in looking at cancer survival rates across Europe so you touched nicely on international studies last month Lancet published the third Concord study which compared countries across the world in terms of cancer survival rates it's obviously done on a UK basis not a Scotland wide basis and on memory we come out extremely well as far as all cancers for children are concerned around fourth but not so well when you look at Cullen where we're 17 out of 28 there's obviously big comparisons here would the panel like to say why the survival rates are so different in different European countries I think it's really important to realise that these studies and I'm sure that David Morrison will want to comment on this but these studies are not always comparing apples with apples because we have such good cancer registration in this country that we have a very accurate knowledge of survival rates whereas other countries with which we're compared have actually got some of them get very poor cancer registration so you're only looking at a very small portion of the population so I don't know whether the new Concord study has dealt with that or not but it always strikes me as a significant problem that I think we sell ourselves down because of that Professor Steele I think that's a very useful point quick glance at the study there was actually 71 countries being looked at but the figure I quoted was within the EU, within the 28 so we were fourth out of 28 but a lot lower for Cullen so my point of making is even if you look at different types of cancers why are we different even within the EU which has fairly advanced NHS relative to some of the other countries in the 71 I think even within the EU I think in Germany for example cancer registration is about 7 per cent of everyone with cancer so even within the EU these comparisons are dangerous but there are certainly differences between the UK and the Scandinavian countries for example where we are pretty sure that the comparisons are similar and I think it's probably related to fairly simple things like levels of deprivation and smoking rates but I'm sure others will have an opinion I agree with Bob saying essentially these kind of international comparisons Eurocare is the other big international European comparison in cancer survival which have repeatedly shown that the United Kingdom's survival rates for nearly every cancer apart from skin cancers do relatively poorly and the biggest gap of all is in lung cancer where nobody's survival is particularly good, nobody's country average survival is particularly good but the gap in the UK is particularly large and to rehearse what those discussions are I mean as Bob says one of the issues is that at an international level we don't have the fine detail that tells you this is exactly the same kind of patient at exactly the same stage with the general other illnesses and comorbidities that we'd call them that contribute to their ill health so we have to look at a fairly high level and we say could it be an artifact is it just that they're being selective and I think that is true in some countries where the Canadian countries return 100 per cent of all their data so it's not the only explanation but I've done some other work with colleagues in Germany and trying to understand some of their lung cancer patients and who they are out of all of the people with lung cancer who are selectively come to their specialist centres I think it's the same story when you look at information from the United States people tend to report a selective best case scenario then you're left with questions of saying is it that we're getting worse kinds of cancers are they more aggressive in some way is it the general health of the population I think that's some of it but we use a thing called relative survival so you're comparing your population with what you would expect within your own population but general health obviously contributes to people's survival anyway and their capacity to be able to take some of the more aggressive types of cancer treatments so being in good health is a good way to deal with everything else Professor Stirling, that's very useful could I just throw one other comment in I'm not meant to judgment in this comment but Professor Coleman who was the author of the study and I summarise his view suggested that the reasons are different is because that some European countries the proportion of GDP has spent in health are higher and that UK has not spent as much as other European countries now there's a big debate about this I think that Sunday Times is an article higher than normal CPI because of technological changes but he makes one view as the author of the study would you agree or disagree with that? Well that's a highly political question and I'd be cautious about coming down and saying that that would explain everything but it's true I think that as we've rehearsed already there is an element where you're looking at the efficiency of a system that you have to accept that in order to be able to capture patients who might not obviously have cancer and let's face it there's one thing to say that people seem to have symptoms of cancer a lot of people are diagnosed by surprise it's an incidental finding you're not principally expecting them to have cancer that you have to allow a certain throughput a certain amount of investigations to be able to identify people with cancer so trying to be highly efficient and trying to capture people at the earlier stage of the diagnosis is a difficult balance to strike I'm not going to side with Michelle Coleman's view on whether that means a change in our total budgets but there's certainly a cost that comes with investigating more people and accepting that a lot of those investigations will be negative I think one of the things that I like most about to take cancer early is how ambitious it is and the last thing we should do is to drop that level of ambition to be the best instead of concentrating on why we're the worst or one of or how it seems but I think we have a unique opportunity in Scotland to shift this so I think when it comes to cost benefit in particular if we were to change that statistics and the more deprived areas at 29% are diagnosed late whose life expectancy is then very short the benefit to that is to the communities to Scotland as a whole is huge Macmillan as you know we have focused on people with cancer and that's where we invest that's where we focus our time and that's where we will continue to do so but we have a community engagement that is unparalleled by any other national agency the trust that people have in Macmillan is enormous and so there's a real opportunity to get to the heart of those communities and shift that story and if Scotland don't grasp that and it's not by investing in Macmillan the wider collective joining in Macmillan and actually adding to the work that we're doing I think we could shift that with prevention messages with detecting cancer early with screening I suppose it's jumping back slightly which is to the why are we worse if we are indeed worse if it's just about poor registry and poor comparison but if we are and maybe I'm taking a slight leap here but there is good solid evidence that some fairly impressive health and social metrics like life expectancy, maths and literacy infant mortality, homicides, imprisonment teenage births, trust, obesity mental illness including drug and alcohol addiction and social mobility are worse the greater the divide between the haves and the have nots and I don't think it would take much to extend that to possibly why we're not doing so well with things like cancer because these are the factors that will play out in every single health and social situation that every single person in this country suffers with and I think it bothers me that we still seem so unwilling to acknowledge something that seems so staggeringly obvious and will have if that was addressed in part the benefits outside of detecting cancer early outside of preventing cancer would just be enormous Brian Whittle Thank you, convener and you've actually led me very nicely into the area that I wanted to address if I could ask a couple of questions give me, I'll just start off with the influence that the 10 minute GP appointment has on the detection levels and the influence perhaps of poor access to GPs if I could start with that That's coming my way then Looks like it I think the simple answer is that 10 minutes nowadays is woefully short when I started in general practice in 1985 we had 10 minutes and that was more or less adequate in my time in practice the complicatedness of health and care and treatment and decision making I think it felt exponential to me I think we also introduced a whole raft of complexity and in many ways very good things I think far more natural involvement of the individual we were with rather than the doctor knows best and even as a young GP that didn't quite feel right for me but it was still quite prevalent I think 35 years ago but the time that we've got with people hasn't changed at all so yes it's got to be and if you look at the population that we are creating through social interventions through health interventions we are creating a very elderly very frail multimorbid population many of whom will suffer with dementia in the next decade dementia will become the commonest cause of death the majority of people I suspect in this room will peter out in a care home being one of the older men I'll be one of the first so that's the reassuring fact you talked about cost benefit but the cost of providing care to that population that we are creating will be astronomical because these people will require what I would call observed care they will not might look after in the family home it's very difficult to look after someone with end stage dementia in the family home so these people are heading for bed somewhere where? I think that's your next topic that's just a marker for that one so I think that that would be I've kind of gone on a bit but 10 minutes is not adequate I think that sorry I think that it kind of led to where I wanted to go and I think that we're asking our GPs to do more and more and I think it was Professor Arneson who discussed the prevention agenda and the idea that in terms of cancer the sort of smoking obesity, alcohol, lack of physical activity has a huge part to play in this and I think I wanted to look at the social prescribing that we ask our GPs to do and I'm assuming we don't have time to do that so that so the access to opportunity to be active especially in deprived areas and get that advice getting included in society because to my mind if we were active you'd be less likely to smoke you'd be more likely to be in control of your weight you'd have a better relationship with food and drink you know that redress of that fatalism or lack of hope or achievement and to be included and have better mental health so I think in terms of the cancer prevention where are we with that because to my mind that's a big element of tackling high levels of cancer specifically in deprived areas Annie Anderson there's quite a few options in there I think cancer prevention is hugely missed it's the elephant in the room people don't like to talk about makes people feel guilty health professionals say they're not trained in the area and they're there to treat social prescribing is something that is of great interest I don't see it rolled out as widely as it could be at the moment we're leading on the act well programme which is inviting women attending routine breast screening that's women without breast cancer but at a teachable moment where they're interested in cancer to say would they like a lifestyle intervention and we're delivering that within the leisure centres in local areas we're finding that people don't really like coming into leisure centres they're big, they're sweaty and women aren't used to going into them so we're offering that opportunity we're making that link but we're also listening to one part of the lifestyle complexity I don't think it's the sole root to getting people through to thinking about food and drink and obesity is an important part of that jigsaw we've got to get wiser and smarter about how we introduce prevention it should be part of all health professionals role the health promoting health service initiative and within secondary care should be flagging that up primary care have a role but they're busy people and we need to look at the totality of where the opportunities are within the dce work we recognise that screening opportunities for screening are an opportunity for talking about prevention and as I've said in our paper I think that that should be explored we've got evidence that women people like it they take part in it and it's something that we're missing I totally agree with all of that I think that the problem and again this is just one of these great examples where the inverse care law is writ large it sometimes amazed me how much time and effort I would need to put in to try and encourage some sort of lifestyle change and I can be very persuasive when I put my mind to it I really can do that and yet it was a struggle whereas it would be relatively easy to get me to shift my mind and yet you'll have the same more or less the same GP workforce per capita across the whole country whereas in deprived areas clearly there needs to be more time available to make these sort of very complex behavioural change interventions The point I forgot to make about that act well is that the people doing the interventions are breast cancer now volunteers that we have trained up an intensive programme and we've had hundreds of people coming forward to be volunteers so we can develop community capacity on prevention Act was ruling out now but just from the preliminary findings that we've got that's an opportunity we ought to be taking Thank you convener I really appreciate the focus that there has been generally on health inequality and the impact that that has on everything we're doing I suppose I've been on this committee since the beginning of the session and we've done quite a lot of work on prevention and I think the message that's come across loud and clear is that messages are preventative for some people but they seem to be the ones that the messages reach and then they act on them and in some ways it increases health inequality so it's about how we reach those people that messages don't reach and I'm getting the feeling here we also heard I should say from Dr Helen Irvine and Dr Margaret McCartney whose views on screening were perhaps quite controversial that perhaps that wasn't the best focus for money I don't know if we want to go into that but I suppose what I'm hearing from Dr Patterson is that longer appointments could be preventative and I've visited the governship project and the impact of GPs having that bit more time could be a way of reaching people for whom an exercise programme might just be too challenging at the moment and as I think as a signpost into something one of the things that I think I enjoyed the fairly high level of trust from most of the people I was attempting to serve and me suggesting pushing quersing somebody to go someplace sometimes and that might have been an appointment to be checked for something it might have been a screening appointment it might have been a live-active referral whatever and so I think that sort of relationship at the start of all is hugely beneficial and that takes time there was some good work from Scandinavia oh five maybe more years ago and I think it was Sweden consultations between the same two individuals in primary care for a trusting relationship to develop and people then to feel that they could work together and that's a lot of time but that's maybe the sort of time that is needed if we really want to see some transformation going on I would not in any way underestimate the importance of using social prescribing things like the links project again great stuff that's what absolutely it's not only about general practice but I wouldn't like to see it forgotten about I mean do you see a combination of both of these approaches as some of the most effective primary prevention strategies that Scotland could be leading is there anything else that you know we need to point out I think what's missing is every I think all the initiatives are very good and absolutely need supported and continued but what's missing in every submission pointed to it was that we rely on that health interaction and the trouble is that a lot of people don't go there until too late so I think there's something about that working through community so you mentioned the link officer program again we've got two link officer programs so we've got improvement cancer journey which the Scottish Government is committed to spreading with us which is a social prescribing model and it is reaching 80 per cent of people and you have another link officer program that is based within a GP surgery that relies on people going through the door so I think what we're missing is that whole community effort round about if we've got good engagement there how do we build those messages on how do we start to change the conversations in communities how do we reduce the stigma how do we use or save spaces where people trust and use organisations that we trust but just build on them now duplicating any effort so I think you could do more The question about primary prevention because much of what we've been talking about so far is once cancer's developed how can you treat people as effectively as possible and try and cure them let's be positive and say we have achieved quite a lot in terms of smoking which is the single biggest preventable cause of cancers but we still lag behind the rest of the UK so I think further effort is still needed it's an old story but it's still one we need to keep pushing I think there's good news in terms of the minimum unit pricing policy that we've about to bring in in Scotland and we hope to see that bring down consumption of alcohol but as I said in my written submission there isn't a safe level of alcohol I'm afraid there isn't a story there I can reassure you with that if you want to minimise your cancer risks then no alcohol is the best policy and then the question about overweight and obesity I'm just taking three of the most common because there's a longer list we're not doing well on that we're not turning the corner on that two thirds of our population are overweight or obese I think a lot of people don't realise that it's such a major risk factor for some of the most common cancers like breast and bowel cancer so we've I think still got a long way to go both on the old enemies and some of the ones that we've not tackled so far to try and reduce cancers if they're occurring in the first place Can I take Sandra White and then Gregor and then Christy? Thank you very much, convener It was one of the areas that I really wanted to concentrate on was the prevention area and I think, Janice, you know the point there we have been talking about people presenting themselves to the doctors et cetera but I see preventative as being you're healthy enough not to have to present yourself to the doctor and that was the way I wanted to look at it and the opportunities it would give us you know, obviously budget wise I wonder if there's enough money spent on the preventative part i.e. advertising I mean you mentioned Dr Morrison in regards to obesity et cetera if you're from a deprived area obviously to feed a family you'll maybe go to some shops I'm not going to name them which you know a lot of the food is not healthy as well so I just wondered if more educational wise we should be looking at it in Glasgow free entry into gyms et cetera the football that type of thing as well but really to get that message out to the community can we use the child poverty bill that's going through the parliament to link that into preventative you know just how can we use some innovative methods are they actually not innovative but hear about the Mediterranean diet constantly how do we get that across to people that the diet they use and obviously minimum price and alcohol but we should be looking at it to some of the stuff that goes into our food stuff as well and maybe labelling or stopping that as well so I just want to open that but I think to try and prevent it when you educate people into eating better and that type of thing Gregor Morirran I mean I think Sandra second the scene and there's been a lot of good discussion around local projects and a lot of ways we can encourage individuals to think about lifestyle and Ewan's talked about what he can do within a GP setting but is that connection of once they step out of the practice what environment are they stepping into I remember hearing a Governhill deep end GP talking about them for their patients there's no fruit and vegetables within their walking distance I mean that's the context we're talking about so it has to go hand in hand with looking to shift what the academics and the wonks will talk about the obesogenic environment but it's where the unhealthy choice is easier and often perceived as cheaper but actually looking at even the average supermarket which Cancer Research UK is challenging that environment somewhat in terms of high fat sugar salt promotions but actually the cheapest foods are the whole foods so the cheapest way to eat is still rice and pasta and whole foods but there's probably an education piece there about cooking skills also there is the promotion environment so there's plenty science and nudge theory etc that shows how people's behaviours within retail environments do change depending on promotions and what's on offer and at the moment that's balanced towards the unhealthy side of things and that really needs to tip towards the healthy side so these sort of environmental interventions like MUP, like around promotion of unhealthy foods they're also absolutely vital Christine Campbell I move back to an earlier point but it might pick up on something Gregor's just said around our broader prevention agenda and long term thinking and how do we get people how do we get all of us to think about that and I think that's where education is really important so we don't have schools around the table as far as I know but thinking about fizzy drinks thinking about what kids have got available in school there used to be when I was in school health economics that picked up about how to cook well and how to eat well even on a budget colleagues in Stirling and elsewhere have been doing work with the Teenage Cancer Trust on raising cancer awareness among young people without frightening them but with giving the dual message of here are cancer symptoms that you might need to think about but here's broader healthy lifestyle thinking so there's a dual approach there and I come from a university sector and just picking up again maybe on the discussion around a health promoting health service including prevention in the curricula of nursing students, medical students allied health professionals sports the whole sports science agenda so that it becomes part of a broader curricula I think might be some ways forward too Emma Harper I just want to pick up on the lung cancer that David brought up I'm interested in that as I'm the cross-party group convener of the lung health cross-party group and we're looking at a respiratory quality improvement plan for Scotland and it looks like we're going to get a person, Dr Tom Fardon to look at a quality improvement plan for Scotland which actually is working in Wales and Northern Ireland so I'd be interested to hear if you think that is something that could then look at tackling lung cancer even though it's a quality improvement plan that will focus on lung health in general I don't know the details of that so I can't say one of the things to draw out of this discussion I'll start with lung cancer is that what is good for your general lung health will be good for lung cancer so not smoking and not being exposed to environmental or occupational risk factors for lung diseases will also greatly improve or reduce your chances of getting lung cancer because even if you do smoke then the interaction with other occupational exposures can worsen things strategy to improve lung health will be a useful strategy for lung cancer but as we've been talking about some of the other issues to do with things like obesity it's also worth saying in this context that what's good for cancer is usually also good for heart disease and for stroke and for dementia and for a number of other chronic illnesses so that we're not sitting in a silo with cancer here I think a lot of what we're looking for to try and improve the general health population will be good for all of us the answers are of course complex in terms of the question about obesity the foresight report, a superb report and broad thinking but if there's one takeaway message then there isn't a single issue education's not the only answer health interventions are not the only answer it's immensely complex in a sense tobacco is one of our easiest ones because there's no good in tobacco but when it comes to our diets then we have to really understand people have to eat and we have to understand people before we can think of something that's fair Thank you very much I think it's very much linked to that I mean, in the 30 years I worked as a GP I honestly think there was one person in that entire time that I encountered who smoked who had a level of learning disability where they really didn't understand the issue but there wasn't a single other person that I saw who didn't know that smoking gave you cancer and maybe some of the other stuff as well but cancer was the big one that's not enough the message is out there for the obvious one I mean, you know again, it lights around the table very quick but you don't need to answer this question but this is a group of highly privileged individuals okay, so everybody hands up if your BMI is between 20 and 25 your fat index is less than 20% you do your five fruit and veg now we're in no alcohol it's not good news you don't smoke, you don't do drugs and you exercise at least 30 minutes a day so if anybody's actually doing that in this highly privileged room maybe not well, a couple I'll leave now but my point would be that that's two out of about 30 odd people and yet we're trying to suggest that this is an education measure that we need to get across the general community so it's just to be cognisant of that sometimes I'm overinfluenced but I thought the seas of programmes entitled the men who made us fat of about maybe five years ago were really powerful and it is arguably a result of aggressive marketing and consumerism and that's an underlying social malaise but that's what's making people fat Annie Anderson okay, I think we have a lot to learn from tobacco control in terms of other lifestyle factors so it's taken a long time perhaps two, three decades to get where we are in terms of pricing availability and you have to look at how did that happen because it didn't just happen overnight and the legislation that we've got wouldn't have happened if it hadn't been popular enough to get the thumbs up from the electorate so you could argue that the first stage on that was, I'm not going to call it education but I'm going to call it raising awareness of the risk between tobacco use and health CRUK are doing stellar work at the moment in raising awareness around obesity and cancer but we've still got diet we've still got physical activity and we have lived for such a long time in this country with these bland messages about activities good for you physical activity can help to prevent cancer we need to get that message out and be clear about it actually it helps other things as well but let's get the cancer message out and clear that's what the tobacco control people did they raised the bar in terms of awareness and then they got people on board where are our role models where are the health professionals saying we need to do something about cancer we used advocacy from really important people in our communities and we need to work on that before we could even get people saying yeah we ought to be doing about the marketing about the pricing about availability and it isn't just about children tobacco control has always embraced young people smoking and Christine you're talking about children and students cancer prevention is possible for adults we know that even after the age of 50 post-menopausal women we can help to reduce the risk of breast cancer so let's not call it education it's awareness advocacy it's role models it's getting people on board let's not just focus on kids it's the whole population and at any age these lifestyle changes can help to reduce cancer and by the way diabetes and heart disease together just drilling down then on Sandra White's point with regard to education are you aware of any work there's a strategy need to look now more explicitly and I know Professor Annie Anderson I thought was quite powerful there when you said to prevent cancer and I know it's not all about children but Christine Campbell said none of us around about here to do with schools I was formally a teacher in a previous life and you talked about schools banning fizzy drinks for example that's a campaign we've got going in fife at the moment the courier have a campaign to ban energy drinks in school and I think that's a really good example of how schools can take action to try and inform behaviours so it isn't just about school children or younger people who have an impact on people's behaviours that can impact upon their chance of contracting cancer later in life would you agree then that there needs to be more of a connection between health and education because one of the things that the committee keeps hearing is that there is a disconnect between health and education and certainly in our session with Dr Burns he talks about that with regard to ACEs the two systems are not talking to each other they're not adequately sharing information do we need health and education to sit down and audit the health and wellbeing curriculum area do we need to really sit down and look at the detail of that Annie Anderson again I have to confess to being president-elect of the UK society for behavioural medicine so I'm going to use my theoretical basis there yes clearly working with children and parents cancer is a disease that has a life course impact so early years are really important what we see and are seeing a lot in children is that the education now food in particular is very good in Scotland there's a difference between what you hear and knowledge and education and what you do I mean one of my party pieces is in an audience to say who knows the 5 a day message everybody puts it up they've learnt the message how many people eat it it's about 3% so education health is so important as a basis but let's not lose the bigger picture of parents going through every aspect of the life course that's entirely true and I think I'm a huge believer in the teachable moment and that isn't just a person that's got cancer but that family roundabout and I think even in schools there's something about not wrapping things up in cotton wool and just actually using the experiences it'll be in school every day to talk about those things and join up absolutely think you need to ground it in reality somebody told me the other day that kid was getting a resilience training for the second day but they didn't quite understand it if you can ground it in the reality of a situation they're going through we've got a programme in Lanarkshire called give us a break geared in 10 to 14 year olds going through a difficult time not bereaved just change actually at that point in time they are open to uncovering their own strengths and using them and building their resilience but when you teach it in the abstract then they can learn the messages but it doesn't guide it on so I think be bold and use the opportunities in school talk about cancer thanks after dinner thanks convener I'm going to change the topic slightly here because I wanted to pick up on something from the written submission of cancer research UK so it was about this idea of GPs referring directly for tests so obviously at the moment if they have then refers them on to a secondary care specialist who then orders the tests so there is obviously a potential there if the GP commonly might know which test order that they could refer for the test straight away which obviously could potentially save money and obviously free up some outpatient time as well so does everything that's something that we maybe could be looking at in Scotland? I think something should be looked at Scottish Government are looking at one strand of that direct access to CT scans for some vague suspicions yeah I think what we're hearing more and more anecdotally in the data is showing that patients are often bounced around a system to end up getting the test that the GP would have asked for in the first place anyway and so long as we're redesigning systems so it is those patients that are referred directly and it's not a huge amount more patients that don't need the test and again there's strong evidence in some pilot areas where that direct access is being used quite well is not being overused and normal fears you might get in secondary care about the system being overwhelmed are not being borne out so I think there is a lot of opportunity in that area I had a couple of other Ewan did you want to respond to that question? General practice has a reasonable amount of access to a reasonable amount of the test probably covering a lot of the more common tumours direct access for CT scanning which is available in some of the boards but not all of the boards is probably more for people who the likelihood is that the boat has been missed these are people who present with the triad of losing weight loss of appetite tired all the time but nothing much else and clearly there's something serious going on at many data biopsychosocial level it could be anything almost but a quick CT might well get to the bottom of it rather than bouncing in the system but they're probably not going to be people who are going to make a huge difference to their life expectancy Thanks David Stewart Brian Whittle I wanted to go back I mean you and Paterson I touched on it and Professor Annasom touched on it as well around the fact that everybody knows that smoking gives you cancer and there's been such great work done in Scotland around reducing the number of people who actually smoke but when we dig underneath that underneath the data we find that the top 20 percentile it's 9% of people smoke and in the bottom 20 percentile it's 34% of people who smoke the actual people who could probably afford to do that the least so there's obviously something else going on here in terms of I think you touched on the fatalism type thing are we putting enough resource I think obviously we know the answer enough resource into that area to carry on the great work that's been done in this place how do we take that on and actually tackle that major inequality Gregor McMeigh I think you're right Brian to touch on the the idea that health messaging to some of these constituencies is probably not the way to approach tobacco the challenging tobacco use I think a lot of detail bear out that for those whose health health messages we penetrate they probably have given up now and the mission is a harder one in some of those deprived areas and it's probably different motivators required to push on in terms of quitting and that might be around the control that nicotine can take over someone's life so the idea of buying more freedom, more independence in your life and the freedom from nicotine dependency it might be around finances but you're also trying to break what in my cases is quite a social glue in a lot of these post codes smoking is very normal as you point to we're touching 40 per cent so you're sort of challenging very very normal behaviours in that sense cancer research you care are investing a lot in research on the potential of e-cigarettes in that regard so long as these devices are in the hands of smokers we see a lot of potential in terms of moving people from tobacco and so far the data is that they are being used by smokers rather than being taken up by those who are not smokers so we think there's a lot of potential in that area and I think we need to try all we can on what's an extremely challenging area so that would be the one area that we'd probably point to in terms of potential wins Annie Andrew With respect to health inequalities in areas beyond tobacco Beast is a very good example in the paper that we've submitted we do highlight two studies that we've been involved in which brings prevention together with screening programmes so in our Bewell study we for people who'd had a positive bowel cancer test and had been invited for a colonoscopy that had not had cancer but had an earlier lesion so they had a polyp and they had that removed obviously at a higher risk of cancer we offered people the opportunity for a weight loss and physical activity programme which was a very successful paper in the British Medical Journal we've just published something recently to show that there was no difference in response by social demographic group so there's an opportunity we all know that people that come through screening aren't necessarily the whole population people from poorer areas are less likely to come through but we forget sometimes that a lot of people from poorer areas do come through and there's an example of an opportunity they were given something and they responded equally well to it similarly with the actual programme I've already mentioned when we did the pilot study for that now in breast cancer screening you've got 80% of women coming through not everybody from deprived areas but a lot of women from deprived areas come to screening it's an opportunity to offer something so far that the uptake is high there is no one way that any of us could address the health and equality issue but what we should be looking at is things that can make a contribution and what we've demonstrated is that offering lifestyle programmes for people that are coming through screening with a teachable moment seems to do equally well for people from deprived areas I hope that Janis Bryson that's absolutely right and whoever's got engagement it's making the most of that point of engagement so actually I don't think it's about lots of extra resources I think it's about how we work together to make the most of every engagement My slight worry and maybe I'm being overly pessimistic about it is that given that these are the people who have attended for screening already we're tipping the balance against people from deprived areas because less of them are going so I think there will be a small difference inevitably that will further widen the gap in health inequalities I think the other thing is that I mean these are great points of intervention you go for your screening and crumbs you get a lucky escape, no wonder you begin to get a wee bit more motivated but the problem is the people who haven't had that point yet and I think that's what I will I mean it was easy enough to, well not easy but you could encourage people to think about things like smoking or infart maybe you were right, let's stop now but up until that point it was very different I still think that we have to do more for the people that we're not reaching at all Sure, but would you ignore that people, that it's an opportunity that they might never come through another health service and would you say, because we can't get them all then we shouldn't do something and that's what I would say and the cost benefit from it all absolutely We'll talk about health inequalities but that covers areas that are rural and urban and for me I'm a South Scotland MSP that's pretty much a rural area so are there specific challenges or things that we could be doing different I know for instance that our local national farmers union group have engaged with the national health service lady to go to the auction march and engage with the farmers to do health checks, blood pressure checks things like that so that's a pretty unique thing that's happening in our rural area but what can we be doing in addition A really important point because deprivation in rural areas is different from deprivation in city areas but we looked at uptake of bowel screening for example and breast screening by deprivation there's a huge difference between deprived communities and non deprived communities in the uptake of bowel screening in rural areas there was no difference at all so what we're measuring using the Scottish index of multiple deprivation in rural areas is quite different from what we're measuring in city areas so I think we need to take a different approach to deprivation in rural areas what that approach is I think is not for us to work on but it's not all about one size fits all Is it a variant of the kind of targeting other witnesses have talked about? I think yes, I think that's exactly right Janis Preston I mean we've got a mobile bus that is growing in its use but actually we target more remote areas with that and again there's that opportunity to attach on other messages we find uptake in those areas is really high given the population so it's a good use of our time but I also think no matter where people come from if you don't do that more holistic needs and identify if people are worrying about where their next meeting is coming from or they're not going to engage in messages about prevention or getting better so you have to, what we've seen in Glasgow with 80 per cent to take it up if you have that conversation and sort those other things out which you can do through current resources not new resources so in Scotland alone 17,000 people were helped with their benefit advice last year £45 million in one year so actually if you can sort those out what we're saying is three months later they're absolutely receptive to that conversation because they're in a better place and that wouldn't matter where you live to respond to the question about rurality I think we still have a bit to learn about what the variations in both early diagnosis and access to care are and one of my academic pieces of work at the moment is to look at access to radiotherapy services across the country to see whether in fact that's a barrier to getting to radiotherapy services because they can't easily be moved and made local with respect so specifically in terms of breast screening there are mobile vans and I know that within Greater Glasgow and Clyde there's an initiative to make those services more accessible to use them more in a more helpful way to try to reduce the kind of travel barriers that people who don't have access to a car have so I think there's both a better understanding to be had just to see what kind of barriers there are getting to a GP, is it getting to screening services is it getting to a hospital I don't think we've got that fully laid out yet the evidence is a bit thin so we need a bit more work on that but I think there are also some practical things that we can be doing and in some cases that we are doing for example in reorganising the mobile mammography vans Thanks very much, Miles Briggs Thank you, convener I wanted to touch upon the future of detect cancer early in terms of the focus to date the three main cancers of lung, colorectal and breast which account for about 43% and to what extent does the panel feel other cancers have been neglected in that case and this week we found out that prostate cancer now is killing more people than breast cancer and so I'd just be interested in the views of the panel going forward where they would like to see detect cancer early develop especially around some of the rarer ones be it brain or prostate and any views that the panel may have Who would like to kick off on that, Bob Steele? I think in terms of the different cancers you have to be very careful about what can be done prostate cancer is a very good example there's been a lot of interest in screening for prostate cancer and we know that it does more harm than good and that's a really important principle that you don't introduce a screening programme where you're actually going to cause more harm than benefit and prostate is really difficult to get at because even symptoms are not predictive of prostate cancer so putting a lot of effort into an area like prostate cancer until we know what would be effective interventions would perhaps not be all that valuable and some of the rarer cancers again are very resistant to early diagnosis I think but the other there's a reverse of this I mean detect cancer early I think has been a fantastic opportunity and I think a lot of the work they've done has been amazing but it is not focused on prevention and I just wonder whether we should be moving to a situation where we're looking at early detection and prevention together and we might get more buck in that way On that point when the Scottish Government established detect cancer early they set a target of 25% increase in detection examination at the first stage of these targeted cancers that Miles Briggs mentioned but fell quite far short the figures fall quite far short of that target would you offer an explanation as to why that is? Because it was a hugely ambitious target Yeah So is the conclusion of that that you set a less ambitious target or that you maintained? No, certainly, no, just keep pushing That question about what we should do next the other thing, because I absolutely accept what Bob is saying that a rational approach would say it's difficult to find good symptoms I mean if people do the obvious things if someone's obviously got symptoms of cancer but one of the surprises in detect cancer early was how much early detection of lung cancer increased of the three and you might not have predicted that because lung cancer is the symptoms of a chronic cough we're talking about people who are smokers anyway and might have other lung diseases that go with that so one might not necessarily have predicted that that would be such a large increase in the early stage disease that's being detected and I have to say from other audit information that's carried out on cancer services the evidence is that more people are getting curative surgery and survival even in the most recent years has started to really increase as a result of that so you can be pleasantly surprised and I think detect cancer early if I had to be pessimistic I'd have said lung would be the one that would be really difficult to shift but actually it's shown an increase in early detection which is both welcome and it just shows you that you can't do that The success in lung is probably beyond what many would have imagined and I think the challenge now is to build on that and do that more there are more people surviving because of that so that's the human story behind that I think the DC programme in general will be needed more with an ageing population we've talked about the early detection challenge and that very much relates to people with cancer and the efforts around that have to be maintained we've talked before about public awareness and being willing to present with symptoms and that needs continued investment it just needs continued feeding those messages to public to present and to know what's normal for them and to report to the GP if that's changed and the prevention agenda the other 4 in 10 cancers but also the benefits to wider disease as well I would contend that 40 million at DC programme has behind it wouldn't touch the sides of a proper prevention effort that I think we need to look to the wider 13 billion of the health budget and really challenge on how much it's going into prevention and we need to put some big investment into that area back to the lung cancer thing one of the again from the nice work there's the symptoms are not particularly good as positive predictive values but you've got a pretty good test that you can offer somebody that's actually relatively well taken up and isn't particularly embarrassing so you can send somebody for a chest x-ray now that's not the be all and end all but it's a great place to start so if you've got vague symptoms of normal chest x-ray then the role of the general practitioner is often in undiagnosing rather than diagnosing and you can be relatively confident within some degree that the person is okay they might need a little bit of watching on the system and ditto with introducing for bowel cancer thank you introducing that as a point at contact test we used to do that not with fit to be fair but that was something that was withdrawn but that would make a huge difference so these are big benefits final question Emma Harper was the self-testing for HPV for the study or the trial or the pilot that's happening in Dumfries and Galloway could prove to be something pretty amazing because of the time it will save for people engaging in appointments and then you take a week at home instead that could actually be beneficial all round to the people who are there's 5,000 women in Dumfries and Galloway who are defaulting on their smear test right now so that was something that you brought up early on that could be a good thing Bob Steele I wonder if you want to respond to the previous point it wasn't particularly important it was just to say that the previous test that was withdrawn was not sufficiently sensitive but the new test is much more effective and much more helpful for GPs if I was to summarise in a sentence the message that we might take from this evidence session it might be that continue to be ambitious on detection but do a good deal more on prevention is there anyone who doesn't support that view among our witnesses if not that allows us to reach a consensual conclusion to this session can I thank you all very much for your input it's much appreciated we will now take a short break before our next session thank you very much on our agenda is two evidence sessions on care home sustainability and I'm delighted to welcome to the committee this morning in public session Fraser McKinley the controller of audit and director of performance audit and best value with Audit Scotland and Claire Sweeney the associate director welcome and I believe Fraser you are going to open your evidence session with a short statement thank you very much indeed for inviting us along today and we were fortunate enough to listen to that fascinating evidence session so delighted to pick up on any issues that the committee have following that discussion and while it's fair to say that we haven't done a lot of work specifically on the sustainability of the care home sector we have as you know on behalf of the Audit General and the Accounts Commission done a lot of work over the years on the sustainability of the health and care system overall and we are very pleased to answer questions from the committee on those issues today I think there's probably two reports I would highlight that we've published in the last couple of years just to give you a flavour of the kind of work we've done in this area back in September 2016 we published a report on social work in Scotland which sets out how effectively councils specifically were planning to address the financial and demographic pressures facing social work services the reason we did that work was that obviously integration authorities were coming into being integration joint boards were being set up but we felt it was important to remember that local authorities still had specific responsibility for social work services and that was why we focused on that area so in that report we reported that the current approaches to delivering social work services were not sustainable in the long term we estimated that if councils and IGBs continued to provide services in the same way that social work spending would need to increase by between 510 and 667 million pounds by 2020 that's somewhere between 16 21% increase and we also recognised that social work services faced significant challenges because of a combination of financial pressures demographic change and the need to implement a wide range of new legislation and policies so we highlighted that there's a real need to engage the public in a debate about how we deal with the challenge because indeed as we heard earlier all of us are likely to need some of these services at some point in the future the second report community I just wanted to highlight today was the report we published back in March 2016 which was called changing models of health and care and the point of that report really was to look at the whole system of health and care and to try and draw out some of the more innovative and changing models and different ways in which health and care services were being provided particularly evidence of services being shifted to provide care in people's homes or in homely settings in that report we found that new approaches to health and care were being developed in parts of Scotland many of which were aimed specifically at preventative measures and indeed we've heard about more of some of those this morning but I think we also recognised that the transformational change required for services was not happening fast enough and the new models of care were generally speaking small scale and not widespread and one of our conclusions in that report was that the Scottish Government could do more to help make that transformational change happen and remove some of the barriers facing boards and councils in trying to make that work and finally in that report convener we showed that the growing number of people with very complex health and social care needs particularly frail older people together with continuing tight finances means that the current models of care were unsustainable just finally convener we're carrying out more work on health and care services in particular we're planning to produce our second report on the integration of health and social care later this year and obviously we'd be delighted to speak to the committee about that when it publishes but for now we'd be delighted to answer any questions the committee has, thank you I wonder if you could start from essentially where your statement concluded with the response of the Scottish Government to the report on changing models of health and social care and their response suggesting that the health and social care delivery plan meets your recommendation there I wonder how far you believe that to be the case and whether there are things that need to be reinforced there and in particular whether it provides enough clarity to public bodies in carrying out their duties I'll kick off and then ask Claire to come in if that's okay it's funny as I was preparing for today I was reminding myself that this is now nearly two years ago it's amazing how time flies in March 2016 since we did this report and I think while I think there is, as we've heard a lot of good stuff happening the government has been active on many fronts I think the delivery plan sets out a direction of travel that feels like the right one but my sense is that some of the stuff we found two years ago is still the case which is a pattern of lots of very good stuff happening locally but a continuing question for us I think about the extent to which that's genuinely being co-ordinated and driven to ensure that it's being delivered in place and at scale I didn't count exactly but in the session you had earlier I think I heard reference to 8, 9, 10 different initiatives all of which I'm sure are doing very good things but it is striking that there are so many different initiatives in roughly the same area of service delivery being delivered across the country I'm not at all advocating a one-size-fits-all and everything should be rolled out centrally but I do think there is still something about the way in which we are learning lessons and ensuring that the things do seem to work are actually then delivered more widely One of the major issues we've been highlighting over the last couple of years around the delivery plan is the great consensus around the overall policy vision that's a good thing in Scotland what we don't see though is the connection between that overall vision and how it's implemented how realisable it is so we made recommendations in our most recent NHS overview last year that there needed to be something that showed the workings between here and now and the overall vision so there's work under way to develop a financial framework which essentially will start to show the workings of how we get from here and now to achieve that vision of more people cared for in a homely setting the right care in the right place and we think that's not just important in terms of accountability although that really is important it's important for the system to understand the steps and the stages that they need to work through to start to realise that change because we're acutely aware that there's so much pressure around some of the acute needs within the system so we look a lot at ANE needs about arm delay discharges the pressure around GP services and the like that that can take up so much attention and so much resource that this framework that will start to show the stages people need to work through should hopefully start to move us a little bit away from just focusing on more of the crisis that's facing some of the system as it can feel on the front line I'm sure and do you have a sense of whether there is a pace of change where change is happening because clearly as I've just described there are some very good initiatives and developments but is there a sense that things are happening quickly enough so I would say that in some local areas we absolutely see people grasping this and running with it and starting to make some real inroads into local services I would say what we see in a lot of places though are still people getting tied up in debates and discussions about whose resource it is where it should be best spent how the governance arrangements are going to work and I think key for us has been areas where we see people putting the time and attention in to getting those building blocks in place so they can then start to really focus on improving outcomes which is what all of this change around integration is was really meant to achieve we see too many parts of Scotland that are still tied up in some of the mechanics around it I would say rather than actually focusing on the what is this about to deliver for people locally I think just briefly convener building on the work of the committee last year around integration and support that we'll publish later this year we'll put in as a better place to answer that very specific question I think that's in a sense what we're trying to get at that's the second of three that we've committed to and this one really is beginning to get a sense of well where are we and are we as well advanced as you would expect Thank you very much Ivan McKee Thank you sir, coming along to talk to us this morning very interested in what you had to say about the financial framework getting set up and also talking about specific local areas where you see there is progress being made I suppose I'd just like to drill down into that a wee bit further in the areas that are most advanced in implementation do we start to see measurable results in terms of improved outcomes but also in terms of what the big prize is which is more effective financial performance in the secondary sector so we will be able to give a very clear story about that when we publish our second in the series of work around integration but we've been keeping a very close eye on this over many many years that shift of caring for people more in the community and truth be told pace is not quick enough we've highlighted that in a number of reports I would say the early signs of impact for integration that I've seen have been two fold where it's worked it's on one hand it has been around demonstrable and measurable change but on a small ish scale around things like reducing delayed discharge about better responding to people's needs what really matters to them locally so that's one way that integration we're starting to see some signs of change but I would say the second way and potentially a bit more hidden a bit less visible to people are the changes about how the local care system works together I think what integration is starting to do is to surface some legacy issues around how the health system and local authorities particularly have worked together in the past so it's starting to shake some of that up and address some issues that have held things back for a long time now the jury's out I guess in terms of the extent to which that will lead to a real big and systemic change but we are starting to see people have difficult conversations in some areas that you could argue have not been had in the past which has got to be a good thing I was very conscious in the previous session about the mention of education services and also about housing services and the question about the extent to which that they are starting to become involved in issues health and social care integration so those are some of the things that we'll be looking at and testing out a bit more fully in this second piece of work but certainly some emerging signs coming through for us okay good I think there's something for me about us trying to unpick the extent to which where we can see real successes delayed discharges in some places being an obvious example the extent to which that is a result of integrating health and social care in the way that we have and or the extent to which that is as a result of really good people just working together locally to what extent is the change of the system and the change of structure actually helping drive that change and some of those things that we might have seen anyway so I think there's a bit of a cause and effect there thing that we'll try and tease out Are you comfortable that there's a good process then for taking best practice where we are learning things and figuring out how to apply that across the piece We've made the point before that there is scope to do better around that absolutely there's a need to learn from what's working well and think about what is transferrable now we accept that it's not a case that the size fits all, if it's working in Fife it can work in Glasgow but we think that more care and attention could be paid to thinking about what are the things that make it a success and what can you transfer so there's more to do there Thank you very much Thank you very much Can you now just to follow on from I was looking at the vision and the workforce and the delivery plans and one of the second recommendations that came forward was about investment and when you look at the actual amount of investment that's been put in and I think you raised the figure Fraser at the very beginning and we're talking about investment health funding into social care discharge primary care fund integrated care fund and enabled care as well and if my addition is arithmetic is correct we're looking at £765 million which has been transferred over and I hear what you say about the difficulties of health and social care and local authorities working together and I think we're all pretty aware of that unfortunately I just wonder with that amount of money that's been transferred over to both in the budget do you think that the setting of the budget is from health boards, local authorities social care do you think it's an integrated authorities as well do you think that's sufficiently has that been monitored as well to ensure that as I say, £765 million has that been monitored in place enough to deliver in 2020 with the plan so I think that's one of the things that the financial framework work is designed to help with I think I would also say that I think you said in your own report last year that the budget setting process locally still feels like it's more difficult than it needs to be because of the issues of timing between health boards and councils and that's been a difficult process and it comes to Claire's point earlier about up until this point people still being very focused on some governance and budget issues as important as they are but I think that taking precedence instead of actually asking ourselves the question will walk in that money deliver I also think and I know this is an easy thing for me to say but I also think there's a kind of between NHS boards and councils and integration joint boards is how are we managing the reduction how are we managing the 5, 10, 15 per cent cut in our budget different approaches to that across the country what we see less of is how are we spending the whatever it is £700, £600 million locally to deliver the best outcomes for our community so as I say, I know that's easy for me to say from an audit perspective but I think that's the kind of shift now we need to see that these things are up and running and the governance systems are in place I just wanted obviously Audit Scotland will be looking at that and you mentioned a report do you think that the health committee should perhaps be continuing on in that particular aspect of the budget because £765 million is a lot of money and obviously we want to know why? We are all for more parliamentary scrutiny of budgets so any more of that that you want to contribute to would be very welcome from us we will continue to bind the drum around clarity and transparency we've had as well as the NHS overview report that Clare mentioned every year the Accounts Commission produces local government overviews and trying to figure out how the money works now between local government health is complicated because there are an increasing number of these pots of money that are designed for very specific purposes in some cases put into a budget line over here for use in a different sector over here so we will continue to try and bring some transparency to that and absolutely anything this committee and other parliamentary committees can do to keep a watching briefing that would be very welcome from our perspective Thank you very much Oh sorry My apologies, Brian Clare Suni had some additional point I was just going to mention that that also speaks to the point we've been making for a number of years about the need for long-term planning so we find it quite difficult sometimes for good reason to be able to identify the money that's spent on more preventative interventions and you heard a lot about that this morning part of the challenge I think is that you are looking at investment sometimes quite small scale but the payoff might not be happening in a number of years that can be really difficult in a partnership context particularly if people are planning their budgets year on year on year you're not thinking about the impact 10 years down the line and you've got a lot of pressure in other parts of the system so that can make it really really difficult so as first I said it is about that shifting in focus that we need to see locally to start to be a little bit more ambitious and think differently that's incredibly hard to do given the pressures on the system I would say in the earlier panel session it was very helpfully pointed out that most of us will end up requiring some sort of intervention in the social care market someone will sooner rather than later but I wanted to talk specifically about the care of the elderly and the care homes and the very welcome introduction of the living wage it's not necessarily being mitigated against costs and income staffing levels are mostly imposed so they have very little flex and how they can run their system and the big cost is in staffing so with that in mind is there evidence there that there's a strain being put in that system that potentially unsustainable? Yes and I think you heard a lot of that in the earlier evidence session and also in the submissions that absolutely mirrors some of the messages that we've said in a number of previous reports particularly the report Fraser mentioned around social work services in Scotland where we explicitly said that the way that services are provided currently is not sustainable that was talking about social care in the round but has things to say about residential care homes in particular the challenges we drew out on that report they still remain valid our pressures around the funding model about ability to secure that workforce and the value that's placed on them and I would say there is a real push and a real challenge around people seeing that sector as something that they want to work in that children want to be trained in and go through higher education and then become employed in the care sector that's really difficult and not to forget that it also actually employs an awful lot of nursing staff as well so it's not just the social work side of things so I think some real challenges in securing the workforce fit to deal with often people who need an awful lot of health and social care support so those challenges highlighted and that report still remain If I could communicate I think correct me if I'm wrong but I think the way that care homes have developed not that many decades ago there was that whole idea around being a granny farm almost 10 days people are going into care homes much later in life and a lot more specialist care is required as you've mentioned around nurses are we adapting quickly enough to that change in model so there's no doubt that it's a different model now than it was before you heard in the previous session about the way that GP workload and the way they need to interact with patients has changed significantly over the next of the last say 5, 10 years so that's a very different system now and again that's why we thought it was so important to have something that showed how you achieve the overall vision of caring for people in the right place at the right time with the resources that are available in a system that has changed beyond all recognition in the last 10 years the needs of people in care homes now compared to where they were before is very different so we might have talked quite a lot a few years back about the ability to stop people going into residential care homes because they were defaulting there and actually they could be cared for at home accepting that some of the packages that needed to be in place to keep people in their own home were quite significant and there have been programs to recognise the support that's needed for unpaid carers so if you have a relative and you want to keep them at home the support that you need to help you in your care and duties has increased a lot over the last few years but I think we still would have the question about to what extent everybody has recognised the way that resources need to be used differently in that context so what it is to run a care home now is a very very different ask than it was even five years ago and have the funding models changed to reflect that I think there's a legitimate question you saw some of those concerns and risks coming through in the evidence session and we would have them too Alex Cole-Hampton Good morning to the panel and to the presentation I think one of the obvious problems to the changing demographic in our care home needs in respect of the future is the lack of capacity that exists in the sector certainly in Edinburgh we are 600 fewer residential care home beds than we probably require now and a country mile behind where we'll need to be in 20 years time but one of the barriers to this is the tension that exists with planning and that oftentimes particularly big build residential care homes bring in objections particularly when developers aren't considering the needs of overstretched local health services and what they're going to the demands that are going to be impacted upon that and indeed the concerns of local residents about the change of character within the area is there anything we need to do through planning law to make a life easier both on communities and planners in terms of where we cite residential care homes or have we got the balance right? It is an excellent question and I'm not sure I have the answer for it unfortunately but I think what it has got me thinking about though is the planning bills going through stages at the moment the local government committee has asked for views on that so that's going to be something I'll go away and have a look at with that in mind and the extent to which planning is a barrier is clearly something you might want to look at being joined up I think that an additional question for me is just thinking about what kind of service provision and therefore what kind of to use the auditor term assets we need to deliver it so what do we need in terms of buildings? Is it big care homes? Is it sheltered housing? What is it that we need? I was very struck by one of the contributors earlier talking about the increased need for observed care I think he called it increasing incidences of dementia and I think what's interesting is that this is very much a moving feast and I think we need to keep checking our assumptions because I think if the principle of the policy is that we shift the balance of care away from institutions to care at home or in a homely setting I guess you would assume that you might therefore need fewer care home beds but actually at the moment that doesn't feel like where we are and if actually where people are right about what's happening I'm not sure that necessarily falls into the future which comes back to our challenge around long-term planning both in terms of finances, workforce buildings, looking 10 years ahead what are we going to need for this and clearly if things like planning are one of the things that makes that more difficult then you'd want to look at it as part of that whole system review One of the other things worth bearing in mind is that the need for local areas to to help to develop a market and we've reported before in a few years ago on a report around commissioning health and social care services about the degree to which local areas are facilitating and developing a market we know that a lot of services are provided by the private sector and by voluntary sector services so we're very interested in the degree to which NHS boards and the local authorities are working constructively with both those sectors to make sure that the services in place locally are fit for purpose and we absolutely recognise that in some parts of Scotland the challenge around the expansiveness of land particularly in the central belt is a major feature and has a huge impact in the capacity around things like the care home sector but it's not just residential care homes we're talking about there so there's a whole range of different features across Scotland that impact on the health of the services that are available locally Thank you very much David Stewart Thank you, good morning and welcome Can I ask your view on the improvement hub, the so-called I Hub which as you know was set up nearly two years ago by the healthcare improvement Scotland. I watched their online presentation last night and perhaps needed to get out a bit more often because it was an excellent analysis of the work that they have done but what assessment have you made about the effectiveness of the I Hub's leadership and speed of manoeuvrability to affect the changes that are needed? We have absolutely commented on this in previous reports about the importance of having an improvement focus and about giving the space for areas to learn and develop the improvement approaches that fit them well locally that's absolutely essential we're really interested in the extent to which NHS boards in this instance predominantly but not alone the IJBs working with local authorities are able to invest in that kind of central support it's essential that they have that what we've seen when that's developed really well though is that it's not necessarily just a central team that makes that work there are tools and techniques and the learning that needs to happen so boards need support to get that moved locally but what's really important is that that happens at a critical mass in the local area so we know that there is a focus on that nationally, that improvement focus we think that needs to develop even further we've not looked in great detail in terms of the resource ask around that but it's certainly something we'll bear in mind in our second review of integration authorities we think it's an important part of what can help to make this work In your general assessment you take account of the effectiveness of iHUB it's two years, nearly two years long enough for you to assess how effective they are so the short answer to the question is we haven't really done that specifically so we haven't looked at the effectiveness of iHUB specifically and the extent to which two years is long enough I guess would be a bit of a judgement call I think for me it's one of those things that you would rather have it than not I think anything that helps practice and is a place to which people can go to learn has to be a good thing and we can pick that up as our wider work as part of our wider work I think that the wider point I would make is that it does strike me that we are still guilty of looking at health problems from a health perspective still and our system is designed and indeed I think some of the conversation this morning kind of came from quite a health perspective and struck at how little councils were mentioned for example I know that there was mention of working in leisure centres and other places but it does seem to me that if the general consensus as it seems to be is that issues of inequality and deprivation are central to this then improvement resource needs to be about a joined up response to that rather than or possibly as well as specifically health related interventions it does seem to me that we are still while we have the analysis that you nailed in terms of what the issue is and you heard from Sir Harry Burns not long ago and he's been saying this for a really very long time it still feels like our systems of accountability and improvement are still struggling to catch up with that and I think that that has to be part of the shift over the next while We have to be careful then not to be in a health silo but you're really saying this is about poverty and inequality that these are the big issues and I'm by no means an expert in this so you had the experts in earlier but my sense is it's not an either or of course there are going to be things that you can do in terms of the delivery of the health intervention that could be better when you learn lessons it also seems to me that we need to be better at joining up our approaches and learning the lessons of community engagement a lot of the great stuff we heard from Macmillan earlier today seems to me that fascinated by the way example of an NHS board in the south of Scotland working with the national farmers union locally and a range of things seems to me the kind of innovative work that we need to be seeing happening kind of everywhere really It's just one example on the health stats today that the bowel screening figures for disadvantaged areas are quite disappointing and that was I think mirrors what we were discussing earlier about disadvantaged areas and problem with health I wanted to pick up on a point Alex Cole-Hamilton raised with regards to future provision and really to see to what extent and this goes back to local authorities which you mentioned is there a disconnect between what we will need and we know we'll need and actually what we're now planning towards and I know Jones Lang McSale did a report on this specifically recently saying that in 2018 Scotland will be 3,000 care home beds short but actually to meet the future demand there's about 10,800 they predict we'll need on top of the capacity by 2028 in terms of your work do you think we're getting anywhere near actually meeting what people are saying we're needing and why is that not being reached is it within the Scottish Government or within local authorities and where's the disconnect to actually realise that in the future so there is work now with the introduction of IJBs to look more closely at local need and think about projections over the longer term so that's absolutely something we intend to look at as part of this second piece of work again back to the two reports we're talking about today particularly the social work in Scotland report we've said that that's not being in place in the past we recognise that that can be challenging because we are talking about a different level of demand as we've already spoken about the make-up of the people in care homes particularly is different now the challenges around securing a workforce are different so things like Brexit have a potential impact there also so there is a need to look very closely at future demand and back to the point we made earlier about the need for longer term planning around that the financial framework we talked about should help to a degree with some of that connecting up the policy vision with how that will actually be delivered on the ground with a sense of the stages that need to be gone through by all parties involved to achieve that so the simple answer is we're not quite there yet and there's more work to do you would argue that the creation of integration authorities is designed to do exactly that kind of thing so that's why I think it's important as we've already said that IGBs in particular are now able to get beyond issues of governance and setting themselves up as new organisations into exactly that kind of discussion about what the local need is and what kind of service model is required in future of course there is a bit of crystal ball-gazing in all of this and that's why scenario planning is important and that's why I think ensuring that the focus is on an assessment of people being able to access the care they need in the most appropriate setting is key and that's always a difficult judgement and the people based locally are the best people to make those kind of judgments I just have a follow-up one of the things that we've heard in different pieces of work is actually what's destabilising the current provision we have and a number of aspects of that from the Scottish Careers living age not necessarily being properly funded to actually just cities being more expensive like the city of Alex Cole Hamilton I represent of Edinburgh and Aberdeen actually the living wage isn't going to necessarily attract people into the sector so I just wondered if you had any comments on that there's a lot about that in a previous report on commissioning social care that challenging making the work attractive the profile of it in Scotland the numbers of people that when we project forward that it looks like we will need people to go into those services in far greater numbers than are possibly available at the moment so yes there is absolutely something there about affordability attractiveness of that as a profession to go into and we know that there have been examples of work to try and shift that but the underlying issue is of course one of resources about how much is paid for those services and how the funding works around them so the challenges will be different across Scotland but there are some things that are absolutely common pressures another strand of our work recently you'll be aware of is the work that we're doing around workforce specifically we published our report last year on the acute bit of the system a piece of work around primary and community based care building on the work that Government and COSLA have done at the end of last year about the beginnings of a workforce strategy for that sector and we think for exactly those reasons that's why that's really important I was struck by some of the responses you got to the care home inquiry before Christmas that on one level absolutely you can argue that paying the living wage is a good thing full stop beyond that I was interested to read saying that in terms of it being able to ease the recruitment difficulties that some areas are having it doesn't seem to be working so again you've increased your cost base in simple terms without any real benefit beyond the fact that it's a good thing to do and these people will feel more valid than all the things that come with that but in terms of actually helping ease some of the pressures that some services are facing we'll need to wait and see Emma Harper in the document that we have it talks about the recommendations from the changing models of health and social care report and it says that one of the recommendations is to ensure that new models of care here and abroad that work is shared and that was one of the recommendations and I'm aware of the two projects in Dumfries and Galloway which have been promoted by the IGB which seem to be functioning quite well actually there's the co-sync project which has seen community groups invited to tender for delivery to health and wellbeing centres in the region and there's another project which is 8.7 million of European money funded it called the Empower project and that's to look at over 65s with long term conditions so they have to pilot these studies first figure out if they work and then share them so that obviously takes time but I think my point is that all of this is just the process takes a long time to evidence what works and then how do we shift it and change it so what would be the recommendations for moving things along so we've spoken quite a lot about this in some of our previous work we recognise that things are you can't have one size fits all for Scotland certain things that work in a certain area will not work in other places we absolutely get that people need to be involved in how those services are changing so the importance of involving communities in the thing that works best for them we've talked a lot about things like self directed support where people will have a much more even and shared focus with healthcare professionals in determining what's right for them which will be very different person to person let alone from IJB to IJB area so there's a whole lot of issues there that mean the care that one person gets in one area might be very very different from another part of Scotland none of this makes it very easy to audit not that that's the purpose but for having the services in the first place but we do need to take account of the fact that people will want different things so I think that's absolutely right and that's fine I think that where we would shine a bit of a light is to see that if there are things that work really well if there are things that are success factors or principles that can be applied to other areas that they need to share that need to learn from that across the whole of Scotland and need to move on it it's absolutely right that the improvement focuses on supporting local areas to work out what needs to change the solution for the local area with the staff involved with the people who receive the care that's all correct but there must be something in this about improving how we share good practice and learning across the whole system and I think there is still scope to do that we talked at the start of the session about some of the things that may be getting in the way of that and one of those things is no doubt discussions about agreeing budgets and a focus on governance and structures when actually leaders within the system are just as focused if not more focused on what positive impact they're achieving through the changes so yes a need to have a greater focus on learning and improving things as we go one of the other things I would mention that we've seen over the years is a lack of evaluation so it's really important that the work goes in to make sure that projects that are piloted are evaluated properly and then the lessons are shared if that's not happened right at the start of setting up a new project to prove what difference it makes and argue for the resources to be put against that okay very much I just want to pick up on the area that Emma Harper has started to speak about which is the changing models of care and models that we might move to into the future so in your opening statement you mentioned that there are new models that are happening but they're quite small scale at the moment and they're limited to certain parts of Scotland so I'm wondering if you could just give an example of that type of thing and then whether you think they might be scalable across Scotland or even whether that would be desirable so I think the work we did on changing models health and security we actually produced a whole supplement which listed a whole range of individual case studies there's 12 different areas we looked at in places like For For Some and international approaches Canterbury is one that's often cited and I think in a sense that's the point we're making in this report and we continue to make which is there are good things happening in every part of the country so it's not like there are black spots of a lack of innovation I think there are good things happening everywhere and maybe that's okay maybe the approach here it's all about local and that's going to be the thing that's going to make the difference I think what we would observe is at the moment it doesn't feel like that's the case it doesn't feel like the things that we're already doing are going to have the kind of impact at scale that is required to meet the challenge of the system as we understand it and as we've heard all about today with the demographic changes and the financial situation and everything else so what was interesting about that process is that we went and had a look at some things that looked quite interesting and quite good and then there was a big debate about whether they are actually very good on the extent to which you can roll them out and we were very specifically not saying that you can just take something that's happening in Forfer and apply it to Glasgow what we do think you can do is identify the characteristics of the thing that made it successful in Forfer and think about how you would apply those characteristics in Glasgow I'm not suggesting that that never happens but that's enough at scale to meet the challenges that we know the system is facing With regard to the integration in terms of how it's working in terms of culturally between social work, health boards and integration authorities there does seem to be an imbalance and social work Scotland highlighted that integration has created complex governance arrangements are cultural issues therefore impeding the progress moving forward so the short answer would be to say we'll come back in November and December and let you know but we'll try and be more helpful for that I think that in the last report we did the first report we did on integration we recognise the complexity of the landscape now and certainly if you're working in it then it does feel very complex and indeed if you're receiving services my sense is that people aren't are probably pretty unaware of how it all works so there is a degree of complexity and that doesn't mean that it can't work and we have integration joint boards and people are genuinely committed I think to making that process work I think we have seen cultural differences between councils and health boards I think just the coming together of councillors and NHS board members on the integrated joint boards has been a process that they've all had to work through as well as some of the different cultures that you experience on the ground My sense is that again in lots of places people on social work and health boards have been used to working together for a long time so this is not brand new I think that the challenge for us is about how are we really making the step change if integration joint boards are accountable for about £8 billion worth of public spend then we should begin to see ways in which that spend is being done differently how is the integration of health and social care making a genuine difference to how that significant public resource is being used and I think that's the big test for us that we'll be trying to test through this year A couple of things we've observed as we've been keeping quite a close eye on how integration has been progressing since we published our report in 2015 and I've probably said two things coming through for me a set of challenges around some technical issues that need to be resolved, no doubt about it there are still some technical things but that's much smaller than the bigger issue about the cultures coming together as you see and the need for leaders within the system to say yes there may be a few technical issues we need to work through but actually we're all committed to that outcome improving outcomes for local people using our resources collectively to think about how we best use that to improve services for folk in our local area is absolutely possible and that's what we would expect leaders to be focused in and around so for the audit perspective we would expect to see the governance arrangement set out very clearly so we can understand that so local people can understand that but the most important thing is about achieving those outcomes It's on that point that local people point do you think overly complex governance arrangements are actually detrimental in terms of greater transparency they put people off because nobody understands how these systems work and are talking to each other if they're accountable then it perhaps previously might have been so there is absolutely a need for that to be understandable for people not just auditors but absolutely for local people to understand it's important that people who are managing and running the system understand that because we know in some places they don't so there absolutely is a need for people to be clear about what they're accountable for who's responsible for delivering the services that they receive absolutely that's true but we would say that over and above that people need to be focused on improving outcomes and if the whole debate is taken up with governance challenges challenges around funding then that's a missed opportunity I would say I think the only thing I would add to that is that I think my answer to that question about the extent to which people, ordinary folk, understand the governance of it is kind of yes and no so in principle yes of course it's important that people understand how all this works I think what's probably more important is that people are genuinely engaged and involved in a discussion locally about how health and care services are delivered for them I'm not sure if you're going to your GP or trying to get a care package in place you're necessarily that concerned about the governance structure at this level we will be always because I think that's really important in terms of accountability but what really does need to happen and again I think some of the work of the committee said this is that integration joint boards with partners need to be much better at engaging communities in a meaningful discussion about how you design services locally and at the moment that's patchy I think at best okay can I say thank you very much to our witnesses that's been very helpful and we will suspend briefly to allow a change of witnesses thank you very much I presume our meeting of the committee our next session is to take evidence again on the item of care home sustainability and I welcome to the committee the cabinet secretary for health and sport Shona Robison and Jeff Huggins director of health and social care integration minister I believe you want to open with that statement thanks very much convener I welcome the committee's interest in care home sustainability and I'm happy to have the opportunity to respond to some of your questions at the outset I want to emphasise it in seeking to promote sustainability we need to see residential care in the context of the wider health and care system whether it be care at home or care in hospital our vision is to enable people to live independently at home or in a homely setting for as long as possible a sustainable residential care sector will play a key role in helping us to achieve this vision but in partnership with the wider health and care system there is and will continue to be an important place for residential care and care homes in Scotland however they will have a different emphasis in the future whether it be through delivering a higher proportion of intermediate care providing specialist care to people with dementia or with neurological conditions or for end of life care the role of a care home is already evolving to better meet people's needs some of the challenges facing the sector were highlighted by stakeholders as part of your earlier evidence session they included recruitment and retention of staff nursing staff, the lack of care home availability in some areas and instability in the market addressing these challenges has required a change in the way we currently approach social care to ensure sustainability going forward following the same models of care and support simply on a bigger scale or paying more for less will not allow us to create something that is sustainable for the future nor will it ensure we can deliver high quality flexible services that move away from time and task and have people's choice control and independence at their heart much of this is about redesigning services in a whole system way using existing resources more effectively to improve quality and that's why we've integrated health and social care which has opened up opportunities to develop different models of care which reflect the changing needs of localities at the committee as the committee has been made away through this process a number of integration authorities are beginning to make this shift to support an efficient, effective, diverse and sustainable market for high quality care and because of this the role of care homes is evolving to better meet the needs of people in some places care homes are being used to provide intermediate care for patients who require it on discharge from hospital or to prevent hospital admission Fife integration authority is one example they've commissioned intermediate care beds where short term rehabilitation is provided with a view to returning people to their homes when they're ready significant progress is being made around work to address the workforce challenges for example, around sustaining registered nursing workforce within care homes in several areas integrated authorities are taking a cluster approach by working flexibly with care homes to ensure registered nursing input is available to residents and in some localities for example in East Lothian NHS staff are regularly used to staff care homes such cluster approaches are also being seen in the skilling of care home staff and I know that Dumfries and Galloway is currently working with Scottish Care to look at piloting work to support our care homes in the area from an enhanced education and support role particularly with some of their specialist nurse and advanced nurse practitioner work in palliative care Highland Hospice is using a tool an approach for mentoring to support community palliative care across the region in a range of settings including care homes from the approach The national care home contract has been a good foundation for care home sustainability over the last 10 years through this process we've seen year on year uplift which have not been mirrored in the rest of the UK or in other sectors over the last three years funding through the national care home contract has increased by 13.2% from £609.31 to £667.09 per place per week but we recognise that there's more to do to ensure long-term sustainability as well as enable local commissioners to redesign and commission services based on local population needs that's why the national care home contract reform process is currently under way part of this involves working with providers to co-produce a shared transparent understanding of what it takes to provide a care home place through the development of a cost of care calculator alongside this work is being done to enable variation in the contract in order to respond to different models of care our approach to setting a national rate in our work with providers to reform the approach was recently praised by the competition and markets authority in their care home market study going forward we're building a programme of reform for adult social care which allows us to look at what residential care should look like in the future so in conclusion our approach to ensuring sustainability demands that we move beyond the short-term fix to think about longer-term sustainability it needs all parties to work together to meet that happen we're committed to doing this through integration through working with partners to improve our national care home contract through our reform of adult social care and through the actions in the national workforce plan published the second part of which was published back in December so I welcome the opportunity to discuss this with the committee in more detail thank you very much cabinet secretary and as you rightly say this issue stands in the wider context of integration of health and social care and we've heard this morning from Audit Scotland on some of the aspects of that which have a bearing on care home sustainability one of the things that I think came through strongly from their evidence was that although there is as you described some very good practice in particular parts of the country I think they put it as a need to share learning much better and ensure that we're not simply having good local initiatives but actually joining those up what's your take on that and how far do you believe the health and social care delivery plan addresses that Yes, that is critical I'm a firm believer in what work should be spread and best practice should be spread I suppose the caveat to that is that what might work in a remote and rural area might have to be a bit different from an urban setting just in terms of the availability of workforce and there are particular market conditions I mean if you look at the city of Edinburgh and Lothian there are particular challenges here that are not necessarily the same in Glasgow for example so yes absolutely I think there is the need to share best practice we have the improvement work that's ongoing that Geoff can speak about more to help and nobody should be immune for asking for support in terms of improvement no one has all the answers but without doubt is good practice that would be good to share more widely I think the important thing to recognise in this is that what we're saying is across the country how systems of care are evolving when we look at an area like the area where we're in city of Edinburgh and we think of all the different components of providing older people services we draw a diagram which has got about 47 different boxes including hospital care at home respite, support for carers all of which are a system of care and quite often we focus on one of the components of that rather than seeing the whole story one of the interesting conversations for us at the moment is as you begin to think about the evolution and the development of residential care into more step up, step down palliative end of life maybe some of the people who historically would have been in continuing care in NHS facilities you're beginning to describe what in rural areas you might see within a community hospital and in other areas you might also begin to see things which are in hubs so there's probably some general functions or principles but the construction of how you put the system together is probably going to be quite different from area to area one of the most interesting things is how housing which is not a fully integrated service has been one of the areas which has probably seen the most evolution in terms of supported housing solutions in a number of areas and again you're beginning to see how that but that's something which you can probably do within some property markets and not within other property markets so it's the adaptability but the learning we tend to talk about it as a sort of conscious localism you should know the evidence base and you should find the best solution from your area and that includes learning Thank you very much Miles Briggs Thank you convener and good morning to the panel the cabinet secretary perhaps aware that this morning it was named that renaissance care is to close its home in Musselborough and part of the rationale behind that was factors which are destabilising the sector and I printed off their chairman Robert Kilgar's statement on this apprenticeship levy and what's not being put in place in Scotland and just to quote him directly he says here we currently we currently get absolutely nothing back from the Scottish Government for this jobs tax they're making it very difficult for social care sector to claim any credit back from these new extra payments to spend on apprenticeship or training schemes as was intended and as is happening in England so I just wondered if you had any comment on that specifically Well first of all I think we have taken an approach as I set out in my opening remarks to try to support the sector we have as you'll be aware provided significant resources to pay the living wage for example to all parts of the sector including the independent sector that is something that we felt was important in terms of helping them to recruit and retain staff and we have significantly increased the national care home contract as I set out in my opening remarks I am aware that for the care home that we were talking about they had some particular difficulties not least around the fact that they didn't have on suite facilities and that they were struggling to meet some of the standards that were required so I think it's quite a complex picture that that care home was facing and then the requirement of investment there was obviously a decision that the owners would have to balance in terms of whether or not that is something they wanted to do I think the apprenticeship levy is that as I understand we have obviously that was something that the UK Government has decided to take forward that we have worked with employers to make sure that resources are passed on in terms of what we do here in Scotland so I don't recognise the scenario that has been painted there regarding the apprenticeship levy I think there are many issues impacting on the care home sector that is certainly not one that has been highlighted one that has been highlighted mainly to me not least by Scottish care is the impact of the loss of nursing staff through Brexit and the inability of them to be able to recruit nurses into the sector of which of course a large percentage were coming through EU channels and effectively the door has now closed on those recruitment agencies in Europe and that was Scottish care themselves telling me that directly so in all of the issues impacting on the care home sector apprenticeship levy is not one that has been highlighted to me as being a significant issue but I can say that we have made sure that we have translated resources through to support employers as we would expect and I'm happy to write with further detail of that if you'd find that helpful Maybe to add a couple of elements to that so first of all as the cabinet secretary says the apprenticeship levy is a UK levy in terms of the conversations that are going on around the national care home contract and the creation of the cost calculator both the cost of the living wage and the apprenticeship levy are built into that so those are understood as costs that apply as part of the process and the apprenticeship levy was certainly considered as one of the items during the last years negotiations these are also of course both policies, living wage and apprenticeship levy that apply to all care homes which has been applied to this particular care home and so there are a wider range of factors which are not purely about the environment in which care homes operate that we need to take account of and clearly other providers and other homes are able to continue to operate effectively within that framework so I think it's quite easy to identify government policy as the reason but there may also be other reasons that you want to look for In terms of nursing one of the points which was also raised by Scottish Care and some of the evidence we heard which I thought was interesting about 6 per cent of the care home care population and workforce were EU nationals but in terms of future training one of the concerns which is expressed was actually a drive towards the Government's target of just reaching child carers and training child carers and actually a potential loss of adult carers do you have any comment on that and where you're feeding into that system for our college sector specifically to train the people we'll need? So I think Scottish Care had identified nearly 8 per cent of nurses in care homes were EU nationals so I think without a doubt that is going to be a significant challenge around recruiting nurses to the care home sector which is why we are looking at other models we are as I set out in my opening remarks some of the solutions to that I think lie in the workforce that potentially is NHS employed providing locality based solutions to care homes and nursing homes some of that is already happening in some areas and we're testing that further in Dumfries and Galloway not just nurses but HPs and others and I think there is a longer term solution in that direction of travel rather than and of course trying to also meantime promote the benefits of in a nursing career within a care home environment but I think we have to also look at those locality based teams most of your point about child care yes I think there is definitely although it's obviously a good thing the expanded child care provision and therefore the expanded workforce there is a challenge there about it might be the same people who would be attracted which is why in the part 2 of the workforce plan published at the end of the year we were clear that we needed to promote care as a career and it set out the campaign that we would be undertaking this year as one element of that also looking at very clear career opportunities to progress for example on to a regulated profession such as nursing so that if you come in as a care worker you can see a career pathway in front of you that's clear so all of these things are about making care a more attractive career choice not just for young people but for people perhaps in other careers and in other walks of life so a lot of that is set out in the workforce plan about how we intend to do that so that we are minimising the impact of people choosing other choices I think the other thing to add to that is we're conscious of the challenge and so we're doing some cross-government work in other departments or other parts of the Scottish Government to understand the dynamics of that as the cabinet secretary says the second part of the workforce plan also begins to get into using and developing integrated workforce data and better local market analysis because as we go across the country visiting integration authorities we hear very different stories about the availability and again it does take you into the likelihood that you are going to see quite different models of care developing in the context of different available labour forces which is just the reality of where we are Thank you Good morning I often wonder if we have actually even got the words right care home residential care it just doesn't seem right somehow and I'm not going to suggest what it should be called but sometimes that's why it gets what you might call bad press and staff are obviously not living wage in certain aspects and I pick up on Miles Briggs point there as well and obviously the cabinet secretary really you know it should be looked upon as a career because obviously predominantly women low paid so really any care home if that's what we call a provider that can't afford to pay the living wage and the care home contract shouldn't be in the business at all and I'm pleased to see that basically this will be pushed into promotion into other careers as well and I touch on that part because I think it's really important that at the moment we're looking at the changing in care and obviously residents needs are changing greatly and the nursing care is needed too it's greater as well and I will touch on the reason that we had the investigation at the beginning was because of the situation with the bill provision and I would declare an interest in that because relative of mine had stayed in a billed home and got excellent care and I could never fault them for that so I just wonder having went through that and we know the situation with billed small units and communities which worked beautifully and very very well what the Government is doing to alleviate the situation with these care homes obviously that have closed citing the fact that they don't have enough monies in that respect and I just wonder what the Government is doing to alleviate that and what are they putting in place of obviously the situation within the communities that the billed homes are closing Okay well our priority has been to ensure the continuity of care for billed residents and making sure there's no compromise in the quality of care now billed have obviously decided to I suppose go back to their core business that was more focused on housing with care is what they originally did and they see that as the future direction of travel and they had difficulties with the sustainability over a number of years of their diversification into care the care home sector so billed are very clear with me that that decision obviously was a difficult decision but it was based on their desire to go back to providing what they saw as the future direction of travel of housing with care what was important then was to make sure that that transition and the continuity of care for billed residents was the priority officials, Geoff's been involved in this very closely have been meeting with billed on a regular basis along with the the health and care partnerships that are affected to make sure that that happens and that plans are put in place for residents and good progress has been made and there have been a number of new providers that are going to take over some of those care establishments and for others there has been a lot of work put into making sure there is a smooth transition because we know that the important thing here is to minimise the impact of that change for vulnerable elderly people I I mean, Geoff can we talk about the detail of progress being made there but I think there certainly are where they wanted to be in terms of the March position and then the July position and I think they've made the progress that they needed to make perhaps they had another couple of questions first to pick up on me and then we'll get some of the detail on that. Alison Johnstone Thank you, convener. Cabinet Secretary, in opening you spoke about the need for a vision to live independently a home as long as possible and Mr Huggins spoke to about looking at the whole story here and I think we're all aware of the fact that third over the last two decades and more people will be aging in private rented accommodation and often I think when we're discussing this we think about adaptations to local authority housing or social sector housing so I just wondered if there was any discussions that the Government was having with landlords for example because I think involving them in this discussion is really important if we want to lessen future burdens on our care homes with regards to access for carers and any adaptations that are needed out with that social housing model I agree and yes and actually it shouldn't matter what the tenure is the property that the person is living in and it's their care needs that matter rather than the tenure of their rental or whether their own are occupied or whether it's a social landlord or a private landlord actually that shouldn't matter what should matter is what they need in order to remain at home safely and I think the housing component of integration has perhaps been a kind of later addition to being around the table but they are certainly around the table now in terms of engagement directly with landlords I think there's more work to be done on that but essentially so the decisions to put in aids and adaptations to a property should not matter what the tenure of that property is it should be about what the person themselves needs so it's probably fair to say it's something which is less reflected in housing contribution statements in that generally the focus there has been the RSL sector or council or owner occupied it is particularly challenging in the context of the private rented sector because of their desire to be able to rent the residence again so it does take you into some conversations about tenancy as well the discussion around housing over the last 12 months has developed really quite quickly as increasingly people are seeing housing with support as probably over time the replacement for what residential care currently does and the other component which has been quite interesting is the approach to aids and adaptations because historically the approach would be to go and almost do like a health and safety audit and then do everything to the house but when local systems have had the conversation about what the individual feels that they need they tend to ask for a lot less and they tend to believe that they've got more capacity and capability as a consequence of it so actually approaching the issue in a different way and thinking about the potential for rehabilitation and to maintain mobility rather than to adapt is also part of the rethinking from the perspective of the individual but your question is entirely on point and there is no work to be done there Jeff, in your contribution you talked about sort of advising the symptoms of increasing demand rather than having a bigger picture approach and you also referenced Edinburgh and our last panel of discussion I raised the fact that Edinburgh has some 600 fewer residential care beds and it needs right now but that comes jarring against sort of tension with planning I wonder if both yourself and the cabinet secretary can give us an idea of what discussions you are having with potentially Kevin Stewart and other ministers around that kind of whole systems response to our growing care needs Without a doubt there needs to be a bespoke solution for Edinburgh and mobility and there needs more generally because we have a local market here that is very challenging and actually we are already paying well over the national care home rate in order to secure places within a limited availability and we also have a very delayed discharge issue within Lothian that is accounts for a large percentage of the overall delayed discharge and growing so it has to be a bespoke solution there are a number of things being looked at but it has to be a whole system solution so we need to look at more intermediate care so being able because a lot of people can still get home but they need that support on their way home and also looking at some of the changes that are happening with care at home there is more locality based work going on in order to try to secure a more sustainable workforce there in order to keep people in their own homes and then you have the on-going needs of people who are no longer able to remain at home and there is some innovative work looking at you do so for example there is a work going on on a business case around the concept of what's called a training care home it was mentioned in the workforce plan and this would be a partnership with universities it's actually a Norwegian model that works very very well in Norway that looks at a very kind of high quality training environment where you would have student nurses and student care workers coming through a training like a teaching hospital but a teaching care home now that's not going to happen next week but it potentially could provide quite an interesting new model of high quality but affordable care that would also have a training and innovative research component to it so what is on going on that to look at how that might progress so there will have to be some short-term work done and we're working very close with the partnership, Geoff spends a lot of his time working with the Lothian partnerships to try and help them to make some short-term progress while these other models of care are developing you're closer to I suppose a couple of items there I'm not entirely sure where the 600 figure is because I guess it's when we benchmark we would say that City of Edinburgh probably has slightly less than residential care home places than elsewhere but not significantly less we do see this as a system of care issue rather than an individual component and I guess one of the reflections I would have on how other similar solutions have been resolved in City of Edinburgh is like some of you may have done this as well I came to university here a number of years ago and was in private rented accommodation if I was to come to university here now I would be in one of the 20 or 30 purpose-built student accommodation so they've resolved one component of the accommodation and land problem so there's really the potential to resolve these but it requires that system solution we do spend quite a lot of our time talking about City of Edinburgh 600 figure came from a rebuttal to anoral deputation I made to Edinburgh City Council planning committee in objection to a particular care home in my constituency because of where it was located, the impact on local health services and the rest of it and that was used as the overriding argument to councillors to reject my objection as it were so that sticks very viscerily with me a very specific question then on that because that was a 64 bed care home in Crammond just off White House Road and one of the reasons I went into bat for the community in opposition to that care home not that I have an ideological objection to the development of new care homes in my constituency but the problem with that was the impact on the Crammond medical centres that they had no capacity to deal with potentially 100 new patients who had high end needs is there specific guidance to new care home developers about patients bringing their doctors with them if they are reasonably close or how local health services can respond to the imposition that some of them feel of a new care home in their area so there's a couple of things on this as part of quite a lot of the dementia work one of the issues that we were looking at in terms of the quality of medical care within care homes was the fact exactly that people did take their doctors with them as they moved and that brought with it particular challenges about access and engagement so our general assessment is it does make sense for there to be practices which are connected to particular care homes but those practices then need to take appropriate of what the requirements are likely to be and I guess the cabinet secretary talked about the nursing component earlier but looking into the future you're looking at AHP physiotherapy, you're looking at social care you're looking at general practice geriatricians and probably some specialist geriatricians in the psychogeriatric sort of space so you're looking to think about that's part of the purpose of integration is to enable you to build that sort of mix of services rather than think for a particular locality rather than think about how many of this and how many of that do I have so I think that is part of the future I guess I just wonder was the particular home that you were objecting to was it also a private home or privately purchased places? Because again that's another component of the Edinburgh story which is the development of an increasing number of homes which are only intended for privately funded occupancing. Thank you, convener, and thanks for coming along to talk to us. Just for clarity the early discussion on the UK apprenticeship levy is that training levy is a reserved and that's a UK levy tax and the Scottish Government doesn't get any additional funding streams as a consequence of that for example to fund modern or foundation apprenticeships is that your understanding? I think there has been some negotiation around that in terms of what would then come to us but it's been quite a difficult set of discussions as I understand it but the point that Jeff was making was that there should be no detriment to the employer because of its inclusion within the national care home contract discussion. My understanding it's sometimes difficult to be an expert in everything all the time because we've had the conversation before is that the benefit of the levy is applied in Scotland whether that's through reserved powers or devolved powers but we would need to write to you to make sure that all that is done is replacing funding that was there through Barnett anyway so that's not additional. So there's no new money exactly. That's clear thank you for clarifying that. I want to talk about the area of the outcome being delayed discharge and it's good to see some numbers out in the late discharge. Some progress is going in the right direction but it was specifically about the area of flexibility around the care home contracts that you've alluded to because clearly you're looking at rough numbers at costs the same I have somebody in an acute bed for a day as it does to have them in a care home for a week so clearly there's a huge disparity there in the more people that can be moved through that process the better and if there are blockages there. It was really to assess how much you feel of that blockage is down to issues round about the amount of money that's paid to care home providers because there could be situations on the margin where a certain service costs a bit more but they're stuck in the acute bed that's costing seven or eight times more because of the blockage and lack of flexibility around the contract. So is there work to be done there to allow some more flexibility so that more delayed discharges can be actioned? The picture on delayed discharge first of all you're right that there's been continual reductions in delayed discharge and they're generally running at 10% below the previous year and 34 out of the last 35 months have seen bed days associated with delay below the equivalent months of the previous year all of which is good however as I alluded to earlier on there are pockets where a smaller and smaller number of partnerships are now accounting for a larger and larger number of the remaining delays and the city of Edinburgh and Lothian is one of those and that's why we need a bespoke solution to resolve that. In terms of the work going on around the cost of care calculators so there will be, there is a negotiation around this year's national care home contract rate which is on-going and will reach a conclusion alongside that is work going on around the cost of care calculator and part of that is around the actual cost of care but recognising within that there will be variation in terms of localities so the cost in Edinburgh is different from the cost somewhere else so it's about building in enough flexibility and then you have a growing complex care need so because people are older and have more complex needs before they go into a residential care home place by definition their needs are going to be greater and that has to be reflected more within the cost of care calculator so all of that is trying to be wrapped up into this quite difficult complex piece of work the other thing we're trying to look at about so do you wrap up the nursing component of that and just include it in the rate or do you provide that in a different way through locality based teams that are NHS employed and that is part of the discussion that is on-going because I think we have to think a bit more innovatively around that and again that would add a bit of complexity to so what does the national care home rate then pay for and what does it not pay for what is provided directly through a staffing component that might be NHS employed but there's obviously a cost that you would expect the care home sector to either meet or deduct from so it is quite complex but I guess in summary what I'm saying to you is this is a critical way of resolving I think over the medium to long term this annual debate around the rate is we need to move away from that and look at more of a framework solution that takes into account palliative care needs complex care needs and local variation in the market as well there's two quite interesting aspects to that which is first of all if we have an inappropriate admission to a care home one that could have been avoided that will probably cost upwards of the basis that people will then be in a care home for an extended so if you're thinking in terms of the financial costs rather than the human costs the costs of an inappropriate referral because somebody once having been referred to the care home will probably stay there are quite significant and also in terms of overall system dynamics the other side which is interesting is that one of the early bits of work that we saw under integration was the work in Glasgow around step time which used residential care as a process by which people would be assessed in respect of their needs and then move on and they've seen a significant reduction in the number of people who having gone through step down have then gone on to residential care so you get the benefit both of better flow but also people are more likely to return home with the capacity and with the support that that means in terms of the human benefit so I think the simple translation for weekly costs to individual it's a really important thing and we have to always have it at the front of our minds but we need to think about it in the bigger picture again Brian Whittle As you alluded to earlier on as we heard in an earlier evidence session the evolution of the services that are happening in the care homes is very quick and that their complex care needs are ever growing and the age in which people are coming into care homes is going up the care homes themselves have a limited flex around the costs how much their income is and what their staffing is and I know that within my own reason we've lost a couple of care homes under the banner that the welcome introduction or the living wage wasn't fully mitigated against and given that the staffing levels are a big percentage of the costs and I wonder if you recognise that strain if that's continued it's unsustainable and without that bed the cost to the NHS of staying within an acute care system is much increased and I wonder if there's something you could comment on Let me address the living wage issue first of all which has been quite a controversial decision for Government to essentially provide public money to private sector to help them pay their staff the living wage it sometimes feels a bit counterintuitive that they would then complain about that maybe it's just me but I think that that has been the right thing to do because it is important to sustain the workforce I don't think they would have been able to deliver that public subsidy we are very clear that money needs to find its way to the front line to the staff and the health and care partnerships are very clear that is part of their negotiation that money has to go where it was intended to go in terms of the figures in 2016-17 we allocated £250 million for social care almost £0.5 billion of front line NHS spend has been invested in social care an integration which also covers the living wage as a component of that and to support that this 1819 we are going to give an additional £66 million for social care again a part of which is to maintain the payment of the living wage and ensure that that continues to benefit the 40,000 people who were previously not getting the living wage on top of that despite what we have said recognising some of the complexity of care costs the national care home contract has increased by over 13% over the last three years which is a significant increase not replicated elsewhere I am not saying that I don't recognise some of the challenges but I also recognise what the Government has done in terms of stepping into that space that is not seen anywhere else in these islands and there are the same pressures elsewhere so whether it is the increase in the national care home contract and we pay a higher level here even before the increase this next year that has been negotiated is paid elsewhere in the UK and we pay also a contribution to the living wage what I am saying to you is I think there are business decisions that are being made within the sector some of which are difficult and it is sometimes as easy as Jeff alluded to earlier on to turn and blame the Government for some of the challenges which I think is not always a fair assessment of the situation I think that it is also important to remember that the national care home contract took account of the living wage changes and in the first year that we undertook it because of the representations that we had about small or rural or single care home owners one of the things that we added to the agreement was that if there were particular challenges to particular providers because of the structure and because of the changes in what was being required that they would be open to local negotiation and reference that and understood that if I could just to clarify Cabinet Secretary, if I wasn't blaming I was merely passing on information that's come from care homes themselves to say that even though you might have put money aside to pay the living wage the suggestion is it's not necessarily making its way to where it should be or indeed it's mitigating against its cost not just in my area but that's a recognition across many areas that's becoming increasingly difficult to maintain the care home system I think that the solution here is around the cost of care calculator bringing a level of transparency to all aspects of this not just in terms of what is paid through the national care home contract but transparency around what is now a reasonable profit level for example for the independent sector to take because there is huge variation there you have over the last few years some where I accept the margins have been very very tight indeed but you have other providers where actually quite a healthy profit has been taken and we need to bring a transparency to all of that so that we can make sure the public contribution we make leading to an improvement in quality of care staff are paid the living wage but there is a reasonable return for the provider where there is a profit element involved which obviously not all providers have so I think that that is the reason the cost of care calculator is so important in bringing transparency to all of these things Thank you very much Thank you, convener I suppose coming back to the future sustainability idea and I guess I'm talking more into medium and long term that clearly we need to do some work around maybe identifying what these innovative new models of care might be and obviously the cabinet secretary has already mentioned one example from Norway which does sound really interesting are there other ideas or pilots projects that are being used in other countries that perhaps Scotland could learn from that? I think that we have been very open to looking at best practice elsewhere so that the boots org model that we've been trialling here around the idea of really empowering the front line staff working in more of a care at home environment that they would manage their case load and be able to make those changes and adjustments to care that enables more rapid changes if someone needs more care or less care so that they essentially can be making more of the front line decisions around care rather than passing it back to three sets of managers and the time that that sometimes takes so we've looked at that in terms of the care home sector I am very taken with the idea as you probably can guess I've probably mentioned it three or four times now of looking at more of a what are the skills needed to support a never more increasing complexity within a care home environment rather than who employs them and I think the reality is even with the promotion of the benefits and the attractiveness of a nursing career within the care home sector I think even with all of that there's going to be challenges because the NHS is a very attractive proposition for nurses because of the career opportunities and diversity of opportunity there and I think therefore the idea of locality based teams not just of nurses but of other skillsets providing that to the care homes and nursing homes within that locality for me is a very strong proposition in terms of a way forward now that's already happening in some areas but I would like us to look at if that is a viable proposition and obviously we're increasing the number of training posts for nurses so we're increasing the workforce overall so we'd have to there are always demands on the nursing workforce so we have to recognise that but I think we could make that quite an attractive proposition for nurses and other allied health professionals as well which would increase quality would bring sustainability and potentially would be a way of avoiding the care home sector having to pay agency nurse rates in one case of £1,200 a night that is not sustainable so we have to recognise that Thank you Good afternoon to you both Can I raise a general point about the improvement hub that was set up almost two years ago by Health Improvement Scotland I mentioned in the last session that I watched the online presentation last night which I thought was the first class on things like sepsis and the new fit procedures for bowel screening but is it the right vehicle to manage change in the sector I think it's probably one factor although you're right it does some really really good work I guess what we would want local partnerships to do is to analyse their own problems if you like so that they know what their local needs are and where they've got challenges where they've got strengths and where they've got weaknesses and to ask for support I think the partnerships that ask for support the most are the ones that are actually getting on and doing the best and perhaps where there's been a reluctance to ask for support is where we've seen most of the challenges and it should never be seen as a weakness to actually ask for support it should be seen as a strength that you've identified where your challenges are and you actually want support in overcoming those and some of our strongest performing partnerships have actually asked and received some quite significant support so... I think it's a good question the frailty work also that the IHUB has done on a pallet basis in Fife has also been really effective and we see it as one of the reasons for the improvement in a number of the indicators there but it goes alongside the data work and the objective of creating capability for change within local partnerships could I add something just to the previous question two or three things which we're saying is greater use of technology looking also across the housing solution, care home solution community hospital solution but also mixed use environments one of the areas that we've become aware of in England that they developed an Italian restaurant as part of a mixed use environment and as part of the overall funding model which apparently made £8,000 during its opening weekend so if you begin to think you don't have to do it the way in which you always did it but you can find different ways to do it and I guess the other component of that is where you locate care do you take it to the outskirts of the town or do you try and put it in locations where people are able to tap into other sorts of facilities as well so there's a lot going on but it will learn but it will also be bespoke thank you very much, Emma thank you convener I just have a quick question we now use the language of models of care that strips off our tongue quite easily it's a common language that we use but I'm wondering has there been a need identified that people don't still understand what changes of care means as far as respite in the home versus respite in a place or it's not just about bricks and mortar it's not about dementia care in a place it's about the wider connectivity to the community and everything so I'm just wondering if there's a role or a further remit required in the engagement and awareness raising regarding the language that we are using for better care models someone mentioned the language earlier on it might have been Sandra I'm not sure and I think there's something in that that rather than compartmentalising this is that actually it should be about the care needs of the person and whether or not where they receive respite it should be tailored to what their needs are and I think we started off by saying that you can't look at one part of the system in isolation you know it has to be you have to look at the whole system so there's definitely something in that I think and perhaps changing some of the language or adapting some of the language I think it's a more general issue as well because we talk about going to the hospital or saying the doctor there's pharmacy in the social care side one of the things which I find really interesting is just how surprised people are often by what they receive and how pleased they are with what they receive and it's a surprise because it's not hadn't been their understanding of what this was so speaking to a colleague whose mother had returned from hospital and lived in a terraced house and had expected to need adaptations but instead got rehab that was six to seven weeks later was able to go up and down the stairs and had the capacity to use the whole house and that was just a mind blowing outcome and that's normal but it's not the dialogue that we have about one of my colleagues about ten years ago suggested we should do a documentary soap to explain but I don't think that the broadcasters would necessarily find that to be a it's really quite hard to get across on that thank you very much colleagues that's been a very full session can I thank the cabinet secretary and Mr Huggins for their attendance and we will now move into private section thank you very much