 Good morning, and welcome to the 35th meeting in 2015, our last meeting in 2015 of the Health and Sport Committee. I would ask everyone in the room, as I usually do at this point, to switch off mobile phones as they can often interfere with sound systems, but those in the room will notice that some of us are using tablet devices and this is instead of our hard copies of the papers. Our first item on the agenda today is a decision on whether to consider themes arising from the draft budget scrutiny, 2016-17, in private. As we normally do, future meetings cannot have the committee's agreement. Agenda item 2 is our first evidence session on the draft budget scrutiny, 2016-17. I welcome this morning to the committee, Julie White, chief officer, integrated joint board and chief operating officer, NHS Dumfries and Galloway. David Williams, chief officer, designated Glasgow HSC partnership, Lane Meade, chief executive, NHS Highland Health and Social Care partnership and Jim Forrest, director with Lothian Health and Social Care partnership. Welcome to you all this morning. I am not expecting any opening statements. We will proceed directly to question. Our first question this morning is from Malcolm Chesham. I think to the exciting things about integration, where the pool budgets and the locality arrangements and so I was a bit concerned when I read the Audit Scotland report on health and social care integration that those were two areas of concern that they flagged up. So if I could take each of those areas, I'll start with the budgets and then have a second question on the localities. The sort of opening statement was that there was great difficulty in agreeing budgets but then it went on to talk about set-aside budgets. I suppose that this mainly applies to Edinburgh and Glasgow rather than the other authorities but there's particular concerns about disaggregating the larger hospital budgets and deciding which ones went into the integration authority and which one didn't. Then it went on to say even perhaps when agreements were reached about what was going into the integration authorities that the health boards might be wanting to keep control of it. So all that was really rather depressing in terms of the potential for pool budgets. So I wondered whether you could comment on those concerns that Audit Scotland does flagged up. Anyone? David, I've seen you sitting upstate this week and you've been nominated for the first question. My first response to that question is that it is still early days yet in relation to the integration of health and social care. We are expected to have a strategic plan in place and operational from 1 April and certainly in Glasgow we are out to consultation at this moment in time in relation to that strategic plan. As the Audit Scotland report highlighted, many—and ours is not exceptional to that—many of the strategic plans are general in expressing a direction of travel rather than being explicit around actual actions and reforms that could potentially be happening. I think that one of the things that we have to remember around the aspiration of shifting the balance of care for which there needs to be a shift in the balance of resource—potentially from acute or other forms of institutional care—into locality planning and community-based support to enable more older people and more adults to remain in their own homes in the community, is that that shift is not something that is going to be achieved overnight. From a Glasgow perspective, I think that the expectation is that, although we have not agreed the definitive aspirational budgets of future IJBs—of the future years in terms of the IJB, my expectation is that, broadly speaking, the budgets that were set out when we agreed between the health board and the council a year or so back of what was in scope in terms of functions and services and the broad parameters of what would be involved in budgets—that is the starting point for 2016-17 minus inevitably the budget savings that will be expected to be delivered on and achieved. In terms of the set-aside budget, we will see the first year in reality being a shadow year in terms of what that actually means. The truth of the matter is that there is nothing substantial going to change in terms of how acute or the shape and size of acute services within Glasgow over that first year of that provision. From a Lothian perspective, many of the things that David has said from a Glasgow perspective are equally relevant. Setting up the budgets for a health board area in Lothian's case that has four partnerships makes it a more complex issue. In terms of the partnerships in Lothian, clearly from a West Lothian perspective, where I am from, most of the acute activity will go in through St John's hospital, so it makes it to a degree more straightforward to look at the set-aside budgets that will be involved in the partnerships that are being set up. That work is on going at the moment. The complexity in Lothian is that we have one or two hospital campuses in the city where not only do they serve the population of all of Lothian, but they are also regional and national specialties, and the complexities that there are around that, as well as that, the royal infirmary in the western also serves the populations of Lothians, so each of the partnerships east, mid and west, as well as City of Edinburgh, have issues around the activity that goes in and out of those partnerships as well. It is certainly days and setting up the budgets. We have not fully agreed them all, but, like all of the services that are part of the scheme, they will be part of the devolved budgets that are agreed and are in the process of being re-appointed to the partnerships. On the localities, from a West Lothian perspective, we have worked as a health and care partnership for a number of years under a voluntary arrangement with aligned budgets. We have very good relationships with GP practices. There are 23 GP practices across West Lothian. We are currently working with them about what the representation in the localities would look like. Importantly, what kind of commitment, time commitment from them or their practice would be involved and how we would accommodate that to free them up to do any of the locality work that we take forward. That is in the process of being built up and will be part of a strategic plan, which will be signed off by the end of March by the integrated joint board. I thought that I would comment on the question about the pooled budgets, as we have made a decision in Dumfries and Galloway to include all of acute services in the budget from the outset. The reasons behind that are numerous. We write in the early days of setting up a proposal on integration. We wanted to ensure that there was transparency of the entirety of the health and social care resource right across the partnership. We recognised that the potential impact of our increasing population of older people, increasing demands on health and social care services, would be felt right across that partnership. Decisions made in one part of the partnership in acute services, for example, have no consequences in primary and social care services. In Dumfries and Galloway, we made the decision to integrate all of acute services because we were committed to ensuring that we maintained the integration of health services. We maintained the integration of primary care and secondary care services and did not create any divide unnecessarily between the two. We are fortunate in many ways in Dumfries and Galloway in that we have a one co-terminus boundary with one local authority and one district general hospital, which obviously facilitates us to make decisions around the entirety of our resource that is available to us. That enables us to have incredible support. When we presented our integration scheme to a meeting of the full council earlier this year, we had incredible support from the local elected members on the inclusion of acute services in the integration scheme from the outset. We also recognised that one of the other reasons for including acute services was that we recognised that there was that assumption implicitly in some areas and explicitly in others that we could reduce the cost base in acute services and transfer that resource quickly to primary and community care services. However, with the pressures that we are currently facing within acute services, whether that be around increasing demand, around access targets, around medical locoms, it makes making that shift actually very difficult in practice. However, we felt that within our pulled budget, if we had transparency on the totality of that resource and the pressures across the totality of that resource, perhaps over time we could reduce that increase in expenditure in acute services and see an increase in the percentage of the funding that is available to primary and community care services. Thank you. It is probably appropriate for me to go last, as our model, as you may be aware, is slightly different in Highlands. The Highlands-led agency model has allowed us to completely integrate the budgets from the onset, so that was back in 2012 when we first moved to this model. We now have, in terms of a budget, it is a single budget with single management and single governance, which we believe works well for us. That has been very important because it has allowed us to look right across the totality of the funds from acute into secondary care and into adult social care. As my colleagues in Dumfries and Galloway have described already, having the whole system within one budget does allow you to look in a very different way at how you deliver those services. It is a significant budget. It is over £100 million, £116 million, and there has been investment into that budget from both the Highland Council and NHS Highland over the last four years. Importantly, we need to look at how we use every single penny of that budget. It is really important and one of the things we set out to do was to try and lose the identity of the budget over time. It no longer was a health pound or a social care pound. It actually was a care pound and we could move the money to where it was needed. Clearly, it is very difficult to release the pressure on the acute sector. We are in the process of redirecting resources from the acute sector into the community sector, primarily in primary care, to support particularly general practitioners to lead teams in all of the localities. One of the examples of the way we have done that in NHS Highland this year has been where there was some investment from the Enrack parity funding. We actually redirected £5.4 million of that into adult social care rather than putting that into health in the first instance. In terms of localities, we are organised in Highland in nine localities with district partnerships overseeing those we are considering just at the moment under the community empowerment act how we want to build on that experience. It has been successful in some areas. Maybe it has not got quite so much traction in other areas but the clinical and social care teams are now fully integrated in localities with single points of access for each locality for either health or care or public to be able to access services in those areas. Thanks for that. In terms of the budget, it seems to be easier under the lead agency model, which begs the question why it is the only authority in Scotland to go down that route but let us just leave that sticking to the wall. I move on to the locality issue but I think that we are really interested in what Dumfries is doing but I think that we accept that Edinburgh and Glasgow cannot do that because the hospitals obviously serve different local authorities and so on. I am still intrigued by how the set-aside budgets are going to be determined but we will leave that as well since you have given an answer on that. The locality question sprung from the comments again in the Audit Scotland report, which said that arrangements for localities are relatively underdeveloped. I certainly recognise West Lothian as a head of the game but I would be interested in further comments on how you see the localities. I suppose that when we were doing the legislation a lot of us thought that this was one of the most important and exciting parts of it but it is concerning when we read that they are under developed and I would be interested in how you envisage the scope of those locality arrangements, for example would they include locality budgeting and so on. I do not know if Glasgow wants to comment since I think that you were actually criticising the debate last week by at least one speaker not myself in terms of being a bit top-down rather than locality focused. In Glasgow, we plan to have three localities. I think that one of the concerns that we have within Glasgow is that what we are endeavouring not to do is to create tiers of bureaucracy and governance as a consequence of this legislation. There is an element of needing to be fleet of foot and part of that approach in relation to health and social care is about how we can build on the arrangements that exist within community planning currently in each of those three localities and that includes area partnership groups and that is taking account of the community empowerment legislation that is coming forth. What we are clear that we do not want to do is to establish additional planning functionalities and specifically and solely around health and social care. One of the things that I am very clear about in relation to the health and social care legislation is that the mere integration of a significant part of a health board in terms of functions and services with a significant part of our council provision is not in itself and of itself going to deliver on the aspirations of the legislation in terms of the national health and wellbeing outcomes. That is the key to the word partnership within health and social care partnership. The construct of IJBs in relation to voting members and more importantly non-voting members and all of the stakeholder groups that are represented in IJBs at the point that decisions are taken in relation to the delivery of health and social care within an area is that that partnership has to mean much more than just the bringing together of two workforces and two budgets because the resource is substantially going to be located in people terms in local communities and if we are serious about transforming the way health and social care is delivered whether it is in Glasgow or anywhere else in Scotland and that includes impacting on the health improvement and health inequalities agenda and the shift in the balance of resource from acute to early intervention and prevention. Our aspiration has to include and involve a better engagement and an improved engagement of neighbourhoods and communities and better support for carers and families. I suggest to you that that is not something that relates to a top-down approach but something that is much more organic and built into the system of how the city works in the three localities. We will be working closely with our community planning partners to deliver on that agenda and that should allow the integrated arrangements to focus on very clear and particular need that is identified for people who actually require health and social care services at different points in their lives. I just wanted to comment on our approach to localities in Dumfries and Galloway. Our plan is that we have four localities across Dumfries and Galloway, each of which are built around natural communities, natural localities and historical arrangements through old district council arrangements. One of the important aspects of the localities is that our communities identify with those localities. What we have said in our strategic plan is that health and social care integration must lead to staff and local communities feeling like we are smaller than we are just now and that we are much more responsive to local need and that integration is not about developing new structures and new monolithic bureaucracies. It is important that the arrangements that we have developed within the localities, where we are looking to delegate our budgets to those localities so that they are as close as possible to those local communities. We are also introducing joint management arrangements and integrated management arrangements for health and social care across those four localities. As David has highlighted, one of the key things that we have learned is that the success of integration is not based on us bringing two organisations together, but it is about real genuine engagement with our local communities and about changing our relationship with our local communities. The development of our four localities in Dumfries and Galloway through a number of groups such as our public engagement groups, where we are engaging with members of the local communities, where we are involved in the third and independent sector in the development of our localities plans. We have four localities plans that are in draft at the moment that we are consulting on and they are about describing how in each of the four localities we will deliver against the priorities that are set out in the strategic plan. There is very much a strong commitment within Dumfries and Galloway to devolving as much as possible to those local communities for decision making, but the localities plans reflect how they will deliver the aspirations that are set out within the strategic plan. Can I say to Galloway that I think that you have grasped this way a passion, but I also want to come back on the point that Jim Forrest and you made in a question that I asked earlier. Do you think that we have missed a trick? I am all for local democracy. I was a councillor for three decades, but in north and south Lanarkshire we have two boards. East north and south Ayrshire have three boards, but I understand that they are starting to work together. Do you think that we used to have what you called Stratford fire board, fire and rescue, as a joint board for Glasgow and south and north Lanarkshire and other authorities? Do you think that we have missed a trick in having too many boards? I certainly think that there is a challenge for the smaller partnerships in relation to the ability to deliver what is sitting behind the legislation, which is around the transformational change about how health and social care can be delivered. We have, in Glasgow, an opportunity to substantially change the way that health and social care is delivered. It is not going to be overnight, but it will certainly have a bigger impact, we hope, on how health and social care provision is delivered. However, that is because of scale. The Glasgow budget in terms of integrated arrangements is going to be just short of £1.2 billion. There is a 9,000 workforce involved in that. We think that there are, broadly speaking, another 20,000 of a workforce within the care environment through the commissioned provider sector, the voluntary sector, the independent sector and other bits of hospital care that is not linked to integration planning. We know that there are probably about 50,000 unpaid carers in the city. That is a workforce of unpaid and paid carers of 80,000 people. That is a significant volume of influence if we get the culture and the approach right in relation to how we want to address the issues that are significant to Glasgow. It is around being able to deliver on that and achieve that because of scale. That sets us potentially apart from other parts of the country where it is perhaps more challenging to achieve that level of change. I think that it is a once-in-a-lifetime opportunity to transform the care sector. I am not sure that it is dependent on scale particularly. My view is that it is built on trust and relationships and maximising the use of the resources and the capacity that you have both in organisations and in the community. That means that you have to redirect the way that you have used your resources. For example, having additional investment that we have made in acute geriatricians, who normally would have been working inside hospitals, but having them working out in the community as part of integrated teams, has had an impact already on reducing older people being admitted to hospital and maintaining independence. That is where we will start to see that shift when we start to find that we can change the way that we deliver care. Just a couple of questions that we have picked up in your earlier comments, Elaine. I suppose that what we have been searching for over a period of time is a shift from whether you have described not just finance but shifting people from an acute sector into the community sector. I do not know where you can describe some of that given that you have had that in place for a considerable time. When we visited as a committee, the hospital was almost at the start, left alone to go on, so I presume that has progressed since those early days. However, how much of the budget has shifted into the community as compared to the acute sector budget? Has there been a significant shift being measured? It is very difficult to measure that shift that has been described by colleagues as a shift in the balance of care because of the continuing requirement for us to deliver care in the acute sector. We need to deliver all that emergency care, but we also need to deliver elective care. That consumes a huge amount of resources, and that is very difficult if you still need to deliver all the things that we are being asked to deliver at the moment. It is hard to switch that off with an increasing population. However, we have, as I have described already, made the active decision when we had additional NRAC money to invest that directly into adult social care. That has given us benefit immediately by increasing, for example, care at home workers. Having a single tariff across all of the providers in Highland has meant that the providers are now working together in zones. It keeps people closer to home, and it keeps people in their homes for longer. Although, technically, that has not seen resource taken out of the acute sector, it has moved what could have been money invested in the acute sector into adult social care instead. Just having the acute geriatricians working in a different way is a shift in the balance of care, there is no doubt. I understand that. That is a good example, but that is an exception rather than a rule. There is a perception growing among us all that we need to shift resources and finances into the community, and the health service is an opportunity to shift that budget and build it. However, that would not be your experience then, would it? Not yet, but that is coming. How long have you been in there? So, we have been doing this for four years. We said we would… Four years ahead of everyone else. Indeed. So, what is the experience? There has also been a criticism of the slowness of this, impact and whether it makes a difference to people or when it will make a difference to people. I am just trying to gauge four years in and you are unable to describe, because it is difficult, and the demand is increasing, that shift of budget. Well, we could have invested the NRAC money directly into acute care and taken out some pressures in that sector, but that would not have helped the whole system. So, if you are looking genuinely at a whole system of care, then you have to look at where every penny is invested and how every penny is spent. So, our approach to looking at how you can genuinely shift the balance of care is by not having people that do not need to come into hospitals, go into hospitals, but also looking at how you spend every penny of the health budget. So, we are looking to take out the waste, the harm and the variation in healthcare in the acute sector, with the view that that will allow us to invest more of that resource, ultimately, into the... As you think that there is going to shift money from the acute sector to invest and preventive and community services, it will be a long time coming. It will take time, for sure, because you have to change, then, the model of care and people being admitted. Sometimes unnecessarily into hospital, we need to manage those in a very different way. So, how far are you on that journey? We think that we are now five years into that journey before integration. We actually were already looking at taking out waste, harm and variation from our system. We think that we can already see parts of our system coming back into balance, which has been helpful to us. But, as yet, we have not got ahead of the curve to be able to say, we can take this resource out and move it into the community. However, we have not been having to extend our acute sector to provide more care. I think that, had we not been working in our whole sector, we may well be under some of the same pressures that the health boards are experiencing currently. I have a look to Lothian and Glasgow, where you have got different circumstances about who you are going to use, which is a great opportunity to invest in some of Lothian and Glasgow, in the acute sector, to transfer to the community. I think that there are opportunities, but there is a challenge. It is not just about moving resources and spending. I think that we also have to take a look at the job profiles and the job roles that people currently undertake. One of the things that we are considering and starting to move on is, in some of the medical roles, where it is not just that you are hospital based or community based, you actually have a role in both elements of the service, particularly in older people's services, admissions to hospital and those who unfortunately get stuck in our system and our system does not do the best by them or older people who come in through medical wards, in particular in assessment units and things. We are looking, as well as having hospital home services, that the geriatricians and the physicians have a dual role. They work in the medical wards and they actually look at how they lead some of the community services, so that there is much more integration of the whole service right across the pathway. We have an analysis of our frailty programme just now that takes us right the way through from social care to being admitted to hospital, where the blockages are in the system during analysis and then changing the type of service that we offer. We have used the integrated care fund and the daily discharge fund, almost as a pump primary for additional capacity in the community element of the services and social care elements of the services, gearing ourselves up to looking at how we deliver the outcomes that are really necessary right away across the board. In touching on the preventative aspect, we are looking at preventing admission in the first place and bringing hospital home straight to somebody's residential setting. We are analysing how effective that is and does it prevent admissions and disruption to that person. If it does, then what effect does it have in the hospital services over time, so that once you start to bed these services in, you can then make the transfer of some of the resources into sustaining these services in the longer term. I would stress that there is an issue about how we change the demarcation of the roles right across a number of the professions so that they have, particularly the interface, a role in both elements of it. They will then start to understand what actions are needed so that it does not have a detrimental effect on one side or the other. We are also, as part of that whole process, looking at a new framework agreement for social care providers in terms of care at home and what the metrics are there that the whole system needs to take people much more quickly, particularly those who require what we would call higher tariff care packages where it is two carers four times a day. How do you respond to that as quickly and in a way that supports the whole service and improves the quality of care for those who are receiving the service and get it on time? We are at a stage in which more people have been treated and cared for at home than there ever has. We have still got 90 per cent bed occupancy and we have still got bed bottle. David, what is the integration of social care that we are going to do? I think that you are right, chair. There is potentially a higher level of opportunity for that shift in the balance of resource from acute to the community-based provision within areas like Glasgow, which have multiple numbers of hospitals—the greater Glasgow this is—in terms of multiple numbers of hospitals and so on and so forth. I think that there is something around about being able to develop an evidence-based that allows—and there is almost chicken and egg in there, and I think that Jim is correct to reference the use that we are making of the integrated care fund—for instance, the additional funding stream that the Government has provided as part of the transition arrangements. You cannot just shift resource from acute to the community with not really knowing how people are going to be supported at the point that those people previously would have just pitched up at A&E and expected a service to be provided, so there is a need to develop not just an evidence-based but also a range of appropriate provision in order to provide alternative forms of support and care and to make better connections between the community and acute, particularly A&E at the point that the individuals and patients turn up for A&E. In Glasgow, specifically over the past 12 months, we have flipped completely the approach to addressing the issue of daylight discharge and bed blocking and focused rather than on delivery of the two-week delayed discharge deadline that came in to effect from 1 April to going beyond that with a view to looking at, can we get as many older people out of hospital as close to their discharge date and preferably within 72 hours, as we possibly can? In doing so, we immediately do not hit the two-week problem, we immediately do not hit the delayed discharge issue. I think that we have had some significant success in being able to deliver on that, and that has reduced the level of bed days lost within the acute system significantly in relation to Glasgow. It has reduced significantly the numbers of people over the age of 65 who have been delayed unnecessarily in hospital, and it has been about moving individuals and supporting individuals back into their own communities and into their own homes. We have done that by way of substantially changing the approach and the principle that is about getting people out of hospital quicker rather than waiting for things like assessments to happen and for assessments of need to happen in a more community-based environment in something called intermediate care beds, which we have significantly increased in number over the past 12 months. We have used the integrated care fund to deliver on that. The strength of that approach has been that, for every 100 people who have gone through our intermediate care beds on a four-weekly turnover basis, 30 of them have gone home. Prior to a year ago, the chances are that all 30 of those individuals would have gone permanently into residential nursing care placement instead, directly from their hospital bed. We are shifting the resource not necessarily from acute in the first instance but from the residential and nursing care sector. Implicit and, to a certain extent, needing to happen more explicitly, but implicit in that is a re-evaluation of what we would call a threshold of risk. Empowering individuals to take different decisions about where they want to be, and most older people tell us that they want to be in their own homes, that is where they want to see through to the end of their days. It is about how we enable that to happen. There has to be a re-evaluation of the threshold of risk in that. We have established an evidence base, and we have been able to sustain the performance over the course of the last number of months in relation to delayed discharges. We touch lots of wood all of the time, and we are aware of the pressures that winter can present to us. We are working really hard on sustaining that performance, but, if we can sustain that continuously, that gives us an opportunity to then begin to look at what we can do jointly with acute in the front door provision and the accident and emergency presentations, because part of our challenge and part of our responsibilities in the health and social care partnership is to look at how we look at anticipatory care, how we prevent things from happening, how we avoid unnecessary admissions at the front door. There are things that can assess that that we are working on straightforwardly right now, which is a roundabout communication. The communication between—and that is ICT systems, for instance—the A&E departments, GP practices and local authority social work provision about an individual patient. One of the changes that we have made already in Glasgow is to do away with the single unique identifier that social work is historically always given to service users as I have come through the door of social work and change that to using the person's own kind number. There is an immediate connection that can be made there. We are working to create a technical bridge that will allow A&E departments to understand who else is involved in an individual's life. That might enable a different decision to be made by the A&E departments about whether to admit somebody or whether to divert somebody back home with a slight change or amendment to the kind of support arrangements around them. That is the next challenge and the next approach that we need to take within Glasgow, and I think that if we can tackle both ends of the hospital system, I think that necessarily what should follow from that is a clarity around what use—I do not mean that in any pejorative term—but what use needs to be made of acute functionality in the future. That might realise efficiencies that can be delivered at somewhere else. I will build on David's comments, which I fully endorse. I think that the use of intermediate care beds and changing the place where assessments are undertaken is absolutely critical here, looking at just that whole system approach. I think that David was describing that you can ultimately then reduce your occupancy of the acute beds, and that is where we need to get to, and that is the long game that we are looking for. Increasingly, we recognise that we need less beds in our hospitals, but those are full of people who, at this moment, are struggling to move through a system. However, if we can use intermediate care beds if we can assess people and change that threshold of risk that David was describing and support people at home, we have had really good experience—a reduction of over 80 per cent in care needs for people who have been through a reablement system. That means that we can redirect some of that care at home support to others who really require that and move others out of hospitals. I think that it is a long game here, and it is not something that you can change immediately, but the resources are tied up significantly in acute beds at the moment. I want to look a little bit at the announcement of acute and primary in community care and how that fits into integration. If someone presents A and E because of visual issues because of cataracts or they have a slipchip or fall because they are reading a hip replacement, that effectively has to present at the acute sector the cost of that and the on-cost to enable them back at home as a higher cost. I was using that in a private session that I had with Audit Scotland in relation to £200 million that will be spent in the acute sector at the Golden Jubilee and in four designated surgical units across Scotland to prioritise making sure that we have a more ageing and frail population that we have the capacity and the system to make sure that at the earliest opportunity to maximise the time at home that people can be fit and healthy and reduce the risk of having those injuries and presenting through the front door at A and E or whatever. That is an investment in the acute sector. In budget terms, that would seem to be going against what we are seeking to do in shifting the balance of spend from the acute to primary in community care. That is why I thought that it was interesting that Dumfries, for example, decided to include acute spend as part of an integrated approach to health and social care integration. I do not want that to be an accounting discussion where we argue where the numbers sit. I know that that is dry and dusty and Audit Scotland and I probably love that, but in terms of how do you get a bit less one-dimensional when you look at investment in the acute sector and how that can drive improvements in health and social care integration and that community agenda, we all want to add. I appreciate some thoughts on that, so we can look to see what is good acute spend and what is maybe a bit more short-sighted acute spend. I think that that is an interesting point. We decided to include all of that spend in acute services, as I said earlier, to ensure that there was real transparency in terms of the use of resources and what they were being used to address. Within Dumfries and Galloway, a number of changes in investments in terms of acute services are about supporting people to be maintained at home for longer. In a medical admissions unit, we have introduced an ambulatory care approach, which means that when someone is reviewed within the medical admissions unit, we are instead of that person going on to a hospital bed. We are looking at how we can have rapid assessment of that individual and rapid diagnosis within acute services, which means that we can turn around that patient back to community services as quickly as possible so that they are avoiding that individual making use of that acute hospital bed. Although that might be seen as an investment in acute services, it is about shifting that balance so that that person does not become admitted to an acute bed. They might have a short-term assessment in there and then turn back to the community setting. There are also investments in things such as outpatient antibiotic therapy, which, in the past, you would have had patients admitted for that type of therapy within acute services. That investment is intended again that that antibiotic therapy can be delivered as a day case, which avoids the need for admission to a hospital service and supports that person to remain at home for as long as possible. That is another area where we would see, potentially if you looked straight at the figures, an increase in resources around acute services, but that has a positive impact on delivering the aspirations that we see through health and social care integration. I think that, in terms of that whole shifting the balance of care, one of the key areas that we really need to focus in on is reducing that rate of emergency admissions to secondary care. Again, within Dumfries and Galloway, we have undertaken a range of tests of change that have been supported originally through the reshaping care for older people funding but also through our integrated care funds, which are about supporting the use of technology for remote monitoring of individuals so that they can be monitored from acute services but remain at home. We are also looking at community early warning scores for people with respiratory patients. That alerts both the patient and our teams within acute services to any changes in that individual's condition that might require some interventions. There have been quite significant shifts in terms of our resource and the use of the integrated care fund monies to develop new models of care and new ways of supporting individuals to remain at home for as long as possible. I am interested to know if other witnesses have a perspective or review on the use of acute monies and what is good acute spending and why they did not go for putting it as part of that overall pot of cash. Just to respond, if I may, on the comments that we make about the investment in elective care centres, if we look a little lateral at that, it has a long-term benefit for older people for sure. Rather than just being more investment in the acute sector, which clearly it is, cataracts surgery prevents falls. There is no question at all that that will be a significant investment for older people. Hip replacements allow older people again to maintain independence. Both of those things support the models that we are trying to describe to you today, with day cases or short lengths of stay and separating them out from the acute hospital streams. Briefly, I will answer the question specifically. The acute system is a system that, as far as I can see, tends to work currently in as much a crisis kind of responsive type of mode. Inevitably, the challenge there is that whatever money comes into it, and our experience, sadly, is that it tends to prop that system up, because more and more people came up. That is the whole point of integration of health and social care. The perversed outcome of the unintended consequence of doing that is that there is less money that ends up coming towards the early intervention prevention model, which reduces the potential for the models of care and the opportunities that Julie has described being developed, because there is a squeeze in the wrong end of the whole system in financial terms, which is contrary to the aspirations of the health and social care partnership. We absolutely need to be very careful about the money that is made available from Government and where it goes into acute system or where it goes into health boards and to ensure that, if we really want to make a change through this legislation, that it needs to be directed towards integration of health and social care. Jim, do you want to... Thank you, chair. I think that briefly going back to your question, I think, like Elaine and the others, the investment in these regional surgical centres will make a difference. I think that part of the answer is contained in your question and that if somebody has to turn up at A and E as a result of having a cataract or has fallen and therefore needs a hip replacement, then there are other parts of the system that we could say haven't worked properly for that person. Having these regional centres will help so that we can manage people and book them in appropriately for their ophthalmic surgery or whether it's a planned orthopedic surgery. The other part of that needs to be that once they've had their acute procedure, their rehabilitation takes place in their own residential settings, so we're discharged to assess their rehabilitation needs rather than cover all of that in hospitals and expensive hospital beds. I think that the idea of investing in that part of the service, if we can use our integrated care funds to manage people much more appropriately and deal with any acute exacerbations and plan people into those services in a managed planned way, then the need for other hospital beds becomes less of a demand and the actual community resources are based on their own residential settings. I think that it's a staging post along the way to where we need to get and see these things in the round. I think that we need to really be careful in terms of community resources that we talk right across all of the community resources. Primary care is under pressure. There's a limited recruitment of GPs, so we need to look at the model in primary care so that it's much more multi-professional and takes on all kinds of different roles. We just target GPs exactly where we need GPs to be rather than the range of other things. We shouldn't underestimate the need to invest in models of social care to support all of those activities because they have a significant effect on individuals' lives and even a small social care package can make all the difference in maintaining someone at home. We need to see those things in the round, but I think that the investment in those surgical centres is a very key investment. I've been able to manage the whole pathway. If you take somebody in Lodian, for example, we can get access to the Golden Jubilee and we can do that, but if you're already medically compromised or if you're frailer, if you're older, that's a really major upheaval—one to go in for a procedure but to go some distance away and all the things that goes with that. They get a very good service when they go there, but we shouldn't underestimate the effect that it has on people and it puts people off actually doing things in a managed way and then ultimately they have an accident through some medical compromise and you have a much more expensive and much more difficult process to manage people. I suppose that Mr Forrest got close to what I was trying to tease out. I think that all of you fleshed out why we should be one-dimensional when we talk about acute care versus community and primary care and that was really helpful for putting that on the record. What I had in my head was that if a health and social care partnership realises that they've got maybe 50 or 100 clients who would significantly benefit from their cataracts operation now but they may be on a par in terms of clinical need, but there's other social dynamics there—how you can then seek to gain greater capacity in the acute sector to get them through that quicker for that social benefit—to reduce the slip, trip and fall and that kind of thing. I didn't want to do the accounting thing, it was whether or not bringing some of that acute budget into that gambit could drive change or not. Can I add just another aspect to that? 200 million pound for that initiative, 100 million pound for A&E initiative, what would 300 million pound do if it was invested in the community and would you have spent it that way? Would you have given the responsibilities you've had, the tightness of finances? If you had access to some of that money, would that have been the priority of the integrated boards for your community to do more cataracts or would it be to help transform services? One of the better examples that I think made us all scratch ahead of me was the investment in A&E services, where I think we all know that the solution to that is not about more doctors and nurses in A&E services, it's about preventing people getting to the A&E department. If that money was available, would you have used it in that way or would you have set other priorities that would have? I'll take that to start with. The experience that we've had and it relates to where Mr Doris was going, the experience that we've had in relation to the digest charges where we flipped the target of two weeks on its head and said that we can do much better than that has proved to us that you could do more in a preventative sense and an earlier interventionist approach if you tackle illness or accidents at an earlier level or frailties such as need for hip replacements or cataracts. That does have a positive social impact, so I would certainly have used and considered using the money for a range of things potentially in that kind of context. We would have had to have done a little bit of work in terms of trying to identify where the big impact issues are. We used the integrated care fund specifically around delayed discharge because that was a big national priority at multiple levels. The balance between cataract replacement for instance and cancer treatment or whatever in terms of scheduled care, we would have to do a bit of work to understand what would be the big impact that might then release further opportunities a bit further down the line in terms of how acute a system is used. If I could come in on that question as well, I think that it's all about balance. If you wish to deliver the waiting time guarantees then we absolutely need the elective capacity. It is as simple as that. There are choices that are made and our job is to put those into practice and operationalise those as best we possibly can. Of course we would want to be able to put more resources into the community. I think that all of us would absolutely agree that that's what we would want to do, but we also need to deliver the other requirements that are expected of us as a health and care system. In terms of the on-going financial pressures that are experienced within acute services such as the delivery of access targets, it means that, if faced with prioritisation, a budget of £300 million or whatever that might be, in order to deliver against the access targets that we have then, there would absolutely need to be some investment in capacity for us to be able to deliver those access targets. It's important to flag to the committee that, if you look at the majority of the performance metrics that are used to assess the performance of NHS boards, for example, most of them are focused around our access targets and our delivery of unscheduled care, so you can absolutely see why a decision would be made around investment in the likes of the elective centres to deliver against those access targets. If, however, through integration, we start to look at a different range of performance metrics in terms of how well are we delivering health and social care to deliver those nine national outcomes from health and social care, that might lead to different investment decisions. However, although we measure performance against a range of indicators that are focused on acute care, elective care or unscheduled care, that does drive investment decisions. What I would say is that, within Dumfries and Galloway, within our partnership and, as I have talked about before, looking at the totality of the resources across the health and social care system, we have identified that there are a range of pressures within acute services that we must address. That includes things such as our use of medical locoms. That is about sustaining safe clinical services on the ground. It is also about us being able to deliver against those access targets, the use of locoms, to create that capacity to deliver against the access targets. However, we also see increased challenges financially in terms of that delivery of our waiting times, our waiting time guarantees, etc. However, within our partnership, we see that that has to be balanced against the real financial pressures and the capacity pressures that we are experiencing within primary care and social care services. We know, for example, in Dumfries and Galloway, that we have a much higher number than previously experienced number of GP vacancies, for example, within Dumfries and Galloway, and when we forecast the number of retiros over the next few years, we see that that is increasing considerably as well. We have to think about how we invest in a different shape of primary care services in order to support more people in the community setting to be supported at home. That is absolutely critical for us. However, in relation to social care, we also know that we are experiencing extraordinary increases in demand for social care, services for older people and younger adults with complex physical disabilities or learning disabilities. As a partnership over recent days and weeks, when we have identified some of the real difficult financial pressures, we have looked at the totality of the resources that are available to us through the likes of our integrated care fund, our delayed discharge monies, to look at how we can reinvest some of that money in the community setting to support more care at home to avoid unnecessary admissions to hospital. I think that looking at any availability of resources, as I say, we have to look across the totality of that health and social care system. Prioritisation of resources is often directed by, as I say, the performance metrics that partnerships are working to. I think that there is a real opportunity through integration to change that performance metrics so that we then start to see shifts in priorities and shifts in user resources. I will ask a couple of supplementaries and then move on to my main question, but things that have been coming up in the elective care centres on the face of it appear like a good idea. However, I wonder how they are going to work. Is there not more investment in acute care because those centres are going to be there and they are going to be staffed and they will not deal with emergencies? My assumption is that the elective care is put off at the moment because an emergency comes in and it takes up in the theatre space, but not only in the theatre space, but it takes up the surgeon's time that would have been doing the elective care in the first place. I assume that we are going to have elective care centres staffed with surgeons and then we are going to have another pile of surgeons sitting waiting twiddling their thumbs because they do not have any elective care to do waiting for that emergency or is the surgeon who is working at the elective care centre going to receive a phone call and said get yourself over here very quickly. We have a theatre waiting but there is no one to perform your operation. Is it really going to make much change unless we are talking about a huge investment in acute care so that we are going to be double staffing the elective care centres and shed your care? I think that streaming out the two services, having the acute care, the emergency care separate from the elective care, allows some economies of scale and allows you to organise your work differently. I would not expect surgeons from one area to be being called to run across to another area. At the moment, we are inefficient in the use of some of our most expensive resources, which is the surgeon. By having an elective centre where you can protect beds and resources, you can identify people who will most benefit from that elective care centre and flow through them very quickly. Who is going to carry out the emergency surgery and the unscheduled care? We will have to look at how we organise the surgical capacity and the nursing capacity. However, there is no question in my mind that we can be more efficient if we run as Golden Jubilee does now dedicated elective cases without the interruption to the process and the system and sometimes from people in beds that then cancel surgery and our surgeons are stood without work to do. It will be logistics that we need to work out, but it can be effective in the way that we are proposing that the elective centre should work. I just do not get how you are going to staff them. If you are going to pull the staff out that currently do the unscheduled care and put them somewhere else so that they work away, they will get through all that. Who is going to then be there for the unexpected, the emergency, who is going to be waiting? There will definitely need to be some additional recurring resource to go with the capital investment. It is a shift in the opposite direction to where we are going. There will need to be in order to resource and manage those elective. We could not run elective centres without additional capacity in my area. Another supplementary area question. People are talking about fast discharge, fast turnaround, rehab in the community, getting people home. It takes me back to when we are doing the carers bill. Some horror stories we have heard about people being discharged in the middle of the night, people being discharged on oxygen when they have got gas central heating and gas cooker and been told without left a fortnight without any heating or cooking facilities. Assessment in the community fine, but sending people at home without the correct support is not only doing them a disservice, but it is doing the people looking after them a disservice. How do you square that circle? I was not given the impression that we would send people home without the appropriate support. If I take my own partnership, I already managed the allied health professionals both in the hospital and the community across an integrated system. I managed a number of services that were already in the St John's campus, all the community services and all the social work services. As part of the programme, if we are going to discharge to assess, it will be mobilising those services to ensure that people get the rehabilitation and assessment in the community rather than sitting waiting in hospital to get it. We would look to have discharges in a managed basis so that people have the appropriate discharge time with the appropriate backup facilities in place to do that from their discharge prescription right the way through to any sort of health and care packages that they require when they go home. Clearly, if people are on oxygen, as a number of our clients are, that that is managed in the appropriate way and the appropriate checks, risks and precautions are taken. I think that the key to it is about managing the discharge whether individuals need a fairly low level of support or a complex assessment. However, there is the need for a risk assessment rather than a community care assessment, a risk assessment of where an individual can go, whether they can go home or whether they need to go to an intermediate care bed within Glasgow, and that is carried out jointly by ward staff. In the main, our home care provider organisation will be the first port of call for the delivery of additional supports if that is in place. That is the whole point of integration of health and social care. Is that partnership working not just between community and acute but looking at other services and supports that are in place? What role for the unpaid carer in all of this? What support for them and what involvement of them in that process? I have been very public in my comments about that in the last year and a half in Glasgow. I am very clear, and I have already mentioned it in terms of the number of 50,000 unpaid carers that we have in the city. The reality is that, because of the demographics of the country, because of the health and wellbeing of too many of our people related to long-term conditions, most of us in this room, if not all of us, will at some stage become a carer. That will be the case for most of the country's population, or if they are not a carer, they are a recipient of care from somebody who is a loved one. That is an unpaid workforce that we have to value, cherish and nurture, support much better than we have historically been able to do. I think that part of our responsibility in health and social care partnerships, and it is certainly a priority for Glasgow, is how we encourage and support the people of Glasgow to get used to the idea that, because of things such as demographics and health and wellbeing, regardless of how well or otherwise we are able to impact on things such as health improvement, there are still certain trends that tell us very clearly that there is a demand that is going to be there, that paid services are not going to be able to deliver exclusively. We must and need to rely on unpaid carers. We need to be able to support and encourage people of Glasgow to get used to the possibility, perhaps even the probability, that they will become a carer. In order to support them to do that, we need to ensure that they feel confident and competent to be able to carry that task out with dignity and respect and the appropriate level of care that their loved one has. They can only do that if they know that the support is going to be there for them at the time that they need it. That, as I say, is a step change in terms of where we have been historically. I think that in Glasgow we have done an awful lot of work jointly between ourselves and health and with carer organisations over the course of the past three or four years to get to a better place than where we were, say, five years ago. I think that we are halfway through that journey of support for carers. No, I think that we have a long way to go on that, but that is where we expect to be going in terms of support for carers. Coming back to the very first question from Mr Chisholm about locality planning and that top-down approach, there is nothing more bottom-up approach than supporting the multitude of carers and looking at the kind of resources that are in place locally for folk in terms of human services, not just health and social care provision but human services, so that carers can feel supported where they are to carry on the important work that they do. We need to get a stage where we need quicker questions and sharper answers, because as people went back in for the other questions, we will go in. Okay, okay. Mrs Stantall's question was, given that we are looking at the budget, what would be your ask to us or to the Government for something to change to allow you to deliver services better and more appropriately? Elaine? Ideally, I would like to see some protection afforded to adult social care budget. That might sound strange coming from somebody in a health board, but the whole model of care now needs us to be able to plan into the future with certainty. It is very difficult, even in the lead agency model, where we are anticipating some significant reductions to the adult social care budget this year as resources to the Highland Council have been reduced potentially by 5 per cent. That means that it is very difficult then to plan into the future and develop these long-term models of care. Some protective source of income, some accepting that those resources may be subjected to known reductions but that is without having to compete with other council priorities. We have benefited in health from having a protection to the health budget, but we would actually want to see a protection to the adult social care budget as well. Clearly, we are in difficult financial times and I think that we all understand that. What I would be looking for is based on some of the answers that I have given earlier, that health and social care are now linked inextricably. I would like some recognition of that in the budget so that money comes directly to partnerships to look at how we would invest in health and social care across the pathway. I would also like to see some money coming in for primary care to the partnership so that we can look at how we invest money in primary care in its broadest sense so that we can address some of the outcomes that we are looking to deliver and you are looking for us to deliver in terms of the transformational change that we are going to try to make. We also use that resource to empower local communities and look at local capacity-building so that people in general have much more responsibility for their own health in a way that gives us a generational change that we are looking for. I think that there is still a big part of us that still needs to get it about health and social care integration. I think that there is still not potentially really an expectation of that. Although we have had this new legislation put in place, we have gone ahead and introduced integration joint boards. There is still a large element of government, both local and national, within and across health boards, where integration is not probably seen as importantly and as central to the change process that I think was sitting behind the legislation and the aspirations within that. I think that the comments of my colleagues in terms of their suggestion that a focus on resources for health and social care partnerships reflect that. If my personal ask is two-fold, one is that there is a recognition that integration joint boards do have a place and a lead place in relation to the transforming of health and social care provision in and across our communities. The second ask is linked to that, which is around and linked to Government. It is a bit about not having decisions made at a national level about how certain levels of new resource that might come to us are spent, because that limits the opportunity of local decisions and local priorities to be made. To give you an example, and the example that Mr Doris has highlighted at one level in terms of that £200 million, is another example from my perspective, which would be in relation to, for instance, the health visitors and the new money that is coming to health boards in relation to the provision of 500 health visitors across the country to deliver on the GERFEC arrangements. The position that I would hold in respect of that would be that we can have a degree of flexibility about how that money could and should be used, rather than to simply say that it needs to be invested in a certain grade and a certain tier of health visitors who must do a universal provision, whereas what I am looking at in Glasgow terms are huge numbers of children and young people. The integration arrangements in Glasgow cover children as well. I have no ability to influence how that money could be spent in a much more targeted and supportive way for the most vulnerable children. It is a bit about being able to have a degree of flexibility with increasing amounts of money that come from Government about how local partnerships could use that money. I think that, first of all, what I would request is the recognition of the pressures right across the health and social care system from acute services to community health services, primary care and social care services. Some specific requests from me. I think that, certainly in Dumfries and Galloway, we have undertaken a huge amount of learning from some of the tests of change that we have initiated through the likes of the use of our integrated care fund monies, where we have invested in services such as step-up, step-down care and care homes to avoid admissions to acute services. We have invested in re-ablement services to support people to maintain that independence at home for as long as possible. We have looked at forward-looking care plans, which are about identifying people's anticipated care needs and how we should respond to them, so that we are not always reacting in crisis. I talked earlier about some of the other tests of change that we have introduced. One of the challenges that we have is that, when those pots of resources are identified over a short period of time, it is about the sustainability of some of that. Wherever possible, if the pots of resources that are identified are of a recurring nature that enables us to obviously make some quite significant improvements in terms of reshaping that care for people in our communities. I echo the comments that were made about the bundling of resources. Quite often, when we see resource allocations, they are bundled together so that although there is quite a significant investment in a particular area, those resources are very clearly identified how they should be used. A greater degree of flexibility for local partnerships in terms of how those bundles would be used would be very much appreciated. The challenges that we have in primary care and our sustainable models of primary care are something that I would appreciate and focus on. I am very aware of negotiations around the future GMS contract, for example. It is really important that we make that contract as a facility as possible to support GPs to have the capacity to become much more involved and engaged in the integration process. That is some of the specifics around what I would like to see in terms of the future budget process. Where in the patient journey currently does discharge planning start? Discharge planning should start the day that someone is admitted to a hospital. The various teams that I have in West Lodian, who are in the St John's campus, have district nursing and social work teams in the St John's campus should liaise with the work-based staff and make sure that we have that identified of when that is likely to be and what is going to be needed to do that. I would want to add that anticipatory care should, if it can, possibly manage to prevent admission. We would not start that discharge planning. That might sound a bit flippant, but there are significant numbers of people who end up in hospital because they do not have an anticipatory care plan that is effective. I think that our focus needs to be there. I would absolutely agree with what Elaine McLean was saying. In terms of the elective admissions, we should be planning discharge even before the persons arrived at hospital in terms of one scheduled care on admission to hospital. Historically, in the NHS, we have undertaken bed management in acute hospitals, so we are managing our beds. One of the shifts that we have made in Dumfries and Galloway is that we have introduced what we have called patient flow co-ordinators. Those are nursing staff, or OTs, occupational therapists, for example, who are focused on patients not on beds. They are focused on what happens every step in that patient's journey through acute services to minimise delays from the minute that person is admitted to hospital through to their discharge. They focus very much on complex patients who have multiple interventions, but that has been a shift in our focus from focusing on beds to focusing on that whole patient flow right across the system. I am glad to hear all that. That sounds like an ideal situation. I do not think that that is the case across the country at the present time, unfortunately. The other thing was on primary care. I am glad that you have put the focus on primary care, because I have felt that, for instance, I have started talking about integration that GPs had to be pivotal at the locality level. West Lothian is, obviously, somewhere down that road in involving GPs in the sort of locality planning. It sounds like Dumfries and Galloway as well. Do you know about finding the same? I am getting anecdotally that GPs are not particularly feeling involved in a number of areas. I do not know if you have any experience for that or not. I think that it is variable. Certainly within Dumfries and Galloway, it is variable across our localities. I would say that we have identified clinical leads in each of our four localities, who are working very closely with the multi-professional, multi-disciplinary team in the development of our locality plans that I talked about earlier. The reality is that we have a number of GPs who are facing considerable pressure in their day-to-day activity and having the capacity to be freed up to engage in discussions about health and social care integration has not been achievable in some areas because of those real capacity constraints. What we have to do, or work through integration, has to be about how we support those GPs through new models of care in primary care, extended primary care teams, advanced practice to support general practice, advanced nursing practice, advanced A-H-P practice, advanced pharmacists, all about supporting that general practice to make sure that GPs are focusing in on only what the GP can be doing. I absolutely recognise the challenges of us having that true engagement with the wider general practice community. I think that we have made some steps towards that in Dumfries and Galloway with our clinical leads, but I absolutely recognise that we have a long way to go. One of the ways in our localities that we are looking at using our integrated care fund moneys is to support practices, to free up some time of practices for GPs to become involved in the discussions about health and social care integration and the development of locality plans. We are specifically using our funding to address that issue, but I absolutely appreciate that we have a long way to go in making sure that we have that consistency of engagement right across the patch for us. In Highland, the GPs are key to leading that multidisciplinary team based on the localities that I described to you. I agree with Julie that a new model of primary care is absolutely required now. GPs, in my view, are absolutely best placed to co-ordinate and provide support to frail or to people who have complex needs. Getting back to that sort of work may well ultimately help an aid in recruitment of general practitioners. Just to echo some of the comments that Julie has made in relation to how great a challenge it is to engage with all GPs in the city, particularly when they are as busy as they are, we have a number of arrangements in place that we will hopefully expect to develop a systematic kind of engagement at a locality level. We are at the early stages of putting that in place, but it is a big challenge. Having said that, as I have said a couple of times now, we recognise the importance of locality. Central to that is what we view as something that we would call community anchors. Who are the community anchors? What are the community anchors? GP practices are one such thing—housing associations, faith-based communities. All of those community anchors are there that we can engage in a broader partnership approach, and GPs are central to that. Thank you, convener. It was just really a supplementary question. I am being a little bit perlhel here in terms of being an Edinburgh MSP, but certainly some of the problems that I am hearing about GPs and their involvement and the way it is taken across is really a case of—certainly, in the—we had a discussion, of course, the other day there with the chief executive, amongst some of my colleagues, but how do you really see that? There are some specific pressures that Lothian is going to face between your patch, so to speak, in West Lothian and mine in the West of Edinburgh, and there is obviously some degree of growth. How are you going to win the GPs? In many of these practices, they are feeling a bit under siege at this minute and time, and with the potential growth and development in the west side of the city, in West Lothian and the likes, to actually come through and provide this change and take along a group of GPs who are perhaps not really sold on the idea? I think that, as you are aware, and I am sure other members of the committee here are aware that, clearly, there are areas of the country where Lothian is one where there is genuine population growth and there are increased housing developments. We have a number of GP practices across Lothian that are under pressure due to population growth and some of the premises that they are in at the moment. There are plans afoot where we have had an audit of all the premises across Lothian. We have prioritised those who are either due for refurbishment, extension or replacement. In some cases, they will call for additional GP practices and centres to be provided, some of which you have mentioned. The idea is to liaise as closely as possible with their GP community, have them involved as much as we possibly can, both in the locality approach and, indeed, in some neighbourhood-type approaches and have them involved in the design or extension of any other services as we move forward and be as upfront with them as we possibly can as to what is going to be available and what is going to be possible. Just on that one, you have a whole workforce approach. One of the questions is, what is that workforce going to be like? We have got the redesign of primary care services report and Lewis Ritchie and all that. What impact is that going to be on your flexibility to operate, your budget? Alongside that, there is a significant bid for GPs to have a significantly higher part of the budget. According to the representatives, there is anyway. We are getting into a situation where we address an issue with GPs and the opportunity to address it. We are over-investing. Is there a right balance about the role of GPs? We heard earlier that if GPs are not confident in the services that they are providing, and I am talking about those carers that are in five times a day, those people who are looking at you directly, if they have not got confidence in that, they will continue to refer into the acute sector. I am just trying to get the balance here because there is a lot of talk about who can argue with the role of the GP, as a gatekeeper, the important role there, etc. However, some of you will require funding, and they will be bidding for that. They are negotiating a new contract. Where are the integrated boards and health boards in all of this? Where is the proportionality about how important they are and what you are prepared to pay for it, as against looking at the development and the shape of the workforce in 10 years' time? It is not all the GPs on their own. I am not going to deliver any of that, are they? Maybe if I start. I think that GP colleagues understand completely the complexity of the system and recognise that they sometimes put pressure on the acute system by the fact that there are no alternatives to admission at the time when they need them. People understand the pressure that the systems are under, but if you get right to the front line, I have the privilege of being at one of those multidisciplinary meetings recently with the director general, and looking and listening to that team with an acute geriatrician sat in the same room as the local GPs, a social worker and a multitude of team workers, including care workers, they were focused on what was important for the individual. They recognised that the thing that they needed to do was to get that individual in the right place at the right time in front of the right person. That may well have been at hospital, but for a short period of time or ideally to keep those people at home. I think that they do understand that there is an element of what they are doing is compromising what ultimately we were trying to do about keeping people out of hospital. That sort of grouping is when they deal with an individual, every individual case that is presented in the community. There should be an anticipatory care plan for every individual, and GPs are overseeing those individuals. You just described the situation where you had senior social worker, geriatrician and all of those people discussing an individual at a virgin. How many cases does that apply to? In that, they will be picking off the cases that are most complex, that most need to have. I think that we need to be careful for evidence that this is not the norm that you are describing. This would be a complex case that should be. Indeed, but as a team, an integrated team, and that is really my point convener, that having an integrated team, they would segment that population and then identify who are the people they most can as a team support. I think that that is important because the GP has a critical role there. Our GPs are fantastic at keeping huge numbers of people at home. We want to make sure that they are supported to continue to keep people at home. But not on their own at this point, I will make it. As a team, absolutely. When we talk about the GP contract, we have to talk about the role of the social worker. You have to talk about how we value the people who are going in five times a day, what we pay them, what we train them. I am talking about carers. If the GPs have not got confidence in what is delivered on the ground, they will continue to refer to the acute sector, but they will not. They will, and that is why having them working as a whole team in localities, they can understand the issues, they can redirect those resources, they can support keeping more people at home. How much will it cost, how much will we need to give them, how much of your budget will we need to give to the GPs? If you want that one out, have you been consulted on that? David? We haven't specifically worked that issue out in Glasgow. It's a national negotiation in relation to the GP contract, so IJBs aren't substantially involved in that. We have been variably consulted with and presentations have been made to the chief officers from the representatives working on behalf of GPs nationally in relation to that. The language that is used is very much one of partnership working, of engagement with health and social care partnerships, and we have to take that in good faith. I think that there is an issue around about the right to highlight the issue of the level of intervention relative to need that would be required for individuals that become patients of GPs or are required to have more frequent consultations with GPs. The approach that we would want to take within Glasgow would be one of trying to reduce the level of bureaucracy and the level of approach that ties people up in the system. The whole point of integration is around about creating a seamless journey, it's about creating a throughput of people, for some people, and we hope and expect that to be many. Most people, we ought to be in a position where we can provide what we would call in Glasgow a purposeful intervention, whether that's a GP related or a nurse related or a pharmacy related or a social care provision or something that's actually just in the community, all with the intention of avoiding the kind of spiralling up towards a higher cost, higher intervention for the lack of something else. That's where we're going. For workforce costs, we see some of that in the evidence that we've got in the workforce, with a one per cent increase or whatever. What has been factored in for the additional cost to the new GP contract and how will that all impact on us? We haven't factored anything in at this point in terms of the new contract isn't due for review. Which Government will pay that, that will not come out of your budget? I have to be honest and say that in Glasgow we haven't given that level of consideration and I guess my assumption at this point in time would be that if there is a cost added to additional to the current contract then that would be provided nationally, yes. I think that maybe part of that, as I said earlier, part of that review of the GMS contract has to be about how do we create that capacity for GPs to be engaged in that whole process of integration in a more meaningful way, perhaps, than it has been today. There may be demands placed on health and social care partnerships to find resources to facilitate some of that engagement of GPs and I think that that would be justified. In relation to workforce more broadly though, if I could comment just in, because, chair, you asked the question just about how we're planning for that future workforce. Within Dumfries and Galloway we are planning to publish our first workforce plan for our partnership in March of next year and one of the steps that we've taken around that is that we're not just looking at our traditional health and social care workforce that's provided via local authority NHS but looking at our colleagues in the third and independent sector as well and looking at what's the need for changes and roles as we move forward. For example, you talked about the GPs having the confidence in the care that's being provided and the standard of that care that's maybe being provided through home care. We have and we continue to support independent sector providers around training, around the principles of reablement for example, in order that when we are supporting individuals in their own home and no matter who that be, whether it be a home carer, whether it be a district nurse, whether it be a GP, that we are focusing on those sort of principles of reablement and encouraging the person to become as independent as possible at home. We do recognise certainly in Dumfries and Galloway and our challenges I appreciate might be different to the cities in terms of our care at home provision. But certainly we need to make the care at home sector attractive for people to enter and that care at home is seen as having a very professional standing within the community and one of the things that we're looking at is a career pathway. So thinking about as we integrate health and social care is there an opportunity to develop new career pathways for home carers that give them the opportunities to develop and that attracts people into the sector, retains people and develops people. I absolutely believe in the centrality of the role of the GPs around health and social care integration. However, GPs have to be part of that wider multi-disciplinary multi-professional team and I talked earlier about those advanced practice roles that we need to look at developing within primary care to make sure that we've got a sustainable model of primary care in the future and whether that be in hours or out of hours, we need to think about the answer. GPs absolutely are central to the answer but they can't be the only answer and certainly within Dumfries and Galloway when we look at our projections in terms as I talked about earlier the retirements over the future our challenges we have in recruitment we really need to think about that wider multi-disciplinary team. As I say, we know that patients are becoming more complex, that increasing demography, people are living with multiple long-term conditions in the community and that role of that wider primary care team is essential to support those individuals to remain at home and avoid those unnecessary admissions to hospital. As I say, it's work in progress at the moment but there's a whole host of issues related to our workforce that will be reflected in that workforce plan in March of next year. Richard Byer. Thank you, convener. I can't help come back on to the point that I just made. Julie White and Jim Forrest spoke about it as the GPs and the point earlier Elaine was talking about, to have less beds in hospitals. Most people are now having more beds but basically what we need to do is to ensure that people can stay home and basically their home becomes a hospital bed and with also the greatest respect and the point I want to touch on, Scottish budget is now £12 billion, £12 billion, over a 30-hour budget spent in hell. One of the points that I want to come on, I had the great honour of prior to being an MSP of driving for the reverse service for two and a half years with doctors who were very committed, very able but also had with the greatest respect Elaine on that day on any particular Saturday I was driving with them, could admit four, five people into a hospital so your planning went out the window at the weekend and basically that's the problem you have. What do we do to ensure that we upskill out of our service, also ensure that the doctors locally can cope with what's going to come at them because we're now coming to, in an over a week's time, Christmas. Let me tell you, I was in several hospitals over a number of years ago, hasn't changed any, maybe it's got worse, A&E, absolutely choked on Christmas day and boxing day, basically out of our service becoming a second A&E, people realising that they can get an appointment and coming at three o'clock in the morning, four o'clock in the morning, whatever and I was there at those times and I admire what was done in the hospitals and admire the service by all the doctors but what we're going to do to ensure that we're going to cope at Christmas and what we're going to do to ensure that our doctors will feed through and ensure that we can relieve the pressure on hospitals and contain people at home and I've got a follow-up after. I think it goes back to a number of things, I mean, I think clearly we have to give GPs in particular a conference that the wraparound services can respond and respond at a time that's appropriate, so within hours rather within days is really, so the response time for these services. So, if I give you an example, in Westlodian, in social care circles, we've implemented a crisis care service, so it's staffed seven days a week, 24 hours a day and if somebody is already in receipt of a care package in a GP case load, they can phone that number and the crisis care service will then pick them up without the GP having to admit somebody because quite often what we do is we admit an individual and then decide what to do with them. The dynamic has to change that we should only admit once we've decided that mission is really necessary and their wraparound services are unable to cope, so that might be crisis care and adjusting somebody's social care package or it might be implementing a hospital or home type service within a few hours so that we bring the services to the individual and I would suggest a number of these things are a significant step forward and a change from maybe your experience driving with the GP. So, they have to have a conference that will respond within hours and it's as simple as possible for them to make that call and then these other services kick in. I think the important fact also is that we keep mentioning anticipatory care in each. Everybody in a care home facility and everybody who is in a care package living at home should have an anticipatory care plan so that if there's an exacerbation of their acute underlying condition then it's clear what we should do and what should kick in at that particular time without just taking somebody and disrupting them and admitting them to hospital. There are a number of things and a number of challenges tied up in all of that and I think we have to look in primary care and community care in its broadest sense of what the workforce is going to be like in the future. So, there's a limited number of GPs you can recruit and whilst GPs are very important they're also quite expensive as well so we have to look at how other professions are going to fit into that multidisciplinary team so it needs to be about nurses, pharmacists and allied health professionals all working within that team and actually we have to manage the public's expectations and that if you're seeking an appointment in primary care it might not necessarily be a GP that needs to see you it might be one of these other professionals and it might be done in a different way so there is a public expectation that we have to manage and if we're truly going to shift the balance of care we also, with the best will in the world, have to manage political expectations because if we're going to shift the balance of care and take things from our hospital campuses then that's what it will mean rather than the status quo plus so there's a challenge within that resource framework of how we're going to move these things around and we're at a very early stage in that particular journey. I would also like to see in some of your hospital campuses if we're delivering hospital at home and working with people who have dual roles both in hospital and the community they will actually have a set number of beds where we will fund through our partnerships and look at how we use these primary and community care type beds with the backup diagnostic facilities that we need but there will be a small number of them and a quick transfer around of how we do all of that so that you don't need to go through any A and E you can go directly into one of these beds and back out again once you've had the treatment for your acute exacerbation of your condition it's as quick as that and the rest of the thing needs to kick in there. So there's a journey that we're on here and I know people keep using that but we really need to develop this and refine this and develop the workforce that's going to complement that and we need to look at the patterns of care over 24 hours, seven days a week of what's actually required rather than the evidence base to support that and how we're going to target it. Anyone wants to get any disagreement with that? We've had an out of house review and that is coming up and with the greatest suspected doctors I know that they don't get a living wage or the minimum wage they get between £80 to £120 an hour and I know they're worth it but basically the point I want to make is all the different doctors are working during the day in their own job and then some of them have to come out and do out of hours at night time or over to bear with me or overnight I was there. Some are employed by out of hours but not most or has that changed in the last couple of years? Yes, I think that has changed quite significantly in the last couple of years and quite a number of doctors now are employed by the out of hours service and we wouldn't have the old system where you had co-ops marriage in the out of hours service where doctors would work through the night and then go into their surgeries during the day. We don't have that aspect of it now at all. If a GP makes a decision that they want to put their name forward for out of hours work then it has to be a time that's out with their contracted part of the partnership. It does apply to us all but I just wanted to add that of course if you're not familiar with a locality, you're not familiar maybe with the systems and therefore the easy option sometimes is to admit the patient and that's not your responsibility on Monday when it's not your patient to come back to. You still do locums. We still have locums, right? My last question and I made this comment last week, annoys me and annoys people outside that political parties use the health service as a political football. Would you prefer that parties would leave you alone to get on with it or alternatively agree with each other what we want to do in order to ensure? I have to say that Scotland has one of the best health services in the world. Where else could you walk into a hospital and get treated? Okay, maybe a couple of others. Do you think that would it be in your wish list wish that it would stop making you a political football? You don't need to answer that. David, can I make an observation, chair? Essentially the NHS and healthcare provision is a public service and from that perspective there needs to be a public accountability in that accountability is to democratically elected members. Did David speak for you all? Good. Bob Doris. I've got a budget scrutiny question. Okay, so I'm interested in the very brief amount of time that we have left looking a little bit more about the role of GPs. There are certain things that are relatively certain. We know that they have to be central to the process. We know that they are valued. We know that they have to be consulted to help to co-produce that, but we're talking about a budget for how money comes through the system. We've got money coming through to health boards, local authorities, both giving money to integrated joint boards. Of course it's different in Highland in relation to that. At the same time, as the convener mentioned, we've got the new GMS contract being negotiated. Put into that, in the case that I just got this morning, I'm not going to localise it though, that some practices have got something called a minimum practice income guarantee which secures them. I know that the BMA doesn't always think that that's a particularly good idea, but the practices that have it like it. I notice that some, so not that one, so the BMA does like that, I have to say. The one that the BMA is not so keen on is in relation to that localised contract where, I'll do the terminology and go on to my substantive point, you can sign a 17C contract which is bespoken to the health board and slightly separate from the nationally agreed contract or a 17J. I didn't know there was that differential. Sorry for putting all that out there, but the reason for it is cash flowing through the system and this is quite important in relation to budget scrutiny. Some GPs practices employ practice nurses, they contract in pharmacists and they are giving money for a lot of that. Others will have co-located employees of health boards or whoever within the health centres. It's a spaghetti of an organisation. I'm not sure how co-ordinated it always is, and clearly works exceptionally well in some cases, but perhaps not always as well as it could do. Budget scrutiny, as the money comes through the system, is health and social care integration going to bring an order to that? Or is there a strength in that, if you like, spaghetti approach at a localised level? How can we use the money to drive change in relation to that? I'm sorry that that's a bit long-winded, but there's a heck of a lot in the terms of how we scrutinise the cash flow and whether we want to see that drive GPs to employ more people or whether we want to free GPs up to be referring on to people that you guys all employ and how that shakes down with our budget scrutiny. Even just some brief comments on that, I know it's a lot there. Jim, you seem to recognise if one of these issues is true, Jim. There is a differential in the existing contract, so if you're 17 to see practice, it essentially means that the GPs and the staff become employed by the health board and they have a health board contract. There's various reasons for that. Some have elected to do that. Others, if a partnership is in particular in trouble or in distress and can't get partners, then we will intervene and put that in place and have salaried staff in place until we can advertise that the practice is a going concern. There are choices to be made there, and that's the existing contract and the legislation. In terms of what you can influence in the existing contracts for health boards and for partnerships, they're at the margins at the moment and it depends on the new contract and how that will be negotiated and what we're able to do. In my own patch, there is a mixed economy where a number of GP practices like to employ their own staff and others would rather that they're employed by the NHS and that are based on the practices. I guess, depending on practice experience, they would have a different view on that and that gives them within the legislation that flexibility at the moment. It depends largely on how the new contract is going to be negotiated and implemented and the conditions around it of what flexibility we will have to work with practices and whether they'll continue to remain completely independent and make their own decisions. David. Thank you. From my perspective, I'm still in the relatively fortunate position of having had a background in social care, still getting to understand the whole health system, which allows me to ask some daft questions of my own and I'm not suggesting that any other questions here are there, but it is that bit around about— Given all the questions before, thank you. From my perspective, what I see in Glasgow is probably not to similar to the experience that you've described, and that is the variability. From a budget management perspective, it strikes me that there is a very significant level or chunk of the budget from health that will be part of the health and social care budgets infrastructure over which there appears to be very limited scope for manoeuvrability in terms of how that's used. Within Glasgow, I know that there are significant numbers of singleton GP practices, for instance. From a basic management perspective, that would tell me that there must be issues of efficiency that could be driven into the system if that was managed in a different way. I would hope that, going forward, there is an opportunity to have a greater degree of influence from the IJB in relation to how the funding going to GPs is able to be used, not in any kind of directional way, but with a view to recognising that there is difference between localities. The needs of different parts of Glasgow will be very different to the needs of what is in place in Dumfries and Galloway and Highland, but there needs to be an ability, it seems to me, to have a localised influencing of how that money is spent. Does it matter who employs the practised nurse or the attached pharmacist or whoever the advice support worker that is there? Does it matter whether the practice employs them or whether the integrated joint board employs them via the council or the health board or whatever? Does that actually matter when we are doing service design? I would say probably not on the basis that, but that would be entirely on the basis that we have the culture of expectation of what health and social care is going to be delivering and the drive towards delivering on national health and wellbeing outcomes. If we are talking about having genuine partnerships based on equality with the voluntary sector and the independent sector, we place in those sectors a trust that they will deliver what we ask them to deliver and that they are signed up to deliver as part of the whole strategic plan approach, then we must have the same approach with GPs and some GPs might choose to take the responsibility of being employers and some might not. That has to be, in my view, acceptable. I think that if things are going well and negotiated and we all see things the same way, then it doesn't matter. Clearly, if you are a partnership and you are having difficulties with a particular area, then if you employ the people and have more influence on the resources, then it gives you more leverage to negotiate your position. It largely depends on the circumstances that we find. Broadly speaking, it shouldn't matter, but there are tensions around us to how you target your resources and what outcomes you want to deliver. I thank you very much for the considerable time you have given us this morning and the evidence presented and also written evidence in some cases here, but I thank you very much indeed. We are now getting to private session. I previously agreed that I should have mentioned earlier before we get into private session that we have apologies today for Dennis Robertson.