 Welcome everyone to the 8th meeting of the Health, Social Care and Sport Committee 2022. I've received no apologies for today's meeting for many members. The first item on our agenda is to decide whether to take items 5, 6 and 7 in private. Are members agreed? We agreed, thank you. Our second item today is never in session on social care. I welcome to the committee our panellists for the next couple of hours. Joining us online, we have Fiona Collie, Policy and Public Affairs Manager for Care Scotland. Annie Gunnar Logan, Chief Executive for the Coalition of Care and Support Providers in Scotland. Dr Donald McCaskill, Chief Executive for Scottish Care. Judith Proctor, Chief Officer of the Edinburgh Integration and Joint Board and Chair of the Chief Officer Group. Thank you to all of you for your time this morning. We have decided to do this session right now, mainly based on the Audit Scotland report that came out. That will be our backdrop to all of this. Many of the issues that were brought up in that report are familiar to us all. I am going to ask questions around the workforce and the fragility of the workforce. One of the most striking things that I saw in the Audit Scotland report was that statistic that nearly a quarter of people starting a job in social care would leave that job within the first three months, which I found staggering statistic. What is behind that? Is it purely pay? Is it purely that they have gone somewhere else for pay reasons? It surely cannot just be that. If I can maybe get your thoughts on some of those statistics that have come out around the workforce in that report and your own views as to what is happening there. If I can go first of all to Fiona Collie. Thank you very much, Jimmy. Obviously we primarily focus on the unpaid workforce, but certainly carers have noted for a significant period of time the difficulties in recruiting staff, whether that's staff being recruited for services that are supporting them or for personal assistance. Carers, when we talk to them about this, discussed the need to deliver alongside better play, better opportunities for career progression, better opportunities for training, alongside those wider terms and conditions. Probably one of the most important things in terms of conditions and pay cut that sits alongside that is about value in the workforce. Up until now, up until the pandemic, I think that social care was very much felt like something that was a bit hidden. We often talked about the NHS and the really important role that it played, but less so about that significant role that social care plays in maintaining people's independence and enabling them to live good, positive lives to support them to continue to work, for example, should they develop a disability. I think that role of social care has been very much hidden and I think that the profile of social care and around the national care service will be part of this is about talking about how important it is and the difference that it makes to people's lives. I think that that has been part of the problem and continues to be part of the problem unless we make a difference to that. Your question was just about pay. The short answer to that is no, but it does not mean that pay is not significant. We should bear in mind that social care is not for everybody and in some respect it is better for people to find that out sooner rather than later. On pay, a few things to say about that. I think that we need to acknowledge the work that has been done to increase pay at the lowest levels over the last couple of years. You will know that there have been several announcements, the most recent one being that pay will increase to £10.50 per hour at the lowest level. I think that we have to acknowledge that all of that would be much better to present the counterfactual. All of that would be much worse if that had not happened for sure, so it is good to see that focus. The way that the pay uplift has been implemented is, in my view, setting us up with new problems further down the line because all it focuses on is pay at the lowest level. It does not take into account differentials and it does not take into account the career progression that Fiona has already mentioned. When we look at the pay uplift that is coming up for April, there seems to be some kind of question mark even over whether the increased employer national insurance contributions are going to be funded. We are in a very difficult place around all of that. What else can we do about it? We have submitted a couple of papers to Scottish Government colleagues, which I would be very happy to share with the committee, which sets our range of actions that social care employers believe will help based on their experience of the sharp end of recruitment. In the longer term, we still need to address the core recommendations of the fair work report that came out of the fair work convention on social care in 2019. It identified poor commissioning. The critical issue had a lot to say about the pay-per-minute culture of a lot of social care employment and recommended giving social care workers better career progression for sure. There is much more autonomy and decision making authority than just a roster of people to go and visit at somebody else's behest. The recommendations of the subsequent fair work in social care work and group made a significant number of recommendations. On-raising pay levels across the workforce, not just for those on the minimum, and extending the scope of the pay uplift and a strong pitch for pay parity between public sector employees and private sector employees, because we are still operating a two-tier system. None of that has been addressed. Presumably, it is because of a question of affordability. When it comes to workforce, we are not going to solve the on-going challenges in a cost-neutral way. There is not really any point in pretending that we can. The research that you mentioned was undertaken and conducted by a colleague of mine, Caroline Dean. That report was a Scottish Care report. Yes, pay is one of the reasons why people leave within a relatively short period of time, but they know about the pay before they start the job. Although I would not disagree at all with anything that Annie and Fiona have said, there are other factors at play, and primary among them is the lack of societal value for the role and significance of the work of care. We saw that throughout the pandemic. It took eight weeks before we started to clap not just for the NHS but for carers. It took weeks before supermarkets started to recognise social care staff as being just as significant as NHS staff and give them priority. Those two illustrations are indicative of a lack of societal value, but there are other reasons. First of all, I think that people underestimate just how challenging the job of care is. It is a highly technical, skilled, professional job and it is not helped by politicians like the Home Secretary describing it as low-skilled. This is not a low-skilled job and I suspect, in fact we know, that some people are attracted because they think that it is easy. The job of care is one of the most rewarding things an individual can do because it enables you to help another individual to support them to achieve what they want to achieve and that is demanding physically, it is demanding emotionally and psychologically. There are other factors, for instance people often do not appreciate the need for registration and the need for qualification. We are not saying that we should abandon those important criteria which denote your professionalism. One of the challenges is that people think that care is easy, they apply and the reality of the demands alongside the rewards takes some time, but undeniably what holds people beyond that six months is the relationship that they are able to build up with those that they are supporting. What puts them away, because the statistic from six months to 18 months is just as troubling, is the reality that, as Annie said, we do not give autonomy to care workers, we pay care workers at the base and whilst that is improved it is a little bit like trying to put a Mercedes engine into a rusty mini metro. The system of care and support is in need, as Audit Scotland indicated, in need of radical reform and change and it is no point in just addressing the issue of pay unless you address the issue of sustainability. I would agree with most of everything that has been said so far. Care is a really important job and I think that the pandemic has really brought that into people's focus and I think that we would welcome the spotlight that has been shone on it by this committee because it is important for the future. We try and work towards a resolve of that. It is a really, really important job and I would agree with the comments that people come into care perhaps without a perception and then they undertake the role and see how rewarding but yes, how difficult it is. I would agree with the outline that Donald gave. People are asked to undertake caring responsibilities for people with very complex needs. This is not by going in and checking on people. We are undertaking complex care for individuals across the geography that they work in and that can be an isolating job. It can concern people a lot of responsibility and that is quite difficult. I am not sure that people understand the reality of that. I think that there is something that we can do just in terms of valuing the job but really helping people understand what the job entails and the difference that it makes in people's lives. I think that we can collectively do more to talk about care and I think that there is something in that but how do we make it an aspirational job? We see people aspiring to roles in health services and other public services. How do we make care something that people aspire to do and in doing that how do we attract more younger people to come into care? Part of the challenge that we have seen is that the turnover is because it is an ageing population, a physically demanding job but more and more of the people who are providing that care are at an older age group and that is physically demanding. We really need to think about how we attract people to do the job. We need to work in Edinburgh with the colleges, try and shape care roles around the needs of students, try and match the needs of those students into a care role that makes it easier for them to come into care and that will support our workforce. I think that there is a lot around those terms of conditions that we could be doing that is not just about pay but I would agree that it is also about pay. We need to reward people appropriately for doing a job that is significantly important to society and to the individuals that experience and benefit from that care. I would also agree with some of the comments that have been made about poor commissioning. I think that some of the commissioning practices that we have seen over the past decades have not supported us in developing this valued workforce as valued partners. Some of the things that drive people out of care are the lack of continuity that carers have. People enjoy developing that professional working relationship with the people that they care for but we often ask carers to do jobs that are disappointed that they do not support that. That is not good for people providing care and it is not good for people who are in receipt of care. There is a whole range of things around that. Last thing that I would add, speaking about my own area of Edinburgh in terms of the pay issues, we also have an issue in terms of the high cost of living and the high rates of pay have now been given to another sector that is attracting people from care there. I think that there is definitely a geographical element of that. I am sure that if colleagues were here from some of the more remote and rural parts of Scotland, they would also reflect the high cost of care and the high cost who carers in undertaking roles in those areas. That has been a really good start for some of the issues that my colleagues might want to dig in in more depth. I have asked everyone in the panel to respond to me. My colleagues are going to probably pose their questions to each one of you. If anybody is not asked directly, please just use the chat box and put an R if you have anything to add. That would be really helpful. I will hand over on the theme of the social care workforce to Sandesh Gohani. Judith Proctor, you spoke just there about how do we inspire people to get into care and Donna McCaskill has correctly described the skilled and challenging work that care needs. Annie Logan, you spoke of the challenges coming as base pays, the only thing that has been uplifted and nothing further. Can I ask you, Annie, directly, why should I, as a teenager or as a young person, go into care if it is as challenging as Donald has said it was, if I can go to Aldi and earn £10.10 an hour when in fact you are earning far less to do a more challenging job. I could go to work for ASDA and if I go to work for ASDA I get similar pay to start with but there is the opportunity to get a degree to work up through a career focus strategy where you start off, lots of people have done this, you start off stacking shelves, you end up as a senior manager earning hundreds of thousands of pounds. So how can we get people into care if we are in this type of environment? You have just articulated the questions that people looking at a career in care will be asking themselves very precisely. I think the difference between stacking shelves and being a social care worker or a support worker is like night and day in terms of the rewards, the fulfilment, the sense of purpose. Certainly in the third sector you will be working for values driven, mission driven organisations that want to have the maximum social impact they can have. So all of those are there but if you are a teenager and you are looking to pay your bills and make your way in the world then yes, in the short term you are going to get paid more somewhere else, there is no question about that. That is a recruitment issue. What we also need to look at is a retention issue because perhaps one of the more worrying things is that once you persuade people to come in and they see what it is like and they want to do it and they are there and they have accepted the terms and conditions is how you then keep them. That is where the career progression and the autonomy and all the other things that we have talked about will come into play. In the third sector employers are really trying hard to do that. One of the positives in the third sector is that one of the budgets that we have tried very hard to protect will be workforce development training in order precisely that people can move up the ladder if you like. That becomes very, very difficult when you have a government policy which is only about the lowest pay and the differentials are being squeezed. It makes it much harder for employers to offer those kinds of opportunities which will keep people in the workforce. So there are two issues really. One is getting people in the first place and the second is keeping them there. This is the crux of the problem that I see it as. Once you have people in the door, just as you have said, keeping them is difficult because if we see through the pandemic, wellbeing is difficult. The work that people were doing was extremely challenging and even if we take away the pandemic, the work is extremely challenging. Yes, you are right, it is rewarding. I am a doctor because of the rewarding nature of the job but I am not sure that is enough when you are talking to people who are going into care because we need to not only keep them but give them some form of career. Everyone starts off and people accept maybe a lower pay if they can see that career progression. I go back to Asda where you can without wanting to promote them but they pay for you to have a degree while you are working. We need to have this clear career progression happening in care and I would wonder how we can encourage that to happen. I agree with everything that you say. What I would say is that this is not only about teenagers and young people. We need to make sure that we do not dismiss the older workforce who may not be looking for that kind of opportunity to do a degree. Given the future demographics in Scotland, we also need to make social care a suitable environment for the older workforce. There you have a completely different set of proposals where you have the rewarding experience that it is that counts for an awful lot more than perhaps the opportunity to do a degree. Largerly, I absolutely agree with you that the prospects for younger people will often appear more favourable in other fields. That is partly about affordability but again I would refer all of the colleagues here to date back to this report which is now starting to gather dust a bit and that is the Fair Work Convention because it went into all of this and much more. The only thing that has been plucked out of that is the question of pay. I am not saying that pay is not important but there is so much more to it than that. As I said at the beginning, you are articulating exactly the kinds of questions that people are asking themselves when they look at this as a career. To follow on just what Annie has said, we all recognise that pay is a critical element but the Fair Work Commission report on social care which along with Annie I would commend to the committee also highlighted how important it was that workers felt when they were at work that they were treated with value and with equality. I cannot imagine any nurse in a hospital treating a patient getting paid for that activity and then moving to another bed and that journey between patients she does not get paid for. I cannot imagine that worker not being paid in a clinical setting or taking their break and yet that is precisely the way in which we commission and contract social care. It is so important that we do not just look at pay but we look at how we value. For instance, electronic call monitoring systems. Now effectively, as the Fair Work Commission indicated, are the equivalent of electronically tagging our workers. I cannot imagine a nurse in the community tolerating that degree of lack of trust, lack of respect and lack of individualism. I think that we've all said this morning that these women and men are highly skilled professional individuals. Why do we continue to treat people like distrustful teenagers? If we're wanting to attract not just young people but, as Annie critically said, to hold on to our workforce, can we start to treat them in the way in which we contract independent employers in a way in which values frontline women and men in care? I agree with much of what has been said. There is no single fix for that. We need to look at that across the different groups of people that we want to attract into care. I think that there is definitely something about how do we grow that pipeline and that career escalator for individuals that want to come into care and aspire to a career in the wider family of health and social care? How do we attract people into care? It is a fantastic grinding for other caring professions. Where are we, as wider public sector bodies, supporting those individuals who train into other areas should that be what they are? We have shortages and challenges in terms of attracting social workers. Where are we supporting those individuals into becoming allied health professionals? For those who want that as a career pathway, I think that it will be a very valuable grounding. However, as important for those individuals who want to aspire to a career in care, how do we make that a job that restrains people and values them for doing that job well? I think that we absolutely need to think about the terms and conditions of how people do that job, how we support them to do that job, how we keep them safe from that job, how we keep them trained, motivated and supportive. I think that that is really important. We create that as a good career but also a career that can lead you into a longer-term career in other parts of health and social care. I want to say something about encouraging people to join social care. Part of the work that needs to be done is talking about the wider aspect of social care. We have people who are providing direct care but there is such a wide variety of roles. There is such a wide variety of roles across social care and what they mean to people. You know that I will recognise this. I have worked in the voluntary sector my whole career. The work that different aspects of social care provide to support people is not terribly visible but can help to support people to join social care. I also wanted to briefly talk about commissioning and some of the ways that it has been done has been a block to the expansion of self-directed support, particularly for older people. That blocks opportunities. For those who are looking to employ someone for social care as a personal assistant, the issue of pay is critical because if they are not able to offer the same level of pay as the local council, it is very difficult to recruit staff. What services, whether that is in the public independent or third sector facing in relation to recruiting social care workers, go to individuals who are trying to recruit personal assistants. Equalisation of pay across sectors is critical to that. David Torrance wants to come in on commissioning in particular. You have all mentioned that it has been an issue, so I will hand over to David Torrance. Good morning to the panel. Audit Scotland states that current commissioning and procedures have led to competition between providers at the expense of collaboration. How can commissioning and procurement procedures be changed to encourage a more collaborative and less competitive approach by service providers and to shift the primary focus of service providers? I think that it is important that there is a place in decision making from cost to quality. I am going to go to Mr MacArthur. As I said, I have worked in the voluntary sector my whole career. If you want to look at quality instead of cost, collaboration is absolutely critical. We have seen really good examples within the third and voluntary sector of that collaboration of organisations working together to look at being available to be commissioned for a service. The reality is that, when you bring a level, an amount to that commissioning process, it becomes very challenging. For example, larger organisations may have more of a scope to be able to bid in for a contract that is paying a lower level of service. A smaller organisations get pushed out of that. I think that there are opportunities for both larger and smaller organisations to work together. Fundamentally, the HSEPs or whoever is commissioned in services need to encourage that collaboration. That should be part of the commissioning process. We encourage collaboration. We want to see collaboration, because ultimately we want to see what the outcomes will be for individuals. Annie Garner-Logan has asked to come in, but I believe that you also want to hear from Don MacAskill. I will bring in Annie Garner-Logan. The commissioning is part of the issue, and the fair work report highlighted what was the issue in relation to commissioning. It is not just commissioning, it is the way in which we procure and purchase services and then the way in which we contract organisations or individuals. Undeniably, we have known for years that the system, as it is at the moment, is simply driving standards down, ostensibly attempting to improve quality. We know what works. What works is partnership models, alliance models, where you get individual providers to work collaboratively. Indeed, that is happening in some parts of the country, such as Aberdeen. Everybody knows the solution to the problem, but what we lack is the willingness and being honest, the resource to make the significant change. Self-directed support has already been mentioned by Fiona. One of the key platforms of self-directed support was to enable people to have choice. Choice is only possible if you have the ability to have a market to use that term, which enables people to choose between different providers. The way in which we contract and procure is driving organisations out of the sector, regardless of their business model, be they charitable or private. What we need to do is move, as Derek Feeley's independent review report indicated, and we need to do this fast, not while we wait for a national care service. We need to move to a model of alliance co-operative ethical commissioning in which we are not all about price but quality. The Home Care Association recently undertook some work across the UK, and they have highlighted that there is not one Scottish local authority that is paying what would be independently reviewed as the fair price for home care. We know the answers to the question. We just need everybody to get round the table and working together. I always feel like I am on mastermind when this topic comes up because I think that it is my specialist subject. It seems that I have been talking about it forever. One of the first times that I spoke to a health committee about this was 2009. The big issue of the day was reverse online auctions for social care contracts, where providers were encouraged to drop their hourly rates in competition with each other against the clock. We have come a long way since then. That is the first thing to say. That particular practice bit the dust largely due to the attention that the committee gave it, rightly so. After that, we spent a very long time in many years honing guidance that attempted to distinguish procurement of social care support for people from procurement of widgets and treating staff as a largely casualised workforce to be chupied from one employer to another without them or the people that they support having much say in it. We introduced a lot of flexibility for social care procurement in the 2014 reformat. That has all been good. We are in a different place now than we were then. Fundamentally, Audit Scotland is correct in saying that we are still experiencing commissioning largely as a price-based competitive exercise for large contracts to provide services that are not specified by the people who will receive support but by procurement officials who have never met those people before. We are less understood their individual needs. For me, the push for ethical commissioning is a term that we are hearing more and more now. Procurement that recognises fair work and exploration of more collaborative approaches is hugely welcome. Two positive things about that. My organisation is leading a programme of work with Scottish Government funding to support providers, commissioners, people who use support and anyone else who is interested in doing things a bit differently. I am finding ways to develop procurement practices that respect and give expression to the principles of self-directed support, as Donald has just said. Collaboration is not only about providers collaborating with each other. It is about commissioners and providers and the people they support and families and unpaid carers all being around the table for better outcomes. There is a lot of interest in that, so hooray. We have a team of two and a half people doing it. The independent review of adult social care called for a national improvement programme in this area. We would like to see that very soon. The second positive thing is that the Scottish Government procurement directorate has recently issued an incredibly helpful policy note, which says that two commissioners and procurement officials do not wait for the national care service to start now. It is an alignment with the principles of ethical commissioning and fair work. The independent review recommended a revolution in commissioning, but the national care service proposals that came out in the consultation last year did not follow through on that. I would go so far as to say that competitive tendering for social care is unethical in itself. No amount of tinkering around the edges is going to change that. I worry that ethical commissioning is being interpreted as a way of making sure that providers behave ethically, but it has to start for me at the beginning. With a commissioning mindset that is in itself ethical, that would rule out competitive tendering, in my view, as it would rule out any kind of procurement that did not involve the individual in choosing their own support. I could talk about that forever, but I should probably let colleagues get a word in. Dr MacAskill, you mentioned Aberdeen airn clabat of working. Can you expand on examples of best practice, please, on clabat of working? It is very much along the lines of what Annie has just described. The whole process of preparing a social care package begins with that initial conversation with the person who is being supported. She or he has significant input at assessment, their allocated and individual budget, good work highlights that they know the options that are available to them and are able to exercise choice. That is all essentially contracting and involving the person. At that point, we make sure that the providers who give good information, who are able to support the person perhaps through individual interview, so that that person has control and choice. We go all the way through the contractual relationship between those who are paying for the care, which is the local authority, to make sure that that care is autonomous, that the front-line worker is trusted in what she or he does. It is really interesting what is going on in Aberdeen with colleagues of mine around the role of the care technologist. We have so much potential to enable people to live independently in their own home for so much longer by using home technology. That project, as part of an overall work in Aberdeen, is looking at the potential of giving autonomy to front-line care workers and the person who uses the care support. There are no simple answers. There are lots of models, but they have a consistent thread, which is partnership, collaboration, equality of treatment and critically trust. I agree with Annie that a competitive tendering process is unethical. What that has at its heart is collaboration rather than competition, trust rather than suspicion. A couple more members want to come in and commission. Emma, a question for you and then I'll come to Sue Webber. Good morning to the panel. It's just a quick question about self-directed support, because a couple of the panellists have mentioned it and we've raised it in previous sessions of the health and support committee. There's a document here from 2011 that talks about barriers to self-directed support, but also things that help it. I'm wondering if the panellists, Annie or Fiona, have a feeling of how well are we doing with self-directed support, because in my own case work we've got people that aren't really aware of it or what it does, so how are we doing with it now? I think that the position is variable. The problem is that it is inconsistent. Some individuals and their carers will clearly be offered self-directed support. It's a straightforward process within their local area. They're provided with support and information to be able to make decisions. However, that's not consistent. Equally, many carers don't know that self-directed support at all. Our colleagues in the coalition of carers asked about the previous flexibilities in self-directed support and the Government produced guidance to say that, at the moment, when it's very difficult for providers to provide the support that they need, and breaks was a particular example in day services. How can your direct payment or option be used to purchase something else? More than half of carers had no idea that that was happening. They had no idea that that flexibility was available. When we came back and talked to carers about it, they talked about some of the things that would have been really valuable to them to be trusted. I think that Donald mentioned trusted and to have last less administrative burden. If you take on a direct payment, obviously, if you're employing someone, there's a lot of administration about that. Even if you're using other options, there's a lot of administration around that. There's something about removing the bureaucracy around it and staying to individuals and their carers. You know what is best suited to your needs, what will make a difference to your life, and we trust you to be able to use a direct payment to purchase information from an individual provider. We're not going to ask for reams and reams of paperwork. We're not going to ask for loads and loads of receipts. We're going to say to you, we trust you, and we're still away from that. I think that with respect, the fact that Ms Harper has had to ask the question shows the answer, which is that we're doing pathetically. This was one of the most progressive dynamic pieces of social care legislation, probably anywhere in Western Europe if not much wider. Maybe one of the problems was that we talked about self-directed support when what we really should have said is this is now how you get it. This is social care, this is social care assessment and it still dismayes me, sometimes angers me, that I hear people saying there's the social work assessment, social care assessment and that person is on self-directed support. All social care should be self-directed support, so the answer is the fact that we're still talking about self-directed support as if it's a different creature shows that we failed in communication, in implementation, as Derek Feeley said, and from my perspective, the groups that I support in terms of older people. We did research in February 2020, just before the pandemic, and we analysed that only 3 per cent of older individuals living in residential or nursing care accessed self-directed support and only 5 per cent knew about it. That has not changed during the pandemic, and that's the answer. We're not where we should be. Annie Garner-Logan wants to come in on this before I move on to Evelyn Tweed's questions. Thanks, convener, and thanks to Ms Harper for the question. Where it works, it works well, but in my view there are some fundamental misunderstandings about what self-directed support actually means. I still see people confusing it with direct payments, for example, and thinking that's all there is to it. I think that we have to remind ourselves constantly that there are four options in self-directed support, and one of them is that people can say, I don't really want to choose my support providing, can someone just arrange something for me? Fine, but the principles of self-directed support will still apply to whatever service is then arranged for that person and that they should have as much say as they want in how it's delivered to them. One of the things that the committee might be interested to look into a bit more is how self-directed support options 1 and 2, particularly direct payments, were handled during the pandemic. People were not always able to continue the arrangements that they had because the services were withdrawn or because of staff shortages and all the rest of it, that people weren't able to access the same kind of support that they were previously. It was incredibly difficult for those people then to use those resources that they had in a more creative way. Fiona talked a little bit there about the audit requirements and the obstacles that are put in the way of people who want to spend their resources creatively, and that was a huge issue during the pandemic. I said in answer to the last question that the independent review of adult social care recommended a national improvement programme for commissioning. It also recommended a national improvement programme for self-directed support, and I think that we could light a bit of a bonfire under that as well, and we'd be pleased to see that. Donald is absolutely right. It should be mainstream, and it's not. We still seem to be looking for the silver bullet to solve social care, but this Parliament legislated for it nearly 10 years ago, when that act was passed. If we did that properly, we would not be facing some of the problems that we are now. Good morning, panel. It's good to see you here today. It's nice to hear that there have been some positives coming out of the pandemic, which has really shone a light on social care and all the things that we need to think about in terms of how important the social care service is in Scotland. My questions are about leadership, and Audit Scotland has highlighted that we also have an issue with retaining leaders within the social care sector. My question is what can we do to help this? What are the reasons behind it? We've talked about other sections of the social care service, but what can we do for our leaders and how can we make it sustainable in the long run? I would like to ask Annie Gunnalogan, because she touched on that earlier. That's a really good question. It's a topic that's gaining a lot more traction now. The Scottish Government convenes a national leadership development programme that's looking right across health and social care. In some ways, it's trying to address the issue that I think you're alluding to, which is that there's a bit of a hierarchy of leadership in health and social care. Health is definitely still the dominant party in that. The thing in social care that we need to recognise is that most of the leaders in social care are not part of the public sector. They are the leaders of third and independent sector social care organisations who often find themselves completely out of the loop. I was chatting to some of my colleagues about that recently. If you're the chief exec of a £50 million turnover social care organisation in the third sector, then your main point of contact with the system will be a junior contracts office. That's how it works. As I'm speaking, I'm already thinking, oh dear, somebody's going to say to me that I'm obsessing about status and hierarchies and I'm not. It's just that these are people who understand their business, who understand the people they support, who understand the mission that they're on. They are somehow not part of the leadership effort, and they really, really need to be. This is something that I bang on about endlessly in these meetings that I attend around this. At the moment, there is definitely a hierarchy. The independent sector is pretty much on the bottom of it when it comes to leadership. That's what I would like to see change. One of the points that I raise in those meetings is that leadership in the third sector and in the independent sector is a much more risky business than it is anywhere else. If you get it wrong, it's not just your job. It's your organisation that will fall over. We're not called into being by statute in social care organisations. We're here in the third sector because we want to be. For me, that's what voluntary sector means, that you're there voluntarily. But if you don't get the right leadership, then it's a hugely risky business. Dr MacAskill wants to come in on this. Thank you, convener, and thank you, Ms Tweed, for the question. The social care sector and the workforce has shown exemplary leadership, especially over the last 22-23 months. If we are going to solve the crisis of leadership and we are facing a real crisis, then we need to look at the experience during the pandemic. It starts with the front-line worker, the front-line nurse or social care worker, and it's respecting their professionalism and giving them the autonomy and trust that I've spoken of. It continues with the necessity that we need to recognise that simply rewarding and increasing the salaries of front-line workers without recognising the importance of differentials. Senior carer is only getting paid £40 an hour more than somebody who is just literally in the door. That's about valuing leadership or not valuing leadership because those individuals who are supervisors, who are co-ordinators, who are senior carers are our leaders now but also our senior leaders of tomorrow. Lastly, we need to see leadership as a whole-system approach. Thankfully, the new work of the Scottish Government is beginning to do that. By that, we have to recognise the mutuality of our health and care systems. It needs to be the case that the insights, the experience and the expertise of leaders in social care are understood and appreciated and valued by senior leaders in our health system. That involves more conversation, more collaboration and more opportunity to get together. Sadly, in the past year, there have been significant reductions in the occasions and opportunities for health and social care leaders to get together. Leadership is something that affects the whole of the sector. At the moment, sadly, because of the experience of the pandemic, because of burnout, emotional stress and fatigue, we are losing many leaders. In the care home sector, that is significantly because of disproportionate scrutiny, which has resulted in many of the nurse leaders in particular choosing to leave the sector. Judith Proctor wants to come in and I'll come back to Evelyn for a follow-up question. I'll focus on the issues that have been raised already. A number of Audit Scotland reports have highlighted the high turnover, particularly of senior leaders in health and social care partnerships, chief officers specifically. It's a role that's obviously been in place for around about eight to years, as long as we've had health and social care partnerships. In that time, almost every health and social care partnership in Scotland has had turnover of their chief officers, some of them over several chief officers. Not just that, but we're seeing some challenges in relation to the number of applicants and other senior leadership roles in health and social care. I think that there's a question there about how attractive are those roles to people who are middle managers, junior managers? Are we making those aspirational for those jobs that people do not want to undertake? I think that probably every chief officer would then be able to recount the situations where they've just not been able to recruit to senior roles within their systems. I think that there's something in that about how we prepare, select, accession plan for leadership in our system. This is the same in health and social care, health and social care partnerships, as well as in the third and independent sector. I think that there's a national conversation to be had about how we prepare people to lead in public life in Scotland. I think that it took a while to get the national leadership programme project lift to also include and embrace third sector leadership. The opportunities there are relatively small, considering the size and scale of the sector itself. I think that we need to think about what programmes we have in place and the support that goes to supporting individuals once they are in place. I think that, as far as chief officers go in terms of that specific role, there's something about the complexity of the structures that we work within. That was recognised by Derek Feeley in his report. That makes leadership across health and social care particularly challenging, given the three organisations that you effectively lead and work within. I think that we have to really look at leadership. I know that the Scottish Government has undertaken some work on that, so it would be good to see the outcome of that in terms of what it is thinking about how we recruit, retain, prepare and support people to aspire to leadership jobs in the future. I have a follow-up question. Judith MacKinnon has answered my question. I will go to your colleagues. You wanted to have a question on that. Yes, Judith Proctor. You mentioned the outcome of the Scottish Government's work. I am just trying to gather some of the issues around the turnover of senior staff in the councils and the NHS and the integration authorities. Are there working conditions for more senior staff compared with the broader workforce in the social care sectors? Gideath, sorry. Obviously, there are differences in terms of the roles. I would never claim that you are not well rewarded in a very senior role as a health and social care chief officer, but that comes with a range of accountabilities and responsibilities in a complex structure that would differ from different organisations. We need to think about what are the values that we look for and what are the particular skills that we look for in terms of leadership across the public sector, what are the outcomes that we are trying to achieve and to really then think through how we support individuals into those roles and support them once they are in the role. Getting the job is only part of the process that we have to perform in that role and deliver the outcomes of the organisation that we are working in. There is a discussion that we need to have in terms of what we look for in the public sector or in the public life in Scotland and how we support individuals into that. There is also something that Donald touched on about different organisations and support that we give to them and the resources that they have to prepare and support leaders. Donald talked about the care home sector, and I think that that is a really, really important one. Not every care home provider or organisation will have the same resources available to them to support, prepare and entertain their leadership. When we are thinking about the resources that are required to deliver high-quality health and social care, we need to absolutely understand that part of that is the preparation and support of the workforce and part of that is the support and preparation of leaders in that workforce. They undertake a critically important role, and Donald touched on the role of care home leaders and care home managers throughout the pandemic. That would be the same in the care at home sector. If we were to look at the resources available to those organisations, prepare and support leaders, there would probably be gaps in terms of what we would want next to what they have. There is no consistency in that. I would imagine that Donald and Annie would be better able to answer that than myself, but that would certainly be the same in the public sector, and not every health and social care partnership local authority and health board will have the same resources that is important to develop their leaders there. We heard earlier from Annie Gunnar-Logan on how some of the senior leaders are out of the loop and not part of that leadership effort. That might contribute to a lack of trust and understanding of each other's working practices and business pressures. We have a lot of short time posts, an ageing workforce and all those things affect people's leadership capacity. What can be done to improve the understanding and role that the SNP Government has in building that trust between the different sectors and leadership? I ask Annie first and then perhaps Donald if he is able to comment. Annie Gunnar-Logan I think that some of that work is already happening. I mentioned the national leadership development programme that we are now involved in and we are around the table for that, which is great, because we have not been before. Some of the exact same conversations and points are being raised in that forum. There is an issue about how we break out of siloed leadership. There is a view in the NHS that you can only be an NHS leader if you kind of grew up through the NHS. It is the same for local authorities and the voluntary sector in many respects, but I think that we all have to see ourselves here as part of a collective collaborative endeavour. In much the same way as we are talking about career progression up-ladders within silos, we need to look at leadership movement across the sectors and a bit more cross-fertilisation. One more thing that I would add to that is that there was a lot of interest in what we call citizen leadership around social care and putting the people who use the care services and the unpaid carers into leadership positions. That seems to have gone a bit quiet now. I think that it would be useful to revive that as a concept, because there was some really interesting thinking around that at the time. I have always favoured a model of leadership, which is not about being so far ahead of the group that you are leading, that you cannot see them or know their experience, but to be in the heart of the group. That, at its best, is what social care leadership has enabled, and certainly during the pandemic, managers, whether in a care home or home care organisation and senior leaders, literally rolled their sleeves up and did the work of care. We saw that over the Christmas and January periods when we were facing such real challenges in staffing as a result of Omicron. That model of inclusive, participative equal leadership is the heart of social care. In times of real challenge, I think that we have worked really well collaboratively across health and social care partnerships, the independent third and central government. I would like that to continue. My fear is that, as Annie suggested, we fall back into silos and lose that sense of mutuality and collaboration, but also recognise that leadership requires resources due to the vindicated. My worry is that, as well as hemorrhaging gifted women and men from leadership in our care sector because of the stress and strain of the pandemic, we are not nurturing and growing our leaders in more junior levels, such as supervisors. We know how we can do that, and part of that requires a dedicated resource to enable leadership in the social care sector. Just a very brief point. If the committee wanted to get into this in a bit more detail about what is being done around leadership in social care, Nez, NHS Education for Scotland and the triple SC Scottish Social Services Council will have some information for you about that. Convener, just for propriety's sake, I should declare that I am a non-executive member of the board of Nez, just for clarity. A few of you have mentioned some additional information that you want to put our way, so please forward that on to our members or to our committee. Gillian Mackay Thank you, convener. Audit Scotland has highlighted the cultural differences between partner organisations or a barrier to achieving collaborative working. How can we better overcome those barriers and foster collaborative working and greater integration of services? I go to Judith Proctor first on that, please. You were asking about cultural barriers as a barrier towards greater integration of services. I think that a lot of that has been touched on. Donald mentioned the lack of opportunity that we've had over the past couple of years of the pandemic, and I think that that is something definitely for us to reflect on. I think that part of the way that we address these cultural barriers is a greater understanding of the context and organisations in which we each work, and a greater understanding of our roles within that. Opportunities for the development of those relationships across sector leaders is really important, such as we saw with the Scottish leadership forum, which has been quite active in and around that area. I think that the work that Annie has just talked about, and I hope that we will help to address some of that, too. I think that they are very real. I talked about the complex structures that we work with across health and social care. As chief officers, that is very real. NHS culture is very different from a local authority. Identity and culture and, within that, our health and social care partnerships, we are also trying to develop a culture and a way of working that is distinctly different. That support collaboration, that support cross-sector working, that support the integration and delivery of services as if we are a single organisation. That is quite difficult when the terms and conditions of people that work within that organisation are those of the NHS and the local authority. I think that some of the issues highlighted by Derek Feeley and his report identified that, that underscored some of the challenges that we have got and what we have seen for the marriages from the consultation on the national care service. Whether the measures that are put in place, the legislation that is put in place following that, actually begins to address that because it is quite a challenging context to work in. One of the many conversations that I had during the pandemic was with a senior general practitioner who confessed that it was only during the pandemic that he began to really understand what social care was like and what the job of front-line care in a care home, in this instance, was like. Ms Mackay's question about culture highlights the importance of all of us having the opportunities to learn to not quite walk in the other person's shoes but to understand their world. I think that our best during the pandemic, we have taken off the professional arrogance and being more appropriate and humble in admitting that we did not know everything, either from social care about the health system or from the health colleagues about social care. The future I see in addressing the very real cultural barriers that reports before the pandemic highlighted as being one of the major barriers to effective integration. What we need to do moving forward is to build on our experience during the pandemic, which has to include, and at times I have been critical and some colleagues will know this, about the sense that health and social care have talked to each other, involved and engaged with each other at a statutory level, but the children, which is the 76 per cent of social care that is delivered by the independent and the third sector, are not at that table. I think that it needs to be a priority as we move forward, that all those who have something to contribute, who are key players, are working together to change the culture, and that is all about listening to each other, shared knowledge and experience, the building of trust and the mutuality of risk, rather than placing risk upon one partner at the expense of others. I couldn't agree more with what Donald has just said. I think that I would very much like to see us building on the experience and things that we have been able to do during the pandemic that seemed impossible in the past, and particularly the involvement of people who use services and carers at important working groups, for example the Pandemic Response Group. It has very much added value to that group and has built an understanding of what carers are experiencing. I have heard Donald speaking in the meetings as well about the situations in which care workers are experiencing. I think that that needs to continue. I mentioned earlier on about citizen leadership. What is very important is the culture on boards, for example the integrated joint boards, and about building that collaborative leadership. I think that carers were very pleased to see in the national care service the proposal of ensuring that they were equal on boards and that people who use services should have an equal voice and should be equally regarded in making decisions about the development and delivery of services in their area. I think that we have had a problem. There is a little bit of tokenism within the integrated joint boards. In general, one person is from the voluntary sector, one person is from the service user and one person is a carer. It is a huge job to be that person who is speaking for your whole sector or your whole group of people. Often, carers have found that they do not necessarily feel that they have the voice that they could have. They do not necessarily feel that they are valued in the way that they should be, as people who are providers of care and providers of very complex care. I think that there is a lot of work to be done on, as the community health and care boards develop, that there is a lot of work to be done around that collaborative leadership of boards and that equal valuing of everybody on that board in making decisions. Annie Gunnar-Logan wants to come in before I come back to Gillian for the supplementary. Yes. First of all, I will convene a big amen to everything that Fiona just said about collaborative leadership and that culture. When we talk about culture in health and social care, the implication is often that the cultural divide is between the NHS or health on the one hand and social care on the other. Something that I would come back to that I have already alluded to this morning is the difference in culture between the public sector and everybody else. One of the biggest cultural barriers that we have is the persistent inability of leaders in the public sector—a present company accepted, I should say—to recognise providers as partners. We are not just suppliers to be managed through the application of contracts and contract management. From the Audit Scotland report, you will see that the vast majority of social care is delivered outside the public sector, and yet there is still a huge level of mistrust there. It sometimes seems that there is quite a strong impulse on the part of public sector colleagues to count the spoons after we have been around for tea. That really needs to stop. It was one of our key critiques of the national care service proposals. We might get to that later on, so I will keep my powder dry on that for the moment. If all we do is rearrange the structure without addressing the culture at sitting underneath a system that sees people who rely on social care as units of cost and their services as commodities to be traded on a market, then we are really not going to get very far. That is the bit of the culture that I would like to see addressed most of all. I will pick up on something that Donald MacAskill said earlier. Obviously, for some care workers, there is a lot of recording of visits and things like that. Quite often, that is to support families in being able to know what has happened at visits and things like that. However, for some care workers, it can, as you said earlier, be used as a way to sort of try and track them and keep track of that level of almost mistrust in care workers themselves. How do we, as we go forward, improve that culture for care workers in particular? Dr MacAskill. Again, the fair work report, which has been much mentioned already, highlighted electronic monitoring as a disincentive for front-line care staff. Those systems were introduced partly to support loan working and to increase worker safety and wellbeing, partly to ensure that families and others were confident that care had been undertaken. However, the way in which they are frequently used, not least to allocate financial return, i.e. to pay the worker or the provider, has become really damaging. Before the pandemic, it was one of the major reasons why home care staff indicated that they no longer wished to work in the sector. Interestingly, during the pandemic, virtually overnight, most of those systems were removed. The world did not collapse. We did not see inappropriate behaviours or actions on the part of staff because they were and are trustworthy committed individuals. The answer is that we have to develop systems whereby we trust and give autonomy to front-line workers. I would personally like us to get to a context where a home care worker or a home care organisation was able to be contracted in a way that the staff member was able to be employed on a contract that gave a caseload—much as happens in community nursing or in other contexts—to give autonomy to that individual to work through their caseload, to identify more need for intervention or lesser need, in other words, to treat those amazing women and men with the trust and respect that they deserve and, indeed, with the autonomy that they wish. In my view, we can remove the offensive systems that electronically tag those workers. We have a couple of questions that have to be short, supplementary questions on the same for a move on. Please keep an eye on the time, colleagues, Stephanie and then Sandesh. Just very briefly, we have spoken about quite a lot of things around terms and conditions and culture. I am currently a councillor at South Lanarkshire Council. I know that one of the things that families wanted most was having that same front door, but with staff in different paying conditions, etc. You know that that can be problematic. What I really want to ask the panel is, do any of you have some really good examples of success and what that actually looks like? You know whether that is shared budgets, shared responsibilities, shared decision making—just really interested in that aspect. Things that we can do now are not waiting in the national care service coming along. We do not have time to go around all of the panel, so maybe if we may ask— If anybody has a particularly good example of it, they would be really keen to hear it, thanks. Colleagues, please raise your hand if you have something that you want to—or I can come to Sandesh for his question, give you time to think about that and come back. Judith, can I come to you? Happy to address that one. I think that there will be a number of really good examples right away across Scotland in terms of where we have seen integration happen within health and social care partnerships. Regardless of that issue of terms and conditions, certainly in my own partnership, our front-line teams are integrated and co-located. They operate as single teams where we endeavour to ensure that the skills that an individual has through their registration and their profession are used to the best ability, to support the individuals that we are here to serve. We are doing things like our C conversation approach in Edinburgh, where we support all our front-line staff to understand how we work with individuals in support of a person-centred approach, what matters to that individual, what outcome that they are trying to achieve and how we wrap around that with the support and care to help them achieve that. We are trying, in the work that we are doing, to include our community sector, third sector, as partners in that work, to be collaborative. You would see examples of that right away across Scotland—good examples through the pandemic—of support that was provided in relation to care home oversight. Perhaps we had a rocky start with that. For some of our providers, there was a sense of public sector marking their homework, as it were. In many areas, we got to really, really good place in terms of how we did that, collaborating with the sector itself to ensure that our care homes had access to PPE, access to support around infection control and prevention over and above that, which they provided themselves. There have been many, many examples across Scotland where we have done that. However, I would say that those issues of terms and conditions come up again as a barrier to date as being able to do it at the pace that perhaps we have wanted to do. That has been recognised in the period with you. Thank you. Dawn McCaskill? Thank you, convener. Just very quickly, and it is always a risk highlighting one area of the country over and against another when you are in a national role. I keep hearing about what is happening in Fife health and social care partnership is a worthy of greater exploration and that includes a very close alliance between statutory colleagues and the independent and third sector in the delivery of home care, particularly to address workforce challenges during the pandemic and laterally during Omicron. I know that the independent sector lead from Scottish carers work very closely to establish some new approaches to contracting commissioning and to front-line delivery. I know, too, that working in collaboration with the care home sector, there has been a lot of mutual work. I do not think that it would be too difficult, as Judith MacDonald said, to highlight areas where things have worked. We know why they have worked and they are usually because people sit together, listen to each other, remove hierarchy where it is inappropriate and I keep coming back to that word, the word of the day, trust each other. There are plenty of examples, but I would for the moment consider that Fife is worthy of verbal exploration. I will need to move on. My question is about when a problem occurs. Will we have a situation where integrated authorities blame health boards and vice versa, leading to a vacuum of accountability, especially with future changes in mind? That really is to Judith MacDonald. I have mentioned before the complex context that we work within, but the accountability across health and social care in the situation that you described are pretty clear. If you are talking about a health board, the accountable officer there is the chief executive. The chief officer of health and social care parts of the IGB is jointly accountable to that chief executive and to the chief executive of the local authority. The IGB delivers its ambitions through setting directions. Those are statutory instruments that neither partner or organisation can veto. We cannot say that they are not going to deliver a direction, but directions, as we always say, happen at the end of a long process of joint collaborative planning. A situation in which a direction comes out of the blue to either partner and should not occur, the way in which we work is highly collaborative. The planning that we do is jointly across our three different organisations. When a problem occurs, we work through the appropriate governance channels of that and the appropriate reporting and investigation of any issue, but I am not aware of any situation where an IGB has blamed a health board for a problem. We have mechanisms in place through the delivery of directions, we have our various audit reports to ensure the delivery of that. Of course, the unique role of the chief officer is being the chief officer to the IGB, but the joint director is responsible for the operational delivery of that direction. I think that there are multiple routes to ensure that the appropriate delivery of a direction, the planning of the service change, the direction signals and the oversight of that through governance processes is in place. I am very happy to work through an example of that. Annie Gannag, I would like to comment briefly before I go to Gillian Mackay. Thanks, convener. The question is interesting, because it is about what happens when the NHS board and the council blame each other for problems. One solution to that would be to go back to what my colleague Fiona was saying earlier on about widening the pool of the decision makers and giving all the stakeholders a say and a vote on local boards. It is not just the two big ones slugging it out. That was a question that came up when the joint working act that led to health and social care integration formally came up. It was not backed back at that point, but it is time to revisit it. To replicate that at national level with a national care service board that has more than two stakeholders involved in it with a say. That was something that Derek Feely recommended in the independent review, another one of the things that he recommended, which he did not follow through into the national care service proposal. I think that we could fish all of those back out of the pond again and give them another run for their money. In its briefing, Audit Scotland highlighted that no individual social care records are recorded in the same way that each member of society has an NHS record. That makes it difficult to assess whether social care is meeting people's needs. What is the panel's view on introducing a single social care record and could I direct that to Judith Proctor first? It is absolutely the case. Every social care system, some of us will use similar platforms because of the pool from which we can commission, but largely the systems that we have in place for social care recording will be legacy systems from local authority and the proof that we would have put in place around that. A single way of doing that would definitely be helpful for individuals, but it is more complex than just the system that we use. It comes down to the paradigm and the way that we work with individuals. Any system is only as good as the way that you want to work with individuals and how you do those assessments and how you engage in those conversations with individuals about the outcomes that they are trying to achieve. We need to start with that. What is the purpose of what it is that we are doing and what is the philosophy, the paradigm and the way that we work with individuals and then build assistance for that? Is that a national system? All I would point to is the huge challenges in developing and procuring a single system and the huge cost for that, but there is maybe a place that we need to start in discussions around the NCS of what it is that we are here to do, how do we unify as far as possible that which we have and how do we work towards a system that makes it easy for people to move their care across areas and for individuals to have their own access to that and to own their own data. There is a starting point, which is what we are here to do and then building any assistance from that. Developing from scratch a national system would be time consuming, as well as hugely costly. The aspiration of having a national system that Audit Scotland and the Accounts Commission highlighted is absolutely accurate and in the right place. My one organisation together with the Health and Social Care Alliance recently produced a human rights-based set of principles for the creation of whether a national or a more local data system. At the end of the day, we talk about data, but this is about me, somebody who might use social care or health services, only having to tell my story once. There is nothing worse than the continuous reassessment of individuals where you have to go through your story and often emotional and challenging story on innumerable occasions. However, what is critical is that, as Judith said, there will be challenge, but technology has advanced considerably in the past 18 months, partly as a result of the pandemic. We can overcome some of those challenges and it is perfectly possible that we can create a system on a platform that covers Scotland. However, what will be critical is that this has to be something that the citizen owns, so that she or he should have access and determines who has access, whether it is the ambulance driver who comes, the social care worker who comes or indeed your general practitioner. In this day and age, it is a nonsense that I have to formally request sight of my health record. It is my record that I should have access. In partnership with primary care or social care, I think that it is perfectly possible for us to move to a situation where the citizen has control over his or her data and does not have to tell their story on numerous occasions. We have a couple more panellists who want to answer your question. Do you want to get any, Gynnar Loggan? Thanks, convener. We have a programme of work that is supporting our sector to embrace digital technology and data, which is a huge part of that. The situation that Gillian describes there is absolutely the case. It is on everyone's radar. We are running a series of sessions with data labs for our members to better understand and use their own data. In common with Donald, the big question for us is who controls it. We are pushing for citizen-held data as the ultimate goal, but in the meantime, citizens having access and control over their data is absolutely critical. I think that there are some big questions about what data are we looking for. Most importantly, I think that there is data about outcomes for people rather than about system throughput and institutional outcomes. They are important, but they are not only as a proxy I think for data about outcomes. The other big point is about the challenges that we face in our sector. Sorry to grind the sacks again, but providers are still seen as outsiders here in being able to access the necessary data from our statutory partners in order to support an individual and to better understand the environment in order to plan and innovate new services. It is about challenges of working across different systems, technical systems and information governance systems. We support absolutely the creation of shared data standards and we are working with members on that, but I think that it is very risky indeed and actually quite dangerous if we are going to impose a single technical system on everyone, because many organisations in our sector have already invested heavily in that. The last thing that we want is for that investment to be binned and them having to invest in something else because it is mandated from the top. The shared standards on data are absolutely, but not a single system. I think that an individual system, an individual record would probably be very helpful whether it is technically possible. I think that the question is whether it is national or local is not really relevant, but the most important thing is what it is measuring and that there is consistency across that. That is the consistency of what goes into records. There is the consistency of individual access to their own records. I agree completely with Donald that individuals should have access to their own data. The Audit Scotland report mentioned about not having a consistent way to measure the level of unmet need. I think that there is a good opportunity if you have consistency on what data is collected, what information is collected, but critically that across all areas we measure the same thing, that we measure unmet need and we record where individuals are assessed and their support needs are. Do not meet local eligibility criteria. We need to understand the level of need in our communities and there is a way of doing that through the data and monitoring. The point about telling me once is pretty critical, because carers talk consistently about having to tell the same story again and again. As Donald said, it is often a very emotional story, so there is something about who has access to that information and not having to tell that story again. I think that whether national or local is probably up for debate, but I think that something about having an easily accessible individual record. I would want to note that it is a question that was raised by carers around their caring for someone who lacks capacity. I think that those are some of the tricky questions around who has access to that and whether carers would have access to be able to support the care of the person that they care for who lacks capacity. I think that there are some questions around that and I think that we need to resolve all of those issues before developing a significant investment into a national record. Dylan, have you had a follow-up question? We are into our last half an hour, so that is my heavy hint to everyone to keep their questions short and succinct. Panelists, you just have to tell us what you think, so I am not going to curtail you, but members can maybe just keep them short and sharp. Stephanie, you have some questions around financial planning. That is great. Thanks, convener. Fiona led into that really well there, talking about unmet needs. The rise in demand is the population ages and we have got pressures on local government funding. I think that we can all agree that meeting critical and substantial needs really just is not good enough. That is not enough. We need to be looking beyond that. What I am wondering, Fiona, is that has the level of unmet needs been estimated for those people that fall below the eligibility criteria? A second question to that as well, how much would it cost to meet those needs? Thanks. I think that no unmet needs and people who fall below the eligibility criteria have not been measured, so it is very difficult to estimate how much it would cost to deliver that support. To give you a figure that has been worked out around the right to a break from caring and over the pandemic, nearly seven in 10 carers have not had any sort of break from caring. If you were to deliver a fairly universal but limited right to a break from caring, the cost would be around £500 million. That is just one element. If you start thinking about other levels of unmet needs and low levels of support requirements, you can imagine that that number would be going up significantly. It is about how we choose what we invest in and how we value social care about making that investment. I do not like the phrase unmet needs, because I do not think that it belongs in social care. If social care is about enabling support to allow a person to achieve their full potential as a citizen in the community to live independently and so forth, there has to be an element of preventative care and support. What Derek Feeley highlighted in his report and numerous others have said over the years is that we have stripped out that preventative support from the way in which we offer care in our communities. Economically, that is really questionable, because if we intervene appropriately early, we prevent much more expensive, often acute and secondary care intervention. Unmet needs, as we define it, very narrowly is almost—after the horse has bolted—what we should be asking is what resources are required in the social care system not to create dependency but to foster independence, to prevent harm and degeneration and decline at an earlier stage and in that sense to enable individuals both themselves to live more positively, but in terms of the health and care system to see economic benefits. That is great. I am really interested in answering the questions that I had as a follow-up. I am wondering if you could expand on what evidence we have about the relative cost effectiveness of investing in preventative care, as opposed to waiting until things come to crisis and then spending a lot at that point in time. We certainly have evidence in terms of the cost of unnecessary hospital admission. I am generalising here, but roughly £2,900 is the cost for an untreated day over a week in a hospital. The equivalent of supporting somebody either in a care home or in their own home is significantly less. The national care home contract at where it is will not be where I would defend, but at least you are in the territory of saving £1,500. That is the economic benefit of preventing somebody from having an unnecessary admission if they are supported in the community, in their own home or in a home setting in a care home. Much more challenging is to look at the whole system in terms of what would the economic benefit be of investing earlier in the curve to prevent people from having to purchase or provided more expensive care and support. Before we introduced free personal care, the vast majority of home care delivered in Scotland—67 per cent—was what we described as preventative early intervention support to enable somebody to live on their own. It was not personal care as such. The vast majority of home care now is personal care. In fact, at the last data that I saw, only 3 per cent of home care was non-personal care. If we invest in helping people remain well and keep healthy and independent—in other words, a preventative approach, rather than a reactive approach that personal care ultimately is—the fiscal saving is enormous, even if the initial investment is considerable, but much more important than that, the wellbeing and welfare of the individuals who are cared for and supported is incalculable. I think that I'm right in saying that measuring unmet need was another recommendation from the feeder report from the independent review that hasn't entirely been translated into the proposals for the national care service. Audit Scotland produced a report a couple of years pre-pandemic that did actually put a figure on how much it would cost to keep doing social work services in the same way—was it $3 billion? I can't remember. They produced a number anyway. The point that they were making was that we can't keep doing what we're doing because there isn't enough money, and therefore we have to approach it differently. In that report, they were saying exactly the same thing that Willie Rennie said in changing lives—exactly the same thing as Campbell Christie said in his report—that everybody has been talking about ever since, but we've never managed to do it. Two things about that—one, in social care, I've come back to my point. Instead of looking for the silver bullet, we need to get serious about the one that we've already got, which is self-directed support. Ultimately, if there is a resource issue, which there is, we need the people who rely on social care and their families to advise us on how best to spend what we have got rather than making assumptions for them on their behalf. We also need to get serious about what now pleases us to call placemaking. Local authorities are understandably spending a lot of time defending their position in retaining control over commissioning and delivery of formal social care, but the key role for them might more usefully be focused on ensuring that their communities are places where there is a thriving support system of less formal voluntary sector-led wellbeing-focused support, with the ultimate goal of people not getting into the formal system at all. That is where we need to put much more focus rather than fighting over who is going to control social care. That is an absolutely key role for local authorities because it would be brilliant to get moving on that one. I'm going to bring in Fiona Colline, then we must move on to talk about the national care service. Fiona Colline Yes, thank you. On that issue around preventative support and understanding what the cost would be, what the cost is, we know that one in five carers give up worked care. We know the evidence around poorer health outcomes. We know the evidence around disability and mental and physical ill health. We know about long-term poverty. If we look at social care in a silo, investing in social care for preventative support and what that might cost, we are missing out on the other costs elsewhere in the system. I think that we need to have a whole-system model here. I also am Scotland, I have done some interesting work on caring, which I think might be helpful. The Circle project in Sheffield University, Professor Sue Yendall, is also doing work on sustainable care. I will happily share that information with the committee. I think that it might be helpful. A couple of my colleagues want to talk about the national care service. Obviously, we could probably do a whole session on that. We will be doing many sessions on that, but just some initial questions on that from Emma Harper, followed by Paul O'Kane. Emma Harper Thanks, convener. I will be short because I am going to focus my comments on the audit Scotland briefing that we got. One of the key messages says that, regardless of what happens with reform, some things cannot wait. A clear plan is needed now to address the significant challenges facing social care in Scotland. There are things that we can do without legislation. Setting aside longer-term challenges for now, what particular things can be done with the social care sector to address immediate short-term issues? I will just ask my second question in order to be brief. Specific actions that could be taken to address the short-term challenges. Annabelle Ewing Will we go to Annie Gunnar-Logan first? Annie Gunnar-Logan Yes, please. Annabelle Ewing Okay. Thanks for that. Good question. We are broadly in agreement with what Audit Scotland is saying. I will be very brief because I have said some of the things that I think we should be cracking on with already in this session. One is to do something very serious about pay for social care workers. You can get chapter and verse on that from the fair work in social care working group recommendations, because they are all there. They have been before ministers for a while, so we really get a shift on with that. The other thing that we could do immediately is we could put an absolute pause on any further competitive tendering of social care and put some real effort into supporting the push for a more collaborative approach. As I said, we are already doing some work on that. It is on people's radar and there is a lot of support for it, so we can give that a bit more welly, I would say. Annabelle Ewing Thank you. Annabelle Ewing I completely agree with Annie. The Audit Scotland Accounts Commission report is absolutely spot on. We cannot wait for the dream of the national care service because at the moment many providers and those who are employed in social care are living a bit of a nightmare. What I would immediately like to see is that a national summit is held with all stakeholders. In the recent past there have been too many initiatives and instances where part of the system has been involved, but not everybody. Annie has already articulated what is delivered by the independent and third sector. It is stakeholders making decisions and on basing them on a lot of presumption without the engagement of the sector. One critical area has to be to address, as Annie said, the pay issue. However, it is all very well seen to a front-line care worker that you are getting paid £10.50 or £11 or £12 or even £15 if the employer and the organisation, because there is not sufficient sustainable funding to keep going, collapses. We do not want well-paid care workers on the dole. We want well-paid care workers working for organisations, regardless of their business model, which is there to do the job of care, rather than to struggle to keep going. At the moment, my membership fears that we will lose a significant number of care organisations because of fiscal unsustainability. I want a summit where everybody is at the table and not just the usual suspects. If I had my top three, there is more flexibility and real consistency in self-directed support. It is not good enough to have examples of good practice in some areas and, indeed, within areas having flexibility and others having none. It needs to be led by carers as individuals and the addition of short-term budgets to support individuals to be discharged from hospital and support families in that situation. The prioritising of reopening of day services and services that support people to have a break from caring. We need to address charging for social care at a bare minimum, looking closely at every area around disability related to expenditure. Disabled people and carers are the most likely to be in poverty in Scotland. We need to find a way to ensure that care charging does not push them into further poverty, particularly with the additional costs that they face in relation to heating energy and the services that they are provided. I want to follow up on the consultation responses that are analysed in relation to national care service. Obviously, there is a clear degree of support in relation to moving to a national care service. However, there is a lot of information in there that poses more questions. It is interesting that 33 per cent of respondents said that they were dissatisfied with the consultation process. I am keen to get a sense of your experience of the consultation process and your member's experience. What would you like to see in terms of next steps going into the longer-term work on the national care service? What was our experience of the consultation? It was a mighty thing, wasn't it really? It was 96 questions in the end, some of which we did not answer because they were clearly for individuals. We took a bit of a pick-and-mix approach to it and we answered the questions where we felt that we had something to say on some expertise and a stake and we left the rest. I think that most people did that. I have read the analysis and I have read every single response because I think that that would take me a little while to do from now on because there were 1,300 in the end. A couple of things about the key points that we raised in our own response to it. One was to look at the proposals through the lens of the independent review of adult social care that Derek Phoebe produced. I have mentioned a couple of things this morning where we are not entirely confident that his recommendations have all been carried through into the national care service. We are doing a bit of comparing and contrasting about that, which I think is important. We made the point that there did not seem to be, in the proposals, a coherent model of change. It is all very well saying what you want to happen but you need a model of change to achieve it. In Suclaris, there is a model of change. It seems to be A, centralise things more and B, everybody tries a bit harder. That is quite enough, particularly around the cultural issues that I have mentioned this morning. We felt that there was a bit of work still to do on the balance between national and local accountability. I know that other stakeholders who were directly involved in that are very concerned about that but, as outsiders, we were thinking that that needed to be unpacked a little bit more. We wanted to see a lot more of a central focus on co-production, particularly with people who rely on social care and their families and their carers. I guess that we were also quite thoughtful about the scale of it. Are we capable of doing this, given everything else that is going on, but also the widening of the scope? There are still some questions about that, which I suspect ministers and everybody else are still being quite thoughtful about. In particular, the extension of the national care service to children's services and criminal justice, whereas the original recommendations from Fili were very much confined to adult social care. We had all those questions about it. Looking at the consultation analysis, I think that we were not alone in having those questions, so it is quite comforting to think that we will not just keep going out on a limb somewhere with our comments. Those were the big things that I think we want to delve into a little bit more as we go forward. I was going to bring in Donald McCaskill, but I am seeing from my computer that he might have dropped out. I will pull back to you while we get Dr McCaskill back. I suppose that my follow-up was in terms of Nick Stepp's steps. In terms of some of the consultee respondents, they have asked for quite a clear roadmap in terms of how we are going to get to not just the legislation but implementation and what Annie said about addressing some of those points clearly. Is that something that people are keen to see as set out very clearly about how we are going to make those short-term solutions that we have just talked about, and that longer-term piece of work? Short answer is yes. The approach that we are taking to this in CCPS is that we want to help with that. We are putting some pieces of work in train of our own accord to contribute to the ongoing discussion. For example, we have just signed off an agreement with the Fraser of Allander Institute that we will be looking at some of the economics around the national care service and the affordability of some of the commitments that are being made. We want to look a little bit more at commissioning and procurement. Surprise, surprise, you would expect so from us. We want to look at the cost modelling for pay parity between the voluntary and private sectors and the public sector. We have a programme of work that is trying to contribute to that thinking and to support the process that you are describing and where we go from here. We have a responsibility to do that as a stakeholder, and we want to be part of that. Rather than just saying to other people, would you please get on with it? We are very much in the mix here as we go forward. Thank you, convener. Apologies for dropping out another Aishah storm that has not had a name yet. Like many others, I held many consultation events on the consultation. One of the participants, who was a front-line nurse, said that it would burst your summit. She expressed the view of a lot of people that it was long. She went on to say that it asked questions that she did not actually want to answer and asked them in a way that were really quite closed. Our general organisational sense was that it was not as open and as engaging a process as it could potentially have been, regardless of the number that was filled in the form. As an organisation, we have submitted our own response. I do not want to repeat that, although it is along very similar lines to what Annie has said. Just to add that, I think that we felt that the consultation process lacked the vision and the desire for culture change and, in particular, the lack of reference to human rights, which was so central to the Feeley report. That was empty. It was nowhere to be seen in the consultation document. As an organisation and as individuals, our fear was that the sense of real energy and vision that Derek Feeley and his colleagues managed to engender, despite the criticism initially of people like me, but he achieved in doing so, was not present. I do not want the creation of a monolithic system that does not have a soul, because that is what we need. The last comment that I would make is that we found it really regrettable that the prospect and the potential of innovation, not least in technology and its use, was largely missing from the consultation. If we are creating a national care service that is not just fit for purpose today, contains the vision and aspiration that we share now, but points to the prospect of a much more dynamic, creative future, then we have some work to do considering what is in the consultation. Probably just to reflect on the consultation, there was huge involvement of carers in the independent review and lots of energy around that. There was a huge consultation around the national care service. The scope was very wide, and we had to involve carers in what was a relatively short space of time. I think that carers were very engaged in it, but we would very much appreciate a road map. Carers were very concerned that the Government proposals became too focused on structures and processes, and not, as Donald mentioned, human rights and enabling people to live their best lives. The scope goes beyond the remit of the failure report, so there is something around developing the national care service on an incremental basis, starting with adult social care and including other areas once more consideration has been given to the implications of widening the scope. There was one quote from a carer who said that the national care service needs to be properly funded, informed by people who use it and have compassion, good relationships and rights at its heart. There is a significant piece of work to ensure that carers and people with lived experience are involved as equal partners in the on-going development and in the new structures and processes, both nationally and locally. There is a lot of work to be done, so I think that our road map and the steps in the way are very important to help people to be involved in that process. Fiona Hyslif, you have led very nicely on to our final theme on carers, and I have questions from Carol Mawkin. An important part of the discussion, and I know that Fiona has mentioned carers a number of times, so we know that in social care unpaid carers provide the bulk of our care. There is some thought that perhaps there is an awareness of some of the carers to know exactly what their rights are and what things are in place to support them. I wonder if the panel, Fiona in particular, could share some of that with us. I think that, in terms of time, there are just some key things that we should be thinking about in terms of a new strategy, a new way of supporting those carers to ensure that they do get what they are, of course, entitled to. I think that you know that you hit the nail on the head around people identifying themselves as carers. We know that around 400,000 people became carers on top of the 700,000 people that were already caring during the pandemic. How many of those know about their rights and that is an on-going process. Every day, people become carers every single day. Enabling people to understand and know about their rights is challenging, because sometimes individuals will only recognise themselves as a family member who is helping out their mum, or they are helping out their dad, their sister or whatever and not really thinking about that they might have rights. I think that there is an on-going need for public awareness, on-going need for that. I think that it is not a one-off activity but something that is significant at a national level and in each of the local health and social care partnerships of a continual public communications to enable carers to access their rights. It is something that we have grappled with for many years. There are some opportunities with GPs, and GPs have a critical role in identifying carers, but it is not just about identifying them. They have a really important role in referring carers on to support in local carers centres. I have to say that I want to, at this point, to contribute to the work of carers centres over the pandemic. They have taken on huge responsibilities and more activity to try to support carers when very little support was available, particularly for people who were new to caring. It is a very valuable service and we need to invest in it. As I said, there is a long-term issue around trying to get people to identify. It is something that we just need to keep working on and look for every single opportunity in the development of a national care service. I will come to Donald McCaskill. Care staff continually talk about the absolute awe and admiration that they have for unpaid family carers, not least during the pandemic, and the opportunities for respites have been withdrawn. Two things that they have remarked to me. The first is the share mental health impact and distress that unpaid carers are now experiencing in Scotland. We need to give much greater priority to those who have done a lot for paid carers, but we need to give a special priority to that reality. The national working group on bereavement is also hearing as paid organisations of the need for intensive additional bereavement to co-ordinated support for family carers at the stage in their life when they lose the perihion perspective. Nearly a third of paid care staff also engage in unpaid care at home, and the stress and strain of the last period of time has been enormous. I do not think that the carer organisations and paid care organisations have come together as much as we have the mental health issues, especially at this time. I will be brief. All of us involved in social care have been walloped by the pandemic one way or another, but unpaid carers arguably have had the most to deal with, not least because they have had to pick up the pieces when other services were withdrawn. I want to pay tribute here to my former colleague, Susan McKinstry, who sadly died earlier this month. She had a lot to say about this, including to Derek Feely. Her example of what she had to deal with during the pandemic is worth revisiting in this discussion. I moan a lot about how the third sector gets left out of the room when decisions are made. You have heard me moaning about some of that this morning, but it is so much worse for unpaid carers, because they do not always get told where the room even is and the mind is being invited into it. I would go back to the point that we have all made at one point or another this morning. I think about giving carers their rightful place alongside all the other stakeholders as partners and as decision makers. That is long overdue. I want to thank you all and Judith Proctor, who had to leave us as well for your time this morning, and for the very interesting points that you have brought up, which we will take forward. As I said before, any additional information or reports that you want to direct us to please do so. We are going to suspend and come back at quarter past 11 for our next agenda item.