 Good morning and welcome to the 33rd meeting in 2014 of the Health and Sport Committee. I would ask everyone, as I normally do at this point, to switch off all my mobile phones as they can often interfere with the sound systems, although you will note that some of us are using tablet devices instead of our hard copies of the papers. We have apologies today from Dennis Robertson and Graham Day's welcome is here as the SNP's substitute and for the first time to the committee. At this point, I invite Graham to declare any relevant interests if there is any, Graham. Thank you, convener. I thank you for your welcome, but I am not aware of anything that I should declare. Thank you, thank you. We now move to agenda item number two, which is a decision on whether to take item six in private. Item six is our approach to legislative consent memorandum. Can I have the committee's agreement to take item six in private? Thank you. Item three is the first subordinate legislation, the first instrument that we have. A total of five negative instruments before us this morning, and the first instrument is the public body's joint working health professionals and social care professionals, Scotland Regulations 2014 SSI 2014 307. There has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Are there any comments from members? I do not hear any comments from members. Is the committee therefore agreed that we make no recommendation? Thank you for that. The second instrument this morning is the public body's joint working membership of strategic planning groups, Scotland Regulations 2014 SSI 2014 308. Again, there has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Are there any comments from members? No? I therefore ask the committee to agree that we make no recommendations. Is that agreed? Thank you. The third instrument is the public body's joint working content of performance reports, Scotland Regulations 2014 SSI 2014 326. Again, there has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Are there any comments from members? No? The fourth instrument is the public body's joint working membership of strategic planning groups, Scotland Regulations 2014 SSI 2014 289. Again, there has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Of course, the details are in your papers. Are there any comments from members? I think that the products that are not for sale are brain, lungs and foot, but they do not include spinal cord unless I am misreading the policy document summary that we received. I wonder whether that is the case or not. It is not something that can be answered today, but I wonder if someone of our class can check again to see if that is the case. Spinal cord products was one of the things involved in the BSE and if it has been omitted, that seems to me to be an omitted. I do not want to ask anyone to come along on the smaller part. Obviously, we can ask. Our review says such as, so it may be included in the actual order, but I couldn't see it. We can communicate that. I think that I am correct in saying that the Government has given a commitment to correct the points raised with them by DPLR. I think that we should welcome that. Is the committee agreed that we make no recommendation? The fifth and final instrument, Food Information Scotland Regulations 2014 SSI 2014 312. There has been no motion to annull. The Delegated Powers and Law Reform Committee has drawn the attention of the Parliament to the instrument. You will note the details in your papers. Are there any comments from members? There is not. The committee agreed that we make no recommendation. Thank you very much. We now move to agenda item number four, which is a return to our early years inquiry under the health and inequalities theme. This will be a final evidence session on early years. We have with us this morning the Scottish Ministers. We welcome both with a special welcome to Maureen Watt, who is here first time as a Minister for Public Health. Aileen Campbell, who we have met before, Minister for Children and Young People, Alex Young, team leader, tackling poverty, and Dr Fergus Millan, head of creating health team public health division. Angus Roberts, early years collaborator, team leader, Carlin Wilson, operation policy manager, child and maternal health division, early years Scottish government. Welcome to you all. I think what we intend to do is get a short opening statement from the Minister. I have agreed that one will lead off first. Maureen Watt. Thank you for your special welcome. If you do not mind, we would like to make a short opening statement. I look forward to working with you all in my new role. I will seek to set the broader context for our discussions this morning, and then my colleague, the Minister for Children and Young People, will give the committee greater detail on the policies that fall within her portfolio. Of course, I have been trying to get up to speed with my new portfolio, and I would want to say that the subject and remit of this inquiry is one that I and my colleague here feel strongly about. Scotland's health is improving across the piths, with people generally living longer and healthier lives. I am acutely aware that, despite the significant efforts of this and previous administrations to tackle health inequalities, it remains a blight on our society. The committee has previously acknowledged the complexities of resolving Scotland's health inequalities and developing policy solutions that can minimise the impact of the differences in power, wealth and resource that underlie the inequalities in health that we see in our society today. You will know that the First Minister has made tackling inequalities one of our stated objectives, and we remain determined to address the gap in rates of chronic ill health and premature death that impact upon communities right across the country. I know that this committee has focused on health inequalities in the early years, because that is where, as a society, we can make the most difference in long-term outcomes. We know that getting it right in the early years and even pre-birth can have a positive effect on the health and wellbeing of the child and the family. Prevention and early intervention should be what drives our work and that of our partners. That is why this Government has had a strong focus on early years, right from the point that we were first in government in 2007. We look for community planning partnerships to have a focus on the early years in their single outcome agreements, highlighting the fact that addressing health inequalities in the early years is not a job just for the NHS. We need all statutory agencies and partners to work with their strengths, skill and assets of the communities. We have also focused on developing strong evidence-based policies in the early years that deliver the proportionate or progressive universalism that we believe will make the difference. For example, in our work on anti-natal inequalities, we have taken on the messages of the need for a universal approach to ensure that we reach all those in need of services, focusing on improving access to maternity services. We have developed a robust framework to support maternal and infant nutrition, including breastfeeding, recognising the importance of nutrition both pre- and post-birth. We have taken forward the family nurse partnership, but recognise that this only reaches a very specific segment of the population, albeit those at higher risk of poor outcomes. There was a clear message from the session from GPs at the deep end and others that continuity of care and consistency of approach are crucial to reducing health inequalities. All our early years' policies are striving to achieve this. That is why we have invested significantly in strengthening universal services by increasing the number of health visitors to ensure that all families can access the services that they need through this universal gateway of provision. We also need to be clear that health inequalities cannot be reduced by health interventions and policies alone. They are linked to and derived from the wider inequalities agenda of socio-economic and welfare policies. As you know, we as a Government do not yet have all the levers to address those in a comprehensive and coherent way, but that does not mean that we can do nothing and we must do all we can to meet this social imperative. I would now like to hand over to the Minister for Children and Young People. I thank you for allowing me the opportunity to make an opening statement as well. It is significant that you have both myself and Maureen Watt in front of you today. In fact, you probably could have invited a number of our fellow ministers as well, because the issue of health inequalities in the early years is one that crosses all portfolios and, as Maureen has said, agencies beyond government as well. I welcome the opportunity to be here, because the issues surrounding early years are ones that are close to my heart in more ways than one with the imminent arrival of this bump at the end of the month. We want to make sure that, as a Government, Scotland is the best place in the world for all children to grow up. We have a number of policies aimed at doing just that. Maureen Watt has already mentioned some. I would add from my perspective getting it right for every child and the Children and Young People Act, our play-talk read campaign, our commitment to high-quality early learning and childcare and our national parenting strategy, the only one in the UK. What all those policies have in common is that they come from the perspective of prevention and early intervention. I was pleased that the recent State of the Nation report by the UK-wide social mobility and child poverty commission also commended Scotland's early years task force and the early years collaborative for its continued focus on prevention and early intervention. I know that the committee had a session taking evidence on the early years collaborative in particular. The early years collaborative is a vehicle and method to deliver our evidence-based policies with the overall ambition to make Scotland the best place in the world to grow up by reducing inequalities and giving every child the very best start in life. It empowers practitioners and those working on the front line to use their expertise to test different approaches for different children and families, initially on a very small scale and then to scale it up. Is the venue difficult for some families? Is the form too complicated for someone who cannot read very well? Are we making assumptions about our services meeting people's needs? These are all the questions that we are encouraging practitioners to ask when they approach their job. It is also about co-production, building on the assets that are available in families and communities, working with parents and children. We are proud that the early years collaborative is also world leading. We are the first to use this methodology in a complex multi-agency environment and there is a regular flow of requests from around the world to come and visit or to have further information about what we are doing here in Scotland. Far more important is the fact that we are now beginning to see the small tests of change bearing fruit and delivering for children and families. We have the site that has increased breastfeeding rates among vulnerable mothers to 86 per cent, albeit though it is a small group when the local average is, according to ISD, 25.5 per cent. There are sites that are working to reduce the time that it takes to place a child in a permanent care setting. There is also a site encouraging parents to read a bedtime story to their children, which started with two parents and one nursery is now working with 150 parents across six nurseries. The staff continuously evaluate the effectiveness of the interventions and have witnessed outcomes exceeding their expectations, including increased numbers of parents sharing books at bedtime with their children. One setting alone, parents have read 148 books to their children in the past year, improved children's speech and language needing less support in class, established bedtime routines, which have resulted in better behaviour in their classes, improved concentration and behaviour, and improved attachment and bonding between parents and their children. Parents have also reported improvements in their own reading, confidence in their understanding of child development and their essential role in that and their own wellbeing and self-esteem as they witness how their actions are making a positive difference for their child and for themselves. Other sites are using the model to assess whether they are targeting their resources in the correct place with some surprising results. Of course, we still have progress to make and culture can be slow to change, but I have to say that the enthusiasm commitment that we see from the 700 practitioners from all across Scotland attending the learning sessions that are held in the SCCC every few months make us feel optimistic that progress is on its way and is continually changing the culture that we have. Again, I thank you for allowing us to make those opening statements and look forward to answering the questions that the committee may have. Thank you both for your opening statements and our first question this morning is from Mike McKenzie. Thank you. Good morning ministers. I was interested that each of you has mentioned that this is an issue that crosses portfolios and that should involve all statutory partners. In that vein, do you welcome the appointment of Sir Harry Burns to the Council of Economic Advisers and do you feel that that signals perhaps a greater focus on early years in health inequalities? That is an inspiring choice. In fact, all of our work is based on equally well, which I, as a minister for schools and skills from 2007 to 2009, was involved with. Harry Burns was a key member of that group and that is where I first learned about how early health and pre-birth health of the mother can impact on children, especially in their early years. In terms of having regular feeding and nurturing is so important to the development of children's brains, so I think that it is an inspiring choice. It is a clear signal about wanting to align inequality with efforts to improve the economy as well and keeping those closely interlinked. From my perspective, Harry Burns has been instrumental in the development of the early years collaborative. At this time, the chief medical officer was one of the co-chairs of the early years task force. He has been an early years evangelist for some time, making the case around the country and beyond about the importance of effective intervention in the early years about brain development and the policies that we need to adopt to try to improve on that. He has kept his hand in the early years collaborative and has brought about some of the changes that we are seeking to make because of that approach. It is a good move that links Government much more firmly across social policy and economic policy. At the committee's session last week, we took evidence from a number of witnesses who commented that some of the early years' pilots are a bit short-lived and that perhaps they do not collect a kind of data and evidence-based understanding of the effectiveness of those pilots. Do you feel that Harry Burns' appointment will help to make sure that we have an evidence-based data gathering element so that we can really understand where the best and most effective interventions are? I was just going to again mention that the early years collaborative in particular is very much focused on data collection to ensure that we have the knowledge and the confidence to scale up interventions. It was not designed to be a short-term pilot and the early years collaborative approach does not fit neatly into an electoral cycle for either Scottish Parliament or for the local authority elections as well. It is about making sure that we are making the right interventions at the right time and it is about being longer than just the short-term pilot approach that you describe, although pilots have their uses and their importance as well. However, the thrust for the early years collaborative is about collecting the data, making sure that it is robust, making sure that what you do is working. If you do not get the outcomes that you are expecting, it is about having the conference also to use that as a learning opportunity and to not continue beyond with that approach. It is about bringing about change and doing it with the data that is necessary to make sure that we have the improvements that we are all seeking. The early years collaborative approach is certainly one that fulfills some of the points that you raised in your question. You highlight a problem when you do pilots and people get upset if they think that pilots have been working and you stop them because evaluation has shown that they have not really delivered on what was expected in the first place. That has been a problem across Governments. It is important that, built into the pilot, evaluation might be in-house where feasible it might be. Others might be taking universities, for example, undertaking self-evaluation. I think that all the time we are trying to improve on the methodology to make sure that we are getting the right data and finding out if pilots work. Also, in terms of all the people who come to the sessions that we run across the country every now and again, people from their shared data and shared experiences, that is all very valuable. I think that just taking a little further with that particular point on research, I wonder if the chief scientist has consulted on all these pilots to determine what the baseline database should be before they start and whether the evaluations, which I think over both administrations have tended to be more process-driven and self-evaluation rather than outcome-driven, whether other outcomes should be looked at carefully. On the family nurse partnership, we know that the outcomes may well be very long-term. Everyone is signed up to that, recognising it, but we are good to have a list of the intermediate outcomes on all projects at the beginning. On the family nurse partnership, it is an expensive programme, but it is one that I think this committee has been generally very supportive of and continues to be supportive of. I have a couple of questions about that. One is the fact that when someone drops out from the programme, they are not replaced. The workload is already fairly generous. It is a heavy workload with a small number of families for each practitioner, which is seen by other health visitors as being fairly generous. When people drop out, they are being told that they cannot replace them because the protocol does not allow it or because they might come back. You can end up with maybe a drop-out rate of 10, 15 or 20 per cent, and then the workload goes down. It is something that I wonder if the ministers would comment on, and also on the fact that the families just beyond that who are not eligible for what is a very strict protocol, how are we supporting organisations like that in Fife, which did have a programme for families, including the ones that are now FNs, but are under considerable financial pressure. If you present after 28 weeks, for example, you will not get into the FNP programme. If you are over 21 but are very vulnerable, you will not get into the FNP programme. If you have a second child, which must be one of the outcomes delaying that, but if you have a second child, you do not get back into the FNP programme. There are just three examples of people who ask how we are actually concentrating on them as well. That is my first question. I have then a very short one, if I may convene her. There are a couple of questions, but they are important nonetheless in terms of some of the evidence that we have heard. I agree that the family nurse partnership is very impressive, and I have been to visit many of you. Did you suggest that the committee had been out to visit some of the health boards that are further down the line with implementing it? I think that some of the indicators in the short term are things like delays before you have your next child, more confidence when you have your child about the approaches that you want to take and the attachment and the bonding that can go on there. Not least, more confidence from the mothers and the father. I was impressed by some of the examples that I have seen in Fife in particular with the numbers of fathers who were being more supportive around the family. In terms of someone dropping out and not being replaced, I do not know whether Carlin might want to comment on that. It is quite a strict approach and it has to adhere to the rules that are there. We also have the parenting strategy, which was the first for Scotland to have a national parenting strategy, which speaks to all parents, beyond those who are describing that are eligible to go on to the family nurse partnership scheme. We want to make sure that we are helping and supporting parents beyond those groups. We have a number of interventions that we have endorsed through the earlier task force, the triple P, incredible years on top of the family nurse partnership approach. There are a number of third sector organisations that we support through third sector strategic intervention funding or strategic partnerships. For instance, families outside who are supporting families who are affected by imprisonment, making sure that we are supporting them to do the very best that they can through effective interventions and making sure that we can, through the collaborative approach, also target families that are in a bit more need. Through, for instance, empowering health visitors and midwives to know where to direct families to money market services to increase their household budgets or to give that support around nurture attachment bedtime stories is a perfect. There are now more children getting rid of bedtime stories as a result of the collaborative approach than ever before, which is a good—when the face of it might sound not the kind of weightiness of politics that we are used to, but certainly in terms of that child's development are crucial. In terms of the long-term outcomes to flourish as an individual, but Caroline, I don't know if you want to comment on the specifics around family nurse partnership. Certainly in terms of what you've described, Dr Simpson, in terms of replacing the caseloads, it depends on where they are in the cycle of starting the programme. There are opportunities to recruit to empty spaces on caseloads over time. It just depends how far in the cycle the teams are in terms of delivering the programme. We can provide a lot more detail on that, and we wouldn't want to go into every single scenario around that. Initially, there can be lower caseloads than anticipated because people may drop out, but just on that, the number of people who drop out of the programme is very small. It's less than about 10 per cent overall for the whole programme, so it's very, very small. You're right that there are some, but it's a lot smaller than perhaps in other programmes. In terms of an evaluation strategy, that is being developed and will be implemented in 2015. We're also conscious of what's happening in England in the randomised control trial and family nurse partnerships where they were primarily investigating birth weight, smoking during pregnancy and child emergency hospital admissions within two years. We're also conscious of being on the programme and the proportion of subsequent pregnancies that you mentioned. That and a number of secondary outcomes will be evaluated during the programme. It would be very good to get a list of those when they're available. Is there another useful thing to point to? My other question is in a quite different area. I don't have any words to comment on that. That's good. We've got a number of people who want to ask questions, Richard. So, if there are opportunities at the end of that one, if people do us we will. Bob Doris? I was interested to know how on-going government policies will fit in with the newly announced independent adviser in poverty and inequality that the Scottish Government has indicated that they wish to appoint. For example, we've got some on-going programmes such as the family nurse partnerships and the national parenting strategy. We've got some new initiatives announced such as a new literacy and numeracy drive in P1 to P3 attainment officers in each local authority, fitting together in terms of an early year strategy. I would kind of like to know where you see the role of the independent adviser in poverty and inequality. Do you see it as one that would challenge government when perhaps they haven't got it quite right or suggest changes in ways to progress policies forward? We've got a variety of strategies out there. The committee is supportive of many of them. I think that what we're looking for is an independent expert to see the thread that runs through all of the policies and endorse when the Government's got it right and to point them when they have to redirect it. The committee will scrutinise each individual initiative, but I'm keen to know where you see the independent adviser in poverty and inequality fitting into the early years framework. I would think that while they're currently developing the role and remit of the poverty adviser that it would be absolutely right and proper for that person to challenge government and that's where there is most use for people in appointments like that. For instance, we also have the ministerial advisory group on child poverty, which the Deputy First Minister used to chair alongside Margaret Burgess, and I used to attend as well. That forum allowed us to be challenged about the policies that we were wanting to take forward and making sure that we had brought to bear the expertise from beyond the Parliament, beyond government. And from the wider civic society as well, to make sure that we're tackling inequality and child poverty in particular. In my own portfolio as well, more directly, we've got the early years task force in one of the most recent appointments who has just recently agreed to take a role within the early years task forces, Professor Jim McCormick from the Joseph Rowntree Foundation as well. I think that there is a signal there across government, across portfolios, across different disciplines that we've wanted to make sure that there's commonality there about making sure that we are challenged and that those challenges are robust, because I know from my own experience in the task force that when you have people together, like the Children's Commissioner John Carnahan, I know now with the appointment of Jim McCormick that the challenge that you get there is what makes sure that you're approaching your policy. In a robust way, in that they're doing the things that you're wanting to do. I would absolutely welcome the appointment of a poverty adviser and would hope that they are robust in their challenge because we can't afford to have roast into the glasses and nice conversations. There's a real problem affecting families now, so we need to make sure that we're getting that challenge and that that challenge is as strong as it can be to direct us into the correct areas of focus. I mean, constructively, of course, but I'm just interested to know what priority this independent adviser will set their own priorities, but I'd be keen for them to perhaps start in early years, given that the Scottish Government's theme has been early intervention in early years for a number of years. I'm also interested to know, convener, in terms of, perhaps you can't answer this, but you could feed it into government. I mean, childcare was going in my follow-up question in relation to this independent adviser and poverty and inequality, because we've got an increasingly qualified early years workforce. I have to say that the pay they get, the remuneration they get doesn't particularly reflect their skillset now, so we've quite often got a low-paid workforce. We've got a huge expansion of provision planned by the Scottish Government running right through to 2020, but we need to make sure that childcare is in the right place, in the right setting, not just for the child but for the parents who are in work and are hoping to get into work. So there's a relationship with, say, partnership nurseries there as well, and of course there's a UK layer to this with the tax credit system, for example, needing to support people into work or the minimum wage or living wage having to be at a correct level. Would you see your role, or the role of working with an independent adviser and poverty and inequality, working across different Governments in terms of looking at the bigger picture, because if they only look at Scottish Government policies it's going to miss a trick, because it's much more complicated than that? I think there's a lot of merit in what you say and I'm sure that once, and I would not want to second guess the remit, but I would certainly, to be helpful to the committee as well, suggest that we make sure that once that's finalised that we make sure that you're kept up to speed with what that role and remit would look like, but I think what you're saying has considerable merit in terms of childcare. Again, we can keep the committee informed. We've commissioned Professor Siraj, who's an academic with a speciality in childcare to look at the workforce, because you're right, we have an increased and knowledgeable workforce who have got qualifications now in a way that they didn't before, because one of the drivers alongside the economic reasons to make increases in the expanded childcare is around the quality. If we want to have the outcomes that we expect for children, that needs to be a good quality setting for those children, otherwise the effectiveness isn't going to flourish beyond just those 600 hours. Professor Siraj is doing research on the workforce and what more we need to do as a Government to help with that quality and to look at things like the feminisation of the workforce, how do we look at pay and a whole host of other things, and she's due to report back to us in the spring of next year, so we'll make sure that you're kept abreast of that. The 600 hours and the partnership issue that you touched upon as well. We have a mixed bag of different providers, it's not just local authorities that provide the statutory entitlement, it's private sector and third sector childminders as well. We have a mixed economy there and the reason for taking the first step towards the 600 hours expansion was to try and increase that flexibility because we know that families need flexibility, they need to be able to access that childcare and they need quality childcare as well. We're not there yet but the act implemented an expansion that was the first step towards that transformational change that we're seeking. I guess that it's frustrating that tax credits aren't something that we have competency over because there's very much interlinked with childcare and the funding of childcare but we are embarking upon a change that we hope will deliver for families and deliver for parents and deliver importantly for children as well. The first step towards that was the expansion that we announced through the Children and Young People Act earlier this year. I won't have any more questions but it's fair to say that you might think that you're sitting at an education committee rather than a health committee with those questions but we're quite clear as a committee and we have been for some time. The early years is so important in terms of lifelong health outcomes and getting it right at the most very early years including childcare and employability of the parents and good quality parenting and what place experiences for families are critical so thank you very much for that. That's why the two-year-old expansion is critical that the quality is there as well because we need to make sure that those children who are very young are getting the best start in life and that the quality is essential as well as the sound economic reasons for doing and expanding childcare. I would just say that in my portfolio as Minister for Children and Young People that effective intervention and early intervention isn't the same as early years as well and that you can effectively intervene in a child's life beyond the early years as well. I know that you're concentrating on early years but I would just raise that as an issue as well because we don't want to write off children just because they're beyond the age of eight. Absolutely thank you very much minister. My head's in a spin with the amount of initiatives, projects, groups, experts, whatever. There's a comfort in that because that's what we've heard in evidence throughout this committee and indeed Bob in our last role in the local government and communities committee, how do we make sense of it all? We all enjoy these moments in a Monday and a Friday but looking at good projects come away feeling great. The stark figures that we have on breastfeeding in certain groups, smoking, drugs, alcohol consumption are improving, getting better, static, where is the indicator? Single outcome agreements, what have we learned from them? How many local authorities put shell poverty as a priority on those single outcome agreements? I think you convener and Bob Doris make very valid points and I think this is going to come more to the fore as budgets are challenged and we've got to make sure that people are not duplicating work and that the best practice is rolled out across local authorities. As you say we can all visit good projects in particular local authority areas but we need to make sure that where that is proven to work it is rolled out in other areas and that we are making the best use of the workforce there and not duplicating and not perhaps misusing resources. That is happening through, as I say, the coming together of all the lead people in these projects through the early years collaborative and we are seeing good practice being rolled out and the leaders who come to these meetings are very keen to make sure that they learn from others and roll out best practice. The legislation that we passed earlier this year, the Children and Young People Act, was seeking to embed that consistency that we are needing so we had 32 different levels of progress across Scotland about how far the local authorities were in implementing getting it right for every child. We all understand that the Highlands model was furthest along through the pathfinder. One of the most recent members' debates that Dr Sipson took part in was that we realised was an approach that went beyond party politics as well. It had started with the Labour Administration and it's been continued because it's been the right thing to do by ourselves in government. However, it has lacked that national consistency, which is why we drove it forward with the legislation that we passed in the spring of the year. The reason I mention that is because of the wellbeing indicators that children feel included. That's been one of the discussions of topics that we've had through the child poverty action group about how we make that meaningful in terms of children who are facing deprivation and issues around poverty. There is a method in terms of driving forward with the legislation about linking that into the groups that we're talking about, whether that's the child poverty action group, the ministerial working group, the early years task force as well. It's important to note that the child poverty strategy now includes an outcomes framework to give more robust indicators about how we're making progress along those issues that you have questioned and wanted some assurance on. I understand both ministers that we deal with some of this frustration and we take the evidence over years on some of these issues and across politics and across government. I mention the single outcome agreements because they've been in place for some considerable time whereas there are family nurse partnerships that would need to be evaluated further down the line. Given the importance of local government in delivering lots of these policy initiatives on the ground, what does the single outcome agreement show us at this point some seven years in? What does it show us and where are the licence? Do we not know? All local authorities have single outcome agreements that are committed to reducing inequalities. In the opening statement that Maury made, we were making inroads and we were making progress along the way and we have ways in which we can keep monitoring that but there is a realisation that we need to do more and always need to do more as well. The child poverty strategy now has an outcomes framework so that we can not just have the strategy and launch that and that's all great but we have an effective way of monitoring the progress and again that points to the way in which we're working through with the earlier collaborative which is about effective data collection in a way that I think you describe has been maybe not there in the past to make sure that we have the confidence to approach policies that are delivering the results that we require. The ambition of Scottish Government or indeed Scottish Governance over the peace. I'm not questioning that at all. I'm questioning there is policy coming out of arrears. There are experts in groups and discussion groups coming up. What if we look at the single outcome agreements? What difference has that made to the most vulnerable children in Scotland? Like I said, all local authorities have a focus on inequalities. I've all committed through the task force, all committed through the earlier collaborative to have the focus to tackle child poverty, to tackle inequality and to make sure that they're making progress and we have ways in which we monitor. For instance, the task force were required. We have to do a suite to make sure that there are approaching that change agenda in a way that we would expect given the money that we've put up to try and change the way that they have focused. We know, Minister, and you pointed out to us. I think it is very important about that connection with children and parents about reading a book. It's more than just reading a book. But you could tell us 700 children were now reading a book with their parents. I think we're just asking for some indication through the single outcome agreements that are being placed for considerable time. We set up that policy with some ambition to make lives different for most of the most vulnerable two people in Scotland. What was a starting point in our ambition at that point? Have we made progress in addressing some of the issues that we developed the policy to bring about? And what are the improvements that have been made? Child poverty rates have come down since devolution and child poverty rates have come down considerably, so there's a clear indication that... As a result of the single outcome agreements, as a result of the Government policy, that's what we're trying to expect. There's a mixture of policies and different approaches because you can't have the same approach across 32 local authorities. I don't think that you can leave it at the door or lay it solely at the door of local authorities. For example, NHS boards have local delivery plans and this is being more linked up now to the community planning partnerships. With health and social care integration, we tend to think of that in terms of older people, but it's also going to be rolled out in terms of younger people as well. So I don't think that you can lay it solely at the door of local authorities because it's an integrated approach with health as well. I'm not tempted to blame anybody. In health, at least, we've got a list in health. I think that's the challenge that maybe other Government departments have. In health, whether the indicators are correct or not, we have...they are there and we use them to indicate whether we're making progress. That's both weight, smoking prevalence, mortality, whatever, whatever, whatever, and we can measure that up and down. I'm just looking for other types of measurement that I thought would be available to us as a committee this morning to say, well, there the challenges are there. I see Dr Milland. You're right. We've got the indicators that we use to identify progress on tackling health and the qualities. They're just a handful of hundreds of indicators that we could have used, but they're not specifically applicable to what the NHS is doing. They're actually what we are doing across all organisations to contribute to actually shifting those indicators. Those indicators, unfortunately, are not going to change rapidly because, while we've probably broken them down into short, intermediate or long-term indicators, you don't get quick results. Going back to the point about what the SOA is doing, what difference is that making? I think it's actually getting people together to talk about these things in a partnership to actually think about how they're doing things more coherently than they maybe have done in the past. When Equally Well was first published in 2008, it set out quite clearly that the CPPs were going to be critical in actually delivering on this. But if you think about it, CPPs haven't maybe found their feet in that respect up until maybe the Christie report. From that point on, they've started to think more clearly about what it is they have to do, how they work in partnership. The Government has been quite specific in terms of identifying priorities that we want to see reflected in the SOAs. The minister is absolutely right that health boards have their own LDPs as well. It's only in the past two or three years that we've asked them to specifically say, what are you doing to contribute to the SOA? How is this all merging together? It's actually taking what is an enormously complex area with enormously complex organisations and asking them to try and work together. It is a bit of a process, I think. One of the things that you want to see is are they actually giving you a sense of confidence that they are actually beginning to think about how they talk about this, create the structures amongst themselves that they deliver on this. To a certain extent, you're getting some of that sense of confidence in a variety of areas. You see some of the work that they've done around health and social care integration, which is maybe not—it does show that they can work together. It's difficult and all these things are difficult, but I think you get a sense of this progress there and they're working towards the priorities that the Government have agreed they should do. The jury's still out. I think you're trying to shift the way complex organisations do business and engage with each other. Bear in mind that the CPP is not just the health boards and local authorities, it's the police. They've all got an important role to play and that's being reflected back within Government as well as how officials actually work across their policy areas to try and identify opportunities to work synergistically, not just in name, but actually really try and work with our colleagues to join these things up. It's a huge challenge. It's an enormously complex process and it's a huge challenge, but I think we are making progress on that. I want to move on to Rosa Grant. I guess on the same type of theme that Duncan Neil has been questioning on, but maybe an easier one to answer. In what tests do Government carry out when they're developing policies to deal with health inequalities in the early years? If you're developing, we know that this is cross-cutting. It's not health, it's not education, it goes across all departments. So, when new policies are being developed, what tests are put in place to see how they impact on health inequalities especially in the early years? In similar fashion to the response that I gave to Bob Doris, we have a number of different relationships with different key professionals, stakeholders, organisations, third sector, who we don't make Government policy in isolation. We have to make sure that what we're doing will have the impacts that we expect for the child and that the outcomes will be there. So, we have the earliest task force, which is a key kind of collaboration of effort from across the third sector, the private sector, health local authorities and others who are inputting into the things that we need to do as a Government. The ministerial advisory group on child poverty as well as cross-cutting. Who sits in that? Who sits in the child poverty? Well, there's Jim McCormack, who's already agreed to be part of the earliest task force. There is representation from CPAC, John Dickie. I'm struggling to remember all the names, but there are... So, the other people on that group are from Barnardo's and from One Parent Families Scotland. We have the Scottish Commissioner from the UK Social Mobility and Child Poverty Commission. We have Linda Tagastica, who's from NHS Greater Glasgow and Clotied. And Jane Wood from Scottish Business in the Community on that group. And Jane Wood now sits on the earlier task force as well to make sure that we're bringing in to bear all the expertise that we have. And of course, there are other opportunities as well. For instance, the parenting strategy that we took forward was developed in consultation with parents, but engaging those parents through the organisations such as Children First, Families Outside, all those different organisations who already have networks of contact with parents to make sure that what we are doing as a government is what parents tell us that they require. So it's never done in isolation. And that's why, again, you know, pointed to the collaborative, that these approaches are not just about government. They're about bringing together all the players that have an input and a direct influence in the success of the policies that we want to take forward. So how do they interact with government when developing policies on, say, the budget, say, on the environment, on all those issues that impact on poverty? Well, again, you know, it's about making sure that we have that discipline of government that we are across cutting, like I said in my opening statement. You could have asked a number of different ministers to come here to talk about tackling inequalities. So we have, you know, we have, like I said, I've described some of the areas by which we make sure that we've got people coming from all areas and all sectors to influence the policy directions that we take forward. But how do they, I guess I'm looking for the mechanisms of how they do that? I mean, do they sit at the cabinet table? The ministerial work on poverty, the earlier task force, there's raising attainment for all, which is a collaborative beyond the early years that's looking towards raising attainment. There are key players that sit on that in a national sense and also in a very local sense as well. There are a number of initiatives that aren't just about government officials and government ministers sitting on deciding how to take forward policy. Again, you know, I'm just reiterating the point that these are bringing together people who have key expertise in areas and influence in areas that we think we need to have a sharper focus on. But how do they influence other areas, I think, is what I'm trying to drive at. Can I just maybe bring, there's a particular bit of work we do around, well, obviously a lot of policies are put through the Equalities Impact Assessment, but we also have something called the Health and Equalities Impact Assessment, which has been on-going since about 2010. NHS Health Scotland carried these out and I don't have the briefing in front of me. They've done about 30 since then and they put out guidance in about 2011 about health and equities impact assessments. So they take particular policies and they will do in the Health and Equalities Impact Assessment of them to try and ensure that the policy that's being taken forward has taken to account a range of things that impact on people's inequalities. I don't have the detail here with me around that, but that's a specific way of actually looking at a new policy initiative to determine what impact it's likely to have. It might be that after you've determined the impact, you're still going to go ahead, but at least you know, or it might help you to actually influence what you do to actually make it have less of a negative impact. Does that happen on all policy development? It's done about 30 in the last, since 2010. I'm just trying to remember, there's a list on Health Scotland's website and it looks like there's about 30, 30 plus. They've done about five or six this year. So they pick, I don't know if it's just capacity or how they do it, but it won't be everyone, but it'll be certain ones they've done. They've done a lot in NHS and some within the Scottish Government. There are a couple of publications. There's the long-term monitoring of health inequalities, which was published in October of this year. It does show that the progress is being made, but absolute inequality still persists in some areas. Then Audit Scotland had a report on health inequalities in Scotland. So there are a number of publications which influence and will determine Scottish Government policy as we go forward. Following the children's children and young people bill as well, we're developing a child's rights impact assessment tool to ensure that we make good on the pledge that we set out in that and that all areas of policy beyond just education, social work and health have recognised their role in delivering better, delivering more for children in terms of their rights. Okay, but that isn't going on at the moment, and that's what I'm doing. That's part of the new legislation. That's following the new legislation that we've passed just fairly recently. That will focus on childhood hood inequalities. I was just adding to complement the other areas of influence that other parts of the Government will have in terms of inequalities that this child's rights impact assessment, which children have inalienable rights as children, which include being able to participate in society, so that would have an impact on the question that you asked. I can let you know how that develops further down the line. I get the impression that health, social work and education all look at this, but we all know that it goes much, much wider than that. At the moment, we seem only to look at that very narrow field, which deals with the symptoms, not the causes. I'm wondering what tests are carried out on all Government policy to make sure that the causes are being dealt with, not just the symptoms. Also, in addition to the child's rights element of the Children and Young People Act, getting it right for every child requires a broader approach to ensuring that we are getting it right for each and every child, which is requiring of local authorities and health and other partners to make sure that everyone is doing what they can, and that goes beyond housing, social work and education. That's why we're about to go to consultation on the guidance that will accompany the legislation on that and making sure that local authorities do recognise the role that they all have to make sure that we are getting it right for every child across the country to make good on the legislation and the legislative changes that we've just taken forward. That's one way in which we'll be able to make sure that the influence will be on health and education. It might be useful, because I think that much that's going on has been described by the ministers and the officials earlier about how the Government attempt to tackle these issues, because I think the committee are looking at health and the indicators there, but don't see that reflected in some other areas. But I think I hear from Dr Milan ministers that there are genuine attempts to be starting that work and pushing on that work, and I think that's positive. Maybe if the committee could hear more about that, that would be useful. The wider point was recent paper from David Bell, the Professor who was here, giving us evidence, along with the budget on the economic side. David Bell made the point on the recent paper that Government policy, almost like the inverse care policy, Government making policy that unintentionally can make not be of help, if I put it that way, in less pejorative terms, of climate change targets that actually put off fuel bills for the poorest or put a burden. We're looking for information like that that the Government are taking some of these issues on. It seems to be that they are starting that process, that's a good thing, that's what we would like to hear, but we'd probably rather than Labour go on like I'm doing this morning to get some information. In addition to what we've all said as well, the First Minister announced in our programme for government that there is to be a poverty impact assessment to be introduced as well. All of these things can be tied together to give you a broader sense of how we're knitting together the actions of Government to ensure that we're not working in silos, but everything is pointing towards driving forward in terms of making improvements to our economy, but also making in-nodes into tackling inequality as well. That's where the committee is after hearing the evidence we are. We want to hear more about that, we want to encourage that sort of activity. It's how government has operated for a long time, not just the Government at this point. I need to push on. Graham Day, please. Thank you, convener, and good morning to the ministers. I want to look at an aspect of delivery of support. I wonder if the Minister for Public Health can update us on the progress being made with the deployment of the additional 500 health visitors over the next four years that was announced six months ago. Can she confirm that these will be operating across rural as well as urban areas? That's an MSP for a rural area. It's not seen as having a significant deprivation issue, and yet the existing health visitors are having to deliver classes and basic parenting skills for young people. I wonder to what extent the minister would accept the need to ensure that there's appropriate geographical deployment with the new health visitors. Taking account of areas that are certainly more rural than the one that I represent, in order to ensure that there's a support there for all families across Scotland that are requiring that support? I think that you make a very valid point. The Scottish Government announced in June of this year that there would be providing funding £2 million in this year, with a total of £41.6 million over the next few years for additional health visitors with the goal to grow the workforce by 500 by 2018. That is to ensure that funding helps all health boards to ensure that there are enough health visitors to provide universal visits and development checks for children, such as the 27 to 30 months review, and to meet the obligations under the Children and Young People's Scotland Act to provide the named person. That extra money has been going in and, since 2007, health visitor numbers have increased by about 22 per cent. However, we are committed to making sure that that is covering all health boards. I think that it's up to the health boards themselves to make sure, because there is a tendency to think that inequalities exist in particular pockets in our society, but we have to make sure that individuals who live in poverty, particularly in rural areas, have access to services as well. I welcome that commitment, but how will the Government ensure that that takes place across the health boards, because there is perhaps a risk that health boards take additional resources, or better expression, target the easiest target. You would focus them in major cities where you would appear to get the best return. There are always challenges in particular rural areas, the bigger ones, in how you deploy those resources effectively. What sort of guidance will be given to health boards to ensure that we get this right? I'm going to refer to my notes here. We have recommended that NHS boards use a validated caseload working tool to support consistency in determining health visitor numbers across Scotland. This tool is based on population data and allows for local variation, and that would be used in conjunction with nursing and midwifery workforce workload planning tools. Sounds technical, but I think it explains what it means. It's something that you're mindful of, obviously. Dylan Wants to ask to see the questions on a similar subject. It would just be very brief. I can follow that up, but there is a specific example of a collaborative test pioneer site in Angus about tackling and supporting parents in those early years around substance misuse. I think that that would give some comfort that there is that focus there on not just the urban areas, but local authorities are taking very seriously and health boards are taking very seriously the impact of rurality and other areas that they have to help parents, and I can press your information about the improved attachment and child development work that's going on in Angus. Angus has also got quite a good case to make around their approach to getting it right for every child as a local authority in general. I very much welcome the extra 500 promised health visitors, because I think they play an absolutely crucial role, not just in early years, but as children development and just with picking out families who need help. I'm a great fan, actually, of practice-based, primary care-based health visitors, because having grown up with it when my husband was in practice, they really do have an insight into the local families who are facing difficulties. I did raise this last week when the deep-end practitioner agreed with me. She thought in that sort of practice that a practice-based health visitor would be really very useful. I have to say that Theresa Fife of the RCN indicated things have moved on, and she wasn't quite so enthusiastic about that way, so I welcome some comments on that. I think some of the most experienced health visitors have gone into family nurse partnerships, which, whether they're doing a tremendous job, I'm sure. Given that, given the sort of named person role, do you think that 500 is going to be enough? I mean, I know it's a lot, given our standing point just now, but do you think that, full as of time, that will be enough to cover the needs? Because I'm not convinced it will be. Obviously, we will continue to monitor it to see whether it is enough or not, but you're absolutely right that the health visitor will be for the majority of children under five the named person. We've got to make sure that there are enough if they are going to be, as in most cases, the named person. I think that Theresa Fife did say that health visitors will make a crucial, critical difference to the health and wellbeing of future lives of children and families. She does recognise the importance of health visitors. She welcomed the increase in investment in health visitors, and we've got to make sure that that is fully resourced, but Eileen's more reversed in terms of the named person. As well, I just need to caution because there's currently an issue, a legal issue on going around that particular element of the act. However, the named person won't... It's not that every family will ever need their named person as well, so it's important to recognise that it's an important first point of contact. It's an important well-known practitioner in a family's life with an existing relationship, but not every family will need to use their named person either. Also, the money that was announced to accompany the increase of expansion of health visitors was about increasing capacity, increasing their training and knowledge about some of the new requirements around the legislation. It's not just about recruitment, it's about making sure that there's the quality behind that to take a nice of the legislative changes that have taken forward. Will that involve increasing recruitment into the nursing profession altogether? Clearly, it's got to train us nurses before we become health visitors. I'm not sure if there's enough trained nurses ready to go into that role at this point in time. Certainly, the modelling took account of the workforce demographics and the number of health visitors who would naturally be going through the system and then looked at the workforce overall. It has been very closely monitored and it is down to the health boards so they can see what resource they need and where that resource might be coming from. It is a four-year cycle so you can imagine that graduates from nursing degrees will be coming out every year. The hope is that that will not cause a gap in other nursing services by people moving into health visiting. It is very clear now that a lot more nurses are looking to choose health visiting as a profession whereas, over the past couple of years, that's certainly not been as strong. We do feel quite positive that we will be able to build the commitment that we've made in here. This is embedding. The name person approach is not already many health visitors, teachers, in terms of the relationships they have with the family and helping and supporting the family and the parents. The statutory requirement won't be until 2016 so it's not an immediate start and we're about to consult on the statutory guidance that will have to accompany the legislation as well which will provide another opportunity to reflect and make sure that we have all the things that require but it's not until 2016 that the statutory requirement for the name person and the girffet element of the Children and Young People Act comes into force. I'm pleased that this is being looked at and monitored very carefully because it's been based on a previous cut in the intake of nursing students. I think it's important to look at the whole thing and plan well ahead so that we have people coming through the system. Is reflecting that in the budget lines because funding for new posts will rise to £6.8 million in 2015-16 up to £20 million in 2017-18 so the money is going in to reflect the need for new posts. I'll let you come by cut. Minister actually picked up the fact of the nursing student cut. I mean I know this was partially restored but there were cuts of 20% 10% in each of two years and it hasn't been fully restored. There was a cut in the midwifery intake which was 40% which has only been partially restored 180 down to 100 back up to 160 and these two cuts have been heavily criticised by the Royal College of Nursing but they are particularly pertinent in view of the very welcome decision to increase the number of health visitors because health visitors post graduate training you've got to get through the first training first if the student numbers are not coming through in increased numbers how are you going to augment the numbers by 500 I just don't follow the logic of this The numbers are being reversed so that we are recruiting more and taking the need for health visitors into account. So the full nursing complement that was three years ago before the cuts will be restored is that what you're saying? I can't give a guarantee that that's the numbers but I can get back to you on that. Richard Weil Most of the questions I was going to ask actually have been answered but can I turn to the two quick ones if possible? The Scottish Government's increased investment in childcare provision and most parents are required and we all know how good it is for the child. What impact do you think that will have on early years health equalities? The impact of childcare? Increased provision Aha, so the increased provision it's about making sure that like we have said in response to other questions about giving children the best start in life we have also increased the ability of the workforce as well through having requirements to have the BA childhood practice and other areas that we're requiring the practitioners to have more qualifications in as well. The quality is there, that's what we're trying to improve the quality to make sure that the children at those 600 hours are getting a quality experience. The expansion into two-year-olds 15% this year and 27% next year as well as about taking on board what everyone has been talking about if you intervene effectively in the early years that you can improve outcomes in later life but the two-year-old and the three- and four-year-old expansion is also about not just giving support to that child but making sure that we have proper and building relationships with the families as well providing those increasing their capacity as well so that that child is not just getting a nurturing experience in the 600 hours but there's increased capacity to ensure that that child when they're going home is getting the nurture that they require. It's not the end point. 600 hours will do an awful lot in terms of reducing household budgets. Our own modelling has suggested that it will be £700 per child per year for families. That's the saving that they'll make. It's not the end point. We want to build on that expansion by increasing the flexibility by increasing the hours further as well but we need to do that at a pace that allows us to get the adequate number of people in place to deliver on those targets and to deliver on the quality as well. I welcome that. My grandson is now attending nursery and the next question I have is actually my granddaughter is only one soul. Recently we had a press report of a lady in a famous hotel in London being asked to leave or cover up because of breastfeeding. You covered the point earlier at the rates of breastfeeding in Scotland. Now we know that there is a law recently passed by this Parliament in regards to breastfeeding. What actions is the Scottish Government taking to ensure that parents and the public know that people, ladies or new mothers are allowed to breastfeed in public? I guess it also doesn't help when you've got certain politicians making certain claims as well in public about breastfeeding as well but I'll leave that for Mr Farage to explain away. Which I totally deplore. Yeah absolutely. Well like I said some of the test of change from the earlier collaborative point of view have been around the prevalence of breastfeeding providing the support that mums may need because at that point you're very vulnerable you've just had a baby and you're getting bombarded with lots and lots and lots of information as well and so you're not needing to be kind of made to feel guilty as well but actually what we're doing is making sure that the support's there for mothers who need that extra bit of help to increase the prevalence of breastfeeding because it offers the best start in life to children. A number of initiatives, the legislation was passed I think in 2005 as well there's a number of initiatives about baby friendly or breastfeeding friendly status we've promoting it through a number of different avenues UNICEF are taking forward a number of bits of work to get accreditation for places to be baby breastfeeding friendly Maureen might want to talk some more about some of those areas the collaborative example that I gave you through the result of the work there that was at 85% I think 86% of the mothers that they're working with are now breastfeeding now that is important to recognise that's a small sample but I think it points to the fact that if you work effectively with a group of mothers that you can quite quickly turn around more positive results than maybe we've seen in the past especially when I think all results for Fife was 25% as well so I think that shows just the difference that you can make with that approach that the collaborative has brought to bear in Fife so I think it's incredibly important not least as well because I'm about to have a child myself but we have a culture in Scotland that appreciates the benefits and recognises how important it is for mothers to feel that there's a culture there of acceptance around breastfeeding I think to go back to your point about increased childcare it's also increasing the quality of the childcare and the experience that children have while they're in childcare so they're learning how to read, they're learning how to play they're learning how to interact they are hopefully getting better nutrition and all that is feeding back to the families as well but in terms of breastfeeding I think when this was being discussed on the radio the other morning the people involved were praising the Scottish approach to breastfeeding and I think we've got Elaine Smith to thank for the Breastfeeding Act of 2005 which was the first of its kind in the UK and only one of a few in the world where it makes an offence to stop a person breastfeeding and perhaps carriages and other outlets and organisations ought to be aware of that Scotland has increasingly Aileen mentioned the UNICEF baby friendly awards and Scotland has increasingly been at the top of these awards compared to every other region of the UK so I think we should be quite proud of what has happened in Scotland in relation to breastfeeding My constituency office is I have noticed up saying that this is if a mother wants to feed their baby that they can do so all you need I think is to make sure that you've got somewhere that's quite calm has appropriate seating has water so we could all probably take a lead as well on that respect to make sure all our constituency offices offer that I'm sure your grandson or granddaughter might find a variation of that My grandson when he first went to nursery actually took his jacket off and said bye mum ran straight into his mother ran straight into play so I welcome the increase I also welcome Aileen Smith's law in regards to There are key important milestones beyond the early years that show why it is important to get it right in the early years in adolescence to secondary and key developmental milestones that show and point back to a good experience in earlier settings I don't want to be a pain in this and I don't necessarily require an answer but some feedback would be useful in regard to earlier discussions about how we are valuating what our objective is for the childcare policy we mentioned earlier and it's been referred to proportionate universalism I think the minister mentioned that Professor Marmot who gave us evidence mentioned that Given that this is a relatively new initiative in terms of the childcare that we have evaluated for inequalities and what we expect that that would help and that we have not got any inverse situation operating there How do we within that look after the very vulnerable children that will be within that whole spectrum do we widen the gap between the poorest and the better off by the application of that or do we narrow the gap in what a valuation mummy was taking I had struggled was that specifically for childcare On the childcare policy that has been recently discussed and you described what a valuation how is that poverty proofed how do we ensure that the inequality that currently exists is improved by that policy and what valuations took place there I think in terms of inequalities I think that was well set out in the equally well document that departments should be sure that they are not building in inequalities into anything that they do for example we encourage as you know cross departmental approaches and one example mentioned in the last task force report of LINCUP was a project run by Inspiring Scotland which received funding from both justice and health which looked to enable communities that are asset poor to develop and grow so I think all departments are well aware of making sure that they don't build inequalities into their work but you know I think what's been said today and with your panel last week is that you know a lot of the inequalities are a result of things that aren't within control of the Scottish Government and we've noticed for example that where people are on the living wage it has helped to reduce inequalities what was said to me maybe it's my poor communication but if you apply a universal policy that's available to ever Richard Puer how did you ensure that that was a measure of inequality that's what I'm basically asking what evaluation took place to ensure that that was going to none of the gap between rich and poor and how does it do that why is it an inequality measure I'm going back to childcare 600 hours of flexibility why is that an inequality measure there's a high take up of childcare about 90% so we already have a good base of being able to compare and contrast growing up in Scotland a longitudinal study has key data about the improvements that that can make and the reduction in inequalities that that can create is provided though that is of high quality which is why it's important we're not just talking about the economic drivers but it's about making sure that that child has getting a quality provision we know that at the age of 14 benefits of high quality early learning childcare continue at that age and they particularly benefit children who are from deprived backgrounds as well five year olds as well we get improved cognitive development improved speech and language development as well so there are key milestones along the way that point back to this expansion being important because the more hours you give the quality of those hours as well allows us to try and begin to tackle some of those inequalities around attainment in later years through the education all the children those who are in an advanced position in this inequality scale all children will benefit from that policy so how does that how does that policy help so we have the three and four year olds all children across Scotland are entitled to the 600 hours but we're targeting the most vulnerable this year 15% of two year olds up to 27% so we're getting earlier with our interventions and again I'm stressing the point that it has to be a quality provision as well particularly for those age groups as well which is why we're making sure through the Professor Saraj commissioned work that the workforce is as well developed as we can possibly make it the care inspectorate also have a role to play in terms of ensuring inspection and quality is there and again though from the results in later life that if we tackle some of those deep rooted sources of inequality in early years that those children can go on at the markers of milestones around speech and language transitions to secondary school that we can try and reverse some of those trends in inequality and I think it's also important to then recognise that that work plus the earlier collaborative work that then takes forward the work around raising attainment for all which is the collaborative around is it P1 to P7 that work as well there's providing a thread there to ensure that we're tackling inequalities in an educational sense but also rooting it back always to the early years just today convener there's the Scottish Public Health Observatory have published a report on health inequalities and while it doesn't just focus on the early years it does point to the interventions that do make a difference in health inequalities but I think also going back to health visitors it's giving them the responsibility and making decisions that they know where to best spend their time to make a difference with families that need more help and care for the childcare as well it's important that every child we don't just talk about targeting others that all children deserve the best start in life as well that's my point we're talking about inequalities now we reduce the gap between the most vulnerable and the well-off so we've got that targeted universalism as well within that kind of policy in itself we'll be glad to hear some more about universalism that proportional universalism that universalism plus whatever we call it that universalism on its own doesn't seem to be able to do its it's something in addition to that I think we're examining as a committee Colin Kear Thanks convener and good morning to you we've heard quite a lot about health visitors in this morning's discussion I think in morning terms of the GPs the role that they play over the next few years how their role will evolve as these new policies are rolled out I think GPs are just one part of the jigsaw and in terms of community planning partnerships they'll obviously be an important part of that but I think the main hopefully the main point of contact will be the health visitors and I think family nurse partnerships are key here but obviously GPs will have a role but hopefully it will not be needed in the front line because we're hopefully making sure that people are healthier in the early years but clearly they have a role You mentioned the community planning partnerships other things just in the last week indeed the audit committee the auditor general was a bit critical of community planning partnerships generally is they haven't evolved as quickly painlessly shall we say over the past decade in terms of how they work and the likes and do you see any difficulties with rolling out any of these policies everyone buying into it anything particularly difficult having these policies enacted at local level simply because of the difficulties that local authorities have with NHS boards and various others Was that a meeting of community planning partnerships last week and I think you're right the roll-out has been patchy there are some much further ahead than others but I think in terms of the work between Government and COSLA and the health boards this is where we're going this is where we're at and it's incumbent on all these bodies to work together to to make sure that it's rolled out I was just to point to my portfolio around the earlier task force which brought key partners around the table but had a direct link with the community planning partnerships and the key change that came from that was again the earlier collaborative which has shown huge take up there was 700 plus at each learning session in the SCCC which showed in a way not being shown before just how up for it the community planning partnerships were about tackling the issues that they are dealing with in their local authorities and their health boards as well so all 32 local authorities are involved in that all 32 local authorities are taking ownership over the development of their and the community planning partners particularly taking ownership of the ways in which they want to move forward with the collaborative resulted from the task force and the change fund which again that was the first time we had a financial mechanism which brought to bear monies from the Scottish Government local authorities and health boards as well so I think from that point of view that there is a lot to be very positive about in terms of the role of local authorities and health boards and all the community planning partners that are participating particularly in the earlier collaborative okay thanks Colin with your permission committee members do you want to ask another question very briefly the public health review that's going to take place I understand there's no public health directors on it and I find that really interesting because we had a discussion with the previous cabinet secretary about where public health should be placed obviously in England they've gone for placing them in the local authorities although I think there are difficulties with that but that's very patchy the results but I just wonder if we could get the committee to be supplied with the terms of the review, the chair who's chairing it and some rationale for not having a director of public health either a Scottish one or one from externally which might be quite useful to have someone from England who's got experience of how they've gone through their review and what's happened with the transfer it's incomprehensible that there's no public health director on this review as I understand it okay we can certainly get that information to you I did say it was a quick one yes thank you it was very quick for you Richard thanks very much but none the less important but thank you I thank the ministers and the team who have been with us this morning it's a very challenging and complex area and we all struggle with that and thank you all very much for coming along, giving you your time and your evidence which will take into account when I report, thank you again we're going to and to you very nice, you need to remember that this is our last committee before then, Merry Christmas to you all we suspend briefly at this point get the next panel in we now move to agenda item number 5 which of course is to take evidence from the Scottish Government officials on winter resilience and we have Jeff Huggins acting director of health and social care integration Alan Hunter deputy director performance management and national programme director unscheduled care programme Shirley Rogers deputy director all from the Scottish Government and Dr Daniel Beckett consultant physician NHS 4th valley thank you all for your attendance this morning I think we'll only have some brief comment are we form I'm just going to ask the team to say a wee bit more about their experience but we're not going to offer extensive remarks or anything right, okay then thanks for that and then we'll move directly to questions yes thank you so I'm Jeff Huggins acting director for health and social care integration the particular areas of interest for me are around delayed discharge around health and social care integration and around primary care and I'm supported on my left by hi I'm Shirley Rogers I have responsibility for health workforce and for quest I have a particular interest as the chair of the task force on sustainability and seven day services Alan Hunter and I've been with the Scottish Government now for almost a year I came in from on secondment from Greater Glasgow and Clyde health board where I was a general manager in the acute sector for about 14 years and prior to that I've had experience in other hospitals in Scotland and in England I'm Dan Beckett I am the current chief medical officer specialty advisor for both acute and general medicine and also have a role as the national clinical lead for the whole system patient flow improvement project I'm the associate director of standards at the Royal College of Physicians of Edinburgh and consultant physician in acute medicine in NHS fourth valley which is where I spend most of my time thank you all for that Richard Simpson I think is asking our first question we've been fortunate that the last few years having relatively mild winters and hopefully we may be fortunate again but my concern is that the number of delayed discharges has been dropping since it was originally defined as over six weeks and there were 3,000 of them in 2,023 when the programme came in the Labour Government reduced it considerably the SNP Government to give them credit reduced it to zero by March 2008 but the numbers in the last three years have risen and we're now the last report 450,000 bed days occupied the equivalent of 1100 beds occupied in our acute sector every day of the year so given that particular problem and the fact that the local authorities are cash strapped how are you going to actually ensure that our health service manages the situation and even moderately bad winter and is able to continue with elective surgery because from what I hear a number of the boards are predicting that elective surgery, cancellation of operations etc are going to increase significantly over this winter period which means your legal targets are not going to be met for even more Scots than the 10,000 annually for whom that legal guarantee legal guarantee is not met at the present time OK I'll say a bit about where we are on delayed discharge and then I'll bring Alan afterwards to talk a bit about elective and the work there first of all I should refer back to the statement and the comments that the new First Minister made in her speech on the programme for government that the issue of delayed discharge is one that this government is quite clearly committed to tackling and will be taking action to do so in the speech she also set out the additional £15 million that would be spent across the winter period to take additional steps in individual partnerships to reduce the number of people who are delayed discharges and I can say a bit about that work I guess as an illustration of what's actually happening in practice so if we think about the work that's going on in NHS5 they are doing work to increase the number of step down beds so the ability to move people on appropriately at the point when they're ready for discharge from hospital into a location in the community as part of the process of ideally returning them home and they anticipate through the work that they're taking forward and have commenced that they will take a bite of 60 people relatively quickly out of their current number of delayed discharges in Glasgow we have a system where the health board and the councillor are now working towards a process of discharge for assessment so for those for whom again it's appropriate that they would be they wouldn't sit in a hospital bed waiting for an assessment but would return home quickly to then be assessed and then move on so we're seeing that the £5 million offered by the Scottish Government together with the contributions being made by health boards and by local authorities along with the lucap money, the unscheduled care money from earlier in the year and the £5 million that we allocated in the summer is being used in very targeted ways which are both looking at the short-term challenge but also looking beyond that to build systems which don't simply transfer the problem elsewhere clearly the intention around integration and the work on delayed discharge is to release that pressure on the NHS system by ensuring that the whole system works effectively and that means that we need to do more evidence-based approaches within hospital that enable us to then work across the hospital care boundary we're also doing some work on a national basis and we've been engaging with the care inspectorate in terms of work that they can do to assist us in ensuring that care homes are able to take people, that the quality that they're offering doesn't mean that either local councils or they themselves put a block on people going out into the care home so they're now offering targeted support here in City of Edinburgh where access to care homes has been a particular issue but are also taking that approach into other areas where access to care homes is something which may cause a delay we're working through the work of the residential task force to also think carefully about how we would want to use care homes in the future so instead beginning to move increasingly to see them as part of a system of care the objective of which is to enable people to stay at home for as long as possible so we would see care homes in many cases not being long-term residences for people home is the appropriate long-term residence for people that's what they tell us is a different function in the system than they might have had a period of time before so we're taking that work forward in collaboration with COSLA and with other colleagues but we're also working very directly with particular partnerships building on the work that we've been doing in Fife to begin to anticipate how things might operate under integration so in that context we've been working directly with the chief officer to talk through what different solutions they might be adopting during 1516 when the integration partnerships begin to come on stream and we've asked them to think and do that now in that there is no reason to wait to do sensible things and they're clearly as a partnership stepping up to the mark to do that internally within the Scottish Government we've now established a programme board again to actively manage delayed discharge across the winter period which will meet weekly which will look at the I'll describe it as the grade data the data that we get on a weekly basis which is unvalidated which isn't the data that we've published but also to identify across the period whether there are particular challenges or blockages that we might want to become involved in so we see this as an area where local systems are best placed to be able to design and develop local solutions but there needs to be a strong engagement between the centre and localities so our objective is to move the dial on delayed discharge across the winter period Can I say that? Thank you for that very comprehensive reply I have two concerns I should declare, convener that I have two interests and this one is I'm the director of a nursing home but it is based in England so it isn't relevant to the Scottish situation but it does give me experience of what's actually happening in terms of local delayed discharges in the area of the nursing home and secondly, my wife is head of social care for a council so that's relevant to the second question some of the local authorities like Stirling and Clackmannanshire have no delayed discharges because they have reintroduced social workers into the hospital to make sure that there's early assessment on admission, not on discharge not when they're ready for discharge but how are your systems going to ensure that there isn't a perverse incentive in this, in that the areas that have not been successful have not got step down beds have not been using care homes for short term provision temporarily before going home that don't have, as they have in Edinburgh for under under Peter Gabbitas they have good integrated nursing and social care that picks people up for 10 weeks and assesses what they need I'm going to ensure that there aren't perverse incentives that you're simply rewarding the areas that have not been successful because that really in the long term is self-defeating Certainly, I would agree and the approaches that we're looking at and working on with particular partnerships our intention is that those should apply across the system in that what we are saying is the challenges of chronicity, of multi morbidity of more people living for longer and those have become pronounced in particular situations such as Edinburgh and the Lothians where we have challenges around access to particular types of service similarly in Grampian and Aberdeen City but the challenges which are faced here if we don't see reform across the system will be faced elsewhere and so we need to take that long term view about how we're strategically taking forward the whole social care and system because simply the fact that a particular area isn't challenged at this stage doesn't mean that it won't be challenged next year so we're entirely conscious of that sorry, did you want us to say something else about elective care or do you want to take that for a later question Well it may be somebody else who'll come back on that it's certainly obviously a very important important area but I'm really thinking of for example if you have stepped down beds already you're not going to get rewarded by funding to increase your step down beds if you're running a hospital at home scheme and it's effective and cost effective you're not going to get rewarded for introducing that so it's I'm just not clear that areas like Stirling and Clackmannanshire which have got no delayed discharges which have made a big effort which are developing, have got step down assessment etc are they going to be able to be rewarded in deficit, all these local authorities are in deficit every single social care budget is in deficit, they're all struggling enormously and how they can produce 5 million to match when if they've already got these things in position should that not be accounted as as their contribution towards the 5 million you're producing I suppose it's important to say that what we're seeing across partnerships is that in addition to the work that's being funded by the additional money that partnerships are also taking other actions so some of the work that's going on within 5 where we've been very directly involved is being funded directly by the health board in that they have looked at the sums they've looked at the structure and they've identified that it makes more sense for them to spend the next 100,000 pounds in a community location than it does in a hospital location they'll offer a better quality of care it'll be more financially efficient and importantly it responds directly to what it is that people are looking for which is to go home so we're seeing a flexible use of resource if we think about what was said by the former deputy First Minister when she introduced the proposals in respect of integration back in December of 2010 she talked about the need for us to think from the perspective of the individual who was receiving care and to no longer think purely in organisational terms between NHS this or council that and to think about how we applied money and effort across the system so we're beginning to get into that space and our sense is that that's where the solution to the challenge that you've put down which is a real challenge will come from Can I just conclude on that point by saying that in 2009 the integrative resources framework programme started and I'm still waiting to see and I hear from my colleagues in local authorities that many of them don't even know about the integrative resource framework spreadsheet that is fundamental to the integration budget and yet it is not published we don't know we don't know what they are we're within six months of the first budget for these groups and yet they don't have the access to it and they've asked for it I know they've asked for it I think that's certainly something which I can take away because I certainly know that as part of the process that's being taken forward at the moment I have colleagues who are working for me and colleagues outside the Scottish Government who are routinely now using that information on the ground I can think of I can think of five partnerships on the basis that the data from five partnerships recently arrived on my desk and took a space up about this high and the granularity and the understanding that we were taking from that was really good so if there is a genuine challenge there we can certainly follow up on that and I'm happy to do so our objective is to ensure that this process is underpinned by data thank you to that in regards to council nursing homes previously councils over the years have closed nursing homes because of the fact that they weren't on suite what action have we taken to discuss with councils to ensure that they're signing up to this new step up, step down situation we'll be doing targeted work over the next couple of months in those areas where we would take benefit from actually having more nursing home places across Scotland we have a number of unoccupied nursing home places but they're not necessarily in those locations where we would most take benefit we also have the challenge of how much it would take to bring a particular home back into use but certainly at the moment we have City of Edinburgh working with NHS Lothian working to bring Pentland Hills back into use but also there are other properties within the Lothians which could be considered in a similar way and I think within within the Lothians there's certainly one of those which is a council location so it's an issue which we have on the agenda and have clearly identified as an area where we can still are working to ensure that councils are not shutting down nursing homes that we may need within the next period of time we're very clearly concerned that any service which is provided needs to be of a high quality and meet the expectations within that there are small flexibilities around four inches here or six inches here which can be applied flexibly by the caring spectra but there are clearly some homes which it would be more straight forward to bring back into use or to maintain in use than others and we're looking for that proportional sort of approach but that's one of the items which we've clearly identified as an area where we can do more working with partnerships and again that reflects the engagement process between ourselves and partnerships That was my supplementary I still have a question later on That's where I will come in Richard and ask for some clarity around the step down and the flow through that has been mentioned by recent announcements and press for the Scottish Government indeed but when I had to response this morning and I looked at the Clyde's winter resilience plants they seem to identify the step down not just as a winter provision but something that they're doing as part of their forward plan so I think we need to have some clarity about that although the publicity has said this is what we're going to do and we're going to have these step down facilities the scant look at plans is that they're not there yet or are they how much additional provision is actually now available across Scotland to offer winter resilience planning and what is the longer term look at step down facilities because Richard Simpson said earlier unfortunately it's not just in the winter that you can have this high bed occupancy and the delayed discharge so there seems to be a couple of things going on here I'll talk a bit more about that step up and step down facilities are 365 a day 365 days a year facilities and they're part of the they are the future, they're a key component of the future component of care within Scotland they're already in use across Scotland although not in a consistent way in all local authorities the objective around that is that they increasingly should be seen as being the first step either for assessment or for re-availment on the basis that there's an understanding that many people having had a period of time in hospital then require some additional support to get back to the full level of functioning that enables them to then return home my own aunt and this is a personal story around six years ago I went through one of these facilities in Northern Ireland where she's resident and had four weeks and then a further two weeks and has then gone home and is now around 90 and has been living at home for six years since going through that process having had a period of about eight weeks in hospital during which she picked up a hospital-acquired infection and so that's the future because people tell us they don't want to go to a care home or a residential setting where they lose their autonomy they want to take every step which enables them to go back to their own home and to be maintained so it's a strategic approach which will be taken right across the system so there is some additional we're accelerating that in the run-up to this winter and that's what we're offering support to some partnerships and some partnerships are using it for that purpose but it's core to how the business will be delivered so what does that mean then in terms of step-up facilities and what extra has been put in if we concentrate now on the resilience we've got it in the context so as resilience planning what additional capacity are we creating in Glasgow Clyde because when I looked at their plan they seem to suggest that this is something they're doing not for winter resilience planning maybe reading it wrong but it's something that is longer term and strategic so what extra capacity is available in the various health boards as a result of the step-up in Glasgow their intention is to produce 90 beds which are basically beds for assessment which will be a continuing component of their system with the objective that they will then discharge people within three days of being ready to discharge which is also clinically indicated to what's that's additional to what they've had previously in five they are looking at to 30 bedded units so that's how some of the the five million which has been allocated has been used across the current period it's also been used in one or two other areas for the same in the same way in other areas either because of the current structure of the service or the availability of the location where they could offer that the current use of the resource which has been offered over this period but our strategic engagement with partnerships is looking to see it as being a component of all systems and services I'm not sure that we have an audit which enables us to make that distinction at this stage between different types of bed to actually show change over time but we could begin to look at how we might capture that No, your answer is perfectly happy your answer that there is an additional capacity being made available it wasn't clear in terms of the finance can we be more clarity around there's a number of figures being bandied about in the last couple of days, 15 million, 18 million a million it was allocated in August some of that money is in the approximately half of it has already been allocated so there seems to be there's the various pockets of money that have either been added up brought together once or twice and the comparison to the amount of money it was made last year in a letter to the committee from the then cabinet secretary, Alex Neil in his provision of money for winter resilience planning what is the increase on last year and what is the actual figure that we're talking about what's the new money this year the position that we're at during 2014-15 is that there's been three allocations that are relevant there is 5 million that were allocated in the summer and I'm going to say that was June is that correct there was 8 million which has been allocated through the lucap which is part of the larger amount that would have been included within the letter which covered a three-year period during last year and then there is the 5 million which is currently being issued which is also being supplemented by contributions back from NHS boards and from local authorities so effectively we're looking at from central government 18 million which has gone out across the period but also recognising the contributions being made by local partners NHS boards and local authorities and how did that compare on last year we've invested 9 million from the lucap funding last year so the extra 10 million that has been focused in on delayed discharges and additional sun so we've more than doubled the money that went in last year more than doubled that yes the central allocation did that money flow through over the years or was it new money it's new money this year and the lucap money went out in August with the first 5 million tranche and then the second 5 million went out in November in terms of the money as part of the process of encouraging partnerships to think of themselves within the integration framework we're also at the moment beginning to receive the proposals that they have to spend the £100 million integration fund and again we'll be looking to see the degree to which the use of that resource supports our objectives around delayed discharges so that we can use to buy up some of those beds that are that's money that will appear in 2015-16 so that's looking forward to next year but it means that as people are making decisions over this winter they can do so thinking that there will be with the understanding that there is resource support during the coming year Colin, you wanted to do your step yeah, you mentioned Lodion and the fact that they've managed to get a hold of Pentland, the old Pentland care home what kind of numbers are we talking about in terms of what they're going to use it for and the dent they will make in essentially the problem area that they have which is obviously in delayed discharge what kind of help is that going to be and how have they managed to fund it basically and they've used some of the allocation that we've offered but that allocation clearly won't be sufficient for the work over the period of time that they'll be doing it so they'll find money between the health board and the council in the short term their intention is to bring in to use 60 beds for step down and they anticipate that they will have 60 beds available from the middle of January so it will take a significant bite out of the Lodion figure and that's the basis on which they're doing it the home itself I think historically has been 120 beds and the 60 beds which they're bringing in relatively quickly are the ones for which that's more straightforward to do but of course they will want to be confident about being able to staff and to ensure that the new service which they offer there operates effectively as a step down facility having historically of course been run as a residential care home so it will be looking to a different service model but it will take a big bite out of the problem for them Richard Lyle 365 days a year out of our service NHS 24 work to where when doctor surgeries close and basically cope with the service what planning have we got in place for this year taking on board that Christmas possibly doctor surgeries will close on Wednesday and not open until the Monday so out of ours I'll have to cope between 6pm on the Wednesday Thursday, Friday, all day Thursday, all day Friday, all day Saturday all day Sunday till the Monday AM and the same at New Year over and above what they already do what planning is in place to ensure that we've got sufficient cars, sufficient doctors to cope with any possible snow weather that we have on the horizon I'll cover the initial part of the question which is around the resilience that NHS 24 is building in and I'll then bring in Shirley to talk a wee bit about workforce and making sure we've got enough people which I think was the second part the NHS 24 winter plan is on their website as we've asked all boards to place their winter plans on the website and it sets out exactly what they expect at this stage to happen they're predicting that the 2nd of January will be the busiest day that they've ever had this year and there's a couple of reasons for that where it falls in the particular candle in the calendar but also that since the introduction of the new 111 number in the summer they've seen roughly a 20% increase in calls generally so they now have a service which is being more used by the public at a time when they would expect to be busier so they are basing their expectation about what they will need to do across the two four day weekends but with a particular focus on a couple of spikes in that which are the Saturdays probably and they are ensuring that they have the establishment on deck on those days to be able to respond to more calls than they've ever had before in particular they've recruited an additional 65 call handlers for the period so they will have more people available I guess that gives you the story of what they do if what they expect to happen happens and beyond that they've looked at resilience and continuity and contingency should what happens be different from what's anticipated and the story I think for them during 2014 already which is that the 111 number call rates to it have been less predictable than they were to the previous number so they're seeing more day to day and week to week volatility so they've already had to be more fleet of foot across the year in terms of actually responding to different pressures across the current number so they're going to take that learning in but the plan that they've laid out which is on the web deals with the different methodologies that they will take to address different challenges in terms of particular spikes in call volume and the process by which they will prioritise clinically clinically significant calls and the process by which they'll bring people back to the desks the process by which they'll extend shifts and indeed bring people in should that be required last week they take this work extremely seriously and consider their plan again having submitted it having put it on the web and the board spent a significant chunk of their time considering were there other things that they could do to address other contingencies and they're now considering whether there are other steps that they might build into to become more robust on what we've been seeing over the recent period is that we do appear to be seeing something which might suggest that over weekends and in current out of our periods because we run 52 out of our periods every year because every weekend is an out of our period we are beginning to see something which suggests that people are making the choice to contact NHS 24 which may be having an impact on A&E attendances over weekends and that's been quite... It's suggested in some of the data and I'd be really cautious to suggest a big behavioural shift although clearly that's the sort of behavioural shift that we look for but it's beginning to suggest that people are thinking about NHS 24 in a different way and perhaps the 111 number has contributed to that. Shirley-Anne, do you want to say something about workforce? Just about having the people. Thank you. I think you've given a picture around community services and the acute sector for a little in terms of that response. Clearly, overall winter our expectation is that boards will adopt the Scottish Government winter planning protocols and those specifically ask them to look at rotas during festive holidays disruptions from whatever source whether that's norovirus whether it's increased activity for whatever other reason whether that's travel, slips, falls we're particularly asked for a focus around four specialties that relate to those one being emergency medicine for the obvious reasons of that but also gastroenterology geriatric medicine, respiratory medicine to allow us to be able to deal with respiratory conditions arising from flu and those kinds of things. We have a specific targeted piece of work around those four day periods it's not the first time we've had four day periods but nonetheless they are always those that make you thoughtful about service provision so we spend a bit of time focusing on that. You'll have seen some of the data that was produced by ASD Scotland at the beginning of December that data suggests to us that NHS boards properly using the methodologies that we talked about earlier on in terms of rosters and so on should have sufficient staff Over the past couple of years we've moved into risk-based workforce planning and we've tried to make sure that boards anticipate any areas and at this stage boards are not alerting us to any specific areas of huge concern in terms of that four day period. Can I welcome the point that Mr Huggins made I have to say that I had previous experience of driving of ours and the situation is that if you do phone NHS 24 you immediately get an appointment you don't need to wait any you just go straight and get your appointment see the doctor or indeed the nurse in some occasions the nurse can cope with the doctor's situation and basically that would relieve and I would encourage people to do that that would relieve the pressure on A&E at the time because having worked in hospitals on a Christmas and a new year's day and also the second of January I've seen the pressures on A&E and the service at the time Thank you for your comments There has been a bit of publicity over GP practices and not being available and I noticed one of our old friends that Dr Beust was on last night saying that GP practices are available over that four day period Do we know what GP practices will be available I guess I maybe come back to the comment I began with which is that 52 weekends of the year we're delivering an out of our service so our general approach is that during weekends and during holiday periods that we will offer an out of our service which is a combination of GP out of ours plus NHS 24 we've already had one four day weekend this year and that the Easter weekend is a four day weekend so at this stage what we're doing is going through the process with boards of ensuring that they're able to fill their rotas to deliver the four day weekend in the same way that they would deliver any weekend we're staying in contact and as we did with the Easter weekend we will also be using the opportunities when we talk to chief execs and chairs of health boards to get a sense from them interestingly and this might refer to the comment we are seeing some areas begin to think about additional opening days of normal GP surgeries and I guess we'll be interested and that's effectively an experiment that a board is engaged in at this stage we don't know whether that is one that will be taken up by the public we don't know whether they will choose and we don't know whether it will actually be a more effective way of delivering the service and the current methodology which is to go through NHS 24 and receive an out-of-hours appointment so we're interested in the fact that a board has decided to take that approach but I guess we'll want to see what the implications and what the consequences of it are is it a benefit at the same time we will ensure that boards are delivering a robust out-of-hours service like they would do this weekend and the reality which is that normal GP surgeries are closed what was the effect in Easter on the A&E figures then when the I don't have the A&E figures I don't have the Easter specific figures for the four day period but we can get that they were up quite significantly last Christmas weren't they 22% or something over Christmas the previous year the overall activity last year was up compared to the previous year but a performance in terms of long waits was better significantly better in the previous year so it's not just a matter of attendancies to A&E that can influence it, it's a mixture of the attendancies, the admission ratio that comes from those attendancies so there isn't a direct correlation between the two that's an element of risk yes Rhoda Grant I think what's different about this holiday coming up is that out of 11 days we're going to have GP's open for 3 days rather than 5 and 7 so I think we're looking at quite a long period with very little cover that affects obviously people going to A&E which I think you've tried to deal with it be useful to know how many additional attendancies there to deal with any you know pressure on A&E departments I've got some figures on that from each of the boards as Jeff said earlier and we've discussed it's not just beds because if we deal with patients particularly elderly patients and just house them in the hospital it's not always the best so that's why we're looking to step down looking at the different capacities that we can put in place and different processes having said that in terms of extra winter surge beds Ayrshire and Arran have plans to put 14 extra acute beds in this winter compared to last winter approximately 10 surge bed potential to increase further at weekends and they've also increased capacity through converting other beds and they're introducing frail elderly pathways to try and support them at the front door but also get them back into their own home with appropriate care in borders they're also building on an ambulatory care assessment unit concept and they're purchasing extra nursing home beds over that period they've got a surge capacity of 25 beds increasing to 35 beds at the weekend I'll pick Lanarkshire are also introducing ambulatory care units in Wishaw and Monklands with capacity for 35 patients per day in those units and they've also got 30 additional beds and 14 additional beds in Monklands from January so there's a similar range of responses in the other boards Beyond that the figures for last year show that slightly over 5% additional staff beds were available over the winter period and during the previous 2012 winter there was a 7% more than was the norm so as part of the planning process we're looking to do is to both ensure that they're able to staff more beds but also that they have more beds available just to respond to the sort of challenge that we would expect to see Was the percentage this year you were saying 7% than 5% this year do we know how many? What Alan has outlined is capability within the system to open beds so those are beds that could be opened so we'll only know what percentage was actually opened when we get to the what we've seen that would suggest that it's a similar scale to previous years Can I also ask about people with chronic conditions because that is another issue that people become unwell they wait and become very unwell and that didn't enter a period of 4 days rather than being seen to indeed they might have to wait the 11 days if they don't have an appointment in the three intervening days what steps are being taken to deal with people encourage them to contact to keep emergency appointments for those three days available to people We do encourage people with chronic conditions who may require care to approach NHS 24 and the commitment is clearly there that they will see somebody appropriate and they will receive current treatment so as part of the winter message we are quite clear that people who require treatment should come forward and seek treatment what we do look for more generally is that for people who would know that they are going to require a prescription over the period or will know that they would require some other form of activity which doesn't need to be done on a particular day or isn't an issue that arises that they should think ahead into the winter period but it's quite clear that that's not a message that people shouldn't seek out that we're very clear at every stage that people should look for help Can I ask how are you getting that message across you're encouraging people to get to it The winter campaign be health wise this winter it was included in that attend your GP in advance make sure your drug and approach your pharmacy early make sure you're well stocked for any escalation problems that you might have the winter planning guidance that went out specifically around respiratory disease and to encourage boards and hospitals and GP practices to look at the anticipatory care needs of particularly chronic disease patients over that period so we've built it in and boards are building that into their own winter planning arrangements Just to add to that the flu vaccination campaign for folk under the age of 65 with comorbidities much as you described respiratory disease, cardiovascular disease and last year just over 60% were vaccinated and more than 75% so 77% of over 65% were vaccinated and that's a sixth year in a row that we've been above the WHO target for flu vaccination The other things which we've seen over recent years as well is almost as a smoothing across the year effect so activity has probably been maybe less pronounced in winters than it would have been historically but we're seeing more activity across the year so you're seeing a pattern of activity which is people are more busy more of the time but there are fewer spikes in the system in terms of activity and that's reflected in figures such as the winter death figures for which we've seen an ongoing downward trend and I think last year's figure was 17% down on recent years so winter is clearly really significant but some of the challenges now appear to be and it probably is attributable to things such as better work on vaccination better work on chronic care management that you're now seeing that mobilities spread across the year rather than particularly concentrated although we plan on the basis it'll also be concentrated Lynette Yes, thank you I noticed from the Government briefing that last winter there were far fewer boards closed due to virus either suspected or confirmed is that due to any specific measures or can you enlighten me as to why that was the case? Yes there was and there was some specific action that was taken if on current is the senior charge at Health Protection Scotland and they introduced measures so rather than waiting until the whole ward was enclosing the whole ward they actually closed down bays and kept the ward operating but had stricter control of infection measures for those bays they also reduced visiting around that for obvious reasons and they believe in reviewing that that was the right thing to do so they're building that into the plans this year this year they're going to build on that as I say but they're also looking at better on call services for domestics so that we can get the domestic teams into rapidly clean facilities more earlier and they're also introducing hypochlorite fluid because they're going to trial that in four hospitals to see if that actually kills the norovirus earlier and quicker they're also believe that the stay at home campaign had some impact which is a message that we're trying to get out to relatives and people who are ill that it's better to stay at home so that's a piece of this year we hope to be in better figures next year we hope part of the experience from last year also reflected the fact that the strain during 2013 was the same as the strain in 2012 and that's thought to have been related to it at the same time at the moment we're seeing similar levels of norovirus to what we saw last year again below what we'd have seen historically as part of the post winter period from last year they've done an evaluation of what worked because when something goes well it's quite good to know why and a number of the elements that Alan's brought out already have been part of that and we're now looking at norovirus management and recording not just as whole wards but also as bayes I think one of the key things is that there probably is more of a common understanding with the public about why if you're ill you shouldn't go to hospital and that's been cited by a number of the staff in responses to the survey work around that because people understand that people get ill in hospitals as well as get well that if they're ill they shouldn't take it there so it's really interesting we can't know what the story will be for all of this Christmas yet but again it's looking to be in a good place Is there any predictability about how the strain is going to be in those cases with norovirus? There's advice offered by the centres for disease control isn't there? Well, HBS advice thus far is that there's no way to predict how bad the norovirus season is going to be based on the data that we've got at the moment Okay, thanks for that Bob I want to return to the be health wise this winter what struck me with it is that it's a joint responsibility between the NHS and the individual in terms of winter resilience and we've all got our part to play as individuals within more communities now I want to just list you some of the things that have come up in conversations so when to stay at home rather than go to your GP, Surgery or A&E making sure you get code and flu remedies at home should you need them making sure you've got enough prescriptions knowing when your GP's are actually open over the Christmas period where your local pharmacy is and when they're open and when you should go there and I am going to go on because it's quite important the point I'm driving at when to go to a minor injuries unit rather than A&E do you actually know you have a minor injuries unit rather than A&E when to use out of hours and when to use NHS 24 now each of those things tied together gives a pretty comprehensive package of healthcare provision over the winter period but it's a lot of information for individuals to take in we've all got a responsibility to digest that and be aware of that and take the steps we take but the campaign be health wise this winter whose job is it to put all that in the one card the one piece of paper, the one portal and get it to the individual so we can play our part in taking on our responsibilities as individuals within the community so I'd be interested to know if I wanted all that information for my local area who am I contacting NHS 24 are the lead health board fronting the campaign but each individual health board as part of their winter plan were asked and do carry out local initiatives so I live in Stirling and there's articles and papers and all in Lanarkshire and borders specifically they did a lot of work around this in Dumfries and Galloway so each board has a responsibility for getting that information across to the general public through their local media the other component to that I guess is that the cabinet secretary yesterday did the Ayrshire and Arran NHS annual review and as part of that the media that she did after the event she talked about the winter message is that to take each opportunity to either ourselves directly or through our health boards to ensure that people have the winter message I've looked at I'm aware of advertising campaigns that I've seen on television and the like but I didn't want to say that to you to tell me what the message was to permeate it across Scotland can I perhaps give you a suggestion or make a general point before one final question that I have we hear timing again should be at the centre should be a health hub for communities most of us, all of us are registered with GPs I'm just wondering if there's a role to play at this time of the year for a single concise message going to each household that is registered with a GP in terms of their opening times over the winter period but also when to use minor injuries where they are repeat prescriptions and a variety when your whole chemist shop is when to go there and have a variety of messages all in the one place that goes to household just when you need them to use it the most to take strains of the system so again I would say it's great that we've got this publicity campaign but it's a kind of one stop shop message to my constituents that I would be looking for so have you given thought how to capture that my idea okay is the GP and are there a postage cost to that but the cost savings could be huge if a piece of work's done around that so can I get some reflections on that one final brief question which I think is important which is related I think it's a really interesting idea I think also with new technology and new approaches it's something which should be more straightforward to do this year so I think the other question and the challenge I guess back to us on that as well is this is information which is valid all year minor injuries and I suppose the question is whether these are behaviours that you can build in across the year you made the point around pharmacy and with prescription for excellence we see pharmacists increasingly as a frontline primary care service provider so again that might also be a location but I think that idea of local information is something that we can take away okay and I appreciate that many GP you send a letter out in relation to flu immunisation so actually having the winter plan for over the Christmas period as part of that letter and saying look this is one we're going to be open your pharmacy will or will not be open or whatever gives local information I think it's an excellent suggestion that Bob's made and it wouldn't cost a lot to actually say this should be done as a regular thing we've got a meeting lined up with the directors of communication from each of the health boards early in January and it is a good idea we'll build that into it GP's tell us repeatedly that they should be the centre of a community health hub and that this certainly gives them a key responsibility to take that message forward perhaps for next winter my final question was going to be asked how we monitor the effectiveness of all these things so I'd like you to answer that but actually one of the things we haven't really spoken about today is in terms of over the winter period preparedness for at home care packages I think we'll all know from family members that it's not just about having prescriptions, having medications knowing when A&E's open knowing when the chemist is open knowing when the GP's are open et cetera et cetera et cetera but given the nature of leave or these areas or agencies how much work has been done to make sure if you get a care at home package for maybe I can think of constituents of mine who require four visits a day for primary care fundamental primary care assistance and to make sure that that continues seamlessly throughout the winter period because if we don't get that right apart from the dignity of the individual of course what's left open to them is family members taking them to A&E and the like of its very vulnerable free individuals that would be involved It's a really important point and it's probably the location of care that more people will receive care over this winter is care at home certainly the work that we did in 2009 when we had significant issues around access and availability and travel with the snow and the ice and everything we liaised very directly across that period with local government systems to understand to ensure that they had appropriate arrangements in place to provide continuity of care that they knew who was receiving care what the nature and structure and to be assured that it was continuing so we would look to our local government colleagues we don't monitor that in quite the same way that we monitor the NHS but again that's part of the part of the overall resilience work that we will be doing a key component I think of how we've changed the guide in some winter for 14-15 from previous years is also that we're now bringing in the interim chief officers of the integration bodies which will have that responsibility for social care and an expectation that they increasingly play a part seeing that interaction between health and social care at present the arrangements that we have in place are the resilience approach to ensuring that we've got appropriate liaison in place should winter become challenging we don't have the same degree of granularity in terms of individual services or individual authorities as we would for hospitals or health boards I don't really have a follow-up question other than to make the observation it would appear that that's an area that across Scotland we need further work on and hopefully integration will help with that if your care visit doesn't turn up on Christmas Eve or on Christmas Day who do you call how do you get that resolved that kind of thing I'd make a comment on that we've been working with directors of HR from health boards and directors of personnel from local authorities for the past nine, ten months probably and one of the key priorities that we've asked them to focus on is joint workforce planning across both of those organisations for the delivery of integrated health and social care okay, thank you the health boards themselves in Glasgow Clyde there's about 20 bullet points in and around all of that I think what's missing though is the evaluation and it's quite interesting I think to give a plug for the joint initiative for the British Red Cross to provide transport services that supports this charging elderly place so the Red Cross is involved as well with the added benefit that they can take people from A&E in receiving wards particularly well received initiative because the British Red Cross not only transport the patients home but see them settled and ensure they have basic essentials and if necessary can wait for relatives and garers so there is a great detail that's going on in terms of the planning I think but what's not obvious I think Bob is correct is that the same analysis of what works that you apply in the health services maybe not being applied in other areas but certainly the components they seem to be there anyway it's coming together and we can see in preparation for the integrated joint boards we are having much closer contact with through COSLA but also directly with the shadow chief officers the David Williams the chief officer of Glasgow city is on the national and schedule care steering group he's advising us he's working with us and just a comment the Red Cross initiative is a really good one that works Graham Day just to look at the work that's being done the flow of patients through hospitals in the winter time in regard to time of discharge because as I understand it one of the biggest obstacles to getting people who are able to leave the hospital out of the hospital time is accessing prescription medicines that are being dispensed by the inhospital pharmacy and it strikes me if you've found the way to crack that for the winter time we want to watch here for 365 days of the year what works going on there have you found the way to tackle the pharmacy issue we are working on that and one of our key messages through our on schedule care programme and in our winter guidance is that the focus has to be on time of day discharge as well as and weekend discharge rates because we've got a significant reduction in weekend discharge and also the time of day makes the big difference in the balance so there's a lot of work going on to answer your question have we cracked that specific no we haven't yet but in terms of the work that we've got and the programmes of work that we've got with the royal colleges of surgeons and physicians the Royal College of Nursing focusing in on that we believe that we will be able to make the cultural and behavioural changes that we need to do and the issue of how you get the script out quicker is around the way the ward rounds take place and it boils down to the most junior doctor writing the scripts sometimes so therefore what we're doing is looking at the way the ward rounds go change and we're also introducing things like board rounds hospital instead of a full ward round just board rounds that quickly by which patients can go home and then to prioritise that so we are working on that we're also looking at things like delegated discharge and in the Victoria in Glasgow they've introduced that and in the wards that they've introduced it they've moved the time of day of discharge prenoon discharge rate from 13% to around about 35% so we've got learning events we're rolling that out our unscheduled care six monthly learning event in September that we used to launch the winter campaign we rolled that out we had a session on that and we're developing improvement programs around that Just to echo Alan's points the pharmacy script on is quite a difficult one to crack but there are things you can do in terms of the night before make sure if you've got patients who have a care package starting the following day the discharge script can be ready the night before to go home with the patient and I think we're really starting to better understand the reasons why people aren't going home in the morning there's been work done on something called the day of care survey that we've been looking at in conjunction with the Royal College of Physicians looking at patients who are in hospital at any one time and what proportion of those are no longer needing acute care and it depends where you look it's broadly the same be it's Scotland be it England be it Australia about between 20 and 25% of patients don't need to be in hospital anymore and they're waiting for various things it could be pharmacies it could be consultant warjans consultant decisions multidisciplinary team decisions and so having a better understanding of why these people are delayed in hospital allows us then to thank you just to just in the delegated powers of discharge to speed up the process that means that the words this circuit discharge or a allied health professional how has that been received by patients and families in terms of I know that waiting in the consultant doing these rounds can delay it for but there is a certain reassurance in that dealing with vulnerable people or older people in particular that we're not being rushed out of the hospital or whatever criteria is that there's agreement against a set criteria that if the patient's blood's come back and they're okay or if the X-ray result comes back and they're okay and there's no temperature set criteria that gives the reassurance to the point that you've just raised is it widely talked about better? I think that communication with the patient is absolutely key so for example I see patients on the warground and I'll make very clear that I think that you'll get better tomorrow and if your temperature's better and your blood tests look better then this is my junior doctor, Dr Smith he'll come and see you and we'll get you away home if these things are met they know that we're planning to get them away home and you're thinking about discharge when the patient first comes in but they're fully aware of what needs to happen before they can be discharged and also the junior doctor knows that the nursing staff know and the patient and their relatives know and just one final comment on the robotic people can remind me but I think to discharge someone early in the day they would actually need to be in the robotic centre in Glasgow the night before would it not? So it's not you know it's got to be there or there's an automatic delay I think it's not a matter, it would be nice for the script to be there the night before it's almost got to be there the day before it's got to be done isn't it? Yeah, there are ways of getting the scripts obviously expedited for certain patients but yes the standard practice is to get the script down before a set time but clearly as the ward gets busier the junior doctor may not get that script done and then it's delayed overnight so there are reasons in the system why I have a plan this time Is there any way of circumventing that in a work in the local pharmacy and during a busy winter period I think what your point draws out maybe more strongly is the need to at the point of admission and through care be thinking about discharge so that discharge isn't a surprise on the Tuesday morning in that discharge was contemplated on Sunday afternoon and so that the steps that were going to be required are being taken even if they're not things which are done directly by the treating clinician is being part of a system and that it's part of a system that they're interacting with the other health professionals to ensure that the individual gets the objective which they have which is to return home as quickly as possible so it's probably a mindset component as much as fixes that help when you haven't done the thinking properly and that's the objective Is there any other question? What we saw in Glasgow was this centralized robotic dispensing two local dispensaries in the hospitals but the patient's also keeping their own medicines within a defined area within the ward so that can be topped up and got ready for discharge it seemed a very sensible approach a combination of centralized robotics for the whole of Glasgow plus localised dispensing so 4th valley has a variation on that which works very well as well Can I ask a final little point about patient flow just within the hospital as opposed to coming out that clearly the issue of boarding out is quite a vexed one we have a recording system in place supposedly but actually you have to define what's a boarding out and I think Dr Beckett and I have had conversations about this and I just wonder if you'd like to put anything on the record on this because I know he's done some work particularly on that area I think you're right we've traded emails and it's surprisingly difficult to define what a patient who's boarded out is but we've done that, we've redefined that and we're asking boards to report on a weekly basis the number of boarders that they have I think in terms of patients being boarded out it's important to recognise what that is and that boarding is a item of poor flow rather than boarding being the problem itself there are multiple manifestations of poor flow so boarding patients being one crowding in the emergency department being another high readmission rates being another so if we were to tackle one of these in isolation then we would risk causing problems elsewhere in the system and clearly what we need to do and what we're looking at very carefully just now is how we improve patient flow across the whole system measuring boarding as one outcome measure of that also measuring performance against the four hour standard in the emergency department as another marker of that and that's work that's being progressed through the unscheduled care steering group and the unscheduled care programme board as an aside you'll know that we are looking to Scotland really is the only country that's done any research looking at the outcomes of patients who are boarded to publish that I hesitate to put a date on that but within the next six months would be nice and the other issue I've been pressing in a number of forums is the linkage of cognitive assessment to boarding out because the dangers of that I don't know where we've got to on that because clearly if you board out if you have to board out patients and you board out people with cognitive impairment that creates a further problem downstream of how you get them home because you institutionalise them further they have particular difficulties if you move them around so I just wonder where we are with linking those two systems which we've now got in place I'm not aware of any direct linkage between the two I know that a couple of health boards are looking to gather data on proportion of patients with cognitive impairment that are boarded out at any one stage but I think the message that I would be keen to get across is that all boarding is bad and we should look at eliminating all boarding through improving flow a lot of patients clearly a significant proportion of patients that come into hospital are elderly with cognitive impairment and we should be looking at making sure that those patients are getting to the right ward first time through improving flow looking at variation in the system and that's work that we're taking forward and certainly what we're doing in the steering group of the unscheduled care is around eliminating boarding wherever we can and I know that in the older people in acute healthcare audits of hospitals they go round and emphasise the importance of not boarding people with cognitive impairment we have done some particular work around dementia as a subgroup of people with cognitive assessment or cognitive impairment and I could certainly pull together what we have on that if that would be of help thank you Bob I think we've got one last question in this area more of a moping up exercise so we get an opportunity to put some of this on the record we mentioned right at the start planned elective procedures being downsized in the scale over the festive periods there'll be less of them and then some of them depending on other pinch point pressures may fall by the wayside as well and I know that that's been routine quite frankly for many years in terms of managing winter stresses and strains but within that of course what this committee would be concerned about would be particular elective procedures which are seen as urgent or emergency perhaps cancer treatments that kind of thing so we've just a few words on that to get something on the record in relation to that I think it was mentioned right at the start of what evidence session today it's just to get some of that on the record I'll offer a couple of comments certainly one of the areas where we expect NHS boards to be very much on the ball in terms of their winter planning in that elective by the term indicates that this is planned work and so that they should be looking across the period of winter particularly the two weeks around the part which is likely to be the most busy and to be thinking of smoothing work in such a way that they're not relying on beds being available that might not be available some boards have also worked in that way to think in terms of a 9 rather than 12 as being their planning presumption and that means that they're likely to be more robust in that area so that there is work already in place the particular reference to cancer has been picked up in the this year's winter guidance which draws the attention of boards to the need to meet the 31 and the 62 day standard and to be thinking again about that as part of their planning process across the winter period again because 31 days and 62 days are longer than the 10 or so days of Christmas so there is the opportunity with robust planning for boards to perform effectively in that area and so it's a particular area now drawn out in the checklist which they're offered but Alan will say a bit more about elective I mean it's part of the winter planning process and it's an escalation process that the last patients that would ever get cancelled would be urgent patients and all the systems are geared to make sure that that doesn't happen the chief medical officer as Jeff said, wrote out on 30 October reminding boards about the importance of planning for maintaining the cancer MDTs over the festive period and putting in place extra diagnostic support to maintain that if required so our tried and tested systems are and I've witnessed them it would not be the urgent patients or any cancer patients that would be cancelled if they have to but the objective is not to board patients into surgical beds wherever possible so the first thing is to avoid that wherever possible I think that brings this very interesting session to your close I thank you all for your attendance here and the extensive measures that are being taken lots just looking over it over the last couple of days and I think it was very interesting coming along and speaking to that evidence it's very significant planning measures indeed and we wish you a very happy Christmas and I hope that all of that planning is rewarded by coping with all the stresses and strains over the Christmas and New Year period thank you very much for being here this morning we're going to suspend very briefly and we're going to go quickly to our points on the agenda