 Good morning, and welcome to the 7th meeting of the Health and Sport Committee in the Scottish Parliament's fifth session. I could ask everyone in the room to ensure that their mobile phones are on silent. We have some new guidance on use of mobile phones, so whilst it's acceptable to use mobile devices for social media within the room, please do not take photographs or film proceedings if you were inclined to do so. I have received apologies from Miles Briggs and the first item on the agenda is subordinate legislation with two negative instruments. The first instrument is the general dental council fitness to practice amendment rules of order of council 2016, SSI 2016-902. There has been no motion to annul and the delegated powers and law reform committee has not made any comments on the instrument. The second instrument is the Food Hygiene Scotland amendment regulations 2016. Again, there has been no motion to annul and the delegated powers and law reform committee has not made any comments on the instrument. Again, I can invite any comment from members. The committee agreed to make no recommendations. Agenda item 2 is on health and social care integration budgets. It is the first evidence session on integration budgets, and we welcome to the committee our panel, Ron McCulloch Graham, chief officer Edinburgh health and social care partnership, Val De Souza, director south Lanarkshire health and social care partnership, Nick Kenton, director of finance NHS Highland and David Robertson, chief financial officer, Scottish Borders Council and member of the executive management team Scottish Borders health and social care partnership. We are very welcome. We are not expecting any opening statements, so I move directly to questions. I represent the Highlands and Islands region, and I am interested in the fact that Highlands is running a different model to all of the other health-word areas. Can you tell me a little bit more about the perceived advantages and maybe disadvantages of that model as far as you see it? It is important to note that NHS Highland runs both models because we run the lead agency model for North Highland and the body-corporate integrated joint board model in our Gaelin Bute. We have experience of both models, which is in a good position to have a view on it. The first thing I would say is that we do not have a strident view about either model. We think that what is important is what is best for each community, so we have one health board with two different models, so it is important that we have a model that suits the local circumstances. The second thing to say is that it is easier for me to speak about the lead agency model because we are now in our fifth year of that model, whereas the model in our Gaelin Bute is still in its first year of really functioning, so it is easier to speak about the lead agency model. For me, what makes the lead agency model powerful is the fact that operational budgets and management and governance are entirely integrated into one body, so just by way of background and how much members know about the arrangements in Highland, but the situation is that in 2012 we entered the lead agency arrangements with Highland Council and that entailed a GP transfer of around 1,800 staff from Highland Council to NHS Highland along with various bits of non-pay expenditure, a large portion of that being contracts with third sector providers, so we inherited all that. We also came to an arrangement with the council whereby they paid the health board 90 odd million pounds to pay for those resources that were transferred over. Once those resources came over, for all intents and purposes they became part of the health board's business, so there are no artificial barriers between health and social care, and there is one budget for a locality, one system of governance. The higher level and the governance is still, you know, there is still governance which goes to the health board and to the council at the higher level, but at the detailed operational level it is really just one system of governance. So I can give you one actual real-life anecdote, I must have a conversation with one of our heads of finance when they had a vacancy committee where a post came for consideration, which was a district nursing post, and they decided to turn it into a social worker post instantly. That was a decision they made on the day without having to refer to anyone else at any other body, and for me that's the power of the lead agency model, just that anecdote, that's the power of it in practice. We can be a very fleet of foot and respond to local needs, so local decisions made by local managers to respond to needs, so I think that that's for me the power of it in terms of one budget, one management system and one system of governance. In terms of the challenges, what happens is as you start to do the sort of thing that sort of changed, it becomes harder to track where's the money gone if you're a Highland Councillor and you say, okay, we've given the health board 96 million what's happened to it, if we're starting to move things around like that then it's just harder to track, so that's one of the challenges. Then the flip side of the lead agency model is that we've delegated deliver of children's services, community services to the council, so we've passed the council £8 million, we've tripped 250 staff over to the council and they're making similar decisions without direct reference to us, so I guess one of the other challenges is that there's also the professional accountability still goes back to the parent body, so if the health board was deciding to, it wouldn't do this, but if it decided to disestablish lots of social work posts then the chief social work officer is still in the council, so that person would have to have a view on that, so there's a challenge around making sure that as we make operational decisions we still keep our professional lines of accountability in place. For me it's a model that's suited health board and Highland Council, it's genesis was in 2010 so it took two or three years to get there, we know from the examples in England in Torbay it takes five years to see some results, we also want to see a little bit of results coming through now, it's not huge but it's wanting to see something around changing the balance of care, so I think it's a model which is a powerful model and I think it is starting to show results now, so I mean that's probably a summary of where we're at in Highland. Interesting that you think it's achieving the planned shift in the balance of care, do you have any data around that or is it hard to track as you say with the... It's quite hard, I mean I've got figures which have got hard to read out, I'd be happy to send them outside in the meeting but we've seen, we've got figures which show emergency admissions and the trends in 2000 to 2004 was heading in this direction and if you did a regression analysis it would continue to head in that direction but we've seen the trend flatten off, so we have seen a reduction in expected emergency admissions, we've also seen our total spend on non-residential care which isn't just hospitals but care homes is reducing proportionately and our, sorry, increase in proportionately and our spend on residential care in acute hospitals and care homes is reducing as a proportion, so our spend on residential care is reducing as a proportion, non-residential is increasing as a proportion, they're both still going up overall but their balance is changing slightly, it's fractions of a percent but on very big numbers so I think the other thing I'd say is we're starting to see an increased use of SDS packages and that's definitely shown a trend which is doubling in the last three years I think so that's another bit of the evidence but you know it's early days we still have lots of challenges, we have quite a challenging delayed discharge position so you know we're not saying by any means we've cracked it but I think we're starting to see some of the indicators starting to move in the right direction and on delayed discharges we've made a particular attempt to try and tackle care at home related delayed discharges and those have definitely come down and we've redesigned care homes home service to try and focus on the non-statutory sector and grow that and we've got quite a good relationship with our partners in the third sector and independent sector so that's working quite well and because we've grown that sector it's released in-house capacity which we've then turned into enablement and we've got some numbers on enablement which has shown that I think we applied it to 300 clients in 2015-16 and almost half of them didn't need any further care at home care so that was you know we sort of dealt with that individual and that that was them sorted rather than drifting into a long-term need for care so so there's little sort of green shoots but we wouldn't pretend by any means we've cracked it so okay thank you thank you allison do you want to come in thank you convener I just like to discuss shifting the balance of care if I may and I'd just be interested to hear the panel's views on when we might have shifted this balance of care you know what are what are realistic timescales for that I don't know who'd like to start perhaps Mr McCulloch-Rail. It is a bit of a bumpy ride at the moment so the delegation happened in April for our services in Edinburgh and we've had some traction on our delayed discharges in the first six months well from October to April this year we saw an improvement we went from 183 delays down to 50 so it was a significant improvement but we are introducing some long-term changes now which will take time to actually buy it and we've seen that great reduction actually completely reverse in terms of delayed discharges. Talking specifically about the balance of care however we've seen a variance in the use of our care homes so we were doing very well at the beginning of this year but then the delays snuck in again for the present time and we've seen an increase in the use of care homes we did see an earlier shift towards package of care and care at home earlier on and we need to get back to that so if you're asking me for a trajectory and a prediction with the new contracts that we put in place they should be up and running by Christmas this year and so we should see a reversal of that trajectory early on next year so if you want to hold me to anything then it'll be spring and when we start to see the bites but it's going to take a good year or two to actually get embedded within the practice and I think the big change that we've seen is the relationship between NHS and council staff and how we're actually working together jointly on the major issues that we face so previously prior to the IGB there were just far too many handoffs between different sections both within the council and in NHS and across the boundaries between the two because we're working very hard together on that and it's a shared objective between us we're seeing much more innovation actually coming into it and a much more willingness to share budgets and to share responsibilities and accountabilities but again that's a cultural change which is taking a while to embed but the actual legislation is a very brave move I think and it's an inspired legislation of actually bringing that partnership together we now have forums official forums in place that are backed up by law that we have to actually go through and that's provided an avenue for both parties to actually engage much better on a formal basis and so we're able to escalate things to the IGB now that we hadn't been in the past so in the past we've had significant impasses between NHS and council services whereas we now have a forum when that can be debated and actually sewn through to completion and we've had several examples of that over the last year so you've mentioned there you obviously regard to the IGB as a strength in taking this forward obviously Highland to have that different model and I'd be grateful to hear from Mr Robertson and Mr Suza if they think that IGB has strength in shifting this balance of care and also how important you think it is having a financial overview of what's going on because clearly the shift in finance is one way of demonstrating what is actually happening on the ground you know obviously Edinburgh you know regards to Liberton hospital and and other services that have been moved into the community will be recorded on the balance sheet and it's how that ties up with the feeling that things are moving in the right direction. I'm quite happy to come in here. I have to say that I'm about two weeks in post from a South Lanarkshire point of view so I will be speaking in the generality if that's okay and any detail I'm very happy to pull through. In terms of shifting the balance of care I think the IGB is a really important role I think from two points of view both from the management and the overview of the finances the integrated budget but also the work that has gone on nationally around the development of strategic commissioning plans and I think the strategic commissioning plans are signed up to by all partners they've been very inclusive I think nationally and they if you like are our route map for laying out our stall and saying this is how we are going to shift the balance of care and this is how we're going to finance it as best we can because I think it's going to be a difficult road at times and the evidence around that holding each other to account to do that so the strategic plans are three years in most just three years three year plans and I think one of the challenges around for the IGB is the the funding can be annual and the plan is three years so I think that that's something that the IGB and other stakeholders might want to to look at in terms of the freedom and the capacity to actually be able to bring those two parts of the agenda together for us I think I think it's hard sometimes to to evidence very concretely some of that shift in balance of care I think probably my colleagues here and around the country can probably do that with projects I think we've seen a lot in the shift towards the community from hospitals from care homes and the length of stay in care homes has has reduced in in an awful lot of places and you see a lot of these a lot are from initiatives around hospital at home integrated community support services so a lot of effort and a lot of really good initiatives what what skews that sometimes is the pace and the rate of hospital admissions and the demographic that's around just so the a couple of things about the demographic sometimes we think of the demographic just being about the volume of people living longer older people I think in the last few years we've become very aware that it's not just older people but it's people of a younger age with chronic conditions who are living longer and that's a real success it's really good news but it means that they're requiring different kinds of health and social care support in their lives as they go through the different care pathways so when we talk about shifting the balance of care I think we're doing a lot of the right things I think we can evidence quite a bit of that I think the budget and the strategy being more aligned might be helpful but I think the other dynamic things around demographics and what's been presented to us can sometimes make it difficult to see real successes with that but I think they're probably there but we always need to do more and we do need to do more and the strategic plans will set that direction for us I think committee one of the things I would say and from the borders is one of the heartening things about the legislation was that it enabled us to put our partnership together in a way that we feel meets the needs of people in the borders we have quite a unique situation we've got a coterminous boundary we've got two organisations which are are largely of the same size and we're serving quite a distinct geographic population in the border so the legislation that's in place has really allowed us to develop our integration scheme around our health and social care partnership to meet the needs of people locally. As with others we're obviously very focused on shifting the balance of care a real focus for us around early intervention and prevention keeping people out of hospital keeping people in their own homes wherever possible we're using the integrated care fund in order to do that and we're really starting to see some traction in line with our strategic plan around really shifting the balance of care and keeping people out of hospital. One very good example that we've taken forward recently is the refurbishment of one of our care homes the Waverly care home to provide a transitional care unit and really what that's allowing us to do is to keep the focus on delayed discharge providing appropriate care setting for people in a non-hospital setting and try to ensure that we get people back home as quickly and as safely as possible. One of the priorities for this committee is reducing health inequality. What concrete examples can you provide as of where maybe not shifting the balance of care but shifting the balance of resources to address that issue? Do you have concrete evidence that that is happening? Is that a high priority within your strategic plan or is it one words? If I can, it's more than one words and all of the strategic plan is directed towards actually reducing inequalities across the board. The thing with the IGB and the sharing of the budgets it gives us more of an opportunity to get into earlier intervention so early identification of people who need support or healthcare within that and actually putting in services at a much earlier stage so it's reducing the draw on more acute and specialist services which are obviously going to be more expensive within that but actually getting more functionality and real programmes of support in earlier on is reducing that inequality. Now you're asking me for hard facts at the moment. We don't have that as of present time but we do measure it within our overall strategic plan and it's something that we would expect to see that traction start over the forthcoming years really but all of the work that we're actually doing is highly focused on inequalities right across the board and we're working not just within the IGB it's within the wider remit of other services to the third sector and also the wider council services and we're actually making sure that inequality is a feature within the overall vision for the city here in Edinburgh and so we'll be using other services that are not within health not within the IGB but can actually deliver so one of the biggest drivers for instance around good health and reducing inequalities is employment so we want to see everybody getting access to good education and good employment so that that will reduce any health inequality more than a lot of the stuff that we're doing elsewhere so our influence in that through public health and through our engagement in the council is a real strength I think of the IGB so the fact that chief officer sits on both senior management teams in NHS and in the council there's an added strength to that so we can influence those wider agendas as well. Is it just the fact that you don't have the hard facts in the moment but you will have that because you're saying you don't have the hard facts but you're going to measure it? There are facts there at the moment so we can measure life expectancy there's a whole range of factors which you can measure inequality with at the moment so we've started with a baseline within the strategic plan the commissioning plan and we would expect to see them improve over time so it needs some time to bed in so to have an expectation that we will have delivered significantly within 10-11 months is you know that would be a really high expectation but we do acknowledge that it's one of our priorities one of our major priorities within the strategic plan and that's where we would want to see a difference. Emily Elsw in that issue in relation to health inequality what your organisation is doing and how much your priority it is. Again I would support what my colleague Rob is saying in terms of the embryonic stage of the sort of development of the strategic plans and the direction absolutely from South Lanarkshire's partnership a real priority I think there probably are some hard evidence that we could produce in terms of some shift whether it was in terms of the integration or the wider agenda I do again support the idea that it's about the work of the integrated partnership but it's the job very much of the community planning partnerships and of the corporate bodies and again I would touch on the health and social care side of it will be core but housing employment employability corporate parenting there's so many crossover issues here that we need to be cited on to be successful with this but I'm sure I could dig deep and maybe come back with some examples of some concrete examples of some progress in that area. I would just maybe echo those comments in terms the borders and clearly we're very focused on inequality within our communities one specific little example of what we've been doing recently is to recognise that an isolated rural communities transport and access to health care can be a major issue so one of the projects that we've been taking forward to the integrated care fund again is to look at our integrated transport hub and joining up our transport arrangements between the council using the council's fleet and the NHS borders and ensuring that people can access health services locally or through the border general hospital as and when they need to. Just echo the issues raised by Mr Roberts and regarding access to health care or care services in rural areas so that's one area where we're focused on to try and make sure there's a quality of access as much as we can and we're trying to use technology wherever we can as well as linking the transport so we sort of you know smart technology newly designed houses that sort of thing which might help help with that and I think also as Mr Cullock said in terms of employment that's crucial too so in our relationship with our the care sector the independent sector we've tried to sort of give them more assurance around what the income will be and encourage them to sort of pay living wage etc so we've tried to sort of make those that employment more sustainable in the Highland region. One of the broadest and most stubborn frontiers of health inequality in Scottish society is still very much alcohol and drug misuse and its wider effects on our communities. I'm sure many members of this committee will share my horror at the last Scottish Government budget which saw a 20% reduction in funding for ADPs and I'd particularly like to direct a question to Rob McElw Graham in respect of the efficiency savings that you've identified for 2016-17 and Edinburgh drug and alcohol partnership are set to lose a further 1,380,000. I just wonder if you could bottom that out for us whether that is a reflection of the 20% cut in the government block grant or if that is a further cut to the ADP and how that helps Edinburgh address its wider approach to tackling drug and alcohol misuse. I mean it's a very difficult budget settlement it's part of the 20% so it is our share of that and and there are reductions in some of the services that we are providing. Of course we're trying to mitigate any reduction in resource by being more efficient and managing demand. A quick example that we've done in conjunction with the council we've gone for the legal highs so we've removed all of them from the shops within Edinburgh and we've seen a reduction in people actually presenting at hospital as a result of that. So those types of fundamental changes will help with that but there's no getting away from the fact that I would like more money to be able to spend on these services but we live in the real world and we have to operate within a budget so that cut is painful but we're trying to mitigate it as best we possibly can. Alcohol is a particular issue for us and we have got some fantastic projects in Edinburgh which with very high success rates for actually helping people stay sober and actually gain access back into a lifestyle which is appropriate for them and equal from that and those projects we will seek to protect within that so we are being very careful about how we're supporting them and actually how we're actually introducing that level of reduction in those services so again being part of a wider partnership helps with that so if it was limited to one particular area that's a very severe cut but actually because we can wrap other services around them in a wider partnership we are taking some of the sting out of that. Could I just follow up on that and I'll bring Richard in next? Richard, I'm clearing. The point that Alex was making, I spoke to NHS Lodian a week ago and they told me that their share of the drug and alcohol money that they were expected by government to put in, they weren't putting in any money because they didn't have any. Is that correct? It was meant to be covered with the uplift that was passed on and it would have been passed on to us but the uplift is not sufficient to miss again. So how much was their contribution that is now being made because they don't have the money to make that? That'll be the amount that Richard Scott is saving so that we're about to make. That's right, that's right, clear. I'd just like to take his back slightly if I can to what we were talking about with shifting of resources and each of the health boards had given us some examples and the questionnaire that you very kindly provided to us before the committee. I'd just like to explore some of those and if people could maybe elaborate on exactly how they are shifting some of the money from in-patient settings into community settings. Okay, could each of you briefly want to just give an indication up? Start. The way to shift, the major way of actually shifting resources from acutes into primary care for instance is actually the closure of some of the beds. So we're reducing the capacity within the acute side and we can transfer that funding directly across to us. So in Edinburgh we're looking at our hospital-based complex continuing care and we're reducing some of the capacity within there and that money will be directly available to go into primary care. So there's an example in Astley Ainsley of reducing the ward base that we have here and we're expecting a transfer of funds this year to support some of the work that we're actually doing within primary care within that. When we're going forward within that you mentioned Liberton hospital earlier we're looking at a different way of actually using Liberton hospital. We have a step down facility in the north of the city. We're looking to provide something similar within the south of the city so it's a shift of usage within that and again that's a shift of resources to actually support that and a reduction in size will shift the some of the funding to be able to enable us to do that. If I can give some examples, I think first though before I just get into the example I would say that in 2015-16 we received £6 million increase in funding from the Government because NHS Highland was below its funding target so we were moved towards target to the tune of £6 million and the health board took a strategic decision to invest that almost entirely in social care and that don't think that would have happened before integration it would have gone into health services so what we've seen is we've increased our spending in community and social care services so it's not a shift in the sense that it's not come out of the hospital but we've tied to that as an investment so I think that's a statement of intent. In terms of specifics and I would also reiterate that I don't view shifting the balance purely from the acute to community I think it's from residential to non-residential so for example in our social care sector we've got real pressures on care home beds so we're trying to grow care at home so we can keep people at home you know because we have this pressure on care home beds so that's one thing we're doing in practice but in terms of hospital beds we have a business case out at the moment to provide a new hospital in this Baden Oaks stress Bay Valley and that would entail closing two hospitals and having a new one in Avymor and as part of that there will be an overall reduction in beds but that will allow investment in community services that's part of the business cases to release resources from inpatient beds to be invested into community services. I want to give you two examples from South Islandshire partnership and from Lanarkshire. One is the hospital at home example and that's a development of over the last couple of years from the integrated care fund and it's basically keeping people out of hospital if there's any suggestion that they might need to go into hospital then actually the clinicians and the nurses and the allied health professionals actually go to somebody's home and these would be in the past these would be patients and individuals who would have needed inpatient care but actually their care has been taken forward actually in their own homes so it's quite innovative it's quite different and that has proved to be really quite successful there's quite a lot of evaluations going on with that particular project at the moment in that programme at the moment and one example of the cost saving if you like from that point of view is even the transport of individuals from their homes to hospital in terms of ambulances so that's just one part of it but the greater gain is that individuals are not moving out of their home environment into a hospital environment and having the knock-on effect of needing to have their package of care restarted maybe with different carers that type of disruption that can happen if somebody needs a short episode in hospital so there are three areas where that's being undertaken in the Lanarkshire partnership at the moment and the other example is the integrated community south teams and this is again there are eight around south Lanarkshire partnership and these are again really integrated partnership teams of occupational therapists, physiotherapists, nurses, social care workers just really working with individuals to keep them at home and again that is completely supporting the shift in the balance of care for these individuals they would in the past maybe have been it would have been suggested and referred that they move into a care home or may move into a residential setting so it's really trying to support people and keep them as independent as possible at home so there are two examples from the sort of Lanarkshire area. One of the areas that you put particularly in the information that you provided to us was about AHPs and I've certainly had concerns raised with myself about the role of occupational therapists within integrated services. Concerned that they were seen as a generic workforce whereas obviously they are actually quite specialist practitioners. I wonder if you've got any comment on that and how occupational therapists are being utilised across the IJB in south Lanarkshire? Yes, I suspect that as we go further and deeper into integration that a lot of the allied health professionals and other professionals and social work professionals as well will start to look at their role in terms of some of the generic tasks that they undertake and then the very specialist tasks that they undertake. For occupational therapists they absolutely have very specialist tasks that they undertake and they will continue to do that and they will be professionally supported in that and directed in governance around their tasks. There will be an element though of a lot of the professionals in the community and power professionals in the community where their skill set will overlap so there will be an element of as we go further into integration we will be looking at that in terms of our workforce to see if any individuals can maybe undertake their specialist core functions but also try to undertake some other tasks as well so that will I suppose be around the multi-skilling and multi-tasking that we undertake as we go forward and have really joined up teams and that will be about trying to reduce the number of individuals maybe going into somebody's house on a daily basis. I think last week or the week before I had an example of two OTs being in somebody's house at the same time now that was a hospital OT and a community OT so I guess our job of work is to try to work out do we need to have two OTs because the world always had hospital OTs and community OTs can we explore whether or not we need to have two OTs involved in one person's care or can we look at where that overlap might be and integrate their tasks a little more? I've got to see I find that a very unusual way of looking at it you wouldn't look at doctors for example and say you shouldn't have two doctors going into someone's house when you're talking about hospital home you have a geriatrician going in and you have a GP going in so I'm concerned that perhaps some of the allied health professional skills aren't being recognised or are being merged? I don't have any information to suggest that any of the skills aren't being recognised and acknowledged but I think we are looking at different ways of delivering the best quality of care whether it's from the medical point of view or from the care point of view from all of the professionals so I take your point about the medics but even around the medical profession there are some areas where enhanced practitioner nurse practitioners are starting to look at some of the functions that again that will challenge us in terms of our professional identities and the way that we've always been established and organised but I think these are areas that across the board we're looking at hopefully without any threat to people's professional identity and governance. Richard, then we're going to move on to probably what's the main issues about budgeting and financial issues. Sorry I was going to come on to that. Right well good timing perfect timing as always. Right one of the reasons why the Government brought in this bill was to reduce bed blocking make it better for patients and also that would deliver savings but when I look at some of the budgets you know with the greatest respect to Mr Rob McCulloch-Gream Edinburgh hasn't set its budget for yet for 2016-17 not finalised that we're six months down the road we actually now should be looking at 17-18 looking at and being a former councillor it astounds me that you know and Mr Robertson earlier made the comment that maybe it was easier for you because one council one health board and in Lanarkshire we have two councils one health board but how is it if you've got a council budget book and an NHS budget book and you decide what services you're going to integrate so you extrapolate those costings and those budgets out those books join them together hey presto you've got a budget so why are we six months down the road you don't have a budget and with the greatest respect to you and we're now should be looking at 17-18 has this been very hard for some councils and easier for others I think it probably has I can give you the chapter in verse on where we are in Edinburgh so on the council side we went through due diligence what you just described we looked at previous budgets and what spend was on that and that formed the basis of the forthcoming budget that we're going to do we took a share of the savings target that every council service was undergoing and that was a fair share then was the advent of the social care fund which put a change in the mix within there and the stipulation that was sent from Scottish Government Edinburgh council no longer met that stipulation so it was short from the test that was set relating to the social care fund so we were unable as an IGB to accept that and we were negotiations until very recently with the council Scottish Government and ourselves to see how we would actually fix that gap now I can report now that that has been the case and we are ready now to sign off the council's budget so that will be done and yes I would rather do this before March in any financial year but we are in that position now the IGB could not accept it because it was following the guidance that we had and there was a disparity there on the NHS side the NHS Lodian had set a budget with a 20 million gap within there there was 5.8 million of a savings target an additional savings target to close that gap passed into Edinburgh the other IGBs in the Lodians the three other IGBs were given smaller targets but they had to make there we couldn't accept that we were going to be running services with a gap within our budget there that didn't meet the due diligence test because it was an additional shortfall now we've been in on going negotiations with NHS Lodian and we were assured that that gap will now be closed what we're waiting to see is whether the 5.8 million saving will be reversed if that is reversed we'll be in a position to sign off the budgets now saying all of that we haven't stopped working it's a very close working partnership relationship we have both the NHS boards the council and the IGB board are being very cognizant of the challenges we've been facing we've been working very closely together so nothing has stopped the strategic plan is in actions are taken we're in the right in the middle of a restructure which is going to deliver some of the savings targets that we have to do and we're seeing some of the projects that we're doing take traction now so nothing's stopped we just didn't sign off the budgets within there so there was a gap it now looks as if we're very close to closing that gap and it looks that we'll sign probably within the next month if not definitely before Christmas on both of those budgets as a director of finance within the IGB my director was not in a position to accept that but she is very close to being able to do that now because of the on-going relationships we have right and the regarding we've heard this from a couple of boards and a couple of associations delays discharge a number of councils and number of gebs and intricate joint boards have reduced the number of delayed discharge so that immediately throws in savings surely some people are tracking that some people are saying yes it is other people like Glasgow haven't tracked it and they're saying and the concern I've got the government when this having served in the health board health committee the last time the government said that we would make savings at roughly 130 140 odd million I'm now seeing that with the greatest respect that some boards now are predicting that they won't make savings and they actually will go into the red is this a case the the delayed discharge is there's a number of factors which impact on that the way that you would make savings from it is if you're able to close some hospital beds so if you've reduced the number of delays down to a significant level then you don't need that level of capacity within the hospitals and therefore within the legislation we can do the shift of monies from acute into the community we can do the saving there but we need to have succeeded on the delayed discharges now I started to to say what's been happening in Edinburgh we were successful to begin with between October last year in April about bringing them down from 183 to to 50 so over 50 improvement within that but we need a long term solution for this so in moving to localities I'll try and keep this short but moving to localities we want to reduce the travel time for people that are delivering home care for instance we'd had a set of contracts with external providers which really wasn't fit for purpose that those agencies were able to refuse our request for a package of care if it wasn't economically viable for them so we had to change the contracts and the time to do that is not in winter it's in summer so we started that process in May and it's finishing now and the contracts are being transferred now in that transfer we've dropped in capacity and people need to start employing more care workers to lift us up and at the same time we've actually dropped in our capacity within our reablement function because we've changed the nature of a reablement which was blocked earlier so those two factors have had a negative impact on our ability to keep on the trajectory that we had to delete discharge we expect to see a return to that and we've set ourselves a trajectory to get back on to the same level that we were in April by the end of November and it's a very challenging target for us but we need to see that traction before we get into the midst of winter so it's a long answer I'm afraid but we will see savings once we've started to reduce to such a level that the hospitals can start to close beds and reduce capacity that's the factor that's needed. I urge people to give brief answers and brief questions because it's a timescale but welcome anyone else's comment on that. I think in the border's context we were able to set the budget at the 30th of March so that the IGB had its budget for the start of the year albeit that was subject to final confirmation from government around the overall level of NHS finance. From our perspective we put a little work in at the front end to ensure that we did the diligence around the budget and that we had a sustainable budget for the IGB that's not to say that that budget is with the risks any budget that you set will always have an element of risk but we felt it very important that the first year of the partnership that we were basically starting that in April with a budget for the IGB to operate to otherwise we felt how could we plan the effective shift of resources and the deployment of services effectively so we were very focused up front on getting that budget in place and moving ourselves forward of course there are savings to be made by both the NHS borders and the council £7.7 million this year but we felt in terms of our planning it was very important we got the budget set and moved on with what we've been tasked to do by government. In terms of the budget process Richard described that this year it sounds relatively simple because you extrapolate what the health board and what the local authority spend on adult services and you have the budget but obviously despite that there's obviously been some significant problems across Scotland in determining IGB budgets so going forward can you just for the benefit of the committee describe what process you'll physically go through to set the budget for future years because it won't be a case of the council on health boards basically just extrapolating what they spend because it's now over to you guys so what process the local authorities and health boards and the IGB now follow to actually set the budget for future years because it's not entirely clear to me and what happens if there's a conflict between what the IGB think you should be getting and what the health board and local authorities are prepared to hand over. I think it's very important that in future we develop these budgets in partnership it's probably fair to say that informing our IGB budget this year that exercise the council undertook its exercise the NHS undertook its exercise we brought those together moving forward as one IGB with the three partners we'll need to make sure that we work very closely around the identification of efficiency savings the identification of cost pressures that we're building in demography to reflect the increasing numbers of older people that we're managing and that we're doing that in a timescale which allows the IGB to have its budget in place for the start of the start of the financial year so much more close working closer understanding of the challenges that everybody's everybody's facing around this and a timescale which allows budgets to be set by the 1st of April. I'm back at that point but ultimately a local authority will set its budget by and large in February legally they have to set the council tax in February so they'll set their budget in February so they will effectively agree a figure for the IGB if you like in February so how will you engage in what process will you go through between now and February not to understand the fact you won't know what the local authority funding settlement is until probably December. I suppose to do a process of negotiation and an agreement. I'm looking at the the floor of projections around the pressures that the IGB have. Councils set their budgets in February I think legally they have to set their budget by the 11th of March every year actually councils set their budget in February for council tax billing purposes so that we can get bills out on the 1st of April. It's quite clear there is an ongoing process around budget development it would be much helpful if we could get information from government earlier in that process. As you say the local government tends to get an indicative settlement in December that's before the health boards tend to get their finance I think we're just going to have to work through this process and ensure that we set the IGB budget up as robustly as possible for the 1st of April taking into account what risks we can manage. Next. Just to give you the lead agency angle on that in 2013 we entered into discussions with the Highland Council and of course the situation is slightly less complicated because there's only two partners there's no IGB and we discussed then the concepts of a three-year budget taking into account exactly what Mr Robertson described of demographic expected changes cost pressures expected funding etc so we reached a three-year budget for 2014 through to 2017 and that's what we would like to go back to what happened for this year the year that we're in now do things happen first of all the council's settlement was much lower than it had expected when it made the three-year settlement and also the announcement of the £250 million investment in social care came in as an extra complication so those two things led us to having to renegotiate with the council but we still managed to do it by the 1st of March but I think but I still think the principle would still be we'd like to have a mutual three-year budget agreed but it will it's inevitably going to be subject to any sort of anything which changes which has a material impact on any of the assumptions. Edinburgh has set a three-year budget for itself and for what passes over to the IGB but it's subject to what's for any other factors that they might get so the settlement will impact on that so it gets from Scottish Government and it's true in the NHS as well as my colleagues have just said so the non-alignment of those two budgets is not helpful so having a budget that was decided by the 1st of June for NHS and for councils in March it just didn't help with setting a budget overall for the IGB within that we expect it to be more to be simpler for next year however those two factors are always going to be the case so it will depend we've got predictions we've got savings targets rolling on to the next three years however they will change subject to the settlement that actually of the council and the NHS get from Scottish Government. Can I ask about the social care funding which seems to have been very badly addressed when it was passed over to authorities and it seems to be right up to the last gasp indeed and still today we don't know whether the living wage element of it is going to be implemented and there's all sorts of debates and discussions going on about whether that is going to happen or not. Can I ask from each of you your experience of this, was this handled well or badly? Did you get the money that you expected to get? What did that mean for your authority in terms of the contribution that you had to make and as it is going to deliver what it is supposed to deliver? I don't mind going first on this one. The social care fund is very welcome but I think initially it was difficult to work out exactly how we were to apply and how we were to work on it so that I think provided a challenge for the partnerships. I think from a South Lanarkshire partnership point of view I'm comfortable that the money has been used well, that the living wage element has been applied and I think we are one of the partnerships that actually can say that we are delivering on that from the 1st of October. I think from again it's the detail in it but I think there was an allocation of six months for the living wage and I suppose there needs to be some reassurance around the continuation of that funding from the living wage point of view. In terms of the rest of the spend, some of that was around activity, demographic activity, some of that was to support some of the projects that have been taken forward under the integrated care framework, some of it was to support the shifting of balance of care particularly around care at home in South Lanarkshire. What did your authority have to come up with in terms of finances to make the living wage element work and where did you get that money from? I haven't got that detail just now for the partnership but I can find that out for you. You can forward that to us? Yes, we'll do no problem. If others could maybe address that point if they're answering. David? We received an allocation of £5.267 million from government in terms of the social care funding and we are confident that the aspects of that fund that relate to the living wage can be accommodated within that overall funding. The problem for us is that there are a whole lot of other issues which there is an expectation can also be accommodated within that funding. In particular, the regard to demand pressures around demography. What we can say is that we're making progress around the living wage. We will have that implemented for the first of October. We've been negotiating with all our care providers, our external care providers across the council and we think that we will reach agreement with them around the implementation of the living wage. In terms of living wage, yep, we've funded within the money we've got a whole lot of other issues which are also having to be accommodated and that's much more difficult. We saw the £5.267 million as very much an internal to the overall budget. What the council was already doing was already paying our own internal staff a living wage, all the people who were working within the care sector. What we were trying to do with this funding was to ensure that everybody operating within the care sector was actually being paid that living wage. The council effectively has made a significant contribution to the overall package and the aspirations of government around that funding. Did the additional money come from the private providers who were employing social care staff or whatever? No, the evidence I think is that on the back of the move to implement the living wage across the care sector, we've had some very difficult negotiations with our care providers and what we have seen are costs increasing as a result of that re-tendering process. That's been, in many cases, we feel directly driven by the impact of the living wage. Care providers are simply coming back and saying, we can't deliver that within the funding that you've previously provided us, you'll need to provide additional resources in order to sustain services and we've done that largely within the budget. Nick? Yes, in terms of you asked how it was handled, I think it would have been helpful if we'd had the guidance out earlier than we did about how to utilise £250 million, particularly the question as to what extent the local authority would expect some sort of a share of it, I guess, to help with its pressures, because that wasn't entirely clear to me and that was one of the negotiations we then entered into with the Highland Council. So that would have been helpful to have the guidance outs sooner. In terms of living wage, yes, there is sufficient within that to deal with the living wage, but as Mr Robinson indicated, there's other pressures as well, which would be charged for that budget. So we will spend more than our share, the £250 million, when we take account of somebody going back to the Highland Council, there was, in terms of what NHS Highland are contributing, it's over £1 million in a sense health money to balance the difference. In terms of the living wage specifically, we'd already implemented that with our care at home providers, so we're now implementing it with our care home providers and what we've done is followed the COSLA guidance with, there's been a negotiation with providers nationally on the national care home contract of a percentage uplift to allow for living wage and we will apply that to both our national care home contract providers and also those who are not on the same contract will apply the same uplift. So in terms of have we, the question, the detailed question, have the sector contributed their share, well our view is by using the COSLA percentage uplift then the onus is on then to sort of deliver their share because that was part of the negotiation. And Edinburgh said that it failed to comply with the guidance, is that the elaborator? I think it was open to interpretation, so the guidance as it was come out you could look, you could take a couple of perspectives on the guidance and that was the difficulty that we had with the council. We've now redressed that and so we're able to clear that now but it has taken us this period of time to get to this stage. On the living wage we've done that for council staff, we've done that for our contractors as well and the annual costs for us will be £8.8 million to deliver on the living wage. Just on the actual implementation of living wage just for clarification in the four areas you covered, does the payment of living wage include payment for sleep over shifts and the deals that you've done with the providers? We've followed whatever the COSLA guidance is so I don't know the detail to that. We're certainly looking at that at the moment. The impact of the living wage in our night time support sleeping has been quite substantial. We've gone from the position where we had a rate of around £36 a night for somebody to provide a sleep over in a social care setting to a cost where that's going to be in £153 a night so there's quite a significant financial impact in terms of the impact of the living wage. If you're paying somebody to work however what we're then saying is well we're not going to pay them £153 for a sleep in what they're going to be doing is providing a waking shift and that will then give us the ability to maybe redesign services around that. So there are a number of technicalities around the implementation of the living wage that we're currently working through with regard to sleepovers but are we implementing it? Yes, absolutely. We had a session a few weeks ago with 25 or 30 social care workers and what the evidence that they gave was frankly shocking in the way in which some of them were employed, the way in which they were not paid for travel time, some of them had to purchase their own uniforms, some of them were using their own mobile phones, some of them were not paid for any gaps between visits during the day. Frankly, the conditions that some of them were employed under I believe were completely unacceptable. Some of them who were making those claims were employed by some of the local authorities, not directly employed by some of the local authorities but through contracts. I wonder if you would comment on the overall package and value that we put on social care in our country and whether you think that that is acceptable as people who are managing a service that involves some of those workers. I'll only comment from a Borders perspective and certainly the issues that you've outlined there with regard to travel time, non-payment between contact visits, that absolutely doesn't happen in terms of those employed. Directly employed staff, but I'm talking about staff who are employed by local authorities on contracts for providing social care. We I believe are very very clear in terms of our contract specification what is acceptable and what is not acceptable in terms of external care providers. We are working through a process of ensuring that all staff are paid the living wage, people are remunerated appropriately, they are paid travel time where that's appropriate and that we're trying to ensure consistency across the care sector. That's very welcome to hear and I hope that's followed through. I would support what David is saying. I think that the difference is the internal and the external market and certainly from the unus of the posts that I'm in I will certainly be going back just to check out what the relationship with the external providers that commission services are. I think that we are as local authorities quite good over the last few years to try to mitigate any of those particular issues that you've raised, but I think that with the external providers that sometimes relies on very good relationships and a lot of monitoring, so I'll be live to it and we'll report back as well. Yes, I can only answer your question generally rather than specifically. I would say that this is a really crucial group of staff, absolutely crucial to the whole health and social care economy, both the directly employed and those working for contractual partners. What I can say is that we have definitely done some work to increase the payments that we make to care providers in order to allow them to pass on benefits to staff and part of our contract monitoring will be around that, but I don't have the detail to hand that I have to go back and check exactly what the arrangements are for monitoring the way they are treating their staff. Rob, not a lot to add except from my colleagues just to take us back to we're talking about a living wage here for what is quite a challenging and difficult job and I think all of us would want to be in a position where we would actually remunerate all of these staff at an appropriate level, but that's eating into the budgets and we've got to share that and put priorities in there. In Edinburgh we are competing against the likes of the supermarkets here in terms of the wage, looking at care staff, they carry out a vital job, very difficult job, very skilled job that they undertake and yet if you do a comparison straight with the retail sector it's the same, so our providers are finding it difficult to recruit at this level. We may have to go back into this debate and see whether we have to look at whether the wage is sufficient or not and it is a question, it's a very difficult question that we have to face within that, but looking at standards across the staff we would expect, in Edinburgh we would expect exactly the same as my colleagues have said here around these staff, we cannot provide the services without these staff, they're vital to what we're doing across the whole of the sector, not just in the home care, if they fall down or hospitals fall down or primary care falls down we all do, so there's a great emphasis on actually getting this right, we might have to challenge what we're actually offering. I might suggest giving the evidence that the committee heard from people that you might, each of you and your colleagues across Scotland, might wish to do the same exercise as we did because we heard from people on the front line and certainly the perception that we got and the evidence that we got has quite appeared to be quite different from what you're telling us today and maybe it's just that we've got four local authorities in front of us who are doing things right, that might be the case, but certainly I think the evidence that we heard was very powerful from the social care staff and it was quite different from what we're hearing today. Anyone else like to come in any of the financial elements? I want to shift gear, I want to focus on the outcomes framework and just understand a bit more your perception and understanding of how effective or otherwise that could or should be in terms of driving effectiveness forward. I understand that there's nine national health outcomes, but sat below that there's 23 indicators that are measurable, so I suppose the question is in your mind are those the correct things that we should be measuring if we get those 23 right or recover on all the bases? Secondly, the relationship between budget lines and those indicators both on the input and output side, what I mean by that is if you fix those indicators would that lead to spend reductions in certain lines because you're doing things better from a preventative side? Also, are you focusing on the input side, the spend on the activities that are going to deliver on those indicators? I'm happy to kick off and see if I can make some sense of this. I think it's really, really important to have the national outcomes and I think we've over a number of years gone through with different kinds of legislation and policy and we haven't had that framework and I think it's really helpful to have that because it gives a sense of direction, it gives a sense of focus. I think again the indicators that lie underneath them are very helpful. I think where we get into meaningful information is probably when we start to look at our own local indicators and the work that we're undertaking at the moment to try to have some indicators that will measure progress locally on local issues, whether that is something to do with health inequalities, delayed discharge, whatever. I think the exercise that we were faced with in the summer in relation to allocating the funding to the outcomes was particularly tricky because there are a number of activities that we might undertake that will lead to a whole range of outcomes. There are some that would be difficult to track from if you like input to output to outcome and there would be some that would be very tricky to allocate the funding to it. I think the exercise in itself was was fairly tricky, probably something that we could spend some time particularly from a local and a detail point of view sort of putting some funding against that, but I think that overall the national outcomes are going in the right direction. I think that we've got the freedom to be able to put some framework and performance framework in place that will make a difference over time and give us something that we can measure progress on a monitor. Anyone else want to comment? I suppose so, but it isn't atoriously difficult to budget for outcomes. When you're dealing with people who have multiple conditions and require multiple interventions in a healthcare setting, what you're actually interested in is how quickly you get them out of hospital and how do they come back again to hospital. From my perspective, I think that we need to look at the, I sometimes worry that we're too focused on delayed discharge specifically as an issue. What's also very important to us is keeping that person out of hospital, re-admissions is a huge issue for us and we just need to be careful in spending too much time in trying to align budgets to outcomes when what matters to that person is their quality of life and how good the care they receive actually is. It's absolutely true, but I mean delayed discharge is only one of the 23 measures and there are, I think, 10 measures that are focused on exactly what you just said, which is the quality of the care. So I suppose the question is, do you think that the 23 are the right ones? I'm kind of understanding what you said about local indicators. Are you saying that or doing it locally? I've always thought that you would have been able to have indicators that were applicable nationally because at the end of the day the outcomes are all the same everywhere, so are you saying that locally those are being tweaked or you need additional ones? And I know that I think that Edinburgh, you've actually inputted quite a number of additional ones, which I'm kind of intrigued why you need to do that. Enough indicators to be quite honest. The nature of any of the IGBs is they're serving a local area, the local areas are going to be different, so you're going to get some different drivers within each of the different places that you're in, so some of those additional targets will be because of the different nature of the places that we're actually operating in. And just to reflect the exercise that we're given, I think that there was only one IGB that made an attempt to actually split their budgets according to the outcomes. I just think it's impossible to do, really, because those outcomes are interrelated. Our actions that we fund will cover a range of those outcomes, so actually doing the exercise that splits up a million pounds has been spent on prescribing or whatever. There's a different impact on it. If you're successful in prescribing properly, then you could reduce the number of visits that's required in a package of care, so you'd be talking about your delayed discharges would be impacted with that million that's spent on prescribing. I think that it's a too simplistic approach to actually expect us to actually divide up our budgets according to the outcomes. We just hit all of the outcomes. In terms of actually the national outcomes being a driver for us, yes, definitely, but I do think that there's a local need to be cognisant of what your locality needs are and to have some drivers specifically around those as well. Yeah, I suppose what I'm trying to get to is that you're right as complex. It was easy, anybody could do it. It's difficult, that's why we're asking you guys to do it. But does it not bring clarity of thought to actually having to go through that process and saying, I am spending this million pounds and I'm expecting to influence five or six or seven or ten of these indicators and then influence it in this way. Surely there's value in that process because otherwise all you're doing is pumping cash in. You continue doing what you've always done and you get what you've always got and there's no thinking as to what the result is going to be. The strategic plan drives the budget. The outcomes of the strategic plan drives the budget. We do do that exercise and we do prioritise on the funding and we look at the consequences of investing in one area and not in the other. That is done, definitely, and I'm sure that's done in all of the IGBs. There is a nicety around sticking to a national reporting line that makes life simpler for sharing information and things like that. I think that we do that to quite an extent, but we're going down to the detail that was requested of us for each of those outcomes. We wouldn't be able to give you any. It wouldn't serve your purpose or ours to be able to do that. Hi, just quickly. Do you think that the joint boards are getting too much thrown at them at one time, particularly in North Lancer? The joint board is now taking on the care alarm system and sending out a bill for it to people who are quite shocked. Do you think that you're set up to relay discharge to remedy that? Now you've got to take on other things. Do you think that councils and NHS boards are thrown too much at you at one time? I've been interested in your four comments. I think that the governance is right. You could answer this in two ways. The whole essence of the legislation was to bring accountability into the one board, into the one place, and I think that that's right. You have individuals with quite a big span of responsibility, but that's the whole point. We can move funds easily, we can redirect staff, we can look at the professions and say, have we got enough of them, then I'm going to take less of a health professional and investment. We have the ability to do that now. If we didn't have that span of control, we wouldn't have that ability. The other side of that is I've never been busier in my life about how much we're actually doing, but I think it's a stage that we're at. Just remember, these services exist now. It's not that we've created new ones yet, but I think we will in the future. Right at this moment of time, these exist within the council and in the NHS. What we're doing aboard is sharing that governance and accountability. It will evolve over time. I think what would be challenging if the expectations of change and the rate of change were higher than they are just now, then I think that would be problematic. I think it's really that people have some patience with the way that we're actually going because it's the right way to go. If you talk to any of the partners across the country, but definitely I know in my own partnership and the Lodian, they would all agree that this is the right way to go because in the past we got stuck with the silos, we got stuck with the arguments across budgets, we got stuck with the allocation of staff and we were duplicating left, right and centre and we were missing some major areas because we'd blame one and the other for missing it. So I think that the legislation is right, the span of control I think is right, there's some variance in what we've got at the moment, but again that's down to what the local needs are. So I think at this moment in time and the progress we've made, I think we're on target. We've got a huge number of difficulties, so several crises I'm dealing with in Edinburgh, but I think I've got the way with all to actually deal with them because the legislation has given me the levers to pull, whereas I didn't have those levers in the past. Well I mean we don't have an IGB in North Island to throw things at, so I guess it's a slightly different feeling, but the perspective looking back to when we became integrators really just managing expectations and when we became integrated in 2012, our initial year first year was really about stability. Let's try and make sure the services we've inherited are still being provided, at least as well as we've provided before, rather than having sort of two ambitious expectations. We wanted just to make sure the transition which was quite risky went well, so I think there's a really just expectations need to be realistic, that's what I'd say. Mr Kenton, you're down the road now. Are you finding it's getting easier? Are you finding you are? You are making, I'm not saying making savings because you've got to reinvest, but you are doing a job and you're doing a job with the money you've got. Have you found it that way, or are you, some of the boards are saying we don't have enough money? Well I think all boards always say that. I think we're all under financial pressure and we're in a period of really sustained financial pressure and we are feeling that, but I think what I would say is we're more likely to find a way out of it if we have this integrated approach and if we remain working or if we weren't working separately. We've got to find a way of trying to relieve from the pressure on the acute sector and that's by investing and growing social and community care, so that's what we've used, that flexibility by redirection our resources towards that sector when we can. Fawr, you're all down. Sorry, Fawr, you're all down. How are you feeling? Fine, fine. I agree with my colleagues, I think it's the right way to go. I think nationally one of the, from the perspective is, you know, it's to try and keep things as joined up as possible. I come from a social work, social care background and I have my eye to childcare and I have my eye to criminal justice. I have my eye coming from a local authority point of view to housing services and trying to, you know, as my colleague is saying, the real synergies are going to be if we keep all of these things together. Some of the risks are if we create boundaries and barriers to these. So from the IJB point of view in South Lanarkshire, we have adults and older people services in the partnership just now and up and down the country there are different elements of services in the IJB, so I think that's a question for the future. But I don't think it's too much, I think it's how we do it and I think it's important that we have the connections across the different public bodies if we're to go forward with the levels of efficiency and effectiveness that we're being challenging ourselves to take forward. I suppose from my perspective, the integration gives us significant challenges but it also provides us with huge opportunities and our challenge is to make this work and make it work as effectively as possible. Before we put anything into the health and social care partnership, we want to be absolutely convinced that that's the right thing to do and that's the best business model. So to come back to your alarm's example, we are currently delivering that through SPKs, our arms length allio in my case, so the recovery team are responsible for recovering all the charges associated with that and the debt recovery. Before we move to put anything into the partnership, we want to make sure that that's absolutely the right thing to do in terms of our business model and if there's a better way to do that out with the partnership, then we'll do that. I really came out of a question that Claire Poppy asked about the occupational therapist and it seems to me to get to the nub of the issue of integration which is, is integration about the merging of health and social care or is it, as I understood, about working alongside each other and just looking to the future, do you see integration as a merging or actually really about working alongside, where Rose may be duplicated? I'll start, but I'm only going to say a little bit about and let my colleagues come in on it because I feel I've had a bite at this one. I see it as neither particularly, I think it's about something in the middle, so it's not about just being co-located, it can't be. I don't think it's about losing our identities and being completely merged, I think it's about co-existing but having a function, having a reason why you're doing something and I think we always have to keep the outcome for our customers as core and then we work out what our functions are, specialist ones, generic and we find a way of working forward so that we're not duplicating, we're not over-presenting ourselves to members of the public who are needing some of our assistance for health and social care. So I think it's somewhere in the middle. I would agree that it's somewhere in the middle. It sounds like a very simple question but it's actually quite complicated in a way. I think there's a definite need for some merger of some provision that we're doing and I think we should be ambitious enough to actually carry that through. We are talking about individuals though who have spent a career on a profession or a specialism and somebody who's chosen to be trained and to do that particular specialism but then on the other side we've got four specialisms going into one household so if you stand back and look at it there needs to be a bit blurring sometimes between some of these professions so that we actually deliver. I think if you talk to the clients, if you talk to the patients, if you talk to the residents they don't really care but what they do care about is good quality healthcare that they get when they actually need it and in the right place by the right person but we have to be cognisant about how we move to that. There's always going to be a need for specialisms, always, because of the specialist nature of our own needs but there is a need for some generalised workers as well. I mean the question earlier was about, it was mentioned around the GPs, we are looking to seeing how GPs function. We're always going to need general practitioners but they need support but it's a changing world so we've got greater demand, people living longer, more complex needs and our model for GP practices need to be cognisant of that and actually look at it's more than a GP that we need to serve a community so we've started talking about advanced nurse practitioners and others and pharmacists supporting in the surgeries. I think we do need a new model for that so my plea for the future of IGPs is to be ambitious around what we're actually addressing because I think if we're not I think the needs are going to overtake us and we need to be planning for the next five, ten years I think and what we're actually delivering. There's a number of places where we've slipped behind across the country and what our delivery is because the needs of the population has changed more rapidly than our services are so I think we have to be brave courageous and ambitious about what we're doing but remember we're taking a staff force with us and they have got to have time to develop into what the new models are going to be. I think really integration structural integration is about removing the barriers so you make it less difficult to work together but it doesn't of itself force people to come together in a changed way that is a cultural thing so I think by integration we make it possible but it doesn't happen you need to grow and change the culture it is a cultural development so I think as Rob said if you put the client or patient at the centre that's really powerful because if you know that will help bring professions together and if they view that that is their ultimate aim is to serve the client the best then then naturally automatically start to break down any false professional barriers. That's a quick point and I'm a quick answer if possible to this. I think it's picking up a point that Nick made as earlier there was a business case for reducing beds to free up resources for primary care but simultaneously one of the motives and main motivations behind IGB financial anyway is to ease pressure on acute. Given that we're talking about a five-year timescale to actually see the benefits come through there's clearly going to be a gap. How do we affect this transition without seeing a reduction in the services provided at an acute level where these pressures are still resisting? I think what we need to do is what obviously we do have time to plan ahead it's a business case which takes some years to implement so we're already redesigning the teams in those areas to try and manage people at home as best we can and try and reduce the pressure. I mean these are actually community hospitals so not under quite the same pressures as acute hospitals so it's more easy to make the transition but it's still as you say there's a point where you have to make the step change and so we need to plan for that and make sure if possible we manage the bed size down before we get to the actual transition by investing upfront in the community but it does make it difficult to make the transition. We don't have to spend money sloshing around so we need to make sure we can redesign services in existing resources to put more emphasis into keeping people at home rather than in the hospital in the first place. Question is that I have it really fundamentally is it possible to achieve this without a one-off transition fund of some sort and do you feel able to do this? I don't understand if you don't have a transition fund how it's actually possible it has to be a loss at some point. Do you have a transition fund through the integrated care fund? Would we like that to be larger of course we would but we recognise that the resources are very tight. I'm supposed to come back to your question it's maybe a bit of a personal use of forgiving me but I've always struggled with the concept of taking resources from the acute sector and moving them somewhere else because if I look at the borders general hospital without closing a ward in that hospital I really struggle to understand where we can take money out of the acute service where we can make big inroads in terms of our community services the linkages with social care the interface with the parent but patient out with the acute setting I think the notion that we can take resources from general hospitals and shift them out given the operating models around those hospitals is a significantly challenging concept but maybe that's just my little hardwired accounting brain talking I don't know. Okay do you mind just a couple of things it appears you know we had the financial information and only the western isles could provide information to demonstrate the financial scale of the planned shift over the next two years and clearly there's an issue in how we report those type of things and I'm not asking you to comment on that but the one final thing I would say is one of the things that frustrates me is when we see the four authorities and the question they were asked about the savings to be made we got some people give us a block figure this is the savings other gave us some detail for example Edinburgh drug and alcohol partnership 1.3 million that's not a saving that's a cut so why are we reporting savings cuts as savings surely those should be divided and it be absolutely clear if you're saving on paper clips then that's all very well you can tell us you're saving on paper clips but if you're cutting the drug and alcohol budget people want to know that you're cutting the drug and alcohol budget and the reasons behind that which you've already explained and they're perfectly valid reasons but we don't want that I personally don't want to see that called savings because it ain't savings anything that we anything if we've got a reduction resources there's an implication for that we can mitigate the impact on the public as much as we possibly can within that I did not want to reduce any of the funds that was going into the alcohol and drug partnerships at all I don't think any of the professionals in here would do but we recognise we've got to operate within the budget that we're given and we have to prioritise where that spend is so some of that is done directly on services others other areas paper clips that you say I wish that was the case but so we have a direct impact on setting priorities and that does impact on services but we manage a lot of services go back to the scale of the the i gbs so we do have the ability to mitigate the impact on those individuals so in terms of the reduction in costs or the cuts whatever you want to call it in terms of alcohol and drug partnerships we are working very very closely with the provider of services with the users of services and predicting how we might actually mitigate some of those savings within there I'll give you a very quick example we have a function a service called milestone which is for alcohol brain and damage so it's mental health issues related to to alcohol it had a three-year budget was coming to an end it's a furlough pressure on our budgets of about 600 000 that we have to do we know that that service saves probably in the region of 1.52 million people who would have been turning up at accident emergency if that wasn't there and there was no furlough budget for it we need to create a budget we'll have to move that around it means stopping some services elsewhere because we're prioritising in this so I think any criticism about cutting services means we're probably saving services elsewhere from what we're doing so it's quite a complicated picture and when it gets to the public I completely understand their frustration when they're seeing a reduction in budgets in particular areas but what we have to juggle with is quite a complex arena of who we're funding which services we have and at the bottom of all of this goes back to your first question around equality we have to drive through making sure that everybody's got equal access equal opportunity to good health as everybody else and we balance it with the budget that we've actually got the only reason I raise that is because you reported it and the fact is if other authorities and some had gave us headline figures and if we delved into them I would almost guarantee would be fine similar cuts as well but they're reported as savings and that's a frustration sorry Marie I did say that I would bring you in one final before the start of the meeting so this is the final final final thank you so as ever as a Highlands and Islands MSP I'm keen to share some of the innovations we have particular challenges in the Highlands and Islands in terms of geography in the vast distances that we cover and probably in a slightly different situation to some parts of Scotland where people don't really want to go into hospital because it's very far away from their communities and when in terms of the difficulty of providing specialist rehab and things all over the vast geography that we cover so I have been hearing a couple of times at home in the constituency about the new tech enabled houses that you're looking into and I'm pretty sure that my colleagues around the table would be very interested in hearing that it takes a lot of boxes for us in terms of using technology to improve healthcare providing equity of access tackling the lead discharges have you gone to speak about the care campus that's you know being proposed and workforce issues so I think that everybody around the table would be interested in hearing about it if you don't mind we're currently in discussion with a social housing provider and there's a pilot which we're hoping to go live with in April in the first one is in in the Gordon working with them with some new type of module housing which has been designed with input from potential tenants so and the concept of the housing is it's a very sort of technology enabled housing with a sort of smart hub and it what it's doing is monitoring all sorts of indicators within the house not just sort of when doors open and close but there's also sort of ambient temperature monitoring that sort of thing so you can tell if the heating has gone off or whatever and and the but the the clever thing is it can actually send messages to a potential respondent so if something's happened with the client in that house then the respondent might be a member of the family it might be ourselves or member the community might go and respond to that what's happening in that particular house very eco friendly housing as well so the concept is is to try and keep people at home as as you say work in their own communities in terms of using that more widely and as you say care campuses are possibility on on one of our hospital sites but that is still very early days on that so so i don't think it probably not in a position to talk too much about that now but the concept if it's proven to work in in the Gordon then potentially it could work in in one of the hospital sites and provides up a step down facility it's it's you know filling the gap between sort of residential and nursing care that's what we're looking to do it's quite quite an innovative innovative proposal so we're certainly excited to see how it turns out okay thank you very much thanks very much to the panel for their evidence this morning and as agreed we're now going to private session