 Miheillewin. Welcome to the 27th meeting in 2014 of the Health and Sport Committee. I would ask everyone who is in the room to switch off mobile phones as sometimes they can interfere with the sounds. Although in saying that you will notice that committee members, and some of the class are using the tablets instead of the hard copies of their papers. Mae'r first item on the agenda today is a decision on whether to take consideration of a draft budget report on the Scottish Government's draft budget in 2015-16 in private at future meetings, as the committee agreed. Thank you. Agenda item number two is subordinate legislation. I know we have two negative instruments before us this morning. The First Instrument is Scotland Act 1998, Agency for Arrangement Specifications Order 2014 SI 1892. There has been no motion to or no, and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Is the committee agreed to make no recommendations? Thank you. The second instrument is Food Hygiene, Official Feed and Food Control Scotland Amendment Regulation 2014, SSI 2014213. There has been no motion to or no, and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Are there any comments from members? No, there have been no comments as the committee agreed to make no recommendations. Thank you. Agenda item number three is, of course, our draft budget scrutiny, and this is the first this morning, and we begin with our witnesses before us this morning, Dr Andrew Walker, University of Glasgow, welcome. Professor David Bell, University of Stirling, welcome to you this morning. I don't know whether we're going to write to questions or do you wish to make some points at Professor Bell. Thank you. Yes, I was going to make a few introductory points if I may. Can I just start off with the share of the budget, so how much does health spending account for as a share of the Scottish budget, which is an issue of some interest? For 1516, compared with 1415, the share appears to drop from 33.8 per cent in 1415 to 32.5 per cent in 1516, but that is somewhat misleading. In fact, the share stays pretty much the same if you discount the AME spending on the Scottish pensions provision. There's been a huge increase in the AME budget for pensions, which apparently results in a reduction in the share of health spending, but that's actually to do with something that's not really under the control of the Scottish Government. Can I also talk a little bit about spend per head in Scotland? Between 2008-09 and 2012-13, health spending in Scotland, compared with that in England, has gone from a higher spend in Scotland with a margin of 14.3 per cent down to one of 11.7 per cent. There has been something of a fall in the relative spend in Scotland compared with England. At the same time, there hasn't been a huge amount of change in Scotland's overall extra spending. In 2008-09, Scotland's overall public expenditure per head, the margin was 18 per cent, considerably more than the margin in health spending. In 2012-13, it was 19 per cent, so it hasn't changed that much, but there has been a bit of a change in respect of health spending. I'm happy to take questions on that. Can I also say a little bit about targets? I think that Andrew has commented on targets in his piece, so I'll be brief. I consider targets just to be one snapshot of experience and what people are interested in is the broader perspective of the health service and their experience through the health service, what kind of care they're getting, what quality, what availability. Perhaps we would like to see more broader public involvement in the issue of how we come to decisions around what it is that we want from the health service. Interestingly, the Scottish University's innovation project is doing something on wellbeing at the moment. We are looking at how we might engage the public in the national performance framework to a greater extent than has been the case up to now. As an economist, what I try to do when thinking about things like what's the level of productivity in the Scottish health service, I look at the information services division statistics. It is quite difficult to figure out what really is happening with productivity in the Scottish health service. How, for example, are costs changing and whether the GDP deflator, which is used by publications, not only in Scotland but the SPICE publications, the GDP deflator to get to what they would describe as real spending in the health service, whether that's the appropriate measure of costs in the health service. It's not entirely clear to me that there is sufficient evidence to back that issue up in Scotland. Something on social care and health, the mix or the interaction between social care and health, it seems to me that we are in for a long and extended period where local government budgets are going to come under increasing pressure and where health budgets are likely to be protected to some extent or to a greater extent than local government budgets. That will put more and more pressure on the interface between social care and health care. It is important to make as efficient and as well evidenced as possible the use of resources that go to the interface between those two areas. The final point, which is perhaps from left field a little bit, I noticed that the CME campaign today has produced a document asking for an end to the stigma around mental health. It seems to me that maybe Scotland is a little bit behind the curve in terms of its focus on mental health, not just in relation to stigma, not just in relation to wellbeing, because the evidence is absolutely clear that mental health is one of the most significant predictors of low levels of wellbeing. Of the economic case for investment in mental health, which has been made quite strongly south of the border, where NICE has recommended a number of policies in relation to a switch towards mental health. Now that the Scottish Government has control over at least a proportion, perhaps an increasing proportion of its income tax revenues, there is a case for looking at whether, for example, investment in more mental health capacity within Scotland would lead to a larger increase in income tax revenues than an increase in investment in childcare, which is a proposal that seems to be out there. Anyway, that is a set of points that I thought I might make, ending on a slightly controversial last point. Thank you for inviting me. Having been a Biasruwn witness, I think the only role left to me is to get elected and be a committee member as well, but I tell you I have no ambitions in that direction whatsoever, lacking so many of the skills and talents that the committee exhibits. Listening to two economists for an hour, you are very brave people. Having read draft budget documents since 2001 as part of my role with the committee in the past, I see a lot of continuity here in terms of the style and presentation of the document and that continues to frustrate me. I don't think it's specific to this document. It's in common with all documents. It's essentially an allocation statement where we take a top level line in the budget, roughly £12 billion, and say which lines in level two and level three of the budget it's going to go into. There is some accompanying text, which is loosely linked to the budget, but isn't always clear what line it feeds into, and having seen the spice briefing that became available yesterday afternoon, I can see some more of those links, but it continues to be a frustration that the text in the document doesn't really tie in with the tables terribly well. I think the committee's questions that they sent out this year in terms of the national performance framework was helpful to remind us that that was there, but it does kind of highlight the fact that, again, they don't really link into the draft budget document. Certainly the mention of national outcomes is there at the start, but in terms of specific indicators, there isn't much analysis of what's going well, what's going less well, and whether budget spending should be allocated in line with that, and I think that's an issue we might come back to. As I looked across the different indicators, some are improving, some are staying the same, some are going in the wrong direction. I think the two that caught my eye probably were some of the public health ones that are staying static, and the possibility that the committee might like to pursue the line of why is apparently there no progress on improving levels of physical exercise and smoking cessation in Scotland. Both things we'd like to see improving, but according to the indicators, are currently stalled, and is there a case for more government spending to be put behind moving those in the right direction? The main other line I commented on, given my role in the area, it was the New Medicines Fund, and just to remind the committee that I do have conflicts of interest in here as I do work with pharmaceutical companies. But I think the New Medicines Fund clearly responded to the debate you had in Parliament and the cross-party consensus that came out last year on better access to medicines. I think we can see, put in the historical context of about £10 million per year extra going into prescribing costs, the fact that the fund stands at £40 million shows what a difference that decision did make and will make. But there are still questions about whether that's the right sum of money, how the Scottish Government plans to stop medicines accumulating in that fund and it building up, and next year we need £80 million to go into it, and the year after we need £120 million and so on, and also bringing it back to the issue of health gain and how much are we getting for this money. I hope I've gone into those in a bit more detail in the paper. As I read through, I did notice I had a section 1 and 2, section 3, so having exhibited the inability to count to 3, I'm happy to leave at this point. Should the committee wish me to, convener? Otherwise, happy to take questions. Thank you both for those introductory remarks. Richard Simpson, I think you've got a first question. It's really a general question to open with, and that is not just the Christie commission, but really since 2001, Dr Walker said that he was involved with us and I was on the committee at that time. We have talked about a shift in the balance of care from the acute sector to preventive, and that this was fundamental to ensuring that we were at a sustainable health service. Do you see anything in this budget which actually evidences a coherent attempt to make that shift, given the additional impotence of Christie, which was absolutely clear that we were going to fail if we don't get this right? Is there any evidence in this budget that that's going to happen? I mean, I know it's, you know, some of it has to be level 4, you know, it has to be the health boards, but really unless there's a central drive for it from the parliament, from the government, from this committee, you know, we're playing at it, I think. So, you know, I wonder if you'd just like to broaden a little bit on that. Absolutely, and knowing Professor Simpson before 2001 will know that for the decade before that, we were talking about it as well. So, this has been an extremely long, long running theme. I think the best answer to the question that I can see in the document is probably the integration fund and the assumption that that by, because it will be linked to local government spending, that it will be community based services and therefore place the emphasis on getting people out of hospital. That's the clearest thing I see. But as you suggest with your question, some of this has to be implied, and I'm glad that the committee will come back and ask more questions in April when they see health boards delivery plans. I agree that there needs to be a central commitment. I guess in the Scottish government's defence, £70 million is quite a big chunk of what was available to put into that. I guess we would all feel a little more comfortable if there was a firmer commitment to what we will see in 12 and 24 months as a result of that in terms of something maybe measurable. But that, I think, is the best we can do with the draft budget at the moment. I don't know, David. I actually looked at some data from the ISD website. I did manage to find some on activity measures. It is quite surprising, it seems to me, how rapidly acute speciality throughput has been increasing over the last six years. So you take 2008 to 2014, inpatient stroke day case discharges have been growing annually at 2.1%, where, well, day case discharges at 1.9%. A&E has been increasing at 0.7%, and consultation with GPs has been increasing at 0.3%. The way that it looks to me is that acute throughput has been increasing faster than has, say, GP consultations and so on. In fact, the case may well be being made that the reverse of where the Government has been trying to go should be the one that is being followed. I am not saying that I agree with that, but it clearly, somehow or other, the system does seem to be focusing on the acute side rather than on other activity. There is a big section of the budget improving health and better public health. There is an increase of 1.3% this year, but if you strip out Family Nurse Partnership, which will all support evolve, it is a very interesting programme, but it is hugely expensive. If I said to one of my nursing colleagues when I was a GP, we are going to give you a workload of 20 patients. If they drop out, you will not have to replace them. They have bitten my hand off for that job, bitten my hand off, because it is not intense work with these families, but 20 as a case load is just extraordinary. If you strip that out, everything else is going down. The food and health budget has a huge problem with obesity. The food and health budget, down by 48%, grants to voluntary bodies, which are critical to delivery of many of the public health issues, down by 13%. Healthy working lives are static. I just wonder if that section of the budget, the whole thing about health improvement and health inequalities, is appropriate. I know some of it is shifting and we have got to tease that out because the keep well thing is being put into the health board. There is no evidence that the keep well thing is actually working. Would you like to comment on that section of the budget? That is the only identified preventive spend. There is tobacco and alcohol down another year, despite being a major problem. Tobacco has been flat for four years now, tobacco cessation. These are the big public health issues and obesity being the other one. I think I said in my written evidence that there is a question about if we could have put £70 million into an integration fund or a public health fund, I can see that there is a case for both of them. I think my instinct would have been towards the public health fund to tackle inequalities directly. I don't know what that would have done to health board finances. I guess that poses a choice for us, although whether we are talking about moving money from acute into primary care or from curative care into preventative care. The public health one would push us more towards the latter one, the prevention of ill health before it happens. The integration fund would push us more towards when people are sick, where are we going to care for them. I would distinguish those two, but I would certainly like to hear those cases more clearly argued and understand on what basis Scottish Government decided to bet the budget on the integration fund. I think that that is the key issue from this draft budget. I agree in the sense that what is missing here is the information that we need to clearly make the kind of decision that you are implicitly referring to. There is quite a lot of evidence that public sector costs and tax revenues are very skewed towards the real problem. The question is whether a case load of 20 would, in the long run, if you take everything into account, still be valued for money. It wouldn't necessarily be the best value for money, because you might have alternatives that would give you a better rate of return. But what we don't yet seem to have is the case that helps us to make that kind of decision. I want to make it clear that I'm not against the family nurse partnership. We're all committed to it. I think it's a valuable thing that's proven in America to be functional. Given that you have to make choices in budgets, it's a really difficult one to know whether we should be expanding that as rapidly as we are because of the costs involved. Dr Simpson started with a really important line of questioning. Every year we get to a stage where, actually right at the start, we say, are these the budget lines we should be looking at or should we wait till health boards set their budgets and is that the real scrutiny? My reading of this is that the political commitment is passed on by Barnett consequentials to territorial health boards for direct patient services. I think that SPI shows that it's a 1.1 per cent real terms increase in relation to that. More importantly, I think what we're trying to do as a committee is rather than looking at those numbers, which take the politics all out of it completely, it's how we spend the moneys. I'm just wondering if this is a transition budget because we've moved to health and social care integration and what I've no idea about is when I look at the draft budget for 2015-16 and I see £9.474 billion going to NHS and special health boards. The revenue resource allocation is what chunk of that will find its way into the first health and social care local delivery plans across all 32 local authorities and then what those priorities are. I don't know if this budget processing part is a little bit of shadow boxing for the real scrutiny that has to come ahead and in years to come whether or not the real robust scrutiny we need is to look at those health and social care plans at a local level. That's still a very important scrutiny, but other than arguing and debating about headline figures, I think that Richard Simpson made an excellent point about the family nurse partnerships, but what I would say is that the Government is accused of not thinking long term because it's very costly up front and you don't get the benefits for a generation or so. The family nurse partnerships are one of those actual initiatives where it doesn't bear fruit for a number of years, so that's the bind politicians find themselves in. I know I'm drifting on my question and my apologies, convener, for that. I'm looking for a steer, quite frankly, for the politicians to do the scrutiny, but you guys are economists and health economists. Where is the real detailed scrutiny that we have to do as a committee? Do you look at those headline numbers and how they relate to national performance frameworks and outcomes and targets and all that? Or do we already start turning towards health and social care integration? It seems to be the real big A at the moment. I mean, I think that the health and social care issue is critical because of the demographic change that we're going to see over the next couple of decades. We've got budgets, as I mentioned earlier, that are probably going to go in slightly different directions in the sense that health is most likely to be to continue to at least be stable in real terms, although we know that if current age profile of spending doesn't change, then it should be increasing in real terms just to stand still in terms of giving the same level of care to older people, for example, as they're currently receiving. On the other hand, the local government budget, which has already come under a lot of pressure, is likely to continue to come under pressure because it's unlikely that we can foresee a situation where there will be any substantial increase in overall spending. Indeed, it's likely that overall public spending will continue to contract for the next three or four or possibly longer years. You've got these two organisations that are being funded, whose funding profile looks a bit different, who are being asked to integrate and produce some new joined-up provision. It seems to me that that's going to be a critical aspect of the success of Scottish Government policy because it covers the two areas. It's a cross-cutting issue. It's not the success of the health budget, it's not the success of local government, it's these two together. It seems to me that there is an argument for looking at those in particular detail, and that would be a more useful exercise than the kind of exercise that we're going through now. Going back to what Dr Simpson said, the issue of preventative spend is also very important in those areas. It may be over a shorter time period, but how do we deal with older people to ensure that they don't end up with needing acute care for prolonged periods of time and so on? That seems to me to be an issue of great importance for the committee. From my point of view, I completely echo what you're saying, Vice-Covina, that 80 per cent of this is just going to the health boards, and we can't see that. I'm very glad that the committee comes and does it scrutiny in April because it's the only effective scrutiny that the health boards get of that. I think on top of that, as we all know, about 98 per cent of it gets spent on the same things as we spent it on last year, so we end up talking about quite small changes around the margin in the context of a portfolio that's controlling one third of the Scottish Government's budget and organisations within that, like NHS Greater Glasgow and Clyde, which have budgets bigger than some portfolios that will receive parliamentary scrutiny. So that the whole thing does get a bit skewed around. I think some lines in here are very important and interesting, and it certainly merits some of the committee's time to look at those. I think the key debate is the one that Richard started, integration, public health, new medicines, where's the balance, given that those are all three things that we would like to spend money on, where is the balance between those. I think that's a really important thing to look at at this stage. I think the amount of time the committee devotes to looking at the health boards, and presumably this year, to the health and social care partnerships, as you say, is appropriate. But if I cut back a little bit on the time you spent scrutinising the national budget at this stage, I might devote it a little more to the performance framework and the number of targets and indicators there are, because as I did my background work for the committee meeting, I found the national performance framework, various iterations of the data. I found a website called Scotland performs, which may or may not be the same thing. I found the heat targets that we know about from the NHS and reading the SPICE briefing I found out about a thing called the quality monitoring framework. I'm not sure whether those are all overlapping, whether they're intended to overlap or integrate, and I think maybe the committee's spending a meeting or two just getting to the bottom of that and maybe encouraging Scottish Government to demonstrate to those outside of Scottish Government how these link together and make them a little bit better. I think that that does take you somewhere with our scrutiny. You mentioned the integration fund. You mentioned the new medicines fund now in the year coming up. That amounts to about £111 million, if you add those numbers together. That's a significant amount of cash, but I still suppose that, in the greater scheme of things, a relatively small chunk to that headline figure that territorial health boards get, although I take the point that you're making a lot of those costs are fixed, so the room for manoeuvre there. Would one of the main rooms for manoeuvre be, as I think you've suggested and Dr Simpson suggested, reviewing the targets that the territorial health boards have to meet, whether that is in terms of surgical procedures and inpatient and outpatient waiting times? In any review of that, that would surely have to be twofold. It would have to look to see what patients are looking for for outcomes for the NHS. In other words, does 18 weeks make a significant difference to someone for a hip replacement compared to 16 weeks? I just use those numbers off the top of my head, but if it didn't make a significant difference, can you monitorise the cash saving to have that extended time and therefore the cash release to then put the money somewhere else? You could only obviously do that if there was patient support, because it's a national health service for the people that we all represent. So yes, we can do the consultation with patients groups in the NHS and our communities and constituents and government and the committee can do that. But I suppose what we need the health economists and economists to do is to monitorise what the cash release savings would be for any decisions that the Scottish government would take, that we would of course scrutinise, convener, to get cash out of that suite of targets and outcomes if we rearrange them or slim them down and we have the public support if they know how we're then redirecting that cash. Is there any work on that you could point us to, or is it what you'd be itching to do? I'm just about to agree with everything you said up until the last statement. Wow! OK. PhD length piece of work. No, but to come back to the bits, I completely support that. You know, one thing I really welcome that the committee has done in the last three or four years is step out of this annual scrutiny at this stage and start to look at what the health boards do as well. I think that's a terrific advance. And I think the sort of thing you're proposing where you look at the targets as well and whether they're set at the right level, whether they carry cover the right range of things. And I guess also noting things the BMA might say in the second session how they are actually, whether they appropriately drive decision making at local level. I think those would be excellent areas for the committee to have. I would suggest almost as an annual item and maybe give up some of the time you spend looking at this fairly arid, you know, level two and level three document at the moment. You asked a specific question about whether I was aware of things that would monetise those targets. The answer is I'm not. And it speaks to the fact that I think both Professor Bell and I have alluded to in our evidence that we really don't have a lot of the data that we need to help us make decisions. We would like to know if you set the time to treatment target at 18 weeks versus 16 weeks versus 24 weeks, what's the cost difference of that? Scottish Government might have that information. So what we might be talking about is structuring some questions for Scottish Government to provide the evidence that the committee then considers and scrutinises. I'm not aware of any independent economists working on that unless Professor Bell is about to surprise me. I'm not. And to make a nerdy point following up on Andrew's last remark there, it may well be the case that not all weeks are equal in terms of cost. So, you know, if making the going from 12 to 18 may cost you X, but if you went per week, but if you went from 12 to 24, it might cost you quite a lot less because you're not having to put people out to say private providers for the necessary care just to make that particular target. So it's not the average that we're interested in, but it's how much you have to spend right at the margin to hit that target that you're interested in. Thank you. Just following up on some of that. I think we've had a bit of a debate about the boards and that scrutiny still to come. But when we look at the recent debate which became public, which was a leaked report of those people who are actually running the service, it isn't simply an allocation, is it? Because they complain bitterly that the introduction of new legislation places binding financial resources and obligations on the NHS boards. They complain about policy decisions being made which require boards to prioritise additional investment in acute care and we have seen that that is increasing in conflict with the 2020 vision. The draft budget, where is the big messages there, of course, and boards and politicians and Governments come in all guises and you make the point in your submission, Dr Walker, about the drugs bill that we got caught up in. But there hasn't been any real evaluation about whether that money is well spent or indeed the provocative point. Professor Bell made about should we invest in childcare early years or mental health. There's no real evaluation on that. They come to the conclusion that there's a £400 million, £450 million additional savings required to meet some of these challenges that have been faced by boards. They all have an impact. It's not just a budget allocation, it comes with all sorts of catches and clauses and demands, which are not very open at all. Indeed, those discussions are taking place with Government and the health board managers in secret. It's a question of governance, it seems to me. How do we run this system as a whole in a consensual way that everyone understands and accepts? It's a really difficult problem because politicians often want to interfere. There's a question about how democratic are the boards themselves. How do they come to make decisions? What would the public accept in terms of how far they would like to see politicians interfere with the processes and so on? Given what Dr Walker said about the different sets of targets that are out there, as a health board manager it must be a very difficult space to live within. When the committee looks at the health board's plans for next year, there will be a chance to try and quantify some of those targets. I know you tried to quantify the prescribing uplift, etc. Maybe scope for a broader question about other cost pressures, because we want to see the evidence base for those. I'm aware, as you are, convener, of the £400 million figure. Obviously, I don't know the detail of that, how that was arrived at. That would be interesting to know whether the committee wants to wait until April next year when the board's scrutiny is planned to find that out is another issue. I think that that would be very important to know and to find out the pressure, whether the 3 per cent savings target to come to one of the seven questions you asked, whether the 3 per cent savings target that is imposed across the public sector is going to be enough, whether the £400 million figure implies it should maybe be four or five per cent within the health portfolio. I just want Scottish Government's reaction is to that figure, whether they accept the figures and agree with them, yes or no. I think that these are very important, but my frustration with the budget document, and I think I agree with you on this, is that it doesn't give us any of that information at all and neither has any previous version of it going back to 2001 either. It's a frustrating business. The paper was released to us by the Government and you may ask for it. It's £100 million in pensions, changing access to drugs as projected to be £50 million in 2016-17. So they have applied some figures here. We have a political consensus, of course, on progress or lack of progress on the 2020 vision, but we don't see that political consensus across the Parliament, across the parties, by Government itself being reflected in the draft budget in terms of the priorities to push this through. In fact, the contradictions of the case that we're still investing in beds and staff and buildings and hospitals. As I look at the Parliament, obviously as a voter, as somebody who comes here and advises and things like that, I think one of the terrific advantages is the cross-party consensus we have on so many aspects of health policy within the Parliament across parties and that things are not usually controversial. Most of the fundamentals we agree about, I think what there isn't a consensus on is a sense of priorities. So everyone agrees integration is a good thing, everyone agrees public health and prevention is a good thing, everyone agrees more access to new medicines is a good thing, but what do you do when you can't have all of those three things? Which one of those is the most important across parties? That's the part of the debate that's still missing. Everybody quite likes hospitals, but everyone quite likes primary care as well. So when you can't have both, which do you choose? And I think it's that debate that I guess I'm still waiting to happen in Scotland. I listen intently to Professor Bell and Mr Walker. Can I turn to Mr Walker's comments in the written submission that you've given us? If you bear with me, I'd like to read into your record some of the points that I've highlighted. You've been reading the draft budget since 2001, doing each year. Another decade long problem is the lack of any link between planned spending and planned outputs or outcomes, and this stifles debate about the allocation. The debate falls back on sharing the cake and roughly is in line with last year, a little more or a little less than others. Debate goes on, not beyond how great are the pressures and anything like to go seriously or wrong before we do anything in 12 months time again. However, we end up with a pattern of spending that's probably different to the one where we achieved the maximum health gain, and the last paragraph I really like, and this is the point that I want to ask you. To repeat, this is not a criticism of the present cabinet secretary or the Government, but rather a frustration with the way the Scottish Government and the Scottish Parliament is setting into a pattern of accepting this as a norm. I invite MSPs to reflect on whether we should have a fuller debate. Basically, along with questions that Richard Simpson, Bob Doris and the convener have made, do you feel that we should have a fuller debate on health of all the parties on the way that we project for the next 10 years how we're going to make spendings, or should we do as previously a lot of people have just done thinking about at the edges? I think I welcome your question. I think a case can be made for the incremental approach that essentially you would be getting into some massive issues. Bob Doris asked me a question about sort of spending on various levels of waiting time targets that would be, you could have a guess at, but to do the detail work might take months, frankly, to come up with the answers to, and you would ask some really fundamental questions. So the alternative is to do the incremental thing to maintain public confidence in services, but to leave it a lot of the decision making to local people. Or does Parliament try to become a little bit more interventionist in this and to look for, as I say here, links between the spending and the outcomes. So what are, what is the health of the population? What is the health service going to look like in five and 10 years time as a result of what we're doing today? And at the moment, you know, yeah, we've got the 2020 vision, but it doesn't quite link in with the budget document which stands alone and that doesn't quite link in with the national performance framework which stands alone. And I'd be very happy to know that some people in Scottish government have an overview across all these things. Of course, you'd expect the Cabinet Secretary and the chief executive to be in that position. But to have it there for outside consumption so there's an integrated plan, the different parts seem to stand alone. And I guess my paragraph that you read out kind of came from the heart because it's why I'm not the advisor again this year because it's been just a frustrating experience of dealing with fairly arid documents that don't really give us the information we need to have the discussions we want to have. And, and lead to the sorts of issues that the convener led me to a minute ago where we're not really choosing between different priorities, integration versus public health versus new medicines because we can do just enough for each of them to keep them going. And I come back, there is a political case for doing that. That might be a perfectly respectable thing to do. But is it the one that's going to give us the best long term outcomes? Professor Bell, you made comments away at the start about this has went up, this has went down, all the different figures, all too often political parties, battery, and I suspect the comments made by Dr Simpson earlier on. Political parties throw at each other. We spent more than you last year and we spent less than you or whatever and your targets have went up, your targets have went down. Are we too focused on so much on targets that we forget at the end of the day? At the end of the day, we have one of the best health service in the world and we have to rationalise in one way that we go along with the staff and the people who work in it in order to help them and also to help the situation that our demographics are changing with the elderly. We are all getting older, none of us are getting any younger. Basically, in ten years time, I may need that situation of going to the health service. I am very seldom, I am in a hospital. I take pride in the fact that my doctor sees me about once every seven years. The situation is that we are all getting older, so should we nationally, everyone, including yourselves, be looking at the whole situation of the national health service in order to make it better for the people of Scotland? I agree with your first point about sometimes the batting about relatively small numbers is not a terribly useful exercise, it seems to me. A very large resource is being put into the health service. Probably at the margin, a small change matters less than how efficient the system as a whole is. As this debate has exemplified, we are not in a terribly good position to know how efficient the system as a whole is. We have a reasonably efficient system, but we also have some very bad health outcomes. We still have levels of life expectancy that compare poorly with other parts of the developed world. We do a lot in terms and we are good at interventions both in health and in social care, but we still have overall, and we have had not all that much impact in a relative sense on these outcomes since 2001, where we started debating the budgets. It may be a silly question, but if in 2001 we had said, right, okay, 3% savings a year have to be made, which we have been doing almost continuously, 1% of those has to be applied to public health instead of just going back into, every time, either to the government as it was at one point or back into the health service to be used for the acute service. If we actually directed to that extent centrally, on top of the integration fund, so that would be a separate thing, then would that be something that would be worthwhile doing? Because it's not directing them precisely where it should be used, but they must do it in the most evidence-based effective way. But if you said you can't just put it back into acute services, you've got to put it at least 1% of those 3%, it's got to go on that. Would that be? I think as you've illustrated yourself, not everything done under the banner of prevention is cost effective or particularly effective, but nevertheless I would welcome the point you're making. If we assume that roughly on average, the NHS budget in that time was £10 billion, then a 1% saving would be £100 million per year, and I think that would make a substantial difference to some of the public health indicators that we've seen. So I would personally very much like to explore that option, being careful what it was actually spent on. I agree with Andrew there. I think that we need to educate people and the press about the importance of public health measures and that the beneficial outcomes may take place over decades in the future, and that is often quite a difficult sell. Journalists sometimes draw the distinction between the deserving sick and the undeserving sick who've bought it on themselves. I put the quotes around it with my eyebrows. Most of this spending will be devoted to people who have fallen to what the press would regard as the latter category, and I think we have to bear that in mind as well. I understand it's hard when you have a child with a genetically inherited condition who is in no way to blame for their condition, who needs a medicine, and we're putting the money into maybe drug prevention programmes. These are difficult issues. I don't think anyone pretends they're not. Lynette, please. I think we're all very committed to the basic principles of NHS, that patients should have their healthcare as they need it for the point of delivery. But how sustainable do you think the current system actually is, and do you think it can be sustained into the future? I'm optimistic on that point. My history of studying the health service goes back to about 1990 or something like that, and I would say, out of those nearly 25 years, for at least 20 of those, the NHS has been in some form of a crisis, and people have been talking about the fact that it might not be sustainable, and it's underfunded and gaps are building up and stuff like this. You could find almost exactly the same speeches in the 1990s that we're hearing today about it won't last much longer unless something dramatic is done. That's not to say there isn't a problem. That's not to say there aren't pressures, but it's to say there always have been pressures. The only gap I would see in fairness was in around 2002-2007 when the Labour Government put resources into the health service at a rate I don't think we've seen before, and possibly never will again the way the economy in the UK is looking just at the moment. But it did give a level of resourcing to the health service that arguably it couldn't absorb very well, but it did give a level of resourcing that took those pressures away. So I think it is sustainable. I think we've got a very, it's a weird thing. In a way we've got lots of fixed costs within the system and lots of fixed elements, but it's also very flexible. People are just, people are dapped. We rely on the likes of Richard Lyle to only go to his GP once every seven years to keep us all, keep enough space for the rest of us at the GP system. The system is a very flexible and adaptable one. The principle at the end of the day is a system that is largely funded by the taxpayer to pay the bills and to have the services provided within the public sector. That's quite an adaptable idea and it stood the test of time. So personally I'm optimistic. I think it has been interesting how the last five or six years compares with that period 2002 to 2007 when money was being thrown at the health service and instead now money has been, it hasn't been withdrawn but it's been much more difficult to see new resources coming into the health service. So in a sense that's evidence that it is quite adaptable that that has happened. Interestingly the issue around costs, so why has the health service managed over the last five or six years partly because wages and salaries have been much more restrained than they were in the 2002-2007 period. I've seen an article recently that suggests that in fact over this whole period of time wage costs in the NHS haven't increased more rapidly than those in the economy as a whole. But what is important and affects costs is that the health service is unlike your standard manufacturing enterprise where as you use new machinery you replace people. In the health service as you introduce new and more sophisticated technology you switch from relatively low qualified people into more higher qualified people and that actually just in itself that changing mix drives up wage costs rather than wages per person being driven up. One area that I think is still however where I'm not necessarily optimistic is around the social care aspects and the costs of those. We have free personal care in Scotland that doesn't mean free care and that is an important distinction to make. No country has all that effectively set up a long term care insurance system but we do have issues and will have them increasingly as the population ages of effectively people with dementia having a quite different outcome financially from those who have cancer. That I think is still an issue that we need to think about. What does equity mean in those circumstances? This is where adaptability has to come in and look at maybe different ways of providing services for the increasing number of people who are going to need increasingly complex services. I think about doing some work in comparisons of England and Scotland in respect of social care. It's not obvious to me that it's necessarily the case that Scotland is more expensive because of the effectiveness of the free personal care policy in respect of keeping people at home but we have to do the work on that. I suppose that contradiction there as well, things get more technical or highly skilled in the acute sector and the cost more as we push out that other level of care either in the acute sector to nurse assistants or in the community to carers etc etc. It's the opposite that's in place in terms of driving down costs and it becomes a driver to push out the acute sector into that because it is cheaper with all that goes along with that, sometimes impacting on quality, sometimes on the patient experience but not always but on the people that are delivering that care. Accelerates are inequalities, it accelerates the problems associated with good wages etc. If you roughly, these figures are not necessarily absolutely accurate but of the right order, a week in a acute ward, say the average between that and geriatric, maybe £4,000 per week, a week in a care home £600-700 a week and then you're paying somebody maybe £40 hours at a cost of, £7-10 an hour looking after in their own home. Clearly those are not complete substitutes but working at the margin if it's possible to move things to lower cost outcomes it can make a huge difference. But one of the big barriers is that it's hard to take the £4,000 out of the hospital because the £4,000 is the fabric of the building and the staff who work there and we're not planning to take any of those out. So part of the block that come back to Richard Simpson's first question about is that it's so hard to take money out of a hospital structure. Does that, in terms of focus on the 2020, and some of the criticism that you had about recording information, comparing outcomes and performance levels etc, does there need to be some sort of review of that whole system? So the information that we are collecting is useful in terms of describing the outcomes with things and getting better or worse or whatever and how we can improve them. And I suppose financial planning for all of that and the third question is should we just be doing that in the health service or do we look at health and social care well-being? As a new model, we're just looking at health here and we know from our previous work that while health is dealing with a lot of the outcomes, dealing with this issue is much more complex and it's about people's life chances. Bring them there earlier or later or whatever. Are we just looking at this? You're just in a box. Even within the box do we need to look at that in a more simplified way? Do we need to review the performance, understand the performance in financial planning and needs much better than we do now? Is that something useful that you could do? I mean if you were, as Andrew said, maybe the way of incremental budgeting that we've done since the inception of the Parliament is appropriate, but if we thought that wasn't appropriate and you went to a zero-based budgeting approach, would we have information in place that would help us or inform us how it would be the best way to go about that? And it's not clear to me that that kind of information is available and I think the committee could do an important job by trying to have a look at what kind of information those people who might plan the system somewhat differently would need to be able to take that kind of plan forward. In relation to the health and social care interface, I'm doing some work with the Scottish Government at the moment on the first joint dataset that has been made available, which integrates social care information with health information. There are people from all over the world who think that this is really innovative because basically other healthcare, stroke, social care systems haven't got as good data as Scotland has, but we're just at the moment scratching the surface in relation to this. And I think it has huge potential in positioning Scotland as one of the leaders in terms of the way we understand this integration between health and social care. I wouldn't necessarily advocate a bonfire of the indicators, convener. I don't think that's what I'm suggesting. It could be tempting to say that we've got 120 indicators in total, that's too many, we only want 20. But part of the fascination, I think, for all of us involved in scrutinising health is its multifactorial nature going right the way through from very simple public health interventions through to very complex hospital-based things for very sick people. And you need a range of indicators to catch all of those. I think my frustration at the moment is they're all put under one heading. And if we started to think of them in groups like the public health group and the healthcare experience group and other groups like that, then that would be a way forward. So when we look at things year to year, so when I looked at the performance indicators for last year, it looks as though a lot of the public health things are stalled. If you look at the trend, it's actually in the right direction, but there's not much change year to year, and we should probably put those to one side and say, let's only look at those once every five years or something like that. And let's focus on a different set. So it's having different sets of indicators more clearly for different purposes, where the clues to what they do is in the title, and they don't have very general titles like quality monitoring framework and heat and things like that, because that doesn't tell you what's in there. So I would keep probably the range of indicators, but have them more clearly grouped for purposes. And I would definitely think about the integration of data systems across the health and social care divide, because one thing we do know, and as we're demonstrating with the draft budget document, is attention tends to go where the numbers are. We're focusing on the 20% of the budget where there's the numbers, because we don't have the numbers for the other 80% of the budget. If we get that equivalent situation in health and social care where all the information, let's say, is on the health side, despite Professor Bell's misgivings about ISD and their contribution, and there's very little on the social care side, we're going to end up with a skewed debate about what's going on. So I think it's really important that we get those integrated data systems from the start. What's going to be happening in the decades time is important to understand that we're on a journey. And Bob mentioned the problem of poor politicians who need to deliver on a five-year scale. A hospital manager, a chief executive, is judged annually on some of these things, and all of these in the care. I think that approach is open to challenge it, and my idea of grouping them would be more clearly about if something is going wrong in the system this year, that leads to a waiting time problem for instance, and that is something which should be setting a red light flashing. The fact that physical activity in a population in a particular health board didn't go down from 2011 to 2012 is a long run warning, and if it didn't happen again in 2013 and didn't happen over five years, you'd be worried about it. But it's how quickly it triggers a response, I guess, and making everyone in the system aware of which ones are the ones where there will be questions asked within weeks if they're going wrong, and which one, frankly, we're talking about a five-year timescale. I think that's the essential difference between these things. Is there any other questions? Can I express the committee's appreciation for your attendance here and your submissions, and thanks very much indeed. Thank you. The suspend at this point, until we sit up and have a bit of round table. Our agenda, which is number three, the continuation of draught bridge and its scrutiny, we now have a round table of stakeholders. My name is Sam Camille, convener of the Health and Sport Committee. I'm Joel Vickerman, I'm the Scottish Secretary of the British Medical Association. Richard Simpson, MSP Mid Scotland in 5. Hello, I'm Annie Gunnar-Logan, director of the Coalition of Care and Support Providers in Scotland. Convener, I should state for the record that I'm also a non-executive director of the Scottish Government, but I'm not acting in that capacity today. Richard Lyle, MSP Central region. Good morning, Llyr Llyr Mesa, unison Scotland, convener. Colin Keir, MSP for Edinburgh Western. I'm Kim Hartley, representing the Allied Health Professions Federation in Scotland. My name is Milne, MSP for North East Scotland. I'm Rachel Cackett, and I'm a policy adviser for the Royal College of Nursing in Scotland. I'll kick off the general question, and hopefully the members will understand that I always give our panel members precedent here before I'll give them the opportunity to ask questions. I suppose the general question will be as the allocation of resources in line with the Scottish Government's stated priorities are set out by the draft budget. Who's going to be first? Rachel, please. Thank you, convener. I feel like I should somehow justify my invitation, which is very welcome to come and give evidence by saying something new. Having sat through the previous session and having come and engaged in these conversations before, it's sort of hard to find the thing to say that's quite different from what's been said before. In a simple answer to your question, I think the answer is I don't know, and I think that's probably what you got from your previous speakers. What I would welcome is I think where I heard the conversation going in the first session, and I do think we have a set of documents in front of us that probably set up a set of parallel conversations that should be joined up, and it's that joining up that I welcomed in the earlier conversation. We've obviously got a set of documents that give us allocations within an envelope of money that's available, and on that basis we have to acknowledge that the NHS budget, the health budget, is in the fairly privileged position in the context of fairly straight and public sector spending. I think it's also worth noting that there isn't much change between the 2015-16 proposed budget and what was proposed for 2015-16 in last year's budget, but I think it easily pushes us towards that discussion around allocations at the margin and whether the budget lines are right. The information that we have doesn't allow us to have a very easy conversation around the bigger issue, which is the second conversation in parallel that should be joined up, and that is how do we create a sustainable and quality future for health and social care in Scotland. That is a conversation that can't be at the margins, and that's why I welcomed the discussion that the committee was having earlier this morning. I think those aren't discussions around small changes in individual budget lines. I think they are discussions that we need to have with the public, with staff working across all organisations, with the various political parties, around how do we take into account not just where the allocations are, but how those are then reflected and how we meet demand. How we meet expectations of our services. How we meet the cost of very welcome developments in technology that Andrew Walker was talking about extensively this morning. We've discussed how to have that robust and transparent debate before. I guess we are in a different position now that in the past few months we've seen civic Scotland engage in discussions around the future of Scotland in a way we may never have seen before. I suppose that my question is if we can't get that discussion on the table now, then when. That seems to me the question in this that we really can't quite answer from the documents that we have. Anyone else? Arnie, name Kim. I agree with Rachel that there's a sort of Groundhog Day element to some of this. I was looking back at the evidence sessions from the last two years and again I was struggling to think of what I might say that's new or different because I think a lot of these issues are still with us and are quite intractable and that's come out in the previous discussion. With your other witnesses, from my point of view, it's the social care element of this that is of most immediate concern because my members are delivering social care rather than healthcare. Once again, I'm drawn to the budget document talking about health and social care in Chapter 3 and then only talking about the health budget in Chapter 3 whereas Chapter 15 is a local government budget and that's where social care has always come from and probably will continue to come from. It's very much the last discussion you had. I think Professor Bell was absolutely right in saying that it's at the local level that this will or won't be resolved and so the scrutiny of the health and social care integration authorities is going to be extremely important in relation to the targets that we have. And yet another thing that I said last year that I'll say again as well which echoes your previous evidence session is around the plethora of targets and outcomes that there are. Your witnesses mentioned the national performance framework outcomes and indicators and the heat targets but we also now have national outcomes for health and social care integration which may or may not link to any of the other two. You've got single outcome agreements at community planning partnership level and then you've got care standards which are under review as well. So it's not just the ones that were mentioned before there are all of these targets and outcomes and it's very difficult then to figure out which ones are the priority, which ones are national, which ones are local and how you actually marry up these budgets together. And as well as that of course you've got a whole series of policy initiatives such as reshaping care for older people, shifting the balance of care. So if your question is, you know, is budget allocated appropriately to priorities, I think you first have to figure out what are the priorities in effect and they might be different at different levels and for different organisations and I mean in effect that's the challenge of integration. Thank you for the opportunity to come back for a second year, just our second year to talk about where HPC this budget is even though it's just a second year for us, it's a bit of a groundhog day but really to pick up on the points that quite a few other people have said, we can't tell, the Federation can't tell how this budget is going to play out for services. The current trends are definitely not encouraging. The impact that this will have on either the targets or the aspirations or the experience of patients will all depend on the awareness and buying at a local level really of awareness and buying to the value of HPs in local authorities and in the NHS. From the HP perspective, the money definitely is not shifting at the moment and as I said, we can't even tell from the figures that we've got that things just don't look very good for us. If we can take some of the table that was held at the end of the spice briefing, table 5, which tries to align the expenditure lines with the different commitments within the budget. The one bit of budget that we are mentioned in, which is about the end map budget, which has in fact been cut, is meant to cover nursing, midwifery workforce and workload, which is obviously fantastic but they're just part of a much larger workforce. We know that it's to cover all the health visitors, so increasing health visitors, so that's us not getting a look in there either. The other budgets are important to us, things like e-health, tiny amounts of money going to the source of value that HPs deliver. We know just from those figures that it's not good but the trends in the health boards from previous years and health committee knows this doesn't look good either from the funding from health boards or from local authorities. I think we are sadly not in the, a lot of the previous witnesses and a number of people talked about information. I think it would be, it's really important to state that we, the level of data that we have on the productivity, the experience, the performance, the difference that HPs make anything and waiting times. Waiting lists, anything like that, the inputs. We don't, we don't have a clue about that at national level, so being deciding what impact the budget is going to have for those, for the care groups that we work for and that the major input that HPs have, we don't have the intelligence. So we can't, neither at central level or at local government level, do we have any means of telling, you know, they don't have the intelligence that they need to use the money effectively for HP services. So, yeah, really I suppose we can't tell but it doesn't look good is the short answer. Thank you very much. I appreciate that the BMA has had the invitation to speak here before but this is my first opportunity to do that so I can't repeat myself from the last time but I will try to not repeat too much of what others have said because I do agree with a lot of the comments that have been made but instead to try and build on that. I think in terms of the answer to the specific question, like others who have commented, it's very difficult to tell whether or not the allocation is in line with Scottish Government's aspirations. I think that the conversation that took place earlier this afternoon, this morning about whether or not you can change the high-level budget lines to drive change in the way that health services delivers is slightly worrying. I think that our perspective from the BMA is that we really are actually in different times now. There are significant and very worrying pressures across the health system. I don't have the same level of optimism that if we carry on doing what we've always done, we're going to be able to manage to do that within the approach to budget allocation that we've currently got at the moment. I think that the point that Annie made is absolutely right. This requires a stand back and an assessment of how services need to be delivered in the future before a decision is made about how then budget lines are applied to them and at that point we might be in a better position to see something about whether or not we're applying budget lines in a way that reflects the aspirations of Scottish Government. The BMA, like many other stakeholders and ourselves, entirely supports the high-level aspirations in terms of the 2020 vision, but we don't yet see the way that that is being played out in terms of the approach to delivering services, the way that health boards are able to make decisions themselves locally. As again others have said, it's really important to free up that ability to make the decisions locally about how to pursue that vision. The pressures that central government are putting on health boards through the existence of targets is diverting some of the ability to do that. As I say, in terms of the specific question, it's not possible to tell at the moment, but it's a serious concern that the range of pressures that exist and the lack of flexibility does not allow underneath the high level of budget lines for resources to be applied in such a way that they will achieve the aspirations. Lillianne Lennon, thank you for the opportunity to have the debate and the discussion on the budget and the proposals that are related to that. One of the things for Unison, in terms of Unison Scotland, we are probably from the staff side organisations in a very unique position where we organise not only in health but have significant membership in the local authorities. For us, we see that as not a challenge but an opportunity around health and social care integration to bring both of those workforces together in relation to delivering better outcomes for the population of Scotland. We see that primarily as an opportunity. Again, not to disagree with what colleagues have said in the room, there are significant challenges for health boards in Scotland for me. I suppose that I need to declare an interest. I'm not only Unison Scotland convener but I'm also working in the health service and indeed a board member as an employee director within NHS Lanarkshire. I've got very practical knowledge of how budgets are allocated within the health systems and how those are delivered for the population of Scotland. The desire to move the budgets from the acute provision of care, we heard earlier the discussion about the continued investment in acute, not only in beds but in facilities and indeed staff. I would suggest that one of those opportunities in terms of that is around the investment in staff, which is absolutely crucial to the agenda for delivering health, social care integration but also health services in Scotland. The one thing that you can absolutely guarantee is that investment in staff is not a wasted investment because those staff have transferable skills that can move from an acute setting into a community setting. Therefore, that is an excellent investment, I would suggest. In Unison's submission, we have laid out some of the areas where we think we should be looking in a bit more detail and I would very much welcome that debate and discussion this afternoon. We heard earlier this morning that this situation and the crisis in the health service has been around since we've been around. Even when lots of money was going in, there was a crisis and it hasn't brought us down yet, so what's different? There clearly have been peaks and troughs over the course of the last 20 years and no doubt more than that in terms of the sense of crisis and the levels of morale and the concerns that there are among all the different staff groups involved in delivering and planning healthcare. What we are seeing in doctors at the moment are some very specific and new problems that are hugely concerning. We have in two of the health board areas over 20 per cent vacancies and consultants. We've never seen anything at that level before. We have a weekly crisis to deal with in terms of whether or not a GP out of hours and accident and emergencies units are going to be properly staffed. We have some significant problems in terms of filling partner posts in general practice and we've got some real issues about trainees choosing to train in Scotland and fill our training posts. Those are levels that we haven't seen before. Andrew and David talked at some length about the range of different factors that are contributing to the pressures on the health service. Those have come together in a perfect storm in a way that we predicted but we haven't had the economic pressures, the level of population change, the increased life expectancy but with increased levels of multimorbidities. The pressures of the expectations and the behaviours of the public are all coming together in the way that they are right now. We are genuinely seeing on the ground through our members a very significant difference in terms of what has been experienced before. We've got levels of planned early retirement where we haven't seen them before so we can see this continue to get worse unless we have that very honest debate about how we change the way that services are delivered if we're going to continue to manage to deliver high quality services in Scotland. The whole demography demands we do things differently that we have to have a different model to not letting people get ill and if they are dealing with them in much more providing care and much more efficient, further away from that expense of acute care. The whole agenda around shifting. I think the patient expectations, the needs of the population have changed but the political expectations and needs have changed and become a lot smarter in terms of, as you said earlier yourself, there's a consensus in the way that we should need to be delivering care but although we've got that impetus we've not got the actual change on the ground because we're not changing who and how we're making decisions. That's why the crisis is getting more and more acute. I mean I do think we have to bear in mind that one of the reasons that we're facing this very particular crisis and I'm not going to repeat what Jill has said and I think that is a fantastic summary of why we're here is down to the success of what we have done over the past. We do now have much longer life expectancy though that is not always good healthy life expectancy. I think some of the figures that were in the report down south on the five year plan when you're looking at cancer survival rates are significantly better but that does place an additional strain on the NHS in terms of healthy life expectancy and how long people are living and how people who are frail into very old age require very complex services so I do think that is a real addition but I do think we have a real opportunity here because there are really creative things that I think we could be looking at to how we deal with some of these issues. So Jill was talking about some of the issues on recruitment. Now that's an issue for many parts of the service but I know when the Auditor General reported on issues in Orkney and we have issues in our remote rural areas that are very particular sometimes to the recruitment of staff, how we're dealing with that specialist input that we were talking about in the first session as things become more complex so you need more specialist input. But also there are really creative ways about how do we think about what this workforce of the future will look like, who has to be doing what, do we always have to rely on the traditional models that we've had in the past or actually do we have skills that are spread both through the professional workforce but also how we take into account people's ability to and desire to manage their own care, the role of carers. We need to be doing this in a very, very, very different way rather than simply throwing money at what we have known and that I think is the big discussion in terms of sustainability and quality that we need to be having rather than simply looking at where the gaps are and saying how do we fill them in the ways that we always have. Bob Doris. I suppose just kind of briefly, because we are scrutinising a budget document and I'm listening very carefully where the BMA has made powerful cases before in terms of recruitment retention and filling vacancies across a range of specialities and they've spoken about distinction awards and the 911 rota system. So those are on the record before and I've met with Cymhack and other colleagues in relation to how allied health professionals can help to support a seven day service and stopping daily discharges and a variety of other things. These are like workforce management, workforce planning and skills development and all those things and I get all that and I know there's a number of work streams on going and this committee could look at those as a standalone but what we have in front of is a budget document. So I suppose it's how we tie in a high end budget document to if you like the concerns or the comments that you're making here this morning because we look at a budget document and we go oh it's a 1.1% real terms increase to territory of health boards budgets. That becomes meaningless in itself. It all depends how that money then feeds in and what it's spent on. So can we read anything into it? As much as I totally respect and take on board all the pressures and tensions and stresses and strains in the system that you bring here today, how do we tie that into this if you like headline budget document? In the obvious question we always ask convener every single year and this is deja vu for everyone who's been at this committee over the years is you can't spend the same pound twice which is obviously why the conversation earlier on headed on to will what might you not do? How might you reprofile some of that expenditure? How and that's why we're talking about targets and outcomes and then other savings from that and can you redirect that? So as always we do it this time of the year convener. How can we look at this headline document to the specific concerns you have or do we have to wait to later on where we look at NHS boards setting their budget and what would you do differently? Apologies for everyone who's heard this question again and again and again. It should mean that you've got pretty slick answers for it I suppose but we do have to ask these questions. I think that's the right question to be asking and my answer to it is always look at what's in the budget that will leave a change and we heard from the previous witnesses that there's the integrated care funds, there's the resource going into support integration out of this budget but if you look at chapter 15 again we hear from our witnesses that it's the local government settlement that's going down. So social care will be under much more pressure than NHS services and I don't think £100 million worth of an integrated care fund is actually going to make up for that. So I'm always very interested to look at what is it in the budget that is going to push forward that change. There's something in there but it's not quite enough in my view, it's the scrutiny of what the health and social care integration authorities do next which is going to be answering your question and what stimulus is given to them to do things differently. To go back to my point about targets, if you're a health board and you are very seriously performance managed on things like treatment time, waiting time guarantees then you are probably going to prioritise your resource to meet those targets. You're then going to look at the national outcomes for integrated health and social care and you're going to see a number of aspirational outcomes such as people who are frail are able to live as far as reasonably practical independently as at home and you're going to look at that next to your treatment time target objectives and say which of those am I going to prioritise. So there's a bit of confusion in here about exactly what the objective is and how far that's shared across the different agencies that are now being expected to come together to deliver some of these things. And I'm not convinced that the levers that are in there in the budget are sufficient to drive that. What we'll see is joint strategic commissioning locally. I mean we had a bit of a discussion there in the earlier session about incremental budgeting versus zero based budgeting versus outcome budgeting and it seems to me that what health and social care integration authorities locally are being expected to do is what the government is not doing in this budget. If this is an incremental budget joint strategic commissioning is supposed to be about not quite zero based but certainly outcome budgeting so that's where the focus is but this budget doesn't do it itself. I'll go back a little bit to the answer that I gave at the very beginning to the first question which is that there needs to be a piece of work done which we do not underestimate the size of this and it really goes back to what Rachel was saying earlier about revisiting how we deliver healthcare services. It is not possible, as the leaked paper that was discussed with chief executives in the Scottish government, to continue to do what we're doing every year and have a marginal increase in the health budget and be able to sustain the delivery of healthcare services. For me it's more a case of if we carry on doing what we've been doing year on year here and have this level of increase in the health budget, we're not going to be able to deliver healthcare services by 2020 so what's missing for me in this is the message about what's going to change if we're going to make the healthcare system sustainable. That's the point that Annie is making as well. There isn't evidence about what the levers for change are here, there's very much a continuation of the same as last year and the same as the year before. What we want to see in even the high-level budget is a signal that there's a recognition that there needs to be a shift in the way that the budgets are spent and that will largely be when you get to the stage of looking below the health board lines but there's nothing even at this level which gives that sense of a commitment to make that change. Annie was saying and really support that. We as you know as the committee have been looking at health board spending for some time now at the Royal College of Nursing and we're having to really rethink what that might look like once health and social care integration kicks off from April because the level of detail that we get at the moment won't necessarily transfer into that new world. So I would agree with Annie that the levers that should be in there should come through Joint Strategic Commissioning and there is something about how the expectations on Joint Strategic Commissioning to do some of the things that we haven't yet managed to do nationally around choices on investment and disinvestment are a tall order for brand new organisations that are going to come together and have never done this before. So my concern I think is that we are going to place that expectation on our new integration authorities to make really difficult decisions to consult on those appropriately with people using services, carers, staff, the general public and they are going to be very, very new. Now one thing is that we don't know how that scrutiny yet is going to play out. There's obviously a lot of work going on with the scrutiny bodies but certainly in terms of what future budgets look like and how we sit round this table in 12 months time and look at how decisions made at a local level impact on your questions around outcome and impact. I don't know yet and I think that's going to be one that we're going to have to really grapple with because those big decisions will not be taken at this level within the budget. They're going to be taken at a very different place but certainly as a college we've started looking already at the first iterations of commissioning plans that were put together around older people to look at what's the impact on our constituent bodies on nursing. What are the things that we're looking at that will make a difference? What is this telling us about what the nursing workforce will need to look like in the future? My hope is that those strategic commissioning plans will help all of us to start doing that. ISD is doing a lot of work at the moment to support the needs assessments that will go into those plans that will hopefully ensure that services are designed in a way to meet outcomes and improve outcomes. But I would also just make the note of again going back to the auditor's reports on Hyland and I know that was specifically around acute spin, that was around Raydenmore, but there was a comment in there around the speed at which the shift of the balance through integration, obviously Hyland being head of everyone else by a couple of years, how long that is likely to take. And I do think we have a situation where the first joint strategic commissioning plans I would guess are unlikely to be radically different from what we already see because these are new organisations finding their feet. It may take us three or six years to get to the point where there is the evidence and the consultation and the decisions made to do something radically different. The difficulty is we have an issue now with pressures, whether that's through social care and Annie's points around the local government budget or whether that is the discrepancy between the welcomed increase in the health budget but the impact of other cost pressures within the health service as well. So we do have that timing issue at play here and I think we have to be careful on what our expectations are of integration authorities come April 2015. They have a massive job ahead of them. The things that perhaps I could pick up on and absolutely hear your question and if it was a straightforward answer you would have had it all those years ago when you started to ask the same questions. There is however I think it would be worthwhile having a discussion around some of those pressures that colleagues have described in relation to our population living longer. That's an opportunity for us to celebrate some of the successes but within that we need to understand and recognise that that population doesn't necessarily a healthier population. Therefore that becomes another issue for us to deal with in health boards and indeed in local authorities where we need to put provisions in place to support that elderly population but not necessarily that healthier population that we are creating in Scotland. Again one of the opportunities that we see certainly within unison around the strategic commissioning is also around some of the procurement elements of that. Where we have the opportunity as the public sector organisations with the biggest spend in Scotland to procure goods and services that will enhance and support health boards and local authorities aims and objectives to make a more healthier population. That is a real opportunity for us to make sure that the spend that health boards have, the spend that local authorities have in relation to the day-to-day running of those services is spent in the local populations. We have said in our submission that we need to look at some of the community benefits realisation that this opportunity will afford us and I think that for us in unison is a real opportunity and we should take that forward. Within some of the pressures that have been identified and I know Bob in your question that you said we hear the pressures on workforce but I think that it is absolutely crucial that we have that discussion around some of those pressures on the workforce. Gill rightly said about the vacancies in consultant vacancies within health boards in Scotland. It is absolutely right that we have the senior decision makers in the boards making those decisions but it is also absolutely right that we have staff in those boards who can support all of that work. That might be in minor injury units, it might be in major units within accident emergencies in Scotland where we have some fantastic initiatives around minors and minors and minors where the work force, nursing work force and the work force are delivering on those areas. Again, we need to look at that, we need to look at some of the support staff within those areas as well. We are a healthcare team, we need to be a health and social care integrated team and again I think that Goonison is the best place to support that with that cross-sector membership. One of the areas that we have looked at in Scotland and we have looked at for the last two years around the 2020 workforce vision is indeed Pan Scotland workforce planning. We have got some fantastic information and evidence around the Pan Scotland workforce planning, we have got some information and evidence that we need to produce. However, health boards currently do not have the capacity to do that, they do not have the capacity to undertake the scenario planning that was identified as an absolute must. To look at those areas where perhaps we have cliff edge of staff who are about to retire as we move to new pension provision in 2015, people are concerned about the increase in contributions in their pensions, something that has not been mentioned already in terms of the workforce and they are also looking at how best they can use their own pension provision going forward after 2015. We have an ageing population, which means that we have an ageing workforce and that workforce will be looking, as Jill rightly said, at some retirement provision for themselves as individuals. I think that there is a huge amount of work that we need to do in terms of workforce planning. I think that there is a lot of work that we have done but I think that we need to join all of that up. We need to join up the work that has been done for the workforce within the local authorities and within health and look at an integrated workforce and we are not there yet. We are not very good in health boards at workforce planning but we do have some tools within our systems that will allow us and afford us that opportunity to do that. That plan Scotland work that was done over a two-year period, I think that we should be looking at the 2020 workforce vision that we have and we have staff representatives in health boards dealing with that and indeed at a Scottish level and also some of the work that we are doing with an engaged workforce around iMata. There are some fantastic initiatives out there. We need to allow those opportunities to develop but we also need to look beyond the health service workforce and into the integrated workforce. One of the areas where we have sadly not had the opportunity to put into legislation is around the staff governance agenda. It is a significant issue for unison in terms of that workforce but it also would give us the opportunity if we had a staff governance framework across the public sector and indeed in the private sector, the opportunity to bring in the community workforce. We have got the opportunity to bring in the public and the private sector and if we did have that staff governance framework that would give people the support and the assurance around making that integrated workforce a reality. I thought I'd have a go at answering Bob's question in a different way which is not what isn't in the budget but what would have been nice to see in it which would have made me backed up some of these policy initiatives and outcomes that we've all been talking about since the year dot. One of them would be a budget that said that we are now going to make a massive investment in social care and we are now going to make a massive investment in the kind of community support, a lot of which is in the voluntary sector, which is going to keep people well and out of hospital. If you have that coming in then you might be able to look at some of the savings that your previous witnesses were talking about in relation to the health service because there are any number of voluntary organisations out there that can say what we do will save somebody being in a hospital bed for £4,000 a week. Actually that's a notional saving because they're not going to save that money while the lights still have to be kept on and the staff still have to be employed and so the savings will come from actually stopping doing things completely rather than making differences at the margin. Huge investment in social care will be what will change that and a huge investment in community capacity through the voluntary sector and instead of that we have a local government budget which is shrinking. You have a social care sector which in many respects is being corporised. You have a lot of social care, home care for older people being delivered by workers who are on minimum wage, with absolutely minimalist pensions, you've heard me say this many times, this budget isn't doing anything about that. We are expecting to see that happen at joint strategic commissioning level but as Rachel has said we are early days there and some of these same kinds of discussions are going to play out at local level because the drivers just aren't there. That's one way of answering your question Bob. That's what I would have liked to have seen in it but it's not there. Like Annie I was having a think about how to more directly answer your question Bob and unlike her though I was going to have a look at things that were in the budget and have a look at the level 3 and I guess that takes us to the conclusion that we've reached that this budget document does not have a joined up narrative and plan as to how the various different lines of investment that are described here are going to come together to deliver the aspirations of Scottish Government. I guess that this dips into the conversation that was taking place earlier with evidence that you were getting from Andrew and David but we don't have clear evidence base for why we should be investing 55 million in health and health improvement and 41 in alcohol misuse. Those are very important issues clearly but we don't at the moment have a clarity about how we make the decisions about how much we invest and how we prioritise those and how we prioritise them not just within the health and better public health category but also how do we consider them alongside the discussions that we've been having here already this afternoon about the cost that we incur by not being able to fill posts right from consultant posts right through to the whole range of health service providers. We've got vacancies there where we're having to fill with very expensive locoms, spending massive amounts of money that could be saved with a different approach to workforce planning and looking at the way that we make the range of posts that we have more attractive to the workforce to come into Scotland. Which of the decisions that we should be making about how to achieve our aspirations of Scotland are most sensible then in terms of deriving how we prioritise expenditure in areas where we still don't have a very clear evidence base of what works and what's going to make a change when we've got gaps elsewhere. That's a question that I would raise and a request for a more joined up approach to thinking about how we plan across all these different budget lines in a way that maximises the impact of the investment that we make in each on the ultimate ambitions that we have set out by Government. Thank you. In answer to your question, Bob, that paraphrase is do we have to look at the budgets later on? Very short answer, I'd say absolutely yes. Particularly the reasons I would say that is because if we just look at the budget that's set out, if we look at the briefing that was provided, what this budget is doing, and as we've said in the briefing that we submitted, this simply just reiterates more and more of the same way of doing things, it's not shifting anything. I agree wholeheartedly with many of the speakers, but particularly picking up on what Rachel was saying, this is a massively tall order for the integrated health and social care board, the joint boards of the joint committees. Particularly in light of the fact that they have very poor data on which to base their decisions on how they're going to spend their money, where's the difference made, and several speakers have said that, what makes the difference where and when. They have no direct input in terms of expertise or information, certainly from an HP perspective at the moment, and they have, as has been demonstrated both at a national level and at a local level, is a very poor habit of integrated workforce planning. We don't have that habit either nationally and we certainly aren't going to have it at a local level, even though it's obviously something that's a good idea. It's silly. If you're in a care pathway, it's silly increasing the number of staff that are delivering part of that care pathway. If you're not going to look at, simply all you're doing is creating a backlog in some other part of the pathway. I think it's really, really important that we look at what is happening at a local level, how money is being spent at a local level, but that it would be helpful at this stage to highlight in the report on the budget for the committee that the trend, as we see it in the national budget, isn't promising or in the national patterns. We see how we're all trying to answer your question as directly as we can, and I'm listening to what's being said around the table and thinking about previous sessions with the committee and also thinking about reports from Audit Scotland recently. And I think probably the thing that's missing for me in this is around how do we get that understanding? We keep sitting around the table saying we don't know which things actually make the biggest difference. So where is the additional funding to actually support more of that understanding so that in a few years' time, either round this table or round the table of an integration authority, we are clearer about what is actually starting to make a difference. Now how those indicators and targets are set, and I agree with Annie that there are far too many, and we still don't understand how they're all meant to link in, there is clearly work going on around the health and wellbeing outcomes that are currently in draft regulation and the indicators that go behind those. But how will we understand? Earlier, Dr Simpson was talking about the Family Nurse Partnership, and I would say that that is one area where there is a lot of resource going into looking at what is the impact of that and has been for some time in its incarnation in the States. There are other pieces of work as well, things like deep end practice. These things may not be cheap, but at least we're trying to understand what the impact of that significant level of investment is. And that seems an important piece of work. The Royal College of Nursing has been doing a piece of work with the Office of Public Management over some couple of years now to try and work with nurses to help them quantify the impact of particular nurse-led services. And I know that we've previously given some information to committee around some of the activity in Scotland on that, and that has been rolling out in Northern Ireland and Wales as well. One of the things that I would note from doing that work is that although the health service, and I suspect that it's the case for social care as well, can be awash with data, it's not always collected or the right data is not always collected to allow that level of impact to then be assessed to know where they were putting money into the right things. And we had brilliant examples of projects which we thought sounded fantastic pieces of work, but one of our difficulties in doing a robust piece of work with the Office of Public Management on Economic Assessment was they simply didn't have the right data to allow them to go forward into the programme and do that full economic assessment. So I think that's one thing we could invest in that would make a big difference to how decisions are made in the future. I have to say that I asked the question because it reminds me not to ask it. I didn't expect anyone to say that this is the silver bullet to do this and it will all work of course. I'm not trying to tease out of course. We are scrutinising some headline budget figures and I think that ever since we've been doing this there's always a feeling of a disconnect between what the headline policies are and what practice is at a local level with open health and social care integration. It may help to tease some of that out. I suppose I also accept that we don't expect an all dancing health and social care integration in April 2015 that it has to bed in and I get all that. I suppose the other tension that I would just ask about is looking at our spice briefing. Of course budget lines go up and down across the health portfolio so according to our spice briefing, specifically on the family nurse partnership. Yes, it's a very cash intensive programme but we're all supported across part two on it. According to the spice briefing, it shows a 69.8 per cent cash increase for family nurse partnerships so a huge significant cash increase. The reason I'm mentioning that is we can tie that directly in to this headline national budget that's been set where is of course the vast majority of monies that will be spent as part of the £9.6 billion going to territorial health boards where you don't have that breakdown. I suppose my question is would you rather have that 9.6 billion pounds being a smaller figure and having other figures within the rest of the budget where nationally there's national policies and budget lines and health and social care partnerships or health boards or whoever just have to do it because from what I can see at the moment, it affects our scrutiny at this stage but it gives more freedoms and flexibilities to territorial health boards and hopefully local authorities when health and social care integration comes in and that might be a good thing but the consequence of any saying I don't see the big thing in here would be you'd have to filter away some of that revenue allocation to health boards and put it elsewhere within this health budget. I hope there's a clarity in what I'm trying to put here. People don't have to feel obliged to answer that but that's the only way I can see that you could redirect spend from within this budget to do some of the things that I've heard around the table I suppose. I think that's going to be your biggest challenge with health and social care integration in effect because you're dealing with a centrally managed NHS having to negotiate on targets and outcomes and delivery with a very much non-centrally managed system of local government and you know I hate to say I told you so but we did kind of point out that this was one of the kind of fundamental tensions with this agenda. Just coming back to something that Rachel said about what knowing what works I mean in some respects we do know what works around this we know that if there is good care at home available then people will not be delayed in hospital beds that they will be discharged. We know that if there is good low level support available for people then they're unlikely to end up as emergency admissions in hospital we know all of that but we still find it very difficult to make that shift because there is a complete discrepancy between a protected NHS budget and an unprotected local government budget. I seem to be saying the same thing every time you come to me but I do think that that is what is at the heart of this. I will try not to say the same thing that I have said before but there is a danger of that a bit as well. In answer to the question Bob I don't think there should be a shift in the direction of travel. I think what we were saying earlier was that we need clear evidence about why the investment in the things that are outside the allocation to health boards are going to have the significant impact on driving us in the direction of travel of the Scottish Government aspirations. All of us have been commenting on the fact that we need the local bodies to have the ability to make the decisions about how best to spend the money and to have the freedom to do what is right within their local population. That is where I will go back a little bit to what I said before. What we are not seeing is the clarity about how the expectation and the freedom and the authority to make these decisions is going to be applied to the integrated joint boards and the health boards. What we do see is evidence—this is where I am going into the conversation about targets—that there are things that happen at a national and Scottish Government and political level that stop some of the flexibility about local decision making taking place and create pressures that cost money and redirect resources away from where they have the maximum impact. We have all been talking about the need to look at the effectiveness and appropriateness of the targets that we have in place, particularly from our experience in the health service, where we have real examples of the current set of heat targets directing resources away from people who would do better for having them prioritised. The Public Bodies Act has been passed with cross-party support to devolve a lot of that decision making about priorities and about how money will be spent to that very local level. That is what we are going to see and learn how to live with. I think that there are going to be tensions over the beginnings of that process with a tradition of a very centrally managed organisation, knowing how to work in that very new sphere when some but not all of its services will be within the locusts of the new integration authority. I am not sure that the issue is necessarily about how much is ring fence centrally and how much goes out to health boards and then beyond that how much allocation from health boards to integration authorities. I will remember something that was said at the NHS conference a couple of years ago by the clinical director of the NHS about the fact that the NHS is not always good at upscaling. We have a lot of initiatives, we have a lot of projects, we have a lot of new ways of doing things that can be very very good at a local level and then don't necessarily get the traction they need or the leverage they need to be expanded out in a way that makes sense in other parts of the country. And maybe that's where some of that central funding over things like family nurse partnership is actually very very helpful to give that government support to trialling a new way of working, to evaluating a new way of working and making that available to partnerships. Again, or rather, saying about the allocation of funding or our concern isn't about whether money is held centrally or that distinction you are making well about should we retain more money centrally and unless going to the boards and to the local authorities. I think what could helpfully happen is that our concern is that wherever that money is it doesn't seem to be working in terms of an integrated fully multidisciplinary planning, whether it's central or whether it's local. I think what we could do centrally is start demonstrating the sort of integrated behaviour that we'd like to see, and we're not seeing that at the moment, and essentially to enable those local agencies to actually make some smart decisions based on the evidence and on the evidence base on real data. And that's not available at the moment either, certainly in respect of the HP impact. OK, I'm tempted to come back to me, but I think that we are getting you know over the period of time we've tried to focus on the last couple of years what's changing. We all agree that there needs to be a shift from the acute sector into the community and there's been bits and pieces legislation and all of that sort. But in a draft budget we don't see the shift in the money going in there. Indeed we see contradictions and demands on the health boards and the health service 24-7 working trauma staff. We see, you know, we played a part in that as well, increased spending on prescriptions where we expected savings that would have maybe channeled some of this in. We had, you know, the treatment targets which are distorting the whole service and prevents. So we've got a massive contradiction in there. We've got a draft budget that doesn't show any significant shift in terms of the change budget. When the change budget was there for older people with questions about how that was being spent, it was just providing residential places or whatever, so even when we had it in place. And we don't see significant shifts from the health service in terms of money into there and we've got a contradiction in politicians and government placing more pressure on the health service and increasing demand. You know, so, I mean, you know, when is a shift going to take place? Well, we're supposedly all agreed on it. We're all agreed on the 2020 vision as a priority. We have agreed on all of that. We're taking the opportunity today with a draft budget to see whether that's, whether anybody's serious about that or not. And there's nobody, you know, and depending where you come from here, maybe apart from using because I'm struggling both, you'll say, well, it'd be a good idea to get more money locally because, you know, community services might benefit from that. No, no, we can't give it away from the acute sector because we're dealing with this demand. So wherever you come from, it's about where your chances are, you know, there's nothing filling us whole in the middle. I know it's a bit rambling, but I mean, I'm just getting frustrated with it as well. We don't, there is no, you know, when everybody's saying we need to do this, we need to do it quicker than we're doing it, and it's not happening. And the draft budget doesn't give it the boost of an acceleration. It needs to ensure that it will harm. I don't think the draft budget is a place to give it the boost and acceleration to happen. It's going to follow what happens. What we don't have is the plan about how we're going to change the profile of demand, and that's what I think a number of us around the table are saying. We really must have that open and honest discussion with the public, with politicians and with professionals and service providers about how we are going to shift the way that the demand currently falls. At the moment, all the budget can do is respond to where the demand is coming from. As you rightly said, that is from the public's expectation of how they use health services and from the demands that are being placed on health service by politicians. The promises that are being made there as well. We need to shift from that culture, which is where we've remained, despite a rhetoric of needing to shift the balance, to a serious conversation about how we change the way that people expect to use their health and social care services, how they take their own personal responsibility for the way that they use it and the way that they manage and self-care. We need to listen to the range of stakeholders around this table and much more widely about how that shift needs to happen and to stop making promises for new things in healthcare until we've got a clarity about what the plan is to shift the balance. And then we would expect to start seeing in the budget the evidence that that is beginning to take effect. Without a plan, without something that we're all sticking to and agreed to and moving towards, we're not going to see anything apart from a repetition year on year of the same kinds of levels of budget demands where they've always sat. I suppose I'm sharing this, you know, it's been taught by a group therapy, we're sharing this frustration if it's not going to stress, but I'm rather on the committee, but we're great and enjoy doing new things, but we don't like giving up the old things. So we spend all of our money doing what we've always done and we hear from evidence this morning, you know, a view that's not just expressed by the two economists, but we're changing things very much in the margins. And this draft budget doesn't come alone, it comes with conditions. The government's retaining a bit of money in terms of some of its initiatives. It's placing on health boards 24x7 working to all my stuff. It's placing on health boards significant targets, which is distorting the service, I would say now, and prevents money maybe shifting out, and it prevents all of these actions and what we've been doing, prevent new thinking on the evaluation. And we contributed to that in terms of our recent work on accessing new medicines, in particular to rare and end-of-life medicines. Well, we've got in the budget because there was plenty of 40 million pounds or so, which might cost more than that and it could turn in the treble, you know, of that amount going forward. But there's been no evaluation, as David Bell said this morning, between the benefits of investing in mental health and childcare or family nurse practices and any other, you know, against that. There's no quality that applies to anything that we're doing, that applies to new medicines, where people are being asked to justify the spend, the outcome is against the investment put, and most of what we do, none of that takes place. So, how can you have this debate with the public about what's important when we're all defending, you know, basically the status quo? Right, John? I'm not sure we are all defending the status quo. Well, there were good, nice wee examples, mind you. They're all over the place, but there's a shift away from that. I suppose what I would urge is, I think, from conversations having outside of the room, that there are a lot of us who are willing to have the difficult conversations, because if we don't, I mean, if you look at a recent survey of RCN survey of nurses, something like two-thirds of nurses felt they didn't have enough time to deliver the care that they felt that they should be, we cannot keep doing what we're doing. The status quo isn't going to be possible, so I think there is something important about acknowledging that there are really difficult decisions to be made. Some of those will be decisions about disinvestment. People working in service are not going to be averse to having those discussions as long as they're done openly, transparently, and that there is a really good rationale for doing them, that they're done well. And I think that's where we were still placing a lot of faith in integration authorities to come up with those decisions about investment and disinvestment in particular that have simply not been taken more recently. And we have to have the conversation about what is our hospital sector going to look like? What's it going to look like in the future? Because I think there are lots of conversations that I sit in conferences and hear about the freeing up of money from the acute sector to shift the balance of care to community. Well, I think we have two issues. One is when we were awash with money, we didn't do it in a way that allowed a level of double funding, and now we're in a situation where double funding, 100 million to boards that's actually in their uplift, that is not going to be the sufficient leavers. So how do we do that without impacting negatively on the care of people who do need the acute sector at the moment? Because we haven't dealt with the long-term implications of reducing obesity or alcohol misuse or drug misuse or any of those things that will impact. So I think that's one of our issues. The other is if our hospital system starts to look different, so the people going into hospital are actually the fray list, the most complexly acutely ill, then the costs of that acute sector are also going to change. So how do we do it? And that's where I think by engaging the public, by engaging staff, by engaging people who are using services in a debate about what is this going to look like. It's probably the only way that we will be able to start making some of the radical decisions that will free up the integration authorities to genuinely redesign services without there being an immediate outcry because people have not been brought along with what that actually means. And that's the situation that we've seen repeatedly in the past and we cannot do that in the future because otherwise the quality of our health and social care services will decline in a way that none of us want to see for any of us. HPEs, our service users, have absolutely no investment in the status quo at all. It's not working for our service users. We need a change in culture and hierarchy. Jo made the point that we don't have a plan to change the pattern of demand. We do. We have lots of different plans, but if I can talk about the HPEs, we have a national delivery plan, specifically zero funding for that. Nothing's changed. HPEs are demonstrating all the time how they prevent spending, how they increase self-management. The early years collaborative is a huge example of test of change, the difference, the savings that people are making, contrast the amount of money that's going into the early years change fund stopping more or less, contrast that with the investment that we're making in one part of the early years funding. I think what we need to do in terms of shifting is to start demonstrating and celebrating and off a lot more loudly the evidence that we have in terms of what's making a difference and do that with having different people talking about success rather than keeping focusing on the same model of provision which is about waiting for people to get ill and then dealing with it. A couple of things have occurred. One of the issues and one of the questions that were asked around what can we do within the health, within the budget that would make a difference, that would make a difference in terms of shifting the balance of care, that would make a difference to health inequalities in Scotland. Very recently, I attended a conference organised by the STUC in terms of looking at Adjust Scotland. A couple of the speakers that spoke earlier in terms of presenting evidence were at the conference and gave some really useful and helpful information around not just around health inequalities but income inequalities. For us, one of the biggest issues and one of the biggest constraints placed around the public sector is, indeed, public sector pay restraint. I make no apologies for saying that because one of the biggest issues for us in terms of the workforce that we represent across the whole of Scotland, a public sector workforce who deliver quality services, is around the ability to generate and influence the local economy. When we talk about localisation, we talk about how we can build from the bottom up locally to support public and private sector organisations within that local economy. One of the biggest and perhaps easiest way to do that is to generate and encourage spend. Public sector workers in Scotland, particularly the public sector workers that I represent in Scotland, do not have huge bankbooks. They do not go to the stock market. They spend in their local economy. The ability to spend in your local economy when you are under pay restraint for the last two years having no pay rise and the last year having 1 per cent pay rise, when you have had 3.4 per cent contributions increasing your pensions, that ability has been significantly reduced. One of the areas for me, I think, we need to look and talk seriously about public sector pay restraint in order to regenerate and refocus on the local economy. Again, the issue for us around the health service and the link between the local authority, there is a huge demarcation between one and the other and we need to get some serious and focused discussion around how we can stop that. We need to work force at one point, stop them and then engage in other work force. That is around the care pathways and how those care pathways need to interlink and engage with each other. Unison recently undertook a survey of its members and recently undertook a survey of service users around the 15 minute care visits, which we highlighted as being inappropriate. Again, it is a local authority issue, but it should not be a local authority issue. It should be our issue. It should be the issue for the health service and the local authority. The integration agenda is our issue and that is part of it. One of the other areas that we are looking at is the ethical care charter, where people employed delivering that care are given training, given the ability and afforded that right to have the time to care and that time for training as well to make sure that we have a trained workforce. If we look at health services in isolation, we heard earlier about the Keatwell project, where boards have been asked to implement the Keatwell project with no additional funding, where some are saying that it is perhaps not given the benefits realisation that it was badged to do in terms of health inequalities. I think for me what we need to do is look at where it has worked and allow the local systems and local health economies to look at where Keatwell within a particular area has made an impact and has made a difference. We cannot continually look at across Scotland and say, well, one size fits all locally. In Scotland, Keatwell has made a significant difference for some areas of deprivation. Should we stop that? I do not think that we should stop that. Should we support that through investment? Absolutely. If we say to the policy makers in Scottish Government and policy makers across Scotland that it is not working across Scotland, therefore it needs to be stopped, that has a significant impact on local democracy and how the integration boards will generate localism and deliver health services and care services within Scotland. I think that there are things that we can do, things that we can learn, but I also think that we need to join up and we need to link policy makers with service. Working in the service, I hear all too often that there is an initiative coming out. The policy makers have decided on X, and it is up to us to implement it and deliver on it without any additional resources, without thinking about what it means for the local communities. That needs to stop. I am not saying that it happens all the time, but when it happens once, it happens once too often. I think that there are things that we can do and that we should do, but to say that we need to take a mature discussion about disinvestment is absolutely right. First, locally, when you say that you are going to disinvest, we say that beds are all currency. We want to disinvest from acute provision. The politicians will tell you that their local communities and their constituents do not want that to happen, so it does not happen. I think that we all need to have a serious conversation with the service, the policy makers and the politicians. Absolutely. We know the cost of arguing for change in the health service in my party, but I will say no more about that. Thank you, convener. I am going to say some things that Lillian is not going to like, so I will declare an interest as a unison member right here and now. Let me just preface it by saying that there is an extraordinary amount of good stuff happening out there. It is maybe not at scale and it is maybe not measurable nationally, but self-directed support is something that I am a great champion of. It is doing that right now. It is transforming people's lives. It is getting a bit kind of high-band with the bureaucracy, but let us not forget self-directed support in all of this. I wanted to come back to what Rachel was saying about disinvestment. If you are going to do new and different things, you need to stop doing some of the old things. This is where Lillian is going to get upset because there are things in this budget about pay commitments to the public sector and no compulsory redundancies which do not apply to the rest of the market for social care. Worse than that, paying conditions in the voluntary sector and in the private sector have been driven down by public sector commissioners. The extent to which you can disinvest is much more difficult to disinvest in public sector services because of those things that are also in the budget. That is something that we need to face up to. It is much easier for a public sector commissioner to export pain to the private and voluntary sectors because they do not have to manage it. There are no commitments in our sector from commissioners or anybody else to no redundancies and maintenance of paying conditions and all the rest of it. Even if you look at care at home provision for adults and all the people in Scotland, the voluntary sector is absolutely streets ahead of either the private sector or the public sector. The private sector is cheaper, so you might think it would be worse, but the public sector is enormously more expensive and yet it still does not reach the quality attainment of the voluntary sector. Even on a best value basis, why are we not investing more in the voluntary sector? Why are we not disinvesting in public sector care at home if it is expensive and it is not as good quality? That is why I am thinking that Lillian is not going to like that, but if you are going to have hard conversations about what to invest in and what not to invest in, you have to go to some of those places as well. I see that Lillian is coming in and Rachel is going to come in this way now. Then we really need to get to a stage where we are summing it up by afternoon. I do not necessarily agree with all of which Annie has given to the committee. What we can do is agree jointly that there needs to be a level of investment that means that whoever delivers services in Scotland for the population of Scotland gets the living wage. That is a real significant issue for us. We organise within the voluntary sector. We have fantastic achievements in that sector where our members deliver where they can and where they are able to high-quality services. The significant issue for us is that you are right that when public sector organisations commission or procure services, they pass over the pain. That needs to stop absolutely. That needs to be absolutely clear from Unison. You cannot pass over the pain as you cannot pass over the commitment to deliver the services or the ability to deliver the services and think that you have washed your hands over it. All you do is lose control. When you start to lose control, you lose quality. In that quality, the recipients of that care suffer the consequences of that. When it all comes back to it, the people who have to pick up the pieces of that are the public sector organisations where care providers are no longer deemed appropriate or a viable option to deliver that care can walk away, but the public sector needs to pick up those pieces. I think that there needs to be a level playing field around the living wage and that we should all be committed to, irrespective of whether it is public, private or the third sector, the living wage should be the benchmark for pay in Scotland. If you take some time to look at the working together review that was commissioned by the Scottish Government and the STUC, where significant players are in that, there are some fantastic recommendations from that that look at the workforce across the whole of Scotland, not just in the private sector or with health or social care, but across all of Scotland. Those recommendations look at a democratised workforce that gives worker voice and part of that is around making sure that people get pay and the living wage would offer that security. We do not necessarily disagree on all of your contribution. What will we read back to your agreement? I recommend the committee's report on older care in 2011 and it is all in there. Rachel? Very briefly, a quality service requires a quality workforce. Care is delivered between people, between people delivering services and people receiving services and the dynamic between them. It does not, for me, matter where you are delivering that service. We have members within the Royal College of Nursing that work across the independent third and NHS sectors. We would want to see fair terms and conditions for every single one of those, like Lillian. We would support the living wage. I was delighted that the principles for integration that were put through Parliament eventually contained a quality principle. My hope is that, as that is enacted by integration joint boards or by lead agents who are commissioning and procuring services, that that thought of quality, that quality services require quality staff, will translate exactly into the procurement practices. That includes how they assume that the third sector or the independent sector will be able to fairly pay decent wages to their staff. I do not see a sustainable solution based on sweated labour and poor quality, but I think that it all comes at a cost. I suppose that is a challenge for all politicians about how we deliver this within getting back to a draft budget, which we have drifted off considerably. We are way by our time. Thanks for being with us today. Staying beyond your allotted time and everything else. Thanks very much. We look forward to seeing our regulars again and a special welcome to our newcomers today. Thanks very much for being with us. I propose that agenda item number four, which is a private discussion on health inequalities, be suspended next week to other committees agreement. Thank you very much. Thank you all.