 Fonirable to the 16th meeting of the health and sport committee in 2018. We have already taken our first item in private, but we will move on to item two in a moment. Can I ask everyone in the room to ensure that mobile phones are switched off or to silent? I welcome to the committee our witnesses, but I will do that formally in just a moment. We have Ie ddaeth i'r unig iawn o unig iawn o'r agenda cyfnodd o bobl o'r lleisloedd ddaeth. Mae unig iawn o'r instrumentau erin, y llawd, ddiogel, ddechrau, et cetera, Scotland Act 2000, ILF Scotland Order 2018. Mae gennym, i gyd, i gael, ac y Delegated Powers ond Law Reform Cymru nid o gael i'r instrumentau. Felly, ydydd nhw'n cymdeithas ar g setl sy'n gwneud hynny? Felly, mae'r cymdeithas yw ddefnyddio ran mewn fewn cyfnodol yw y cwmwys? Mwysilio'r cymdeithas, ddugiwch, di— Pwyllach, y gweithio'r cymdeithas yw'r roi ddechrau nhw, ar hwnne i gyd Cael yng Nghylch Cymru, Ymluniadau Aglenedig, 2018. Gidech, mae fydd gennym yn siŵr i'n bywch i arnoon yng Nghymniadau y Llywodraeth Cymru nid o'r ffordd o'r instrument. Rwy'n credu i'r ffordd o'r instrument. If there are not, is the committee agreed to make no recommendations? That's agreed, thank you very much. We now move on to the third and substantive item on our agenda, which is consideration of the budget for 2019-20 as our pre-budget scrutiny. Very formally welcome to the committee, Paul Gray, director general of health and social care and chief executive of NHS Scotland, Christine McLaughlin, director of health finance, Shirley Rogers, director of health workforce and strategic change, Dr Catherine Calderwood, chief medical officer and Alison Taylor, head of integration division at the Scottish Government. I think that we will move directly to questions if the witnesses are content. Can I start simply by acknowledging the progress that's been made in providing financial information to the committee and indeed making it publicly available in the last few weeks? That's very welcome. However, we would of course wish to continue to engage with officials over the content and the format of these reports. This is new territory, I guess, in a sense, and as I say, very welcome but very keen to ensure that we continue to engage with you on what is most useful to us as a committee in scrutinising financial plans. On the matter of financial plans, I will go straight to Ivan McKee for the first area of question. Thank you, convener. Good morning. Nice early start this morning. It's an easy subject. I just wanted to talk through the longer term projections on the budget. Clearly, we're moving into a different environment with the medium-term financial strategy in place. There's always been calls from the ground up, if you like, for more detail in terms of multi-year budgets, but clearly there's a lot of variability around that in the medium-term financial strategy lays it out fairly well. It's kind of interesting if you look at some of the evidence that we've had on this, people were asking for. They know 95 per cent, but they don't know the last 5 per cent. If you look at the numbers in the medium-term financial forecast at that level, the Government kind of knows 94 per cent, because there's nearly 6 per cent variability around the numbers as you get towards the end of that planning period. I suppose that I'm interested to know your thoughts on that process, what you think, how accurate you think we need to be in terms of the numbers that we need to be planning that far out and whether the variability that exists in the medium-term financial strategy is something that you can work with, or do you think that there needs to be more accuracy around about the data that you've got going out three, four and five years? Thank you, Mr McKee. I'll bring Christine in a second, if I may. I think that accuracy and precision are always to be desired, but in fact running a public service is not an absolutely precise matter. For example, we had, as the committee will know, a serious outbreak of influenza earlier this year, starting before Christmas and running into the new year. We may not have one of these every year, but there will be costs associated with that. It would be false to say that we can absolutely predict every element of demand. However, what is also important is that public bodies, such as the health boards and also colleagues in local government with responsibility for integration, have a degree of precision about what to expect. We're always trying to, as it were, walk that balance between pretending that we know exactly what the future holds because we don't, but giving sufficient precision to allow people to plan effectively. Christine McLaughlin could say more about the detail. The main thing that it allows us to do is to come up with a reasonable set of assumptions and get agreement that they are the best set of assumptions at the time and then to work out the level of risk. That's what the meeting term, the Scottish Government framework, allows us to do, is to see where those risks and opportunities lie. That's the strength in it and the ability to flex that as we get more certainty on particular components of it. The other thing that it shows when you come back to health and social care is the importance of two things. One is the importance of a healthy population in looking at your economic outlook and also the contribution of health and social care to the economy. What's very clear is that we can't just look at the planning for health and social care in isolation. We need to think about the impacts on people's employability, on the workforce, on infrastructure development as we go and the more that we can tie in health with education and justice to do that, the better position we'll be in. It gets us into places where we join up all of those considerations in a better way going forward. Looking at the total numbers that are in there, I want to tell you a couple of things. There's a £2 billion number talked about for increasing the health budget and cash terms over the life time of this Parliament. For clarity of that, as a consequence of a manifesto commitment, am I correct? That gets nailed down. Clearly, the Scottish Government's budget could go either way up or down because we've got that band as we go further out. Obviously, you'll say that health could use more money if that does increase. What kind of scenario planning have you got if there is some variability around that? I suppose that that would be in the upside, given that the manifesto commitment is in place. You're correct that the manifesto commitment is the £2 billion. It's what we've factored in. As you're aware, we'll be publishing the meeting term financial framework for health and social care shortly. We've modelled it based on that manifesto commitment assumption. As Paul said, what it also demonstrates is that you can make different decisions based on your funding position. What that means for your ability to invest more in transformation and reform is probably the biggest thing, as well as the potential impact on things such as some of our major infrastructure developments over the coming five and ten-year period. We're ready to build up scenarios. At the moment, what we're trying to set out is within the assumed funding levels for health and social care, what we think we're able to do within that, rather than explicitly look at scenarios where there is more or less. However, the tie into consequentials is obviously a different position for health, the health budget and there is for other aspects of the budget. We need to be quite mindful of the fact that health and social care does make up the single largest proportion of the Scottish Government's budget. Would you view the numbers that are in the medium-town financial strategy as being the base, if you like? You would see upside on that but not downside. Is that how you would look at them? That's certainly the basis on which we've developed the financial framework for health and social care. The next question is about consequentials on Barnett. I don't know if you can answer that, but whether or not those are tied. One way to look at that is if health spending in England varies, then the Barnett consequentials are going to vary, but the other way to look at it is to some extent that the Scottish Government has insulated you from that because they've given you that commitment on the manifesto commitment. To some extent, that money goes into the big pot and then gets allocated depending on what the Government's priorities are. Is that how you see it or do you see it? I guess that some of the points you're making are matters for cabinet sessions about budget spend. The presumption to date has been that health consequentials from the UK Government's settlement will be passed on. Resource consequentials are passed on, so that's the basis on which we've operated today. Clearly if there's a scenario where there's potentially more funding, that would be part of the wider Scottish Government plan. Okay, but on the other side, if those downside from the consequentials, you wouldn't see that eating into your minimum number because that's guaranteed? Insulong as a manifesto commitment is a solid assumption and we're going on the basis that it is, but as you say, there's some volatility in the plans going forward, but when you look at all the different factors in it, I think that what's very up-front in the Scottish Government document on the medium-term financial outlook is that the £2 billion investment is the first thing on the list to me that shows the priority that's given to it. No, that's fine, and I can take away from that. Interestingly, something that we don't talk about enough, I think, is the comment that you made about the feedback loop from health spending, support and economic growth. Yeah, it's absolutely key. That was made me need to talk about more. Okay, thank you very much. Could you confirm for us when the health and social care delivery financial framework will be published? That's a matter for Cabinet to decide, Mr MacDonald. We expect it to be published shortly, but it is a matter for Cabinet. In relation to the questions that Christine McLaughlin just answered about Barnett consequentials, would I be correct to deduce from that that Cabinet has not yet made a determination on the application of any future Barnett consequentials over and above the £2 billion additional that's been already described? These are matters for Cabinet, and I would take my direction from there. I understand. Get forms, briefly. Brief supplementary further to Ivan's point, and in the interests of long-term planning, has the UK Government given any indication when it's setting or publishing its long-term health funding plans, which I understand that they've promised in advance of the spending review this autumn? I don't have a date for that, and I haven't seen any firm detail yet coming through on that. Okay. Thank you very much. Can we move on to the question of regionalisation and the consequences of that, and how that will affect the future financial planning? One of the issues that became clear in the discussion at the conveners group recently with the First Minister was that she believes that regional relationships will grow organically or should grow organically, but she also referred to there being different views on this. I wonder if this is a matter that is simply evolving or is there a policy process which we should be aware of in financial terms? I'll bring in Shirley Rogers in a second. One of the things that I want to be quite clear about is that we are already committed to regional planning and delivery, and there is a governance structure in place for that, and there are regional plans in development, which again will be available once the financial framework is published. Shirley, do you want to say a bit more about that regional planning and delivery process? I'm emphasising that it's not just planning, it's also delivery. I think that's very important. The strategy for the delivery of health and social care has three elements—in fact, probably arguably more than three elements. There are a number of things that are delivered nationally because that makes sense. There are a number of things that are delivered regionally, and that is something where there is an opportunity to be able to look at regional specialties in a particular way. The thrust of the delivery planning methodology was to, in doing so, enable local delivery of those things that make sense to be delivered most locally. The other thing that the committee would probably be interested in is that, although there is governance around that regional structure, there are also quite porous things. Clearly, regions have boundaries, and they're not going to necessarily make somebody who lives at the edge of a region travel a long distance where they can skip over. For example, if we take Forth Valley as an example and Fife as another, there are some things that go from Forth Valley into Glasgow, some things that go from Forth Valley into Edinburgh, if that makes sense. Similarly, Fife to Tayside or Lowe, the independent which that makes sense. It was really an attempt to try and look from the patient's perspective to say what makes sense to have that delivered locally, what are the things that are sensible to do more collectively, more consistently across a regional basis, and then what are the things that are so infrequent or so very highly specialist that make sense to deliver on a national basis. Those things are emerging. There is some governance to manage that process of emergence, so we have appointed implementation leads in the regions, as you'll be aware from previous conversations. There are developmental approaches that make sense to trial in particular regions, and we might come on to that later on when we're looking at some of the specifics of health challenges. However, it's designed to look at what is the process that is required by patients and where does it make best sense for that to be delivered in Scotland. In terms of lines of accountability for that development, how does the Government anticipate that going forward? Each accountable officer in each health board stands at the present time. It is possible that, in future, we may also see an element of regional accountability, but, as Shirley Rogers has explained, the first thing that we want to do is get the regional delivery in place. I have been discussing with the board chief executives and the cabinet secretary has been discussing with the chairs the extent to which that will then require us over time to refine the way that we describe our current accountabilities. However, this year in particular, if I may just stick to that, each of the chief executives remains an accountable officer, and there's no immediate plan to change that. It starts by welcoming the fact that the Government has accepted the need to see monthly updates on budgeting from both the health boards and the IJBs. I think that that's a welcome step forward. However, knowing what's going on in some health boards has become more and more difficult for committee. A couple of weeks ago, NHS Lothian said that it would need £31 million to carry on delivering. The cabinet secretary clarified that he didn't, and on Friday, he wrote to me to say that that's his position still. I just wondered and wanted to know whether there's enough confidence in the Scottish Government's financial monitoring of each board when we have the situation of not really knowing the true financial position? I do have confidence in it, Mr Briggs. I think that what I would say about Lothian's position is that it has said that it would need in its estimate £31 million to continue to deliver as it was delivering at a similar point last year. However, of course, the whole point of transformation is that you don't carry on doing the same thing. That's a point that I've made in committee, both here and in the Audit Committee before. The sustainability of health and care services requires us to transform. The advances that we have in paths of treatment, paths of care, the advances that we have in the way that care can now be delivered much more locally through telehealth and telecare. If we simply say that we need this much money to do what we did last year, that's not exactly a transformative approach. I am encouraging health boards to do what they are doing to engage fully with our transformation process. Part of that runs through the integration partnerships, and they are making an enormous contribution to that. The clinical community is making a contribution. We need to take a more forward-looking approach to that, rather than saying that, if we had this much money, we could deliver in the same way as we did last year. However, I don't know whether Christine Orr surely wants to say more about that. I have confidence that I have spent a lot of time working with NHS Lothian, for example, on understanding their position. There is no doubt that every individual board is its own organisation, and they are reporting to individual NHS boards. If you look at the finance reports, they are all slightly different in the way in which they report, but that's something that's evolved and fits within the board reporting in each area. What we do look for is principles about transparency and simplicity so that people can understand the key messages and particularly the risks. I think that Lothian, from what I've seen, does that. As Paul said, the point about that particular question was not that that was a deficit in their current financial planning. It was a quantification of continuing to deliver as they are, which is not in effect what we've asked them to do. If that doesn't clarify it, I'd be happy to follow up with anything that you feel we need to, but I have a level of confidence in the way in which they're reporting into us on a monthly basis. In terms of brokerage, which some boards have received, given the situation that we saw in NHS Tayside, Ayrshire and Arran have suggested that they might need brokerage. Is there any other boards that you know of who are already making requests around that? I'm happy to give you that. We had clarified it recently through the Public Audit Committee as well. We were quite clear on the brokerage position for 2017-18. It's just been confirmed for the boards that have 50.7 million of brokerage in 2017-18. In developing the monthly report from June, my intention is to show very clearly that there may be a brokerage requirement for 2018-19, so you'll be able to see that very clearly. What we do know just now is that the boards that are currently in deficit are working on the basis that recovery will take more than one year. If we want to support them in terms of their delivery of performance and stability, we accept that it will take more than one year. I do expect that in 2018-19 we'll have further brokerage requirements, but we need to firm that up with boards. I also accept that that position will change through the year. I expect it almost to be more prudent at the beginning of the year and for boards to make improvements through the year. To manage your expectations, that is a number that I would expect will move through the year. I think that what you are asking for is transparency about what that number is and to be able to see that on a regular basis. Does the need for brokerage reflect temporary problems or structural deficits that require fundamental action? I'll hand over to Christine in a second. Boards have annualised budgets, as the committee knows, and that's a matter that's often considered by Audit Scotland and others as to whether that's the right thing. Brokerage allows us to flex over the end of financial years in a way that we couldn't otherwise if it was simply a question of saying that's the annualised budget and that's the end of it. What we've been able to do with some boards is to give them a bit of flexibility over the end of a financial year in a way that allows them to plan ahead for what they need to do to recover. You're asking, does it imply some underlying structural issue? At this stage, I would not say that it does. There are particular circumstances in different boards that operate in different areas, so they serve different populations and will come to light. However, I do not think at present that I would have evidence to say that there is an underlying structural deficit in boards. One of the basis on which we provide brokerage is that the boards have a plan to recover sustainable financial balance. You can't really have one without the other, if that makes sense, but I don't know if Christine wants to answer. Can I just say, in that case, does that mean that you anticipate where brokerage has arranged that that money will be repaid? That is the current situation. The position is that these recovery plans are about getting back to balance but also are restoring restitution in the Government for the brokerage that's been received. That is correct. In regard to where boards are reporting that they are not able to reach efficiency savings, for example, Glasgow and Clyde are reporting £44 million lower than planned. What projections do you then factor in with that, given that some boards, such as Tayside, for example, are looking to make over £200 million over the next five years as part of that recovery plan? Clearly, boards who are not currently asking for brokerage are not achieving those. I'll plan to order Christine in a second, but just to take Glasgow as the example since you've raised it, I discussed the position on Glasgow with the chair, John Brown, last week. As Christine has said, at the early part of the year, boards will make a set of prudent assumptions and continue to develop efficiency plans in the course of the year. That's what we expect them to do. I think that it comes back to the point that Mr McKee was making earlier. The capacity of anyone to make an absolutely perfect prediction at a point in time is fairly limited. I think that you will see greater Glasgow and Clyde bringing forward efficiencies in the course of the year, which will defray that £44 million to a point where they come into financial balance. That's certainly the discussion that I had with the chair, but Christine, I don't know if you want to pick that up. I think that it's just to state the obvious that setting your budget isn't really something that just happens for a 12-month period and then you stop and start again for the next year. Boards are continually looking for efficiency savings, either recurring savings and all, so we need to recognise that there will always be a component of one-off savings. If you look at the figures in Glasgow, they are not dissimilar to the level of savings that was achieved in previous years, and that's also the case with Lothian. One of the factors that I would look at is whether the level of savings in a board is very different from the level that they've been able to achieve in previous years. The other thing to say is that you can't really just look at efficiency savings without looking at the transformational change plans as well, because the longer-term sustainable answer is through the reform of services, as well as a core level of efficiency savings. You really need to take the two together. The transformational change savings, as you know, tend to have a longer tail in terms of the timeframe, whereas you're looking for probably a 3 per cent minimum of efficiency savings in years. For me, you need to look at the total picture. Come back to regional matters again. Can you describe how regional initiatives will be funded and how that will be held to account? Is it simply through partner boards? No, and I'll bring Shirley-Anne in a second. There is money allocated visibly and transparently within the budget to transformation, but do you want to say something about that? I think that the first thing that I would say is that the transformational plans are not just based around hope. There is significant support being given to the boards to help them with that transformational journey, because they're quite difficult things. If I take Lothian as an example since Mr Briggs has raised it, I met with the chief executive and some support work, some expertise around that that we can place into the board only last week and there's discussions taking place this week around how we support the board to take those transformational decisions. There is transformational funding available to help ease through certain things that will be transformative for the system. For example, transformational plans around digital platform for patient records, for example, which sounds like quite an administrative thing but actually has a huge impact in things like waiting times and so on. There's some funding around that. We're also mindful of the fact that we operate with a £13 billion budget, and actually the real gains to be made are not just about how we fund a bit of transformational funding for various things, but how we look with a transformational lens at all that spend in the way that Christine was touching on earlier on around economic viability. The specific processes that we now have plans from each of the regions and a plan from the consolidated national boards, which are with us for consideration. There's a programme board approach that will look and work very, I hope, quite scientifically to look at those things that give us the biggest return on the investment for those transformations, and where are things that are truly going to transform a service for patients rather than just a wee bit of change at the margins, and those financial packages will be allocated with quite a rigorous process of assessing their impact. Clearly some of those impacts will be quite long term, but some of them aren't, so making sure that the financial allocation that is given to those programmes of work actually achieves the things that are set out for. That happens to programme board and, ultimately, through the director general's accountable officer for spend. Good morning to the panel. The public sector pay policy has already been set out for 2018-19, but the Scottish Government has committed to providing a pay deal that is at least as generous as the one in England, so the final pay deal in that sector might diverge a bit from the public sector pay policy. The Barnett consequentials for that for 2018-19 are at £78 million, so I'm just wondering if there ends up being a more generous deal, has modelling been done around any additional costs that might come from that? Yes, we've modelled on actual costs, we've modelled on consequentials to understand the variation, but it's also important to remember that there is a large chunk of staff for whom pay awards will not be associated with any consequentials, so we're modelling the entirety of pay for NHS staff, for independent contractors too, so it's an important factor, but it's one of many when we look at pay impacts for 2018-19 and 2020. Do you have an estimate of what additional costs that might come to you? Yes, we've worked out various scenarios on where we might end up with the pay policy, which includes factors in consequentials. Are you going to tell us what those are? It wasn't going to. Clearly we're in the process of negotiating that pay award as we speak, so I'd really rather not if you don't mind. It's always important to ask the question. Can I ask Sandra White to raise the question? Thank you very much, convener, and good morning. It's already been mentioned that the largest part of the budget is health and social care, and obviously integration is a huge part of that as well. Evidence that we've received from integration authorities, some are saying that it's working well, others are saying that it's not, but if you forgive me, I'm the first time I've tried to use this without lots and lots of paper, and I've actually got the right page as well. They're questioning about true integration, they worry about the fact that they have packages that are labelled health, packages that are labelled social care and they don't seem to meet in the middle. So there's a number of questions that I wanted to ask in regards to that, and just how efficient integration authorities can be. One of the questions that I wanted to ask was about the leadership of the integration authorities. Are they sufficiently robust themselves to be able to question this, why they're only getting, as they seem to perceive? The labels are still on them and it's not true integration, whether the funding decisions anyway are still being dictated by health and social care. There's another question in regards to the chief officers and finance officers, that they're either associated with health boards or local authority, and one of that leads to a conflict of interest. If I could throw those two questions out and then maybe give you another couple of questions, that would be okay. I'll bring Alice Taylor in in a second, because she's ahead of our integration division. First of all, if integration was working perfectly evenly across the whole of Scotland two years in, I would be very surprised indeed, I would think that people were misleading us. So the fact that it's not exactly the same in every place is as I would expect. This year on 5 July we'll celebrate the 70th anniversary of the NHS, and it's not perfect yet, so I wouldn't expect integration to be perfect in two years. But what I would say in response to your point is that I can certainly see evidence of where it is working well, staff in that sense who are delivering the front line services, being identified not with the NHS or with local government but with the service they provide. For example, my mother benefited from the React team in West Lothian. I deliberately asked her one day do you know where they were from? She said, oh, it's just React. So there was nobody with a local government badge or an NHS badge. It was simply the professional that she needed for the care that was appropriate for her. We are bringing together two cultures, if you like, the culture of the health service and the culture of local government. What I'm very clear about is that certainly in the colleagues that I speak to at chief officer and chief executive level, there's a real determination to ensure that that bringing together of cultures is for the benefit of patient care rather than detracting from it. I know that there's work being done to support the leadership that's provided through chief officers. I think also your point about if the chief officer is employed by the local authority or by the health board, is that a problem? Many of these are joint appointments, in fact. The chief officer for Glasgow, for example, and the other chief officers in that area, sit on the health board as executive directors but also have a reporting line into the local authority through the partnership. We are doing all we can to ensure that the senior posts genuinely have the right amount of power and authority and accountability and responsibility that's consistent with what they're asking to do, but Alison could maybe say a bit more in response to your question. Just to build on those points a little bit, I think that when we talk to the people working in local partnerships, particularly the integrated teams who are actually supporting people using services and their families, which is what it's all about, it's encouraging having been working on it for a few years to hear people talk. Obviously they may be saying positive things to us to some extent, but they say that the fact that this is a high agenda item that they have to work together, that they have to be integrated with one another, has made a real difference to how they approach working together. It is in many places in its early stages, but in fact we didn't even start from a level playing field. In some places, as members of the committee will know, people had been working in well-integrated ways for some time. In other places there was a lot more to be done. It's quite an uneven starting point. At a national level of monitoring progress, if you like, I think that what's really encouraging is to see the early evidence—the early quantifiable evidence—for the shifts in the balance of care that we've been looking for. Those are not without challenge. The points that Paul makes about the joint accountability of the chief officers and the chief finance officers, those are really key in structural terms in the systems that we've created. They don't get us past the fact that some of the decisions that need to be made are really difficult. Particularly as you go around reforming and reshaping services in the way that Christine and Shirley have been talking about, sometimes that involves quite challenging conversations with the public and with professionals. The key thing is that people are around those decisions together in those arrangements. That's what we need to support them through. They need to work together and lead together towards the sort of opportunities that Christine has described. Basically, you're saying that you don't see a conflict of interest in this particular aspect of people coming from health boards and local authorities but also sitting at that higher level because of the experience that they have. Is that what you're saying that there's not a conflict of interest there? No, I think that there certainly shouldn't be. As I said, they're deliberately designed as joint appointments so that the health board and local authority have an equal say. Local elected members are on the integration joint boards to ensure that local authority is represented there. Again, using the greater Glasgow and Clyde example, there are quite a number of local elected members on the health board as in other health boards. I'm absolutely not trying to put a council of perfection before the committee. We're on a journey and we're not at the end of it by any stretch, but we're putting and have put the right components in place to make that journey a success. Just to pick up on that particular point as well, it's not all done, as you say. There are some that are working very well and others aren't quite integrated as we would like. Some of the evidence that we heard was saying that the integration authority should have their own funding directly to them. That was raised quite often in the evidence session in 22 May, I think, and I wonder what your thoughts were on that, if they were to be given direct monies from health board and social care to them. If that would help and if that wasn't the case, is it better to stick with what we've got and see it through, or is there any other idea that could give integration authorities some funding? I'll bring both Christine and Alison in and we'll try to be brief for the sake of the committee's time. The legislation is set up in a particular way, but what lies behind that is a genuine and persistent ambition to ensure that health and local government and third sector partners have a joint ownership of integration. I think that it's a good thing that money that is first allocated to the health board in that sense goes into the partnership arrangement, because that means a sustained commitment from the health board to the success of that partnership. It can't be described of or thought of as something that is over there in some way. It is core to the business of delivering health and care services to people. I am co-chairing a series of discussions with Sally Loudon from COSLA and Joyce White and Andrew Kerr from local government and with a number of chairs and chief executives and with members of integration partnerships, so the elected members, to ensure that we do see health and social care integration as a complete picture and not divorced from the business of local government or health. As I say, our third sector partners are an important component. Convener, do you want me to bring in more detail or do you want to? I'd be keen to explore the issue of accountability, given that this is, in a sense, a pre-budget focus, so the question then is who would be accountable in the current scenario for funding of IJBs. Maybe Alison and Christine can come in on that and I'm happy to respond as necessary. The legislation on integration that establishes those integration joint boards, as the committee knows, as statutory bodies. The accountability for decision making is set out clearly there. There are requirements on local authorities and their accountable officers and health boards and their accountable officers to fulfil their duties. What is done with the money once it is delegated to the IJB sits with the accountable officer of the integration joint board. In that slightly technical sense, the accountability is set out. In fact, that was a large part of the drive for the legislation, as it was set out, to clarify those matters, because under the previous arrangements, which had relied on voluntary joint working, it was unclear and it frankly didn't work. It made some progress, but it didn't work as clearly as it needed to be. Christine, do you want to come in on the financial management side of the question at this point? The question that you raise is one that I know I've given a lot of consideration to, and we've got a finance development group that involves all of the relevant parties, and that's one of the things that we've considered, too. If you step back from it, you need to draw a line somewhere if you're going to give somebody a resource that they're responsible for. I don't think that anyone has yet come up with a way that feels better in some sense. There's always going to be a pressure to understand what total resource you've got and for it to come from somewhere. Even if you went down a different route, for instance, like giving a budget direct to the integration authorities, you would probably still have a mechanism where you would need to agree on any increases, any additional funding for something else, and you would still have the reality that within that resource you'd be looking to start to spend it on different things. Where we've got to so far is that the only way that this is going to work is by people coming together from those different sectors. The fact that the resources come in from parent bodies shouldn't of itself be the barrier. I think that sometimes it is put up as a barrier and in those early years it has felt like it, but what we all need to do is try to move on. There are things that we can do to make it easier so that we can take away some of the complexity about individual allocations that we give for different things and how that flows through. I would accept that there's more that we can do, but unless anyone has a different idea, I don't think that we've yet come up with a way that feels like it takes away some of those issues about initial sources of funding. Jess Rowley told us that they remain accountable for money spent. Is there a question about clarity of accountability for all concerned? The way that I explain it, convener, is that I'm the accountable officer for the whole of the health budget, regardless of who spends it, so it's my duty to ensure that there are systems of delegation in place that secure, first of all, clear allocation of funds, clear delegation of responsibilities, and then I expect the health board chief executive, as the accountable officer, to ensure that he or she has a clear system of delegation in place both within the health board and in relation to the moneys that are then delegated to the integration partnership. I know from speaking to local authority chief executive colleagues that they do the same, so there is a traceable line of delegation, but in the same way as I would say, I still remain accountable for the whole of it, I would expect a health board chief executive to be accountable for everything that I have delegated to them. Part of that accountability will be discharged by delegating it further, but I don't think that it erases their accountability. I'm moving on to a specific area within this, which is around set-aside budgets, bringing Emma Harper. Thank you. Thank you, convener. Good morning, everybody. We took evidence on May 22 about set-aside, and I don't know if I'm any more clear about it, because I just read the official report again. We heard about how some of the set-aside is hindering the processes for integration, and one panel member referred to set-aside as a notional budget. I'm aware that Dumfries and Galloway, Argyll and Bute IGBs have chosen to allow the NHS boards to retain the set-aside, but, technically, the IGBs are still direct where set-aside should be spent. Are there examples that you know where set-aside budget is working effectively, or does it support or hinder the process of integration? Should we be doing something different with set-aside, and maybe making it a bit more understandable and clear for everybody? Okay, so I'm just going to say a couple of things and then bring Christine and Alison in, if I may. Since we're talking about transparency, the transparent thing for me to say to the committee is that there are a set of principles around how the set-aside budget should work, but there is within health boards and local authorities and within the integration partnerships, there is genuinely a bit of a contested view about how that should work in practice. That's one of the reasons, in fact, that I convened this discussion with Solace, with COSLA, with the IGBs and with the chief officers and the chief executives and the chairs of the boards, because I think that it's something that we need to work through. I don't propose, at the moment, to try to impose an absolutely similar system in every area, because the whole point about having local determination is that within the flexibilities available we should use that, but it would be fair and transparent to acknowledge to the committee that it's something that we are still working through, so there will be some differences of views expressed to you, but maybe Christine and Alison could say a bit more about that. I should also record, sorry, just for the committee's benefit, that the ministerial steering group, jointly chaired by the Cabinet Secretary and Peter Johnson, who is the health spokesperson in COSLA, is also taking a very close interest in that. The reason why it's managed in a different way is that it's about resources that are within existing broader resources, so when a hospital could be awarded or proportions of awards, so you're part of medical specialties, for instance, so it's not whole, complete components of budgets, and that's why it's been established as a set-aside budget, but that doesn't mean that it's notional, you know that these are real beds with real staff in them, with real patients and real costs, so I think that where I've got to in this and really helped through the finance development group and I think from some of the people that came to give evidence on the 22nd is that the most important thing is that when integration authorities are setting out their plans for services, that it includes the component that is in that acute hospital care, which is the set-aside budget, and if that happens, I think that everything else flows, so it has to be more than just calculating a budget, it's got to be something that features in your plans, and I think what we saw is that when you looked at Aberdeen City as an example that we used, that's exactly what they do. Now it gets harder when you start to look at how you would shift resources if you provided that service differently, but we're already seeing some examples of that starting to happen, so we know that it can. To me, the way it moves away from being something that's talked about as being notional is by clearly being able to see that that acute component of care for those individuals is included within the plans, so if you start from that as being the do, you see that in every partnership, I think that that would be a valid question, because in all those things the money flows, the money should flow based on your service delivery plans and not the other way around. I don't know if that's sufficiently answered or if Alison might want to add to that. The only thing that I would add, if I may, is again, I think that this takes us back slightly to what we were trying to do with this iteration of integration, because this, of course, builds on years of attempts to bring health and social care closer together, and one of the lessons from the community health partnership experience, which preceded the round of work, was that community health partnerships had within their span of control only the services that were already in the community. That was the maximum space in which they could reform anything. One of the things that we recognised was that one of the challenges that we're trying to address now is the potentially avoidable use of institutional care, sometimes in hospitals, sometimes in care homes, particularly for Freeloader people and others. The only way that the new partnerships could get some grip on transforming that kind of care was if they had some authority over aspects of that kind of care. I think that Eddie Fraser, when he gave evidence to the committee a couple of weeks ago, explained that what is in that component of the hospital budget that Christine describes is basically the types of activity in hospital that are most often used because something else hasn't kicked in earlier on in the community that would deliver a better outcome. It grieves me slightly that we end up talking about sethicide so much that I completely understand why, but the sethicide is only a mechanism to enable that idea of shifting the balance of care by giving people that span of stuff to reform and improve that touches the thing that we want to do less of, as well as the thing that we want to do more of. I wonder in response to Ms Harper's question and if it would be helpful to the committee. We could try to set out on a couple of sides of A4 or not more what we are trying to achieve through this sethicide approach, because it is something that is off to debate, and I just wonder if it would help the committee if we tried to give you an outline. I think that that is very welcome and I think that we would appreciate that. When we took evidence last time, Judith Proctor said that cardiac nurses rehab, nurses pulmonary rehab, if you are delivering that in the community, your sethicide budget, which is for acute care, would then help to support transition for the community so that you would have your cardiac rehab, pulmonary rehab delivered in the community. Is that part of the process that would be seen as a good example? Yes, indeed. Sometimes when we talk about shifting the balance of care, it takes us back to this earlier point that we need to see it as being part of a joint responsibility, because it is part of a joint pool of resource, human and financial, and it might be that a different service is delivered by the same staff in a different place. That is shifting the balance of care, too. That can greatly improve people's outcomes and experience of care, and it is a good example. Okay, thanks. So, just for clarity, if an IJB through its activities reduces demand for hospital care, does the finance that is released by that stay with the IJB, come back to the IJB through the budgetary arrangements? Are there any examples of that happening? I will put this back to Alison in a second. The answer, in principle, is yes. The difficulty, and this is why there is this debate around this, is that it is a bit more complex than that. Imagine a service that is delivered at the moment in a hospital-based setting, and some of that service is then transferred into the community quite properly and with proper clinical governance and so forth. Just to make the example, imagine that that hospital consisted of that one ward in which that service was delivered. You do not make the saving of being able to remove the need for that hospital if you have only transferred half of what the ward did out into the community. That is where some of the issue arises. It is absolutely the right thing to transfer it into the community. It is best for the patients, it is clinically appropriate, but realising that the efficiency saving is harder because you have not taken away a whole service, you have taken away part of it and yet, therefore, the other part remains where it was. That is not to say that this is all impossible and, therefore, we should stop trying to do it. That is where some of the debate comes in about where the budget lies. You cannot transfer half of the budget for a service into one place and leave the other half dangling. Those are the things that need to be worked through. That is what we are doing through transformation, but it is just to make the point that it is not altogether as simple as it may look on the surface. I look forward to the paper that you mentioned, Kate Forbes. I want to talk about budgets against outcomes, because I understand that there is a requirement for the integration authorities to report budgets against outcomes, but we have previously heard some questions about how successful that is. What support are you or the Scottish Government providing to integration authorities to help them to develop reporting of budgets against outcomes? Of course, some of the high-level outcomes are set out in the legislation itself. One of the things that we have been keen to do is to help integration partnerships to have the necessary underpinning data to support both their analysis of what they should do, where they should prioritise and then the outcomes that they achieve. Within NHS National Services Scotland, there is an organisation called the Local Improvement Support Team, which can give local partnerships access to data that is very much focused on their area. We have been able to identify in particular areas where the patients are that have the highest use of health and care funding, because they are obviously the ones with the highest and most acute need. Because we have some of that underpinning data already, one of the things that we are doing and can do to support them is to see whether those trends are moving. Are the highest use patients being given a better service nearer to home that is reducing their usage rates? The other thing that we have thought of saying before handing over to Alison, outcomes are not only objective, they are also subjective. In other words, did the person feel that the quality of care was good? It is just as important to me as to whether we can, by some measurement, say that the quality of care was what it should have been. Could I add a quick supplementary before handing over in terms of there must be activities to where it is not meaningful to split budgets across a range of outcomes? I will leave that for you to answer. That is particularly in relation to the requirement to report financially. I will add to what Paul has said about support to local partnerships. I will say a little bit about financial reporting, but I will invite Christine also if that is okay to contribute on that. The list teams are particularly well received by the partnerships. The fact that the analysts are embedded locally really helps. They have put quite a lot of effort recently into, in particular, supporting clusters of GP practices, as well as the health and social care teams, which I think is helping to knit together the idea of integrated planning and delivery, and then understanding what you are getting. They are using a dataset that we have been developing over some years with ISD, which links health and social care data, which is also potentially very powerful, because it allows you to see patterns of service use shifts and enormous variation as well. The other layer in this that is more recent is the ministerial strategic group, which Paul mentioned earlier. About 15 months ago, Paul wrote out to every integration authority and asked them to share with us their historic and projected data against half a dozen key indicators. Those are things such as unscheduled occupied bed use, which is a key point in the delivery plan, bounce of spend on palliative and end-of-life care, etc. We have been gathering that data on a quarterly basis. We have a working group for that as well. It is beginning to illustrate for that ministerial group really interesting trends both in terms of variation in how services are used between areas and in projections for ambition, which I think is quite interesting as well. The point that Paul makes about that which is quantifiable and that which is more qualitative is something that is on our minds a lot at the moment. I know when Janice Heart was here a couple of weeks ago, she asked why it is that we all tend to believe numbers but not narrative. That is a particularly powerful question when you think about our commitment to double the availability of palliative and end-of-life care in communities, for instance, because it is actually quite hard to quantify at any level of granularity. Just as an example, what constitutes really good palliative and end-of-life care? It is even hard to know what to count all of the time. There is a huge amount of work going on in that. A key aspect of it is the exchange that is under way between chief officers, between integration managers, between the list analysts, sharing experience and understanding more of what is afoot. When it comes to reporting financially against outcomes, I think that we have given ourselves a hard task. I think that it is a good objective, but making the link between outcomes at their highest or set out in statute and then filter down to those indicators does risk a layer of granularity that actually is not that meaningful, as you suggest. However, I think that Christy knows more about the practicalities of that bit. We are starting by trying to get the building blocks in place for it. We are looking at the expenditure in high-level. We are spending on acute primary care, community, mental health and so on. You will see that in the first report from integration authorities where they attempted to show mental health spend. That shows one of the issues that spend for something like that crosses the whole of the sector from primary care through to social care. Salisace says that it is important that we get that right. What we have seen so far is that not all of our information systems allow us to do that right now. We have already started and we are going to have to continue to invest in better-costing information systems to allow us to pull that together. On your 2020 rule, we can get about 80 per cent of the way without too much difficulty, but to really make it meaningful on a real-time basis, which is what partnerships really want. You do not want something that is 18 months out of date before you get it, so we are going to have to invest to be able to do that in a meaningful way. What we will start with is those agreed national outcomes. We will look at things like reduction outpage in occupied bed days and seek to translate that into what that means financially. I think that that is the best way to step into it, but we do not yet have a comprehensive programme budgeting approach across either health or social care right now. On the subject, there is always a danger that having targets can distort behaviour. How do you ensure that that does not happen? Secondly, as a supplementary, how do you enable better innovation when a proportion of integration authority budgets are fixed, at least in the short term? Feel free to take issue with any of my premises. I will bring Alison in. We are very alert to the fact that targets can, in certain contexts, have effectively created perversion incentives. On the other hand, I always take the view that the public is entitled to know what to expect from a health and care system. I mean, no-one would do business with a shop that had no prices on any of its goods, or at least if there is such a place, I have never been in it. The idea that we would somehow not be able to say what somebody could expect from our health and care system, I think, would be wrong. The way in which the objectives of health and social care have been set out in the legislation is sufficiently high-level to avoid that perverse incentive risk. One of the things that we do each year is to look at and to review the plans from the integration partnerships and assure ourselves that they are both deliverable and acceptable. We have a number of mechanisms in place for that. I do not know whether you had anything in particular in mind where you thought that there was a risk of a perversion incentive, or whether it was just a general... No, not particularly. We heard it, I think, last week or the week before, the comments that I have put to you. It is more taking a comment that I previously heard from panellists for you to either rebut or to agree with. I do not know quite how far you want me to go on this one, convener, given time. A brief response, Paul, would be helpful, and then we will want to move on. One sentence from me, and then I will bring Alison in for a brief comment. A target such as the 95 per cent A&E performance target, you might say, well, what has that got to do with integration? Well, actually, what you have outside the hospital makes a huge impact on what you have coming in through the front door and how people can get back out again quickly. Does that create perversion incentives to behave in a particular way? Well, no, because it is a clinically appropriate target to have, and therefore there are good clinical reasons behind it. The thing that I would be looking for in any target, objective outcome or whatever it was, is it clinically appropriate? Does it benefit the patient? If you can answer yes to those two questions, that seems to me to be what is important. I do not know if you want to add anything else. On the very briefly, a lot of the integration authorities have added in their own objectives. I am not sure that they would actually call them targets, but they are certainly not working to this half dozen that we are asking for data on for the MSG. What they are doing is, I think in some instances, is really very interesting, even talking with their communities, about what constitute appropriate objectives and ambitions in their local system. Some of that is very new. I would not describe it as well-bedded in, but I think that that matters as well. You can offset the balance of a centrally determined target by working on local objectives. I thank you very much for your evidence this morning, Mr Gray. Your earlier comments on the fact that a ward may still be needed in terms of whether money would go back into the community and so on, was quite helpful. It sounds as if you are agreeing with evidence that we heard from Mr Eddie Fraser, if he stares at our health and social care partnership, when he said the demand on acute services would be much greater if we were not doing what we are doing. With Professor John Connell, who said that society probably needs to move away from the idea of saving money when we look at this in the round, I would like to focus on the idea of shifting the balance of care and ask, is the aim of spending at least 50 per cent of spending taking place in the community health service ambitious enough, given that in 2015-16, the data suggests that the level then was 47.7 per cent? Are we setting a high enough target here? At the moment, we are making progress towards that target. I think that the latest data would suggest that we are now over 49 per cent. You are asking if it is ambitious enough. I would have no difficulty in discussing whether that target ought to be extended. I wonder if I might ask Catherine Calderoo, the chief medical officer, just to say a bit about shifting the balance of care in the context of realistic medicine. I think that we need first to remember that that target we are doing very well compared to other countries. If we look at the United States of America, their acute to community spend is 90 per cent acute and 10 per cent in the community, so we are in a way already far ahead. I would agree that looking at that percentage of spend again when we have got so far is absolutely correct. We now have, as you are aware, services like hospital at home in all of our health boards, and what I hear from general practitioners is that their demand for those is far greater than the capacity at the moment, so there is definitely more capacity that we can put into some of the systems. As you know, I am sure that the hospital at home, although much preferred by the patients and their caregivers, reduces prescription and reduces admission to both hospital at home itself but also re-admission to the acute hospitals. It is a service that people prefer, but it is a win-win all-round, including cost savings. Is that capacity for hospital at home, for example? It sounds as if there is not enough capacity at the moment. Is that a resource issue? Is there enough funding for this transition? I think that what people are doing, Alison, is becoming more ambitious with it. Over the winter, I visited the hospital at home service in NHS Lanarkshire. They have space for 60 people at any one time because of the pressures on the hospital. They up that to caring for 90 people. They did not know that they could achieve that, so they are now routinely caring for many more than 60. I think that what has happened is that people have really gained confidence in these services. The teams are getting bigger and more staff are being recruited. I suppose that part of that is new. Were the patients going to like it? Do people's expectations? I think that I need to be in hospital. How can I possibly get antibiotics that will be as effective at home? There is a concern—a conservatism, I suppose—that that care could be as good as in a hospital bed. Of course, we are now having the data to prove that. Do you think that it is an achievement in its own simply to prevent a future shift towards more spending on acute services? Or are you looking for something more concrete than that? I think that we need to look at patient preferences. The difficulty with that is measuring that. I think that we have already heard that from Alison Watt. We have not got our robust ways of measuring how important patient preferences are. We know that the outcomes can be changed by people having an option of different types of care. Worldwide, we are struggling to find proxy measures to find how that patient experience can actually be measured in a meaningful way that we can adjust our services. However, we are working on that. That is where the measurement of realistic medicine with patient priorities—I am always asked by audiences, how are you going to measure that? I do not think that we have a concrete answer. We are measuring proxy at the moment. As we gain confidence in the patient experience being such an influencer, we need to work out ways of collecting data and using it. On shifting the balance of care, our papers suggest that there have been some modest shifts in budget allocations over the three years of operations of the Integrated Authorities. Family health, prescribing and social care budgets have reduced as a percentage of the total budget. If our witnesses might comment on that, does that decline on spending on family health reflect the principles of shifting the balance of care to the community sector? The overall shift that is counted is showing an increase. The proposed extra investment in primary care in particular, bringing that up to 11 per cent of the budget over time, is going to be another important component of that. I do not know, Christine, if you want to say a bit more about some of the individual components. First, this is one of the areas that we will hope to set out very clearly in the financial framework. We have got to—this is really about differential growth, rather than seeing overall reductions. However, if you take prescribing as a good example, over the past few years, we have seen effective efficiencies in things like polypharmacy reviews, which have allowed us to avoid the increases that we have seen in the past in primary care prescribing, where hospital prescribing in some areas has been around 10 per cent inflationary growth in the past few years. Partly, that reflects some fairly big increases within the hospital sector. In some ways, maintaining that proportion of spend is something in itself. To get it to 50 per cent I think takes more than just a marginal increase. It really does mean being able to keep that focus on both shifting but also making efficiencies in areas where you can. I guess that you would expect me to say that I would not want to stop anybody from generating efficiencies with an overall spend where they can. If you took that out of the equation, you would probably have seen a greater overall growth level in volumes. I raise the issue around mental health spending. A cross-parliament has been a lot of interest from MSPs about spending in mental health. Without being too simplistic, some evidence has been suggested historically that this was seen as a more Cinderella service to physical care. Certainly, what I was struck by an evidence from integrated authorities was the variation in spend from different integrated authorities. For example, there was reduction of 3.5 per cent in mental health spending in borders and an increase of nearly 30 per cent in Shetland. I am interested in the panel's views on why such a huge variation is. I will bring Catherine in a second. I think that what is clear is that, if you like, out-of-hospital spend on mental health is an essential component of ensuring that people can have a good quality of life in their communities. Your point about mental health being somewhat a Cinderella service, to put it simply, is recognised, and I think that it is not right. The fact that the Government has appointed a minister for mental health is a very clear signal of the intent there. The fact that we have a 10-year mental health strategy and are increasing funding on mental health is also a very clear signal of intent. Any individual is a complete person. They have physical health and mental health, and the two interact with one another. You do not have a separate mental health and physical health strategy. One inevitably affects the other. What we are also very clear about is that we are working with a wide range of partners to ensure that, where people do percent with issues that relate to their mental health, we are able to help them at the point of need. I am working closely with Police Scotland, for example, as are many others, on ensuring that, if people present in police station custody suites working with the prison service, people present in prison service settings, I know that police officers often deal with what they call distress calls, which are, in fact, issues related to individuals' mental health, rather than a crime having been committed. We are very clear that we want to enhance our resources in those areas. There is a significant additional investment over the next five years of £35 million, as I understand it, and we are working towards having 800 extra workers involved in mental health. Yes, it has been a service that has been undervalued. We are trying very hard, not only symbolically but practically, with the input of money and people to turn that round to a valued service, because it is essential to people as well. I agree entirely with that summary, and there is a long list of reasons why mental health issues have not been taken as seriously, probably, and also had the spend for care. I suppose that I would summarise those in perhaps that we now recognise that everybody has mental health and wellbeing before we just talked about people who had mental health problems, mental health illness, and there is far greater recognition across society that that is an aspect of everybody's lives. Paul's comment about the police. It is 25 per cent of the police distress calls are caused by people with mental health issues, not crimes, and there is a lot of need for people to have understanding of how to deal with that. Of course, that is not the right person to be dealing with somebody in a mental health crisis. Increased knowledge that we also have about the, I do not like the term, the burden of disease, but our public health colleagues have recently published a very nice graph that I will share with the committee. It is in my recent report that talks about the burden of disease across Scotland. What the committee would recognise is that cardiovascular disease and cancer are right up there as the top. That is the burden of disease as in premature mortality, early death, but it is also the burden of living with disease and disability, the two people's lives that those cause. You may be surprised to hear that, after cancer and cardiovascular disease, mental health issues and substance abuse are the third largest quantity of burden of disease as we are measuring that in Scotland. I do not think that that has been recognised and that is certainly if we were to place a map of the finance across that burden of disease graph that the spend does not match that at all. The issue that you relate to is well about the effect of stigma on mental health is very worrying. I remember that it was in the 1980s that the old health education and health promotion council had a poster of which it said six months after Mary Hadner's breakdown, her friends are still recovering, which I thought was a very interesting way of putting the whole issue of stigma and the effect that that has on health. Paul Gray mentioned the issue about the appointment of 800 mental health workers. Could you perhaps give an outline of where we are in that? That was obviously over a five-year period. Where are we in the appointment of the 800 in Scotland? Sure. Again, I would be happy to write to the committee in more detail on that. We are obviously beginning that process just now. One of the things that we are keen to see is that what we are not doing is saying that we are going to appoint 800 doctors or nurses for mental health. We will need more doctors and nurses and other clinical professionals, but there is important investment in the front line in counselling services and what we are also doing in schools. However, if the committee would find it helpful, I am quite happy to give a more detailed exposition in writing rather than try to do it at length here. I think that I have found the question at convenient and conscious time. I suppose that it is related to that. You mentioned earlier, Mr Gray, about the important issue about transformational spending. How important is that in mental health? How do you work out how effective each pound is of spending that you are having across integrated authorities? Well, it begins by knowing what works. That is really the base point. There are some things that we know work in relation to mental health issues. For example, in some cases, early access to talking therapies, there is strong evidence that that works. The importance is of making that available, but I do not know, surely, whether you want to say something about the transformational spend as it relates to mental health. I think that that point is really the critical one, that what we are looking to try and achieve with the multidisciplinary team is to make sure that early intervention prevents escalation. The spend point becomes even more complicated, because what you are looking for is both an achievement for that early intervention, but also trying to calculate what any failure to intervene appropriately is an early stage that does in terms of clinical condition thereafter. I heard the supplementary from Sandra White. I just wondered when you talked about the finance. Is there anyone looking at the fact of CAMHS? Will there be a transitional period between CAMHS and then adult services? That was raised with us, but there seems to be a gap there. We would be looking at that, perhaps, if we could even send a paper or an answer. It is fine, but that was something that was raised with us. Is that a very important clinical issue? We can provide more in writing, but if you want a very brief answer, I would ask the CMO to give that. I think that that has been something that has not been recognised before. We have traditional child and adolescent services and then adult services. As with some physical health services, that need for an active transition for a plan has not been recognised, but we have recognised that now. Struck by Dr Calderwood's assessment that the third biggest strain on the health services is around substance use and mental health, I am very concerned that, given that reality, the 27 million uplift that the Scottish Government announced to mental health won't even wash the face of the 800 link workers that we've got to point, let alone deliver that transformational uplift. I want to focus on substance use, because one of the most alarming outcomes that we've talked about and drilled down into is the increase in drug-related deaths. The fact that we are now the worst in Western Europe for drug-related deaths and doesn't show much sign of improvement is that there is no direct causal relationship to the loss in ADP funding. I tried to make that a stand-up, but you can't say for definite that that's related, but surely it didn't help. I'm very gratified to see the Government acting on that with the 20 million, but there will be lost institutional memory and experienced staff who have gone out the door as a result of the closure of the services that happened as a result of the cost. Have any decisions been made about the allocation of that 20 million pounds of funding? How will the efficacy in terms of impact on drug-related deaths be measured? I can provide more details, but just by way of funding, we're working on the basis that the majority of that 20 million will go from health boards to integration authorities and with a component of that being held back as an investment fund. That will support the new strategy that is due out in the summer on substance misuse. There is a refreshed approach to that. What we're looking for is for that money to be invested in a way that will get the best in the highest impact rather than just going back to fund programmes, as you say, that were there in the past. A lot of the work that I'm sure you've heard from the team so far has been looking at how we really get the best services across the country in a level of consistency that maybe wasn't there in the past. That's a broad approach. A funding letter has just gone out as my understanding to partnerships and boards in the past week, so we can make sure that you've got that and provide any further information on what happens between now and the strategy that's being published. If that 20 million is being washed through integration authorities, how will it be protected for drug and alcohol services? There are obviously competing demands within IJBs. I think that it's probably important to note both on mental health and on ADP spend. There are areas in which we've been directive about protecting spend, so we expect that spend to be over and above the core spend, particularly in mental health. We've said that we expect the additional funds in mental health to be over and above real-terms increases in base budgets, so that picture that you've got there from 1617 into 1718, we're not expecting to see that when we look at the 1819 figures. I have to come back to you on that once we've got the data, but that's the evidence that we'll be looking for through the year. Can I just ask one very brief supplementary? If IJBs don't protect the money because we've seen that before, they were told to protect the money when the original 23 per cent cut happened, and yet we saw in Edinburgh a 1.3 million cut to ADP services. What happens if they don't protect the money? We'll be looking at the team to understand the extent to which the strategy is being implemented. To be fair, you also need to understand whether an area has been able to deliver what it needs to with less funds. If it's a case of reduction in spend and not delivering outcomes, you would expect us to take action as we would with any area of performance. I think that the thing to be assured of is that it's an area of real priority, and we'll be focused on understanding how that money is invested. I'm very fond of Brian Whittle. Thank you, convener. On alcohol and drug funding, a lot of the services that are delivered through the third sector, and I suppose we could say the same in mental health as well, and I just wondered how that money washes through, is there going to be a link between NHS services and the third sector in terms of working together? I'm in no doubt that third sector services are essential for the delivery of appropriate interventions on mental health, partly to do with the way that they're trusted in communities, and they probably have access to areas where frankly statutory services would be less trusted and people would be much less likely to access them. From my perspective, I would have a strong expectation that the integration partnership will be working with local services, some of which might be quite small. Therefore, we want to make absolutely sure that they have certainty about the resources available to them so that they can continue to provide local services. I thank the witnesses for that session. Clearly, there are a number of items on which you have already volunteered to provide further information, which is always welcome, but we may drop your line if there are other items that the committee will require further assistance with at this time. Thank you very much and I'll suspend for five minutes. Thank you, colleagues. We will now resume and move on to the next item on the agenda, which is consideration of an affirmative instrument. The first instrument that we are looking at today is the Community Care, Personal Care and Nursing Care Scotland amendment 2, regulations 2018. We will hear, first of all, from colleagues from the Convention of Scottish Local Authorities in just a moment and thereafter from the Cabinet Secretary and her advisers. Then, following the question sessions with witnesses, we will then move directly to debate on the instrument. I welcome to the committee Councillor Peter Johnson, the health and social care spokesperson, John Wood, the chief officer for health and social care at COSLA, and Morick Johnson, director of financial and business services at Glasgow City Council. I start by asking Peter Johnson if he would lay out the views of COSLA regarding the instrument and your approach to the principle and any particular issues that you wish to draw the attention of the committee to. Thank you, chair, first of all, for inviting COSLA to give evidence today. As I hope is clear from my written submission, COSLA is happy to provide support for the extension of free personal care to under-65s. However, we believe that it cannot be done successfully without the co-operation of local authorities. In previous written submissions, COSLA has suggested that a staged implementation might be worth consideration. This morning, I would wish to make absolutely clear that COSLA accepts ministers' desire to have full implementation by April 2019 and to stress our absolute commitment to making this timetable a reality. Before we perhaps take detailed questions, it is worth reflecting on the views of the COSLA health and social care board, which has agreed to uphold the principle of charging for some social care services on the basis that it is fair that people who can afford to pay a charge or contribution towards the cost of care services that they receive should do. We believe that co-payment encourages ownership and empowers a person's ability to make choices with regard to the care that they receive. Furthermore, the ability to use income raised through charges to invest in social care services is a key to providing local authorities with the flexibility to focus resources on local priorities and needs. I understand that COSLA officials are working with civil servants and partner organisations to develop the detail of implementation, and we do have some areas of concern that we hope can be addressed prior to implementation. First, we would advocate that the policy must be fully funded with new money to serve as current service levels, the increased number of assessments required together with unmet need, which will be identified as the policy begins to be implemented. Secondly, we would argue that this should not come at any detriment to councils decision on charging for non-personal care in line with the COSLA charging policy. The autonomy councils currently have, we would argue, strongly must be maintained. Finally, the implementation should be closely monitored with agreement to reflect any increase in demand in future financial settlements. Finally, I would emphasise again that COSLA gives our full support to the Scottish Government's policy intent of removing the current discrimination that exists and to extend free personal care entitlement to those adults under 65 years of age who are assessed as needing personal care. That is a quick whirlwind through the COSLA policy statement. Thank you very much. That is very helpful. I can ask Miles Briggs. Thank you, convener, and good morning to the panel. Thank you for the submission, because I think that it was quite helpful in setting some of the background information. It is about a year since I tried to bring forward my members' bill to Parliament, so I am pleased that we have seen this progress and hopefully today we will be able to pass the legislation needed. In terms of costing, that was one of the sides that I am still not completely clear about, where the Government has found the £10 million figure. In terms of your work with local authorities, meeting that unmet need, which clearly is going to come from this policy, how much do you personally think that that will cost? Yes. There is a figure of £10 million to £11 million that has been mooted, and that is based on removing the current charges that do apply to under-65s and nothing else. It does not take into consideration the potential increased demand that would flow from charges being removed, so we are actually working with civil servants at the moment to try and bottom out what those costs would be. Certainly, we anticipate that they would go beyond the £11 million figure through the implementation advisory group over the next couple of months. We would hope to get clarity on that. There have been initial estimates, which would suggest that it is probably at least three times that £11 million figure, but we still need to do a lot of that detailed work to have confidence in any sort of figure. That is very helpful. I think that some of the work that I did around the bill suggested is at £40 million to £60 million costing at that point. In terms of scoping unmet need, what work has already been undertaken by local authorities? We have done that in conjunction with civil servants as well. It has been a collaborative exercise, so it was just us who have been doing that scoping work. We have essentially modelled it on the trends that emerged after our free personal care for over 65s. It was no longer charged for in 2002, and it applied those trends to the current figures for under 65s. That probably would not necessarily flow as a direct comparison, so there has been a bit of modelling that tempers the increase that would be predicted if you applied the exact same trajectory. Those are the figures that we want to do a bit more detail on over the next few months to get clarity. Are you confident that, in your statement, you raised some concerns around full extra assessments and administrative costs around that? Are you still confident that we can put this policy in place in April of next year for everyone in Scotland as the Government is looking to see? That is certainly what we are working towards. COSWA has worked with the Government over a number of such policies. The principle of fully funding is core to that, but we have always managed to work with those things through at least in health and social care and come out with the desired outcome. We are confident that we can do that in this field likewise. That is very helpful. Can I take it that funding includes the funding that is required for staff to make assessments of those who are not currently identified as in need of this case? Certainly. What will be pressing for COSWA-Johnston's point about that additional burden flowing from the assessments needs to be taken into consideration? Excellent. That is very helpful. I thank you very much for your attendance this morning and for your input. It has been very useful for the committee to understand your position, which has evolved as those things often do. Unless there are further questions from committee colleagues, we will adjourn briefly to allow a change of witnesses. Thank you very much. We will now resume consideration of the community care personal care and nursing care Scotland amendment 2 regulations. I am pleased to welcome this morning the cabinet secretary, who is accompanied by Mike Liddle, from adults social care policy team, and Davis Solister. I believe that the cabinet secretary is going to make a brief statement about this. Thank you. Good morning, convener. Thank you for the opportunity to speak briefly to the committee about those amending regulations. This amendment will introduce free personal care to adults under the age of 65, from 1 April 2019, by removing the requirement of age, as stated within the current regulations. The draft affirmative regulations before the committee today reflect our continued commitment to remove the differentiation and treatment of those under the age of 65 in the provision of free personal care. The committee will, I am sure, want to join me in recognising the tireless campaigning from Amanda Copill to bring about Frank's law. Free personal care already benefits around 78,000 older people in Scotland in their own homes and in care homes. It enables them to receive free of charge hands-on care, such as washing, dressing and shaving, and assistance with preparation of food. Of course, it does not include wider social care elements such as daycare. From 1 April 2019, personal care will be made available free of charge across Scotland for everyone who requires it. For those on the lowest incomes and with the smallest levels of assets, personal care is already provided free and will continue to be provided. We recognise that those people with substantial packages of non-personal care will still pay towards those elements of their care packages, but they will continue to have access to those social care resources that they receive now. I am aware that there are a range of opinions around the charging policies of local authorities, but we must balance the best outcome with the appropriate timing of implementing the legislation. Therefore, we have asked for this order to be considered significantly ahead of its coming into force date of 1 April 2019 to enable local authorities to plan for necessary changes to their processes and systems around care assessments and financial assessments. In preparation for the extension, an implementation advisory group has been set up, making use of expertise from local authorities, health and social care partnerships, COSLA, care providers and service users to ensure that implementation takes into account the impact of the change on local authority systems. Those areas will be required to be reviewed by local authorities to ensure that changes to the systems will be in a manner that is sensitive to the needs of the service users and service user choices about their care and support, as well as aiding the local authority. The implementation advisory group is also looking at models of monitoring and review of the policy, which will aid Scottish Government and local authorities to budget for future costs of the extension of free personal care. I am happy to take questions on the regulations. Thank you very much, cabinet secretary. I think that your final reference to the costs of implementation clearly is an important one. We heard this morning from Councillor Peter Johnstone of COSLA, who indicated how keen local authorities are to work with the Government on implementation, according to the timetable that has been set out. I wonder towards that end, if you would like to comment regarding the estimated costs of implementation, which currently, in COSLA's view, reflect existing need and not the potential for unmet need that has yet to be identified. Clearly, as COSLA said earlier, those are matters that are being discussed by the implementation advisory group. Those will be brought to a conclusion over the next few months. There is a recognition that we know that the costs of existing service users will be around £10 million to £11 million, but it is trying to estimate that unmet need. That is the more challenging aspect of that, and that is why we are working through the implementation advisory group to get the best estimate of that and ensure that local authorities can be properly supported in implementing the policy. Those discussions will reach a conclusion over the next period of time well in advance of the implementation date. Is the principle that COSLA laid out for us this morning of fully funded implementation one that, in principle, the Government supports? Yes, we do, but of course there is then a discussion about what does that mean and what are the costs, and we need to land that accurately, and then we need to review it to make sure that that is accurate. Going forward, we will make sure that the review of the actual levels of unmet need to make sure that that is in line with the resources that have been provided. We need to have proper monitoring of the policy as it is implemented. A very quick question on that, cabinet secretary, if I may. I think that I asked you about this when we talked about the Government uplift to the cost of free personal care for the elderly last year around the budget scrutiny, and I think that it was something like 1.8 per cent. This was in the year that the same budget had a 3 per cent uplift for all public sector workers, and my concern is that we are not attaching the value to this line of work that we should be, and we are not making it an incentivised profession to enter it. What is your view on that? I do not agree with that. I think that the latest figure of the resources that we have put into social care more generally is around £550 million. In addition to the uplift of the free personal nursing care policy itself, there are additional resources that I have gone into, for example, delivering the living wage to around 40,000 social care workers. I think that you have to take that spend in the round. It is a significant investment in social care. Demando continues to increase, and we are the only part of the UK to implement free personal care for older people, and, of course, we will be the only part to implement it for those who are under 65. I think that, all in all, we have a system that is much fairer. It is not perfect, but we have a system that is much fairer. The next instalment, if you like, of extending free personal care will make the system even more fairer. As I said earlier, we need to make sure that, in taking that forward, we properly resource that, and that is the discussion that we are continuing to have. I certainly welcome this step forward, but the cabinet secretary will be aware that Scotland against the care tags still has concerns. They are concerned about the fact that not all parts of a personal support package will be covered by personal care, and they would like to see a rebate for people who would help to reduce the overall cost for people aged under 65 for that whole support package. Is that something that the Government will consider in any review? It is important to separate out the different elements. This is about the extension of free personal nursing care to be in line with those who are over 65. I recognise, though, that what Scotland against the care tags are saying is that they want a discussion about care charging more generally and, in their view, they have put forward a proposition about removing charges across the board. Obviously, that would come at significant cost, and that is a separate discussion around charging policy and the cost of that to the discussion that we are having here today. We recognise that there is a need to ensure that, for example, when free personal care is implemented under 65, there is not an additional rise in charges for non-personal care. Those are part of the discussions that are being had around the table in the implementation advisory group, because I think that it is important that there is a fairness there that does not give on the one hand and then take away on the other. Those are important discussions to be had, but it is also in recognition of trying to make charging fairer that we took the decision previously to the cost of £11 million to raise the threshold for charging, which applies to non-personal care as well, which has benefited a lot of those who are on lower incomes and, indeed, the changes that we made to veterans to disregard war pensions and the armed forces compensation scheme to, again, which assists veterans with personal and non-personal care. We have taken those additional steps, but we do recognise the issues raised, but those are for a separate discussion, rather than for this one. Thank you, convener, and good morning to the panel. The cabinet secretary will know of my personal interest in this, given that I wanted to bring forward a bill, so I am pleased that we have reached today in almost less than a year since that bill was proposed. I hope that today is a good day not only for Parliament but for people out in Scotland who need it. That is where the cross-party support for the bill has really been important. I think that looking towards how we implement the bill, it is so important. What we just heard from COSLA is that it now suggests three times what is currently being proposed financially. It also highlighted concerns around full costs of extra assessment and administrative costs. I just want to really say to the Government and to the cabinet secretary that I hope that we are able to make sure that there is flexibility around the additional funding that will be needed, because I hope that we will not see a situation where we try to do that on the cheap. It is important that this unmet need, which we are all aware of, is met and that is scoped as soon as possible. In those two points, I would just like some clarity in terms of the concerns that COSLA has raised for the full assessments that will be needed and additional administrative costs. As part of the work of the implementation advisory group, as well as looking at the estimates of unmet need, of course, they are also looking at the costs of implementation, whether that is additional staffing requirements for assessment and administration. At the end of that process, we will agree with COSLA what the global resources that will be required to fully and successfully implement this policy from 1 April 2019. We will then, of course, bring that forward in a budget to Parliament. I hope that we get the same cross-party support for the budget that will deliver the policy, because clearly that will be important when we get to that stage. Do you have a timetable for when that figure will be? Work is on going on. We would hope to conclude those discussions over the course of the summer, but I think that it is important to get it right. If there is a requirement for additional work beyond that, it is important to get it right and get the best estimate. As COSLA said, progress is being made. We would hope that, over the next few weeks, and certainly well before the implementation of the policy from 1 April 2019, we will have those figures nailed down. I am happy to furnish the committee with further information once it becomes available out of the implementation advisory group. I thank you, convener. It was almost the same as my old Briggs question in regard to on-going funding and how it affects local authorities. I wanted to go a wee bit further than that and seek some clarification. We have obviously taken evidence in the health and social care integration, and this will obviously have a knock-on effect on this. How will that be implemented? We are talking about funding that local authorities are asking for. Will social work and health integration be a part to play in that particular policy? The success of the implementation of the policy is in the integrated space, because for many service users they will receive a range of services that span health and social care. It is important that the packages of support that people receive are knitted together well across health and social care. I think that integration has helped to make sure that we have got away from the old debates around whether it is a medical bath or a social bath and whose budget is it. What is important is the package of care that is required. In the same way, the moment that resources flow through into the integrated joint boards to deliver those services, the same will be true of resources associated with the policy. It is equally as important as it is for free personal nursing care for the over 65s, as it will be for the under 65s, that is seen through an integrated lens in the actual delivery of services to people in their homes. It is more about the budget, but you answered that particular point in regards to budgets. Thank you very much. If there are no further questions from members, we will move to agenda item number five, which is the formal debate on the affirmative instrument on which we have just taken evidence. I will remind colleagues that this is a formal parliamentary debate. There will be no questions to the minister and there will be no contributions from officials, but I would invite the cabinet secretary to begin the debate by moving motion S5M-12210. I move the Health and Sport Committee. It recommends that the Community Care, Personal Care and Nursing Care Scotland amendment 2, regulations 2018, be approved. Thank you very much. Can I invite any members who wish to contribute to the debate on this matter? Alison Johnstone. Yes, thank you. Having led Green Party members' business on the issue of social care in April 2017, where I was calling for social care to be free at the point of need, regardless of age or condition, and funded through progressive taxation, I very much welcome this amendment to the Community Care regulations, but it is important to put on the record that we could and should go further. I welcome the cabinet secretary's recognition of the issue that there will be some people whose social care charges will not end. Scotland Against the Care Tax continues to call for an end to all social care charges, because they inform us in their briefing that only that will remove the current discrimination against disabled people, where they are charged for the essential support that they need to enjoy the same human rights as anyone else. I think that providing free personal care to under 65s in the same way as it is currently done will still leave the vast majority of younger adults facing significant charges to receive the social care that they need for independent living. I welcome this morning's progress. It is a step in the right direction, but we can and should go further. Thank you very much. Can I invite any other colleagues who wish to make a contribution to the debate? I see none, so if I may ask the cabinet secretary to sum up. Thank you for your contribution. I recognise those issues more widely. However, it is important to also make the point that, in Scotland, we have continued support through, for example, the independent living fund, which we will discuss in a moment. That is not the case elsewhere. In fact, the programme was stopped in England, and Wales has also just stopped ILF. Of course, that is a really important source of support for people who are particularly young disabled adults who enable them to live full independent lives in their own homes. We should not see that in isolation. There are other supports that we provide that are not provided elsewhere that help people to maintain their independence. Thank you very much, cabinet secretary. That concludes the debate. The question is that the motion S5M-12210 be approved. Are we all agreed? That is agreed. Thank you very much. I will suspend very briefly to allow a change of witness. Colleagues, we will now resume. I welcome again the cabinet secretary and also Anne Davies from the Government Solicitor Service. We are now looking to further affirmative instruments. These are the Quality Act 2010, specific duty Scotland amendment regulations 2018, in draft, and the ILF Scotland miscellaneous listings order 2018, in draft. We will now remove the questions on these instruments and I would invite the cabinet secretary to make a brief opening statement. Thanks, convener. While the instruments being brought forward to the committee today are largely technical in nature, I would like to provide just a little bit of background and context of their purpose. As the committee will be aware, the independent living fund, or ILF, was a UK scheme making care payments to severely disabled people. The scheme was closed to new applicants in April 2010 and ceased to operate on 30 June 2015. The Scottish Government made a commitment to maintain ILF payments in Scotland and established ILF Scotland from 1 July 2015. The fund makes payments to all persons in Scotland remaining eligible who previously received funding from ILF prior to its closure. The funding is used by recipients for services offer the flexibility that they may not otherwise have to live in their own home, take up employment or education and help to reduce social isolation. An agreement has also been reached for ILF Scotland to distribute packages of ILF support to existing recipients of the ILF fund living in Northern Ireland on behalf of the Northern Ireland Executive. In addition to existing ILF users, the Scottish ministers have committed a total of £5 million annually in order to extend the reach of ILF in Scotland. In December 2017, the ILF Scotland transition fund opened to new users. The new fund supports young people aged 16 to 21 living with disabilities to be more independent during their transition from education and children services. 200 applications have been received since opening access to these payments with a total liability of around £600,000. When ILF Scotland was established in 2015, it was decided that this should be as a company limited by guarantee. This was to meet the very tight timeframe for delivery and to ensure that payments were protected. There was insufficient time then to list ILF Scotland in various pieces of legislation as a public body. In discussion with the Scottish Government legal directorate and public bodies officials, we have identified a number of pieces of legislation within which we consider that ILF Scotland should be listed in order to ensure that ILF Scotland is operating in line with other public bodies in Scotland. The two instruments being considered today, the ILF Scotland miscellaneous listings order 2018 and the equality act 2010, specific duty Scotland amendment regulations 2018, achieved this alongside a third instrument, which is not being considered today, the ethical standards in public life etc. Scotland act 2000, ILF Scotland order 2018, SSI 2018148, which is subject to negative procedure. If the committee would allow, I provide very brief detail of the two instruments being considered today. The ILF Scotland miscellaneous listing order 2018 lists ILF Scotland in a number of pieces of legislation and schedule one of the freedom of information Scotland act 2002. Although ILF Scotland is already bound by this act, by listing ILF Scotland they become subject to the duties relating to climate change contained in part 4 of the climate change Scotland act 2009. In schedule two of the public appointments and public bodies etc. Scotland act 2003, the purpose of listing ILF Scotland is to regulate appointments made by Scottish ministers to the ILF Scotland board by requiring that the Scottish ministers comply with the code of practice for ministerial appointments to public bodies in Scotland. In part 3 of schedule 19 of the equality act 2010, so that ILF Scotland are required to comply with the public sector equality duty. In the schedule of the public records Scotland act 2011, which will require ILF Scotland to manage its public records in accordance with a record management plan, which has been agreed by the keeper of the records of Scotland. Finally, in schedules 1, 3 and 4 of the Children and Young People Scotland act 2014, listing in these schedules means that ILF Scotland will be subject to the duties of public authorities in relation to UNCRC and will become a listed authority in relation to children's plans and a corporate parent. Finally, the purpose of the equality act 2010 specific duty Scotland amendment regulations 2018 is to add ILF Scotland to the equality act 2010 specific duty Scotland regulations 2012. That makes ILF Scotland subject to various duties, including assessing the impact of new or revised policies and practice on the need to set out in the public sector equality duty, reporting on mainstreaming equality, publishing information on the gender pay gap and equal pay and taking account of the equality duty in the context of procurement. I move the instruments and I am happy to answer any questions that members may have. Thank you very much, cabinet secretary, for a very comprehensive run through the purpose of these two orders. Cabinet secretary, we are pleased to know that we considered the third instrument, the negative instrument area this morning and agreed it, however. We will come to each of the two affirmative instruments in turn in just a moment, but first of all can I ask colleagues if there are any questions on either of the affirmative instruments that the cabinet secretary has described in the past few minutes. If there are none, cabinet secretary, we will then move again to take those in a formal way. We will, however, take them separately, and again the same applies as previously, but I would ask the cabinet secretary to move, first of all, motion S5M-1202. Thank you very much, cabinet secretary. Does anyone wish to make any contribution in debate on this instrument? If not, the question is that this motion be approved, are we all agreed? That is agreed, thank you very much. I may now ask the cabinet secretary to move the motion S5M-1204. Thank you very much, cabinet secretary. Are there any contributions that members of the committee wish to make in debate on this instrument? There are being none. The question is, is this motion agreed? It is agreed, thank you very much. We will now suspend. Thank the cabinet secretary for her attendance and suspend and move into private session. Thank you very much.