 Fylltaeth i ddwyg! Fydden nhw'n gwaith gyda Llywodraeth Cymru yn 2017. Mae dda i ddim yn ddatblygu ei dd甿ol swyddfaeth yn fwy yw'r ddweud. Fwy ddu ni'n ddweud i ddweud o bobl o'i sioedd o'r ddweud, maith yn ddweud, maith yn ddweud, i ddweud i ddweud i ddweud i ddweud ddweud i ddweud. Mae gen gan dim yn cynnig draws honno yn llefnol ag Llodau, Mae gen i ddweud o ddweud o ddweud o ddweud o grannu birch yn dweud feithwn, The First instrument is the sale of tobacco and nicotine vapor products by persons under 18. Scotland regulations 2017, SSI 2017-50. There has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments. Is it agreed that we make no recommendations? The Second Instrument is the Sale of Tobacco Register of Tobacco Retailers Scotland Amendment Regulations, SSI 20-1751. There has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instruments. Again I ask to invite any comments from members." Gweithredu yr ystafell dŷodau lleidio yn gweithio'r ddaw71. Mae gweithredu dŷodon i chi gyfnod erioedd oherwydd fel y gwaith y frontau lwyth. Ac eich seinessiadau mewn iawn. I will introduce myself, and will go round the table if people can very briefly introduce themselves to the committee. My name is Neil Findlay. I'm the convener of the Health & Sport Committee at the MSP for the Loedians. Gwethe mwyn. My name is Clare Hawke. I'm the MSP for Radd sweetness and the Deputy convener of the committee. Hello, I'm Ellie Hildersall. I'm a consultant in public health medicine at NHS Tayside. Hi, I'm Jerry McCartney, consultant in public health at NHS Health Scotland. I'm Donald Cameron, MSP for the Highlands and Islands. I'm David Bell, Professor of Economics at the University of Stirling. Good morning, everyone. I'm Alex Cole, I'm MSP for Edinburgh Wesson. I'm also a Lib Dem health spokesperson. I'm Alison Johnston, MSP for Lothian. I'm Damian McElvenny, Statistician and Epidemiologist at the Institute of Occupational Medicine. I'm Neil Craig, Principal Public Health Advisor in NHS Health Scotland. Good morning. I'm Richard Lyle, MSP for the Highlands and Islands. I'm Mary Todd, MSP for the Highlands and Islands. I'm Evelyn McEw, Chief Officer of the Midlodhian Integrated Joint Board. I'm Mary Simpson, Public Health Practitioner with the Midlodhian Health and Social Care Partnership. Good morning. I'm Fraser McKinley, Director of Performance Audit and Best Value at Audit Scotland. I'm Ivan McKee, MSP for Glasgow Proven. We have a few people missing this morning, but I think they'll join us as we travel problems. They'll join us during proceedings. Could we begin with the first question, Alison? Would you like to begin? Thank you, convener. I would like to ask the witnesses who joined us this morning how they would define the preventative agenda. Who would like to go first? Go for it, Gerry. This is a difficult term to define, as you probably gathered already. Different people will define it in different ways for different purposes. A working definition that you might want to think about is spending, usually public spending now, with the intention of reducing public spending or negative outcomes occurring in the future. It can be defined as primary prevention, in that it prevents negative outcomes from ever happening, so the prevention of a cancer occurring or the prevention of a hospital admission. It can be secondary prevention, which is about perhaps preventing complications or further negative outcomes occurring after an initial bad thing has happened, or it can even be tertiary prevention, which might be about preventing other negative outcomes perhaps in terminal care or the likes. I don't know if there is a single definition that everybody would describe to you, but probably spending now to a very negative outcome in the future is probably a working definition that most people could love with. David? I just add in to that that part of the issue that makes preventative, the assessment of prevention, extremely difficult, is the establishment of what we would call the counterfactual, which is what would have happened had the preventative intervention not taken place and statisticians can spend a long time trying to process the idea of what the counterfactual might be and uncertainty about that clouds the whole prevention agenda and maybe makes politicians less willing to get in there, especially when it can take a long time before the benefits of a preventative intervention may be realised. They also wish to comment. I suppose that some of the issue is about defining it, but also about what it is that we should be focusing on. That's the other question. Sorry, Alison, do you want to add anything to it? It's unfortunate that Dr Irvine isn't here, but maybe the point that she makes in her written evidence suggests that some evidence challenges the perception that preventative initiatives should always be prioritised. She says that employing more district nurses and GPs is necessary to enable them to react to genuine need in the community so as to minimise unnecessary reliance on secondary and tertiary care in the future. That's not preventative medicine, as we think of it in public health terms. That's just intelligent, cost-effective health service planning. I think that there's another view there, but convener, if I may, there are some of the submissions that suggest that it's unrealistic that shifting resources to the community sector will actually save us cash or negative outcomes in the long term. There's a feeling that shifting that to where we might see how preventative action taking place isn't going to save us the cash that we think it is. I'd be grateful for any views on that. Thank you. I guess I can speak from some of our experiences in Midlodi and some of the things that we've learned in our journey so far in integrating health and social care. I think, for us, what's key is the opportunities that have opened up around having a different understanding of what we're dealing with. We're able now to see the whole journey rather than fragmented episodes, whether in hospital or whether in the community. We also have better data in terms of understanding our communities. Things like knowing the level of smoking in our areas of high deprivation has been a real shock to us and has forced us to confront some realities and also the opportunities around bringing a workforce together in very different skills. But key to us and all of that is the shift in the mindset. What we're building up in terms of our understanding is we're starting to build up new interventions that are around building social networks in the community as alternatives to what previously would have been solo professional interventions. An example would be the referral of patients to psychological therapies to address mental health issues, whereas increasingly what we've got is new interventions that looks much more holistically and looks at the social determinants. So it's about everyone understanding inequalities and seeing it as part of their job. Shifting resources from hospital to community is part of that journey. It's about seeing the whole picture. It's about much more holistic interventions and professionals working together and having a real understanding of the context and the social determinants of some of the presentations. Can I just ask further to that? There are some submissions that suggest that social determinants are what we need to get at. We need to increase income and improve housing and so on if we want to tackle health at its roots. There are other submissions that suggest that we still need to focus on specific interventions for specific conditions, like obesity or diabetes and so on. Does anyone have a view on that? There's a false dichotomy there. Referring back to your earlier question as well, perhaps it's worth highlighting that those big picture interventions, the reducing inequalities, the social determinants of health end, have a very broad impact. By reducing inequalities, they will improve health in lots of different areas, which makes it much harder to measure in terms of cost-effectiveness. It's much harder to see that widget A has produced outcome B when you are looking at that much, much bigger, much broader picture. I don't think that anybody is arguing that the one is a substitute for the other, because the impact of reducing inequalities is going to be slow and gradual. It's impossible to wave a magic wand and have that happen tomorrow. The problems that we see currently will continue to be there. The people who are developing pathologies today will still be developing them while we are making that impact on society more broadly. Trying to separate them out in that way and saying that we should focus on one rather than the other is probably unhelpful. We need to do both. Thank you. Gerry? I'll add to what Ellie's articulated. We need to address income housing, all the social determinants of health, but that will not reduce entirely the need for health and social care services. Derek Wallace, in his series of reports that he did with the UK Government a number of years ago, talked about not only the need to postpone mortality and to increase life expectancy, but to compress morbidity, to reduce the amount of time that people spend in ill health if they are to generate savings for the services. That's really what a lot of the prevention discussion has centered around is less about the prevention of illness and the prevention of mortality, but the compression of the time that people need health and social care services for in order to make the system more financially sustainable. The desire to compress that morbidity is about trying to keep people healthier for longer, and that clearly needs all the care around all the social determinants of health about reducing income and the quality of housing, etc. It also needs good high-quality primary care and preventive services and legislation specific for things like smoking and alcohol, food and so on. I think that there would be a useful locus for the committee to focus on, is about that compression of morbidity and about trying to prevent unnecessary spending and services to increase the financial sustainability of the system. I'm just building on that point. Not only is it a potential false dichotomy between investing in the social determinants of health and investing in things that might tackle behaviours, I think that the argument is that we would propose from Health Scotland that we shouldn't be generalising about which forms of intervention are necessarily the most effective and cost effective. We should be looking at the evidence to understand what the evidence tells us about which ways of tackling behaviours might be the most effective and cost effective and which ways of tackling some of the upstream determinants' health might be the most effective and cost effective. There is quite a strengthening evidence base out there that we can draw on in discussions about prevention. We'd very much encourage the committee to look at that evidence base to identify which interventions across the broad spectrum of interventions from upstream interventions tackling the determinants of health right down to downstream interventions tackling behaviours, which of those interventions are going to be most effective and cost effective and potentially most effective in tackling health inequalities as well. Fraser? A first point in terms of definition. To some extent, all public services should be preventative and can prevent things. Looking back at Christie's report, which is a good few years old now, that's kind of where they got to. The danger of talking about preventative spend is that it makes it sound like it's in a pot over here on specific projects that's designed to prevent stuff. All, whatever it is, £30-40 billion worth of public money that's spent in Scotland should be preventative. I think that there's a challenge for us all there to refocus our attention on that front, which is an easy thing for me to say, I completely accept it. Given that the general consensus is that we need to both do the housing and the economy and get people jobs as well as more specific measures for specific issues, there is a money question there. Obviously that's where, as Audit Scotland, I'm particularly interested. I was interested in some of the written submissions to the committee about new models of funding that might be available. I think that's definitely worth looking at. There are also, I think, whichever way you look at this, some difficult decisions to be made at some point. I was interested again in Dr Irvine's submission where she talks about the breast screening programme. Now, I know nothing about the rights or wrongs of that. I make no comment about it, but I think it is interesting that there is someone in the field saying, everyone's kind of said is a good thing to do, but what about the cost effectiveness of that thing? Then the challenge is, well, maybe that money, if there is any money to be saved, might be better spent on housing. So there's a big question for government and for the public sector about taking money, potentially, from one bit of the system and spending it somewhere else. At the moment, that is a very difficult discussion to be had. For me, that kind of whole, genuinely whole, system's approach is something that we still need to work at. Do you think that there are enough people doing challenges like that? It's an interesting question. I thought the response that you got to the inquiry was fantastic, six-day odd written submissions. What struck me flicking through some of them was the commonality of view. My sense is that we don't really need to do a lot more analysis of this issue, because most people are saying broadly the same thing. I think that the question is, what are the actions on the ground that are actually going to make the difference? How do we free up? How do we tackle some of the barriers that everyone has mentioned, in particular around that use of resources, to help people like Collie from Midlothian who are on the ground actually trying to make this stuff work? I think that that's where the focus of the attention should be. Alex Sudeigar. Thank you, convener. I was hoping to come in on specifically earlier's preventative work. Obviously, I should declare an interest having been involved in the early stages of the early years collaborative and a member of the baby in the bathwater coalition which looked to improve life outcomes for children by investing in services for them in the first thousand days of life. I'd be very interested. Obviously, you can't get much more preventative than working from birth. In fact, pre-birth around perinatal mental health and the conditions in which pregnancy occurs and the support that's given to expected mothers. I'd be interested in the panel's reflections on how effective the early years collaborative has been in terms of improving health outcomes for children in early years, where we have still to travel and the trajectory we're on and what we should be doing more of as politicians in terms of that work. Who's first? Fraser. I have nothing else just to plug a report that we are going to be doing in the next couple of years on that very question. I absolutely take every opportunity that is, convener. We are looking at the whole early years agenda, as you say, the early years collaborative being an important part of that. It's a good question. In preparation for coming here today, I was looking at online, almost as a member of the public, and if you were to try and find out what your collaborative is doing or has done given that some of the objectives and targets that set itself were due for delivery in 2015, 2016, it's quite hard to find. I couldn't actually find anywhere that said in terms of the infant mortality rate which they wanted to reduce by 15 per cent by the end of 2015. Colleagues might know, but I don't actually know whether we've done that or not. So there's a thing about absolutely great initiative, but where's the follow-through, where's the reporting, where's the evaluation and monitoring of it? I think that's incredibly interesting because I've been involved in the start of the early years collaborative and the great goodwill that was afforded to it by the voluntary sector that was very much an integral part of it in terms of signing up to these very ambitious, as they were called, stretch aims within the collaborative around health in early years and health preventative work, but there was very swiftly a cynicism sort of crept in because we kept seeing the same money being rebadged and announced as new money. We didn't ever really see an immediate payoff for where that investment was going or whether it would actually bring in transformational change and my anxiety was that this was once again something symptomatic of the preventative agenda where politicians rhetoric, which is all very good and all very on message in terms of preventative agenda, has never actually matched with the delivery. I think that if we do anything in this inquiry, it's to shine a light on that disconnect between the rhetoric and the reality and I think the early years collaborative and the fact that you can't find at you, somebody who works for Audit Scotland, can't find online any evidence of what this has done with all the investment and all the froth at the round of its inception and I think that that's a very worrying state of affairs. I should probably say that my team are probably watching this, throwing stuff at the television because they will almost certainly know the answer to that question but I offer it as an observation. Well, I'll put in plug here for a Scottish Government study growing up in Scotland, which is probably the best source of information on early years and picking up on that cohort study which follows children born I think in 2000 and 2005, something like that over time understanding what their family circumstances are and so on having that complete picture gives you the opportunity to do a better analysis the best quality analysis of what effect the programme has had. Is this stuff early years though? Is this completely fundamental to everything else? In this field? At the time, it was absolutely the alpha and the omega of our work in terms of early years You're not a witness, Mr Cole. I'm sorry? I thought you were looking at me. A lot of this goes back to Jim Heckman's work in the States on early years intervention and the fact that ten dollars invested when a child is one or two or so on is far more effective in terms of a whole range of social outcomes including health but health is not the only one than a pound spent when they're 15, 16 or indeed it has been used as an argument for rebalancing education spending away from universities towards primary school The evidence is international in this respect so there is strong support for it and it will be good to have it for Scotland once it becomes available. Jerry? A few points I wanted to make about whether early years should be the sole focus of preventative activity and I think it shouldn't be the sole focus for a number of reasons so first of all the timescales we can't afford to not prevent all the things that are happening to the current cohorts of people who are in adulthood and old age I don't think I suggested it should be the sole focus of preventative work but I was keen to distill this down as to the earliest examples of preventative work but I think it's important to clarify that that can and shouldn't be the sole focus but it's also true to say that you would have greater potential for prevention the earlier you start but it depends on what you do so you have to have effective interventions of that age group so there's no point in focusing simply on an agency and anything we do at that age group and I know you weren't saying that but we have to be clear that the interventions that you put in place at that point are effective which brings me on to some comments on the early years collaborative so in common with a lot of other programmes we've implemented in Scotland we haven't got an evaluation framework that allows attribution of the impact of a particular set of interventions that would be badged around early years collaborative or a number of other things that we've done to be able to say that has had x, y or z impact on outcomes and our health or social outcomes subsequently and we've done that for a number of programmes over a long period of time and we keep making that same mistake and not commissioning evaluations that would allow us to attribute the impact at the start now the approach that's being taken within the early years collaborative as I understand it is an improvement science approach improvement science is really good for checking whether known effective interventions have been implemented sufficiently within a local setting it's not a good approach to find out whether interventions are effective or not and so it depends on whether the interventions that have been badged up as early years collaborative work are known to be effective already and the work that Neil has described earlier on which looks at the cost effectiveness of a range of interventions whether they be health, social and broader socio-economic interventions and compares their effectiveness is the kind of evidence space we would want to draw from if we want to look at whether or not these things have had an impact and just final question if I may convene it and our colleague here has seamlessly brought me round to what I was hoping to ask in my second point which actually is the other end of the age spectrum of preventative work for older people and I had great privilege of chairing the older peoples forum in this place in the chamber before Christmas and I asked them at one point what was the thing that caused them the most anxiety I expected it would be crime or loneliness but actually it was fear of falling was the biggest thing that they cited because of the demonstrable link between falls and mortality in the sense that they had lots of friends who fell and broke a hip you may remember that just a couple of weeks ago when we were debating the patient safety programme in this place, I put an amendment down asking for a national falls strategy to build on the work of the government's falls framework in 2014 and I just wanted to broaden that out to ask the panel in the spirit that we've just discussed early years falls are definitely part of it and perhaps you could reflect on that but what other aspects of preventative health that we can bring to the older population Andy, wish to comment on that what are you doing in Midlothian? Yeah, we're doing lots on falls just as an example I think the approach that we're trying to adopt is to use to have a shared understanding of what the issues are and make sure that everyone incorporates into their roles and falls is a really good example we're working with the fire service so that when they're doing work and going into the homes of isolated older people they're also doing some falls checks as well and they're able to link up with us and it's the same with every other professional that goes through the door lots of public education around working with groups of older people so that we're increasing understanding and I guess much of our work is at the secondary and tertiary level rather than the primary interventions but if we're to go back to the primary interventions it's really about working through the community planning partnership and looking at the types of houses that we're building the design of houses etc so that the lived environment is a safe environment for older people that's just one example but much of our work is also focused on social isolation and we recognise the impact of social isolation on the health and wellbeing of older people and we've had opportunities through various funding streams to change funding etc to build up capacity across the voluntary sector and across neighbourhoods and I think one of the key changes that for me's been particularly important is about professionals recognising the impact of these interventions and making sure that they're well woven into the pathways so that we're moving away from solo professional interventions to a much more integrated approach that involves that educational approach that involves the social network approach and that the professional interventions are located within that Any other comments on that issue? Yeah, Neil? I'd just like to address Alex's comments about the ethos around prevention and I think you used the phrase rhetoric around prevention I think what we tried to stress in our submission was the need to think beyond that there is an adage that prevention is better than cure and that supports that rhetoric around prevention we would suggest that a very strong case can be made for prevention but it has to be made in a discerning way because prevention is not necessarily better than cure if it's not effective if it doesn't reach the people it needs to reach in a way which ensures that it has the impact intended so we would encourage Pete the inquiry to think very critically about the evidence that's presented to it about prevention to try and understand precisely what it is about prevention that it's saying is effective or not cost effective or not rather than jumping to conclusions that broad categories of interventions might be cost effective or not I think we need to be quite critical in our use of the evidence that's presented to us From a health board perspective I think what the IJBs are trying to do is absolutely fabulous and very much focusing at the right end but from a health board perspective the fixation the obsession is on prevention in the sense of preventing emergency admissions and as far as I'm concerned it's far far too far down the line to really count yes we don't want as many emergency admissions but we don't want as many emergency admissions because we don't want people to have the conditions that require them to be going to hospital in the first place and that fixation I think perverse incentive is used in the submissions not just NHS Tayside's it's on that specific indicator means that these much more sensible I'm saying big picture again targets or issues that should be being addressed that will have a broader impact on older people's health get ignored and underfunded because if we can't prove that it will reduce emergency admissions next month then no one's interested I just wanted to make a point around last point I think we've got to be clear why we are preventing are we preventing to improve people's wellbeing in order to reduce or to compress morbidity or are we intervening to manage the health budget and when you're clear about these issues then there is one thing that I think it's important for the committee to bear in mind is that if you do prevent some particular adverse event as far as someone's concerned that doesn't necessarily reduce the health budget you've stopped them having adverse consequences of diabetes but they then catch cancer so the overall health budget isn't necessarily going to be contained because you've had this particular intervention other things will happen to people they will die eventually so it's important to be clear why it is you're preventing Ivan Thanks for coming along today I wanted to focus on the data side of it and the decision making process is data driving decision making and I'm coming not from a health background where these kind of thought processes have maybe been using a different environment and just about background everybody you talked to about the health service throws up an anecdotal example if only they spent someone here or stopped cutting this then it would save a fortune over there and there's no shortage of that kind of anecdotal stuff but when you start to drill down into this it's very difficult to come back with some data now I understand what Professor Bell said about counterfactuals and I get that and I know we're talking big systems but if you take simple examples for example you would know that people that smoke are going to cost the health service more than people that don't smoke now I'm assuming with the amount of data that's out there it's not beyond the people that crunch numbers to be able to factor out other factors like age and SIMD etc etc they still at down and say your average smoker costs X and your average non smoker costs Y so you can spend X on stopping people smoking your saving Y further down the line and your alcohol be it obesity be it falls we talked about be it whatever the way I would typically have tackled that in other environments is that's the approach you would have taken but drilling down into and maybe it's all there maybe you're going to tell me that stuff is all there but certainly from what I've tried to find so far I'm kind of struggling to see that those numbers are there because you should have a point where you say you spend £100,000 a million saving reducing the number of falls and that saves you £10 million on the health service and it will save you in that timescale based on data that we know from the huge amount of data that's out there does anybody maybe want to comment on that in terms of that approach and what data is there already that might help inform that Jerry I kind of feel obliged to answer that I'm also head of the public health observatory and I manage a big team of data people we've probably got a responsibility to provide those numbers for you there's a couple of things that might be helpful the first is the triple I to the informing investment to reduce inequalities tool that allows you to model at Scotland level, health board level or local authority level the impact of a range of interventions on health and health inequality outcomes the range of outcomes is limited to mortality and hospitalisation so it doesn't look at wellbeing and other things that we would be genuinely interested in but it's a limitation of the data available it looks at hospital costs not the broader health service costs at the moment but I'll say a bit more about some of that in a second so the triple I tool is available it's online, it's on the scotful website you can go on and play with it and model different levels of intervention but it's limited to 11 interventions at the moment but we're currently consulting on what new interventions we might add to the tool in the future so if there are particular things which have an evidence base then we'd love to add them in the rate limiting step as ever is the quality of the evidence that allows us to model a particular intervention so much as it might be interesting and important to do something on false we can't model something on false we need an intervention with an evidence base to give us an effect size so when you say an intervention what do you mean by an intervention? it can be a policy, it can be a clinical service it can be anything that we can give an effect size for so come back to David Bell's point about the counterfactual so usually the best quality of evidence comes from a randomised trial where one group of people will have been given an intervention and another group not and then you can look at the difference in outcomes between those two groups and see what the effect size is so it allows us to model what the effect would be if that was applied in Scotland for example so that's what the triple I tool does I'm not sure if I've fixed it I'll comment on that to my mind, based on what I've done before you would typically do that in a two-stage process so you're saying if we do this and that happens if you've got a factor in the middle that allows you to convert from one to the other then it's easier so for example if we say false you know if somebody falls it's going to cost X or somebody doesn't fall it's not going to cost that so you know how much a fall costs in very general abstract terms you're then looking at saying well if I take this policy it's going to reduce the number of falls you don't need to follow that all the way through as far as the intervening factor because at that point you know the result because you've already done that work does that make you... because what you're trying to do you're right there could be thousands of interventions over here thousands of outcomes and you're trying to map one to the other at somebody else so we have done that for something so we've done that for example employment policies so we weren't able to find good interventions around evidence interventions around what generates employment but we were able to see what impact employment had on health model different scenarios similarly on alcohol you can pick your intervention there because we know what the subject is so yes there's a lot of that so you've done that but for a limited number of interventions at the moment because it's complex but again we're very keen to hear what priority interventions people would be interested in as building into the next phase and is that being used to drive decisions not as much as we would like but part of that is because the number of interventions that we modelled in the last phase that are amenable to health and social care partnerships or CPPs is quite limited most of the interventions are actually at the level that the Scottish Government would intervene in and it was subject to various parliamentary debates and people used the data I think living wage was something that came out particularly well in the modelling as having a big impact became part of the political discussions at the time it was first released so it has been used in extent to inform some of those discussions but I think to get down to the kind of detail about whether you invest in X rather than Y it needs all your interventions all your spending to be modelled as part of that and we're some way away from that partly because of the limitations of the evidence base if I could go on and tell you just about one or two other resources that are available that do that to a varying degree so there's the Scottish burden of disease study which we're working on at the moment which looks at both the outcomes whether it be a particular form of cancer or heart disease or whatever that drives the burden of disease generically so that includes morbidity and mortality so illness and death and it also looks at the exposure so things like alcohol or whatever that would drive that that's not been fully published yet but it will be later this year and that will help inform decision making to do that midpoint and say well alcohol is responsible for it and it's actually like an obesity for example and the third thing I was going to mention is the ACE study and I wonder if Neil might want to comment more fully on that he's more familiar than I so yeah so in answer to your question there are bodies of work that try to do what you have described and I think the one Jerry is referring to is a large scale Australian study carried out about seven years ago that looked at a huge number of 200 interventions some treatment interventions most of them preventative interventions modelled them in terms of the impact they had on something called disability adjusted life years which is basically an estimate of the extent which an intervention improves length of life adjusted for some measure of quality of life over remaining life expectancy so it did that calculation for say upwards of 200 interventions and did come up with a kind of ranking of the cost effectiveness of those interventions in terms of the cost per disability adjusted life year generator so it's just a measure of how much you need to invest in the interventions in relation to the health returns that you get back so these studies have been done because other witnesses have said that tends not to be a good counterfactual in terms of what happened to people in the absence of an intervention it tends to be based on assumptions about what would happen based on what we know about the effectiveness interventions so that it tends to involve a lot of assumptions this can lead to an issue in terms of different people modelling these kinds of things, come up with different conclusions because they've built different assumptions into the model so that can be a challenge in interpreting this sort of information but there is this kind of information out there there are issues then that we raise in our submission about how then you interpret and generalise to a different country in this case Scotland compared to Australia but it's kind of occupational hazard in a way there is at least a body of evidence out there that we can begin to think well would that apply in Scotland if we were to invest in that array of interventions that they've modelled there so there's also other evidence that NICE have pulled together the National Institute of Health and Clinical Excellence to inform their guidance similarly they have done modelling work where they compare measures of the impact of interventions on length and quality of life compare those to the cost in some sense of what health returns we are getting back from the resources we might need to invest in preventative interventions some of them if you look at the results of those studies some turn out to be cost saving going back to a comment that one of the earlier panel members asked about some save money some don't necessarily save money but they do generate lots of health in relation to the cost that you need to incur to achieve them but some don't which goes back to the point we were also making earlier that prevention is not necessarily better than cure so there is a body of evidence to draw on it's applicability to the Scottish context I think needs to be assessed carefully but there is stuff that we have to draw on directly or that we can repeat in the Scottish context to get results more specific to Scotland but it's not a short term fix in terms of having a ready made body of evidence that answers all the questions that we might want to to ask. As you see the biggest problem then is being that we don't have the data and the modelling or we don't have the will to follow through on what we already know I would being somebody who has to produce this coat of evidence I would encourage us to use it more certainly encourage us to use it more I think there is a will to it but there's a capacity issue there because obviously as Jerry alluded to there's a huge number of potential interventions that we might invest in so I think what we need to try and do is prioritize the discussion around the areas where we think there might be the biggest potential returns and the biggest problems that need addressed for example obesity might be one that we would think about and focus our energies on these big issues where we think there are the biggest potential returns and try and identify within those areas which might be the most cost effective interventions I think if we try and just ask the overall question is prevention effective and cost effective we are doomed to fail that's a meaningless question because it all depends on individual intervention I'm just thinking through the process that you're talking about I'll just pick a recent intervention as the provision of the baby box for mothers would that have gone through that process that you're talking about to assess whether that is it hasn't to my knowledge that might be because I'm not aware of what has happened but it hasn't to my knowledge David I could speak about data all day but can I start just by saying that I don't think we have enough good people to do the kinds of analysis that you're talking about Ivan that's issue number one secondly in terms of your example of how much the smoker costs we do have a lot of administrative data which means mainly hospital data I think about that you can follow an individual with and what I think we need to do to marry up cause and effect economists obsess about causal linkages is to try to link that data with more social and economic data that people have and indeed even genetic data this is some of the research now is going into the genetics, the epigenetics where these may be sources of future disease and so on and that's what we're trying to do with our study we've got a questionnaire that lasts an hour and a half where we ask people about their occupational history their health literacy a lot of the effectiveness of preventative interventions depends on how people understand them and how they react to the information that they're receiving and it's important for us to be able to understand in the generality how, whether people do have the capacity to respond and so on so Scotland is actually in quite a good position internationally in terms of the amount of data that it's got but it has a way to go before we're telling a more complete story about particularly the social, the economic maybe the genetic origins of later life health problems Colin sorry Colin just a second sorry just to talk very practically from a small area of looking at this local data and also as you're saying looking at the health and social housing and other data some of the work that Elaine referred to that's been happening in mid has been very much looking at that culture change and looking at that shared sense of ownership when it comes to inequalities and there's been a lot of work done across the community planning partnership which I think is key to have that shared ownership looking at inequalities I mean they've opted for health, economic circumstance and learning and that's about getting a shared understanding and a better understanding of local data and we've enlisted support from like the Scottish Public Health Observatory, the NSS and others who are more expert in the kind of things you're talking about that I'm not pretending that we are locally to help us with some of that planning and help us to understand our local data and that's been really interesting I mean people would have said that we're more expert assistants, we've really learned so much more about our area and our people than we ever knew which has been really really helpful but also really helpful to spread that responsibility across housing planning other areas as well so that's been really useful and one of the things we've looked at from a community planning partnership when this was led by the IJB is looking at our gap indicators so looking at our sectories, et cetera but not actually looking where we're closing the gap in certain areas and it's really helped us with the experts coming into us, really helped us to kind of narrow that down and that's going to help in our planning we learned so much more than we knew so it's going to help us in our planning and our interventions and I'm not saying that we have all the resources that you're talking about and all that expertise but it has made a big difference but what are you going to do to close the gap, the inequalities gap using that data? Well it's been really helpful just to pick a couple of examples what we're going to do is very much acknowledging that nothing's going to change in the next year or so with this and getting this from a community planning partnership which again is quite difficult because some of the elected members for example their term will be finished before we'll see results so having that commitment from people we've got about mental health prescribing for example has been really helpful and that's helping us to look at where we position services how we make sure services are attractive to people and applicable to people in certain SIMD groups in certain areas so it really has helped us to plan and design our services I'm talking pretty much on a small scale here but just having that information also we're looking at school attendance we realise the massive variance in school attendance between areas so it's really helping us to hone down some of our interventions and just helping people see things from a different perspective and as I say that's shared ownership across services and agencies Colin Thanks very much convener we made the point earlier that there was quite a lot of commonality amongst the submissions and I think most of the submissions argued that primary and early intervention were obviously key to decreasing demand but some of the submissions argued that it's unrealistic to believe that moving resources to community services on their own is actually going to reduce demand in acute services and we're still going to have crisis intervention in both sectors so we could ask the panel whether the aim of shifting resources from one sector to another is possible or realistic in terms of reducing demand on acute services in a world where we don't have the funding effectively to do both and specifically could ask the panel whether they're aware of any major disinvestment decision that has actually released resources for effective prevention work Thanks very much I'll start with a general point which there's enough old report about moving services into the community and what that says is that the logic that simply moving things into the community to save money is not proven and ties back to what we were saying earlier that when you're talking at that higher level you can be going everywhere from things which are almost certainly not going to deliver what you want them to do and don't have any evidence for them to things which will deliver so in Tayside we've had an early community support model that's been up and running for the last few years which has been targeting frail elderly at high risk of admission to hospital and building a community support team around that individual trying to prevent them from being admitted into hospital and in the first winter that that ran we estimated that that had saved over £100,000 in terms of emergency admissions and delayed discharges and as that has gone on continuing evaluation across our patch has shown that that pattern of preventing emergency admissions has continued in some areas but in other areas it's not realising in quite the same way and we don't know because it's hard to unpick whether that is differences in the population whether it's differences in the implementation of the model whether it's something even subtler than that whether it's just that in one bit of the country doesn't necessarily translate particularly easily into that elsewhere but certainly it's given us hope that there are some bits of moving care into the community which will have quite a concrete impact it's just that we still haven't quite got to the end of that experiment if you like I would say in midlodian we're still at a very early stage I would echo the evidence of the previous witness two concrete examples as midlodian we've used liberton hospital up to now at times we've used 40 beds from the 1st of April we'll have no further admissions to liberton hospital instead we will have people better supported at home or the rehabilitation happening in midlodian I also we've developed a hospital at home that supports people to elderly frail people to avoid admissions to hospital and we're now looking at targeting getting a better understanding of the frail elderly and their pathway where they're at on that pathway and then targeting a more coordinated approach by community services to their needs to better support them in the community our evidence in terms of the work that we've done up to now we're starting for the first time to see our admissions coming down for that group in hospital so some evidence to suggest encouragement in terms of I think we need to be careful not to assume that it's just a straight shift from hospital we need to do things radically different in the community it's about understanding our population it's about working in a much more coordinated way but it's also about new models of care without a much more proactive approach to the use of technology to using our care resources in a much more targeted way than we've done up to now there is a risk that for some people their care in the community could be more expensive than the congregated setting that you have in hospital so I guess as an IJB we're needing to be very thoughtful about what we're doing we're needing to constantly test things there isn't always a straight link between what we do of one intervention and the impact very often you see a shift and it's a whole range of interventions and the bit that's harder to evaluate as a culture a different culture around how we use resources a different culture that's about really understanding what is it that will make a difference in the lives of individuals so it's all those things together that makes our work very complex but we're needing to constantly be alert to what is working and testing I'm not a specialist in occupational health my background is occupational and to some extent environmental health so I say this with some trepidation amongst all the public health experts in the room I'm getting the impression that we kind of from the discussion we know a lot about what we want what is needed to be intervened on in terms of reducing ill health in the community and I guess what the the nature of the discussion seems to be around how best to configure an intervention but I would like to also raise the point that we don't necessarily know everything we need to know about interventions in terms of what might be effective and in particular we don't know a lot about some of the causes of some of the diseases that we might be wanting to intervene on for example with the ageing population there's been a huge rise in the number of people with neurodegenerative diseases for example and we just don't know what causes the majority of those whether they're genetic, diet, whatever so as well as interventions I would also encourage some thoughts about trying to understand better what's causing some of the diseases we want to intervene on as well Just to follow up on that obviously a number of witnesses gave examples of some disinvestment on a number within the written submissions as well and I appreciate Dr Irvine's not here but one of those or a number of submissions talk about ceasing mass screening programmes I wonder if the witnesses have got any views on those types of interventions Speaking in relation to breast screening I think the international agency for research on cancers recently done an evaluation of breast screening and found that on balance and it was on balance that it was still beneficial Fraser did you want to No I'm going to make a more general point about disinvestment OK on you I think that's a very good example again like I said earlier you might be missed this bit Mr Smith but I make no comment about the specifics of that because I don't know the rights and wrongs of it but it does seem to me that we need a conversation with the public and our communities to change services whether that's about a screening programme whether that's about an acute hospital or a bit of an acute hospital being closed or changed these are very difficult conversations to have but in order to achieve the genuine transformation in the way we provide care that colleagues from Midlodin has been talking about we need to have that conversation I'm delighted to hear the dimension of community planning partnerships in Midlodin because it does seem to me that if we're trying to do this in our little bits of the public sector it's just not going to work and a health board trying to make these decisions in isolation of each other with an integrated joint board in the middle that's just not going to work I think we need to be increasingly if a community planning partnership is there to do anything it should be about reducing inequality in its local area and they need to be adding up how much they have collectively to spend which in some places is a very big number they need to figure out what they're spending it on and they need to figure out how they can better use their people, their buildings, their money to really target their collective resource towards reducing inequality in all the ways we've just described if we continue to do it and of course the danger at the moment is as the financial pressures on those individual bodies increase the temptation is to retreat into your own individual organisation and make those decisions on your behalf when it's actually just at the point we need to be opening that up and having a much better conversation with communities using the local knowledge that's available to make those genuinely strategic decisions for the next however many years I think if we go into this with a view to come back to your question that we're doing these things to save money I'm not sure that's the right place to start I think we should be talking about what's the best thing that's going to improve outcomes for our communities and in doing that the evidence is I think that you find better and more efficient ways to work and should certainly save you some money in the future to try and answer those two specific questions so first about is there evidence for disinvestment releasing savings I would just like to remind people that there are other ways of prevention that doesn't involve actually any services that would be about legislation, regulation taxation which are very very effective ways often improving outcomes so just to run through a very quick list reducing the paracetamol pack sizes suicide barriers on our high bridges alcohol minimum unit price and smoking ban on public places, the ban on alcohol discounting all using regulation of some sort very effective at reducing outcomes no great on-going spending requirement so there are other preventative interventions that are really worth keeping in mind other than services which are also important to answer your specific question about screening it depends on which outcome you're interested in so there was a Cochran review the Cochran collaboration brought together all evidence internationally from all the randomised trials around breast cancer screening they looked at all cause mortality and found very little effect of breast cancer screening Michael Marma and his team down in University College London were asked to do a similar piece of work but they looked at breast cancer mortality as their outcome and they found a 20% reduction you'll notice the disparity between those two and the question is whether breast cancer mortality or all cause mortality is the right outcome to look at on the one hand if competing causes of death are important and somebody mentioned competing causes earlier on then you might want to look at all cause mortality but if you're worried that the effect of breast cancer screening might be diluted by looking at all causes and you would only expect a small proportion of all causes to be due to breast cancer and therefore you've got an insensitive measure maybe breast cancer mortality is a better outcome so that's where the debate lies around breast cancer screening specifically and hence why there's so much debate and discussion about its effectiveness David I just want to pick up on Fraser's point I've got a bit of a concern that we're maybe learning lessons in different parts of the country and then if these lessons are of general applicability we may not have the mechanisms in place to roll them out and rolling out of an intervention is in itself quite an issue that has to be thought through very carefully I'm on the board of a body in England called the Economic of Health and Social Care Research Unit and we're looking at pretty big pieces of research on things like does telehealth a randomised control trial about whether telehealth interventions prevent emergency admissions and so on we're two fairly large populations of being compared I don't think that Scotland is in that business I might be wrong but I don't think that we've kind of, as yet, captured the notion of how we identify and then spread out best practice Claire, then I'll come to you Marie you've been very patient I'm looking to really expand on a point that Mr McKinley had made there about disinvestment and about changing services and we've heard lots about how we need to work in different ways we need to look at things in the round particularly with the integrated joint boards but as politicians and as health board and council members we're often contacted by members of the public very concerned about changes to services closure of hospitals, closure of buildings centralisation of services or so on so how do we bring the public along with us if the professionals are saying this is the direction we need to go in good question Evelyn engagement communication and I guess it is about respecting people's views and acknowledging and working through some of the differences one of the things that we do in what we call a hot topics group that local politicians and the public come along to we agenda the most difficult things for that meeting at the moment we're challenged around because we're such a fast growing area in terms of population there's issues around access to GP practices so that's where we come together and we talk about the issues GP's talk about the challenge that they have in meeting the needs of the local population they talk about the strategies that they've introduced to manage that members of the public will tell them how annoying and how difficult it is that they've got a triage system when they're trying all day to get through on the phone the GP's go away and then look at what they can do to improve their triage system but I think there's there's no shortcut and we just can't do enough communicating I think it's professionals working together as well it's about where the public are unsure it's about professionals being clear and having a shared understanding of what the risks are being explicit about that and being able to share some of this openly I guess one of the things that we're constantly challenged about is changing the things that are well established and there's assumptions made about the evidence behind the things that we're all familiar with and we're challenged when we do things differently about evidence as well but many of the things that we've done for a long time there's very little or very poor evidence in terms of its effectiveness but because it's been happening for a long time people feel safe they feel secure and we just need to work through some of that very openly but there's absolutely no doubt but that we need more conversations where there's more shared ownership between the public and between public services of what's happening and understanding of the challenges OK, Mary, or sorry, in your own and in Mary? Just very briefly, there was some interesting evidence in the national conversation to that effect where there did seem to be a willingness on the part of respondents to that and the only other point I would wish to make is to reiterate what Evelyn said about the need to involve people in the longer term in this because I think there is some evidence that if people are engaged in discussions and information is shared with them about the choices that officials and service providers are facing they are willing to embrace the challenges of those decisions as well they face up to opportunity cost of doing things the way they're currently done which is not necessarily the best way of doing something even though there is local support for it neither offered alternatives where a good case can be made about the effectiveness and the way in which those new ways of doing things might better meet needs then that might be embraced even if it's not the position they went into discussion with so I think conversation can work but it's not a shortcut it needs to be for the long term Mary I wonder if I could pick up on something that Jerry said and if we could all explore another slightly politically tricky area which is the reluctance to use the most effective or the very cost effective options of regulation fiscal control and legislation which also don't contribute to health inequalities and a tendency for politicians to fall back on individual interventions such as education and behavioural change which is much less effective and contributes to health inequality Jerry I agree perhaps at times those kinds of interventions can be more politically challenging even though they're often cheaper so they can be seen as anti-libertarian so limiting the sales of alcohol or where you can smoke or regulating the food industry would be unpopular with lots of particular stakeholders but those would be very effective ways at improving health and reducing health inequalities because as you say they don't rely on individual agency they don't rely on people having to opt in to things and it just removes the risk from the context in which we live so they are very effective and they're very cost effective for that reason Can I ask are there examples from around the world so I note that my colleague Alison Seuleth has brought forward some legislation about advertising of formula milk and I know that in the UK I think we have the lowest breastfeeding rate in the world and I know that there are different regulatory systems around the world in terms of advertising and formula milk that type of thing are there examples around the world that we could follow on that sort of legislation I'm not sure I would suspect that that would be an effective way but I'm not sure of the exact evidence Neil, was that included in ACE? I can't remember The ACE that I referred to earlier certainly refers to a number of these regulatory types of interventions and does tend to find them to be cost effective because they are low cost and they are effective because even if the risk for each individual is not reduced by a great amount it reaches a whole population so small risk reductions can still have a big effect which when compared to the low cost makes them cost effective so a number of such interventions were included within ACE and they did tend to be found to be cost effective Richard? I've listened intently to some of the points that have been made and particularly breast screening a number of years ago people were concerned women were concerned about it so they'd done a breast screening program now we're being told it was ineffective and costly lung, oh if you get three coughs there's something wrong with your lungs go to your doctor quickly you know the point is are these programmes worthwhile are they effective I've got a couple of questions by the way are they effective or are we just wasting our money Who do we like to? David? No? David looks away looks away and looks at the floor Andy got an opinion on this I know Helen's not here but certainly I'll be gone to this again we've just had the smokers it's all useful well I'm a smoker I can't remember the last time I was being a doctor you know so it ain't all the smokers will but Fraser McKinlay came away with a comment earlier about basically programmes should be you've got people hammer individual local NHS because it's a postcode lottery but should we not tailor programmes for local people and for local areas and for local problems go on that bit maybe not the bit before so I wouldn't like to comment on Mr Lyle smoking a bit one way or the other so I think you're absolutely right we need to be very careful about the phrase postcode lottery and what we're interested in is unexplained variation so if a place if a health board or a council or a community planning partnership can demonstrate why they're doing things differently to meet a local need that's making a difference that's absolutely right and proper I think quite a lot of the time when you ask the question why is it different here to there they don't actually know and that's the point at which I think it's legitimate for us to ask the question into challenge postcode lottery is absolutely not but I think unexplained variation between places or between populations or between communities is kind of what inequality is all about really and I think these days with the data that some colleagues have described we should absolutely be able to get under the skin of things and to say no do you know what so we've done some work in education in the past and places like East Renfisher and East Dunbartonshire will always come out top in terms of their educational attainment scores because of the areas they are and there is a bit of that for sure but they're also the most improving parts of the country so other councils, other local authorities are saying well even accepting whatever the deprivation impact might be on educational attainment in those places there is something that those councils are doing about education that we should go and look at and I think that's absolutely legitimate Last question Do we have too many targets what should we retain what should we dispense with you know what is cost ineffective programs that we should abolish I think we'll really get down down to the integrity what is the best what is the worst what do we get rid of Easy question Andy any takers nothing now If we hold that round at the end and ask people in terms of this agenda what should we be doing and what should we be getting rid of and it'll give people a bit of time to think or amend or amend In Helen Irvine's submission she says that the task of quantifying preventative spend is so onerous that we have been determined to substitute the right solution which is reducing the opportunity income and wealth gap with a wide and expanding range of alternative solutions that provide a sub-optimal return on our investment I'm very much off the school of opinion that it's all the social determinants that we need to address have been for a long time on that so is she right and that's what the whole focus of government should be because my view is that unless you have the minister for fishing as responsible for health and equality as you do the minister for anything else then we won't see a cross-government approach and actually what we should do is target the first minister should have as their his or her target reducing that health and equality gap is that where we should be going with this rather than all these individual small things that we want to measure and assess we should be assessing the top line which is is that gap decreasing Jerry? The Government has the national performance framework which has a relatively small number of high level outcomes which is aiming to improve so there are a number of health outcomes in there and they're economic and housing so it covers all areas of government and I think that's useful because that gives you a picture of whether we're making progress or not and underneath that there's more detailed indicators in each department if you like then has more detailed indicators and targets below that and I think as long as that's framed in an outcome focused way where you can say that specific outcome that will then make a contribution up the chain to these overall national outcomes and I think that can be useful and it can help to divide up the tasks because if you've just got a single outcome which is to improve life expectancy by x per cent that's great but then you think well what do I do what's my role in a health board and what's the role of the housing department so you have to divide up the tasks and then everybody make that contribution all seeing how they will make a contribution and I think that as long as things are linked together in an outcome focused way that's absolutely appropriate and that should then drive people to look at what is the most effective interventions to deliver those outcomes in their area and people have already said today that often we don't know what the best is by history we've ended up in the place we're in and so I think we should challenge each other more to test out what we're currently doing and see is this the most effective way of doing things can we change it and evaluate it robustly the original way of doing it was the best way that's fine let's go back to that but if we find out there's a better way let's do it differently Are we seeing evidence of a substantial and significant shift in resource to the areas of most need in order to close that gap my assertion is that we don't we aren't seen that and that actually in many ways the rhetoric is not matched by reality on the ground and what we're actually doing is scratching at the surface I think there's some truth in what you're saying but it's complicated by the fact that the areas which perhaps have the highest life expectancy are also the oldest people and so they tend to have health and social care needs that are also high and so shifting that resource is challenging when it comes back that this is the nature of prevention you've got the need now that has to be met and another need to shift resources to reduce future demand but also to reduce inequalities and that's tricky when you're having to spend the money on the demand for services as is the case now so I think there's a genuine challenge there that's quite tricky Neil? I think your initial question was about where we should be investing our resources and the extent to which we should be tackling upstream causes I think Health Scotland's strategy at the moment is very much supporting tackling the social determinants of health given their role in driving health inequalities and the evidence on prevention the effectiveness of prevention Can I ask you to evidence that statement? Sorry, evidence of statement that that's where the focus is I'm saying our strategy is focused on reducing health inequalities and highlighting the needs to tackle the upstream drivers of health inequalities That's the strategy Where is the implementation of that on the ground and the evidence to back that up? I wasn't wishing to comment on that question So we have a strategy I was just going to make the point that the evidence on effectiveness and cost effectiveness of preventive measures in terms of their potential to improve health and reduce health inequalities suggests as well that interventions which are effective and cost effective So in our previous publications on the economics of prevention we've highlighted the case for investing in upstream interventions on the grounds of cost effectiveness and the potential of such interventions to reduce health inequalities That's within the strategy I accept that but it's more difficult to follow that through prevention investment on the ground which is probably Audit Scotland may be able to assist and backing up that strategy I wouldn't wish to comment on that without further analysis of the balance of spending how that's changed in recent years but it's certainly a very productive line of inquiry for the committee Fraser? I don't think at the top level that you have seen a significant shift that you attached to the inquiry the changing models of health and social care report that we published last year says that and I guess our urging is that the principle of moving more care into the community is a long standing one it's not something that's just been invented recently in fact it's been a principle that's applied I think has been supported by governments of all different colours over the years and we're not seeing at scale whole system change there yet but what we tried to do with this report was evidence that there is lots of really good stuff happening and I think the challenge to come back to David's point earlier is how do we make more of that happen in more places more of the time and it becoming a more of the starting point and if it is difficult and it is difficult to turn off a tap in a queue and stick it into preventative or primary stuff then we need to have a conversation about are there different or innovative models of funding that will help invest there have been goals at that the change funds we've had we've got the attainment fund currently in education again I would absolutely agree with Jerry's point earlier about and this point we repeatedly make about the evaluation of those things being built and designed at the outset rather than five years after us all going well what did we get for that money and everyone going well it's difficult to tell we need to figure that out at the start we need to know what we're trying to do with it and measure it as we go whether it's worked or not and that's a gap for me in terms of how we do this stuff OK, Alison Can I ask a question specifically around GPs in health inequality I'm missing Dr Irvine this morning because a lot of this evidence did come from her but I know you're all experts in this field so Dr Irvine's work supports the view that we don't support general practice well enough in areas of deprivation to tackle unmet need in health inequalities and she also goes on to say excuse me, second that we should consider funding a high quality GP service with continuity as the aim rather than disabled general practice and then hope to solve the many problems by adding a series of fragmented problem-specific programmes aimed at patching up the inadequate primary care service so that results I'd just be interested in your expert view on whether or not we are funding GP services adequately particularly in those areas of need Thanks very much General practice funding is part of it the underpinning fragmentation and difficulties in general practice is another aspect of the same thing my perception of general practice from various perspectives is that the difficulties there are part of one of the biggest public health problems we are about to endure that our inability to deliver the services that we want to deliver through primary care through a lack of workforce there through an inability to actually so we say we want something and then we cannot actually have it on the ground because we don't have the people we don't have the facilities there through systematic disinvestment for a very long time at every level and through an increasing unattractiveness of the job in the first place we have a recruitment crisis in general practice at every level because it's not a great job to have a lot of the time I'm really sorry don't shoot me that what we want is to be underpinning moving our care further into the community puts much more pressure on primary care at a time when we have less and less ability to deliver the services there in the first place and so some of that's about money absolutely but lots and lots of it's about culture and about emphasis and about value in the other sense and unless we can fix that bit just bunging some more money that way isn't going to do it thank you I want to draw members to my register my register of interests I'm a registered mental health nurse I want to ask a question specifically about mental health because we haven't really touched on that part from very briefly with Alex Cole-Hamill's question about perinatal mental health and really about I guess I just want to throw open to the panel and ask them about how they see the preventative agenda and mental health services and how they see that that feeds into better services or more accessible services or really just how they view this agenda there I think mental health is one of the areas that we're starting to feel more confident about the progress we're making particularly around the role of the GP and in the primary care setting and I think just picking up on the earlier question I think that one of the things we absolutely must not do is create a more fragmented service and I think that much of our challenge around when we're thinking about delivery is too much of our services and that's where I guess we get the poorest return on our investment is where we deliver very fragmented services that are very episodic in response to individual things that happen we have an intervention and then it's left sitting until there's another thing that happens so key for me is about having really well joined up services where the GP is at the heart of that delivery but is also supported by a team around him or her that compliments their skills and everyone is working to the top of their skills but doing it in a very respectful that's how I think we deliver best but coming back to the issue of mental health I guess what we've been very alert to is the number of presentations there are to our GP's where there's an underline issue that's to do with mental health wellbeing and we have piloted in partnership with the Thistle Foundation the House of Care and a wellbeing service it's been very well received by our GP's we've rolled it out now to eight practices and basically it's a very and some ways it's a very simple service it's about skilled workers working with individuals who are referred by the GP because they've got underline issues it's about focusing on the outcomes that the individual wants having an hour-long conversation and then helping them to make the connections and to use a whole range of different supports that is able to help them to take control of their lives early results were engaged in an evaluation Mary's very directly involved in this area of work but the early results are very very positive but I think what's key for us is about giving mental health visibility calling out where there is underlying mental health issues but using a range of responses many of them it's about being clear about the outcomes that the individual wants but also being clear about a range of interventions it's about professional interventions but they're also complemented by opportunities for learning so that people are able to manage their conditions better but also it's about using the strengths around them much much more peer support with an organisation in Midlodion called Pink Ladies it's very much focused on people using their own experience to support each other and it's just a whole range of different community responses that we've got and of course underlying it we need to be be mindful that many of the issues that cause poor mental health are also to do with access to income housing issues and making sure that we're able to deliver that in a very joined up way so we're encouraged by this area of work and I think it's one that we're starting to make some progress on Emdeals, want to comment on that? Just very briefly because only a few minutes left I just wanted to come back a little bit on that because one of the services that as a committee we met when we were out in a drum chapel a few weeks ago was a work in the deep end practices and obviously like workers are going to be rolled out across the country and I wonder if perhaps some of the areas where you've talked about people being supported through having mental health difficulties and present GP practices if that's something that other areas have been looking at doing? I have a comment on all of the IJPs across the country but I know locally we've, as I said, we've been doing work on it the model we're using similar to the link workers model but I can't comment on the level of activity across the country The final question I just wanted to pick up on Claire and Alison's question and bring them together because I know some of the GPs I've met don't have a huge amount of confidence when they're dealing with mental health and actually what's available to them there's very few tools and I've met with one and sort of asked me to be able to use and they just don't use it so it's that sort of growth of social prescribing in the country which I don't think seems to be happening which actually could have a huge opportunity to, I think, build more preventative opportunities within the health service so it'd just be interested to hear any work going on in the fields or where you think there needs to be a change I would agree with you and whenever Emdy mentions developing a new directory to twitch a bit because it's really not what people need in a 10-minute appointment it's a directory to look through what about this organisation, what about that GPs just haven't got the time for that and that's where the link workers are ideal somebody can have an hour, they can explore what's going on for them and they can really physically support them to a local service most people don't need a psychologist most people tier 2 level community-based, often voluntary sector run support is ideal for a lot of people so having that support for GPs is really important the other thing we've developed locally is a mental wellbeing drop-in so that GPs can refer people to the drop-in or encourage them to go themselves and again, there's somebody there who's mental health qualified who can sit with them and look at what are their immediate needs do and assessment but also physically support them to the likes of Pink Ladies, Women's Aid group work at the Orchard Centre in mind organisation so I agree that in a 10 minute consultation it's really really hard for GPs and also if they don't know Pink Ladies they're very unlikely to refer them because they don't know who they are how they operate whereas if there's that intermediary it makes such a big difference to the person and often people are saying I went to GPs and said I didn't want a prescription and this is looking at the social support but they need that intermediary to get there OK, thanks I've promised Richard we would do our parallel round the table at the end so just as we go if there is one thing that you would introduce or expand on policy area and if there's one that you would reduce or get rid of in this field then I know it's very simplistic but it's really just we're looking at now how we take this inquiry so it will be food for thought for us about where we go on this I get the hard job You get the best one, you've got all the choices I suppose I'm now going to completely ignore your instruction and reflect on what Mr Lyle asked earlier I've had time to think about it a bit and I guess that I've been reflecting on how so much of what happens is chasing the targets that are there at the moment so Dr Irvine mentions the four-hour target in A&E as an example breast screening I suppose in some ways is another example of places where it feels like we have our sacred cows that nobody is willing to unpick and so rather than telling you what to do more of and what to do less of I'm going to give you my mandate to unpick it a bit more and perhaps set aside the political motivations for some of these things and actually go back to the evidence Okay, Gerry So to introduce or expand I would use more regulation around the food industry and the food chain to improve health and reduce, well we've actually heard a number of people proposing a number of interventions and sort of looking for interventions for various things which I'm not sure about the evidence space for so I would reduce the drive to find something novel that isn't evidence-based so I'd urge you to stop yourself from always looking for the novel and think through, okay, if we are going to try something new, let's do it in an experimental context to find out if it really works or not Okay, David Well, I agree very much with what Gerry's just said and I just expand my brief a little bit and remember Gerry's mentioned the national performance framework and the top of that list is sustainable economic growth and we've talked a lot about trade-offs trade-offs get a lot easier when you have more tax revenue and so a key issue around the compression of morbidity actually is having more older workers in the workforce and we've had a huge expansion this has worked a great success story in the last few years in the number of people aged 55 and over who are working in Scotland so the health system can do a great deal or can lend support to the sustainable economic growth which in turn will relax the kind of hard trade-offs that we're talking about between acute care and social care and so on I'll just echo my point earlier that as well as interventions we should also learn to increase our evidence base and understand more what causes certain diseases than we do currently OK, Neil? I very much support what Elna and Gerry have said I think my emphasis would be on looking to cost-effectiveness and effectiveness of preventive interventions and their potential to reduce health inequalities rather than savings due to all the issues we've talked about in relation to savings that's where my emphasis would be and also to pick up Richard's point I think we do need a review of the current regime of targets and indicators to ensure they're consistent with an evidence-based preventative agenda Evelyn? If I can do say two things Christie let's let's make sure that we're still paying attention to the messages in the Christie report at a local level in terms of collaboration and that we're really focusing on the needs of communities and working together with honest conversations about prevention and the second thing is really to do with recognising the limitation of working in really working in professional silos and the need for holistic approaches that embraces people's social circumstances as well as the things that professionals can do to support people Sorry, that was a joint I never even saw your lips move Fraser I don't suppose I'll get away with just saying everything that they've just said a simple one for me I'm absolutely pleased to not use jargon all the time I think the language we use around all this is problematic particularly when it comes to engaging with the public so that would be a thing for all of us to try and be in mind and the second thing, not surprisingly for me, is about the money I think we need to renew and redouble the expectation for public sector partners at a local level to figure out how much money they've got, what buildings they've got what skills they've got and making much better use communities rather than continuing to do it individually Thanks very much We can all look at Audit Scotland reports now and expect them to be jargon-free Good luck with that The next step for this inquiry will be for us to have a chamber debate for all members and all committees to take part in that, so that's our next step and then we will be assessing after that how we take the whole inquiry forward If you've not already done so can you please make sure you submit to our call for evidence that would be really helpful and I just say thank you very much for your attendance this morning and I'll suspend briefly for the panel to leave Agenda item 3 is on NHS Government and it's an opportunity for members to consider the main themes that have been arrived this morning and our formal session and our informal session that we heard earlier today so can I invite any comments from members Ivan? I heard a lot of things this morning and I think there was probably three that stuck out I'm sure there'll be more than other members will have There was an issue about the complaints process and I'm feeling that it was in many cases unresponsive and unreactive in words like as soon as you hear it's a complaint the walls go up and you can't get anything through to them was mentioned setting thing was about person-centred care rather than looking just at the specific what's wrong with you rather than looking at the broader picture of the person rather than a specific medical condition and I think there was a feeling there had been some progress in that but a long way to go about variability of service there seemed to be an issue about different parts, different health boards different services and different health boards so there was a lot of variability depending on where you were but maybe if we focus on that first the first session that we had this morning and if people want to add comments then we'll come to the other one Andy, want to add anything? Who was it? Alison? It was just on the issue of complaints I think the group that I spent time with they were clearly seeking a middle way or a different way they said in so many cases they just wanted someone to speak to to fix the problem as it was in front of them they didn't actually want to have to go through a complaint system that was their great frustration there was a problem and instead of somebody being there available to talk to them they had to go through this complaints process I think that came over loud and clear as did several of them had obviously experienced a review of medicines when things had got to the acute stage one person spoke about reducing from 17 tablets to 8 to 5 and that having a really positive impact but it had taken a long time before there was any review in cases of people being on medication for almost two decades that subsequently discovered they shouldn't have been or they didn't need so those were two issues On the issue of complaints on how to access the system and the frustration about that and who to speak to and how you get an answer one of the participants said you have more rights and ability to complain about a tin of peas than you do about your healthcare and I thought that was quite a telling comment Other issues that were raised I heard in relation to board's decision making particularly of our service change and in effect what was secrecy of how boards operate maybe attempt to confuse and hide decisions within 600 page agendas that go before a committee and somebody spoke about trolling through the 600 pages to find what they were trying to cover up which was quite a again a telling comment so I think the governance there of how boards operate was certainly a theme a whole number of points raised by individuals about how their care was addressed and if you have multiple conditions and multiple appointments then you have to go back and forward to the hospital rather than go in one day and get all your issues addressed in one day and the coordination of that being very difficult and one further issue was about the centralisation of services that people felt they were excluded from having a say in how services are developed and that there's a lot of tokenism in the process where people felt they didn't really have a real genuine say in what happened there are a whole lot of other issues that come up about good practice at certain health centres and certain GP practices where people feel they were getting and so this was not just a group of patients complaining they were actually being very constructive in their comments and I found it very helpful this morning Anybody else? Thanks convener and I think that that was an area that I picked up on too because as well as obviously people need to hear that you're listening to their difficulties but I did ask each group what they felt were positives good areas of clinical care and how they could perhaps expand on that what made it a good episode of care or a good interaction with the health service and I think everyone said it was about that one to one about being heard being listened to and feeling that the healthcare professional had time for them so I thought that was quite tailing right across all of those groups because they had to interactions with lots of different parts and wasn't just one particular department Any other comments on that? Yep Miles? A wider point I think what's really important and from the limited time I've been in MSP what I've really found quite shocking is we need to build confidence in people that they can influence the health service when changes are happening and I think sadly too often people feel that the judge and jury is the health board they've decided this and they'll make the facts fit and as someone who's been involved with the centralisation of Edinburgh's cleft lip and pallet surgery unit and the CIC in Glasgow I think when you actually see the evidence which campaigners are putting forward and then the actual people involved in that decision making within the health board it's sometimes very difficult to separate the two when they're taking these decisions and I think that's something we really need to try to focus on to change in NHS governance so people have the confidence in the health service there's huge changes, yes, to maybe make in the future in our health service but we need to get that right so that people make sure that their voice isn't just listened to, it's actually heard Any other comments? I know a number as well of scribbled notes and I've got lids here that I'll pass on so that we take account of people's comments and we had the Parliament staff taking notes as well so we will capture all of that and what people said this morning I just wanted to put on the record their thanks for them coming in this morning I know it wasn't easy for many of them travelling but it was much appreciated and I thought it was very helpful We did agree at a previous meeting that we would now go into private session for the next item, so that's what we'll do