 Welcome everyone to the Equal Opportunities Committee. It's the 18th meeting of 2014. Can I ask everyone to switch off their electronic devices or put them into flight mode, please? I'd like to start with introductions. We are supported at the table by the clerking and research staff, official reporters and broadcasting services, and around the room by security. Today's only agenda is an evidence session on our scrutiny of the draft budget 2015-16, and I'd like to welcome our panel of witnesses. Can I ask you that when you wish to speak during the discussion, could you indicate to myself or my clerk on my life, please? There will be no opening statements, but when you're introducing yourselves, could you give us some brief background information on the role you play in your organisation? I'll start by introducing myself. I'm Margaret McCulloch, the committee's convener. Members will now introduce themselves in turn, starting here on my right, then followed by the witnesses. Good morning. I'm Mark O'Biagge. I'm the MSP for Edinburgh Central and the deputy convener of the committee. I'm Alex Johnston, member for North East Scotland. I'm John Mason, MSP for Glasgow Sheddleston. Mark O'Biagge, good morning. I'm John Finnie, MSP for Highlands and Islands. I'm John Finnie, MSP for Scotland. Good morning. I'm Christian Ard, MSP for North East Scotland. I'm Joe Macklehome. I'm the manager for older adult services in North Lanarkshire Council, and I'm representing the partnership of North Lanarkshire and NHS Lanarkshire Health and Social Care Partnership today. The role that I have is to oversee the development of services, the day-to-day operational management of services for older people, but also the strategic development, looking forward to the changes in the future of older people services, but increasingly in an integrated world, working across the full age cycle. I'm Iona Colvin. I'm the director of North Ayrshire Health and Social Care Partnership and the chief officer for the partnership. I've been appointed for nearly a year now, and in Ayrshire and Arran we're currently in the shadow phase of the health and social care partnership. I'm responsible for all of social services within North Ayrshire, all of community health services, and all of mental health services for Ayrshire and Arran as the lead partnership director. I'm Stuart Mercer. I'm a professor of primary care research at the University of Glasgow, and I am also newly appointed as the director of the Scottish School of Primary Care, which is a kind of virtual school promoting research into primary care. My main focus of research is on the needs of people with multiple mobility or multiple complex long-term conditions, so we look at that across the board, all age groups, largely of course from a primary care angle, but lots of important interfaces. Okay, thank you. We'll start the questioning by John Mason, taking the lead, and if you would like to indicate who would like to answer that would be excellent. Thanks, John. Thanks, convener. I appreciate getting to ask some questions. The whole thrust seems to be that we should try and keep older people at home as much as possible, and I think that that seems to be widely accepted, and has been touched on by a number of committees within the Parliament. Yet when we looked at the funding, I was surprised to see that the statement has made only 7 per cent of the funding for over 65 in the health and social care area is spent on home care, and I suppose that that could show that it is cheaper, but it could also show that we are not putting enough emphasis on that area. To start us off, I wonder what progress you feel is being made or has been made in shifting the balance of care towards home-based services. Start with an easy question. I think that we have not made as much progress as we would want to make to start with, basically. When you look at the balance of funding, particularly if you look at NHS funding, you see that it is overwhelmingly invested in acute and secondary services. Most of it tied up in big district general hospitals, particularly in Ayrshire and Arran's position. We have grown some elements of care at home through the reshaping care for older people fund, but I do not think that the reshaping care for older people fund actually managed to influence the mainstream of funding as much as it should have. What we are doing now is we are looking seriously at how we grow the community infrastructure. It is not just about care at home, it is about district nursing, it is about community psychiatric nursing, it is about rebuilding services around GP practice. I see GP practice as absolutely fundamental to all of that. At the moment, we are looking at developing our strategic plans very much. I am focused on how we move the money into the community to build and grow care at home. How do we re-specify care at home so that it can take on a broader range of tasks? We are looking to see within the partnership so that we are working alongside our community psychiatric nurses as well as social work. We have not grown it as much as we need to. It has been about trying to shift the balance of care. A lot of that money has gone into care homes and the growth of care homes, the care home sector, rather than into care at home. What we are doing just now in Ayrshire is preparing our strategic plans and they will have a focus on how we do that. There is a bit where we can pull out some efficiencies in terms of what we will manage within the health and social care partnership because there is some duplication. There are barriers and things that do not make sense. As we go through and integrate the services, we will be able to free up some resource. However, the big question is how do we get the bigger resource freed up from within the big district general hospital so that we can begin to invest more in the community. That is the one that we are all currently working on. The 7 per cent figure is quite stark. If you compare it with the prescribing budget in terms of older people, we spend as much or slightly more on prescribing in terms of the health budget. We would really like to see some of that change, a focus around polypharmacy. It is just one example in terms of how we could actually, where we think there are gains to be made in terms of transfers of resource on out. I think the question around the balance and how we actually support more people at home is not just related to spend because if you look at the figures in terms of the proportion of people living in care homes, the number of 65 plus per thousand who live in care homes across the country, there is really very big variation and it is not necessarily only related to spend. It is related also to redesign of services and the focus on how we actually take what we have in terms of that existing home support resource and make sure that it is working, it is targeted, and that it is effective, that it is efficient and that it is well linked to the wider service system. In most areas, certainly in North Lanarkshire, we have a big focus around redesign towards re-ablement, towards ensuring that, as people come into using the home support service, we actually work with them in the early stages to see what abilities can they regain, what confidence can they rebuild in order not to use services so that we are actually helping people to move back out of services, which can in fact be quite an intensive use of resource in the early stages, but it is a resource that you are spending to save because by then supporting people back out of the service, over time you free up the resource that you have to support those people who do have much higher levels of support need to remain in their own communities. It also connects to reshaping what we do with the care home resource. In North Lanarkshire, we have moved away from providing residential care within a traditional long-term local authority model, so the care homes that we have now are focused around intermediate care, two of them are operating fully on intermediate care and two are moving towards that. We have divested from the long-term residential care model without seeing an increase in the use of the independent sector care home, so it is possible to make those shifts in terms of balance of care by that process of redesign. Clearly, if we are supporting more people to live at home, we have to then also make the wider connection to their quality of life, so one of the focuses within reshaping care is the wider connection to the third sector. How can we ensure that we address the question, which is mentioned in some of the written submissions around loneliness for older people, that we are giving people the opportunities by investing in the third sector? We have been trying to do that in North Lanarkshire through our engagement with voluntary action in North Lanarkshire as a full partner in the reshaping care programme. From what you have both said, I get the impression that it is not an even picture right across the country and that things are being done differently in different parts of the country. If that is the case, should there be more of a kind of direction from the centre, or is it right that each local area works out its own, what is best for its own area? I think that all the things that Jo has talked about we have done as well, so it is not either or. To be honest, re-ablement has been a big focus for most authorities. I think that the integration gives us a better opportunity to use the resources that we have across the NHS and the council to do that and to work very much about maximising independence, but also getting people into better care and into the position where they are happier in terms of how they live in the future. One of the things that we are doing is looking at the care home sector and how we work with the care home sector and how we commission services in the future. Jo has touched on that in terms of intermediate care, but I think that it is about one of the things that we plan to do in Ayrshire and Arran is to review all of our inpatient beds and our purchase beds together, so all of those that are provided by the NHS, as well as in Ayrshire and Arran, it tends to be outsourced, it tends to be private and independent sector agencies who provide care homes, but to look at the totality of that and to ask the question about what is it that we want for the future in terms of citizens of North Ayrshire and East Ayrshire and South Ayrshire in terms of their care. That is about, as Jo has said, reshaping the care that we currently have and the expectations. It is about things like extra care housing, which Borders and Lothian have been looking at. We do look at the best examples of practice across different authorities and try to learn from that and look at the extra care housing stuff that is quite remarkable in some of the things that have been achieved about moving people out of residential care into extra care housing. The opportunity with that model is that you are not moving individuals but you are being able to have much more flexible support and health services around those individuals. For me, we need to define and look at how care should be delivered in the future. That is one of the things that we plan to do in the first 12 months of the partnership becoming a real and legal entity, which will happen next year. Presumably, the status core of keeping the big institutions going is a bit of a barrier, is it? Yes. Basically, what happens is that we—I think that what has happened previously is—I do not know that it might be different in Lanarkshire, but what has happened previously is that more and more people come through the hospital and look at the figures in terms of the numbers of people who are turning up at A&E. They have increased year-on-year, I think a couple of thousand each year, extra people turning up at Crosshouse and at Ayr hospital. There is then real pressure on the beds in the hospital, and I am sure that Professor Mercer can say more about that. There is then real pressure to get people back out of hospital as quickly as possible. We think about about a third of the people who turn up at hospital do not need to be there, but two thirds do. That relates very clearly to the impact, I think, of deprivation on people's health and on the fact that we have an older population, which in North Ayrshire we have the kind of large north coast bit, which is quite affluent, and a lot of people who live quite a long time. Then we have Irvine in the three towns, which is fairly deprived. Certain parts of it are. We see people's health deteriorating in their 40s and 50s. All of that leads to a huge challenge for the hospital, and they, in turn, have passed that on to us. We still have a culture where, quite often, we decide when, particularly with older people, when they are in hospital, they are either going down the get-home quickly and into care at home route, or they are going down the care home route. That is one of the things that we need to change. We need to change the options that are available for older people, and we need to change that culture. We also need to get in about what is it that is happening. I thought that Professor Mercer's paper was helpful in that respect, and that is a lot of what we are trying to look at on a day-to-day basis. What is it that is driving more people to present at hospital, and then the pressure comes on to social care to help to clear the A&E, clear the beds, get people into care homes, get people into care at home. The demand is increasing year on year. This year, we have seen an 11% increase in the demand on care homes and a 7% increase in the demand on care at home. It is difficult in the current financial climate to keep up with that. What we are doing now is looking at a much more systemic basis at the whole system. What happens? What is it that is driving people through? What happens when they come through? And what can we do about that? And what points can we intervene? Previously, we looked at that, but we looked at it from a health perspective and a social care perspective. Actually, we did not sit down together enough to work that out across the system. That is something that is now beginning to happen. Professor Mercer, is there something that we should be doing at the parliamentary level, especially at the budget level, which is what we are thinking about, to move this along, or is it going to happen naturally, locally? I am not sure if it will happen naturally, locally. Different areas are different, and that is a kind of historic thing. I think the bigger picture is really important, and I tried to outline some of the backdrop to all of this in the paper that I sent. So, there are just a few things that I think are key. The problem of the elderly is largely to do with having multiple complex conditions, increasingly a mixture of multiple physical and mental health problems, dementia, heart disease, diabetes, osteoporosis, so on and so forth. Now, that is not suddenly going to change. I mean, as the population ages, we are going to get more of that, not less, unless we radically do something about prevention, which is a different task. So, here we have an aging population with multiple complex problems, and 90% of the activity of the NHS is in primary care and general practice, but that does not reflect the amount of budget that goes into primary care and general practice. In fact, the percentage of the budget going into general practice has decreased over the last 10 years in the UK, and the Royal College of General Practitioners has been calling for a 40% increase in the share. Now, I think that is the kind of context, and GPs are increasingly struggling with their 10-minute consultations, quick throughput of patients who are not like the old days who came with one condition. People now are turning up and they have got five or six different conditions. So, I think general practice primary care is absolutely essential to this problem, because they provide a generalist service, and for people with multiple conditions, what they need is generalism and wholism, not the 10 different specialists in 10 different places. So, I think there is a bigger picture that there is a real problem here in primary care being under-resourced for the future, as we look ahead. Something has got to change, and it is compounded by deprivation, because we know that multimobility happens much earlier in deprived areas, 10 to 15 years earlier. So, when we talk about elderly, I think that it is not necessarily an age cut-off. I think that there is a kind of biological age phenomenon here. Do you think that age is like 60, 66? I think so, because if somebody in the most deprived decile of Scotland will have the same amount of multimobility aged 50 compared with somebody who is 70 in the most affluent areas, it is not necessarily actual age, it is about healthy life expectancy. So, we have a huge problem of health inequalities in Scotland, the worst in Western Europe, and multimobility is compounding that, because particularly in deprived areas, the need is not matched by resource. So, the distribution of general practitioners is flat across different desiles of Scotland, different places, but the need, the healthcare need, the healthcare problems in relation to particularly multimobility, is not flat. There is a two to three-fold increase between most affluent and most deprived. So, we cannot possibly expect general practitioners in the deep end, as it has been called, to be able to cope in the same way as if they are working in a more affluent area, because it is not a level playing field. So, this has been called the inverse care law, and the GPs in Scotland working in these deprived areas have formed quite a powerful advocacy group called the deep end. My colleague Graham Wart at Glasgow University has presented evidence to other committees here on that. So, I think that is a bigger picture that has to be taken into account. As we move into integrated care, then it is absolutely about multidisciplinary teams joining up and each knowing what is going on. This is a challenge that I think we are still very fragmented. The GPs often do not know what is happening with a person in terms of their social care and so on. We have different computer systems, different notes. We do not necessarily speak to each other very often. So, all these things need to be improved. And a lot of it is about having systems that enable you to work better together and to at least share knowledge. But I do think there is a fundamental problem of the relative balance of the budget in terms of acute and primary care. And countries that have got strong primary care systems across the world, we know do better in terms of costs, healthcare costs and outcomes. So, we will not survive into the future without having strong primary care. I mean, all the international evidence points to that. And we have got a fantastic primary care service compared with many other countries. But it is under pressure and it is socially patterned in the sense that in the more deprived areas, things are just much, much harder. Do you feel the light to comment? Just to come back to Mr Mason's question about should, from the Scottish Government, be trying to direct more in terms of uniformity. My thoughts on that are that there has been quite a lot of work done in terms of the reshaping care programme now with the integration programme around the Scottish Government setting out the outcomes that we want to see achieved and then handing out those outcomes as the basis for strategic planning and thinking within the partnership areas. Where I think there is scope to improve how we actually direct from the Scottish Government, direct their input or the Scottish Government level input is around some of the performance regime that we have, which can unintentionally mitigate against effective transitions and mitigate against some of the outcomes being achieved. There is huge pressure around the achievement of the four-hour target in hospitals. Iona was talking about the pressures around the emergency department's A and E departments in hospitals. For many, many older people and for many of the people who Professor Mercer is talking about in terms of multimorbidities, four hours is not very long to get a resolution to some of the difficulties that might have brought them into the A and E department. People who have dementia are there for a separate reason than their dementia. Simply trying to establish the information, have the conversation and establish the relationship that is needed to treat the person in four hours, that is a big pressure. That can lead to an unnecessary onward transition into converting that to an admission if people feel under huge pressure to make sure that there are no breaches of that target. It is not necessarily age-related because it is about multimorbidity and it is about the complexity of the person's need. That is more likely to be the case as people get older. But numerically, as Professor Mercer said in his paper, there are more younger people under 65, which is your point. Those age cut-offs are increasingly less relevant, particularly in areas of multiple deprivation. Another focus in terms of how the targets in performance culture can actually create difficulties and challenges in delivering what we want to do is around the delayed discharge. Once the person is admitted, next April, we are still moving towards the implementation of a target of two weeks from clinical readiness for discharge for the person to leave. We are currently reporting on a target of four weeks. That risks generating a pressure. During this period of transition in the hospital, the person may need longer than two weeks, the team supporting them may need longer than two weeks. If we try to drive the performance, which is a laudable thing to do around ensuring the most efficient and effective use of the acute resource, but if we drive that very hard on this kind of time-limited target regime, the risk is that we drive more institutionalisation, people, a premature declaration of need to move to a care home when, in fact, with a different approach, we might be able to support the person back home again. That is a more subtle way of looking at how can Scottish Government work in a partnership way with the local partnerships around the achievement of the outcomes. It is more subtle than saying, can there be more straight direction, so it is more working in partnership around what is the best way to manage this performance? Thank you very much for that. That is really interesting. We will move on now to spending priorities. Christian Allard would like to ask the first set of questions. Thank you very much, convener. It is linear about what we talked about earlier when we talked about the integration of health and social care. You talked about the national outcome, but it is the national outcome of maintaining independence amongst all the people. The way you answered some of the questions already this morning, it seems that we are not achievers because some of the funding is needed up in care homes, so how that does really answer the national outcome of maintaining independence amongst all the people. Are we going in the wrong direction? Are we not putting the funding where the funding should be? I think that if you look at the 2020 vision statement, which is about people being cared for at home or in a homely setting, then fundamentally the funding is going in one direction and the policy is in another direction. That is the reason that we have gone down the road now of integration of health and social care. As I said earlier, there are things that we can drive out of the system because there are barriers. There are things that go on that, frankly, in an integrated health and care system just should not go on. We will resolve some of those issues and we will stop some of the people being caught in the referral pathways and things that goes on just now. Fundamentally, yes, the investment is now because of the demand at the front door in acute services. The investment in many boards is going into creating extra resources within acute services because the demand is there. We need to redraw the line in the community and say that that is where we need to begin to manage more demand. That was part of the objective of the reshaping care for older people. It was about managing some of that demand and developing services within the community. Do not get me wrong, I am not saying that nothing good has been done. There has been a lot of really good work done, particularly around dementia care and developing some of the home care aspects, specialist aspects. There has been a lot of really good work done in the third sector. However, it has not actually shifted the mainstream because the reshaping care for older people was about 1 per cent. We need to shift the 99 per cent of investment that is currently invested in health and social work. That is really what we are grappling with at the moment. That is what we need to do. My view is absolutely that we should begin to do much more. In some areas we will have done this much more but we are out consulting just now and looking at what our future model will be so that we build that around primary care and particularly around general practice and that we begin to shift that way. However, there is a fundamental question about how we actually begin to do more of that preventive work, more of that work in the community that stops people turning up at A&E. In Ayrshire, we are still building for better care. It is called we are building new assessment units at the front of the hospital in relation to A&E so that we can manage some of the demand. It is that bit about trying to manage the demand at A&E but at the same time we need to begin to say that if we are not investing enough in community and particularly in primary care and in general practice I would agree absolutely that we are not going to be able to shift that. That is what we need to attempt to do next. Part of what we are looking at just now is how we can free some resource to begin to invest that in the long term. We have obviously announced the integrated care fund, which in North Ayrshire terms is £2.9 million and our total budget is £200 million. However, we are focused on how we can use that to make the change and free up some resource that then begins to focus. In a way, that is not going to shift the mainstream. The most of the money is invested in the hospitals. The big question for us now is how do you begin to reduce the use of hospital care and increase the services that we can offer? In better services, more joined up services within the community that prevent people turning up at A&E and then being admitted because, as Jo says, we do not know what to do with them. People are admitted. Once you are admitted, there is a whole thing about lack of what that does to older people, not just older people, but to anybody with multimorbidity. All of us, in fact, when the way in which your confidence is impacted, the way in which it then becomes more difficult to return home. I think that we still have a mindset about care home because it moves the person on. For me, that is one of the things that we will begin to tackle and that we need to tackle. We need to do that in conjunction with colleagues in acute and secondary care because it has to be done on a system-wide basis. The short answer is that we have some short-term money that will begin to help us if we focus it, and we will focus at this time very much on learning from reshaping care on the change that we need to make in terms of the partnership. In the longer term, we need to begin to find ways to begin to reduce what we are spending on inpatient care and move it over to the community, and that will be easy. Did you do it back to front? Do you think that we should have maybe, like we heard already saying, spending to save? We should have maybe done more the spending way between need to be with us at A&E. I was at the Crampian NHS Board meeting a few weeks back and they talked about is there really we need to first invest to make sure that the third number of patients don't get admission at the hospital, and how do we change that culture? I've seen some of the programmes starting from 2011. Maybe the funding has not gone to the right places at the start and we are starting to learn that maybe we should direct our funding more to change that culture. I think it's hard to say because I think that they are responding to a demand at the front door and they are trying to manage what is happening currently. I do think that we need to plan more in terms of the financial investment in the health service and look to see how we are going to shift the investment out of hospital-based services. By that I mean large hospitals because we also have a number of small hospitals, and a number of small hospitals, but to begin to shift that into primary care in particular. I think that they were wrong to do things such as building for better care assessment units, no not particularly, because they are doing that in order to deliver the best possible care that they can to the people who are currently turning up at A&E. A lot of the general practitioners have been involved in that work as well. What we need to do is improve pathways and we actually need to focus a bit more on prevention and building community services so that people don't feel that they have their only option is to go to A&E. I think that I can only speak for air from this respect, that we focused very much on getting better pathways around enablement, as Joe has talked about, and re-abling people and getting them out of hospital quicker and reducing the length of stay, and we haven't focused as much as we should have on how do we prevent those admissions. However, to be honest, that is quite a hard thing to do unless the system is joined up, and now we have made a leap forward in terms of joining the system up in a much more cohesive way through bringing the services together. I will throw a question to the witnesses. You are talking about primary care. If primary care is the key, is there issues with GPs being independent contractors? How would that actually work, Professor Mercer? Well, a very authority issue, of course, because GPs have been independent contractors since the NHS was established in 1948, and there is mixed views across the board as to whether that is a good thing or not. My personal feeling is that despite the independent contractor status, GPs have been and will be an integral part of the NHS, and I have seen that. What independent status gives one of the advantages, I think, is flexibility. GPs generally can respond quite quickly to if they are asked by government to respond to something such as the flu epidemic or so on, and they can mobilise quickly. Having independent contractor status probably helps that. I would not go on record saying that I am totally for it or against it. I think there are different models, but I do not think that it is fundamentally a huge problem. We do, of course, have the GP contract, the GMS contract and the QWF quality outcome framework. These are ways in which GPs across the UK are incentivised in terms of targets. I think, again, whether that has been a good thing or not is controversial. I think it is certainly the just variation between practices, but my feeling about the QWF is that it is entirely disease based and it is entirely single disease based. Even within a GP practice, you have a single disease mindset. Do this for diabetics. Do this for heart disease. Actually, it is the same patients who have got all of these things. There is no reward system for high quality care for patients with multi-mobility. We do not have targets for that. We do not even know how to measure it. I think the way in which the intent is pointed will need to change at some point in the future. Increasingly, Scotland has a slightly different contract from England in terms of some parts of the QWF. There has been talk of Scottish contract where that has not happened. I think this is something for the future. I think independent contract of status is not a disadvantage. Generally, it allows GPs to be quite responsive to need, but I think the pay for performance aspect of it, which is what the QWF is, will need to be revisited year on year because it does not really fit. It fits with a very disease specific framework. I think, again, that the bank dropped all of this and the talk about hospital care and so on. The point is that we are working on a 19th century model. Hospitals were set up because of infectious diseases and you went in, you got treated, you got better, you came out. That model fundamentally has not really changed, but the needs of the population has completely changed. Now, the big problem facing Scotland and the rest of the world is non-communicable diseases, chronic diseases. If we were building a health service today from scratch, it would not look anything like the one we have got. Clearly, of course, this incremental change has to go on, but I think that is a fundamental problem having people divided up into these single conditions, which does not always make much sense to them or indeed to the doctors. Can I ask you very quickly, and then will it join? Joe is sitting patiently waiting in the background. You mentioned that the NHS, if it was to be redesigned, it would not be built on the model it is just now. How would it be redesigned then? What would be your suggestion for it? Well, gosh, if I could wave a magic wand, what would I do? Well, I think we would. It should be designed entirely around the patient, so it should be truly person-centred so that the needs of that person as a person, not as a set of diseases, is what's important. Within that, you've got all the good things about patient-centred care, shared decision-making, priority-setting, goal-setting, and so on, driven by the patient. Now, of course, we have policy directions for that, but I don't think it always happens in the way it could. The integration of health and social care, of course, that would be starting from scratch. We would be working together with the same systems, the same computer systems that talk to each other. We'd know each other, we'd have good relationships. Things would be community-based, largely. Hospitals would be a thing of the future that very few people would have to go into. So, it would be turning the pyramid we've got just now absolutely upside down. Clearly, that can't happen overnight, but I feel that that will have to be the future if we are going to continue with the NHS. Thank you, Jo. Thank you for patiently waiting. No, I just really agree with what Professor Mercer has said around that we need to make that shift from single-disease pathways. On the contract, one of the things that has happened in the latest iteration of the contract with GPs is a very small part of the co-off that has been allocated to the commitment by the GP practice to engage with their locality, with their locality partners. We've seen a shift from that, so that's a positive example of how the contract can be utilised to incentivise engagement within the development of a locality model. In other words, development of an integrated model, because it's in with that integrated locality focus that is in the legislation and the GPs will be absolutely central to the successful delivery of that. Thank you very much, Christian. To go back to the budget, the integrated model is good, but we have here in Parliament, we need to scrutinise exactly how the funding is dispersed. If it's measured, if we get any measurement of how this integrated funding is happening, and do you think we can measure already some of the outcomes? Do you think it's too early? Do you need to wait a few years to be able to measure exactly if it made a real difference, if this funding made a very difference? Can we have an assessment soon, do you think? On the question of evaluation and measurement, we would say that it is possible to demonstrate in terms of the reshipping care spend that there has been. There is that shift. The spend within the third sector, just to take that as an example in North Lanarkshire, we made a decision at the beginning of the programme that 20 per cent of spend from the reshipping care budget would be spent within the third sector, and then we established a rigorous evaluation framework around that. Sometimes very, very small initiatives around, for example, digital inclusion, so it might be a small local group in one part from North Lanarkshire saying we are interested in connecting young volunteers who are in second nature to them to use an iPad, connecting them with older people who want to learn how to use that, and that then has very strong connections to their being included, their combating loneliness because they have different ways of connecting with their family, if their family are at a distance and so on. With each of those projects, we have established a framework in which there is regular reporting, quarterly reporting on, okay, you got this money, so what has actually been achieved, and there is quantitative reporting, so the voluntary action in North Lanarkshire is able to say that this number of people learned how to use an iPad, this number of people got a telephone wellbeing check, and so it is actually possible to establish that kind of measurement framework. It's labour intensive, but if we don't do that, then we won't be able to actually make the case for that wider transfer of the resource that we're talking about this morning from the acute into this sector because it's always going to be difficult to demonstrate that by actually doing that kind of work, education around falls, for example, it's always going to be difficult to evidence the connection between that and less people in hospital, but as long as we actually can evidence the contributions, we have a contribution story that is regularly published on a quarterly basis summarising all of this information, then we're making the case for that transfer. That's one of the ways to measure it, any other ways to measure it? Sorry, well there are nine national outcomes which have been set for the health and social care partnerships, and obviously we're just currently working on how we're going to report on those nine national outcomes, and they are very much about, as Professor Mears has spoke about, about person-centred and about what difference interventions make to the outcomes for people's lives. So we're working through that just now in terms of how we will be able to do that, and obviously we're working with the civil servants around the performance framework and what that's going to look like. It's a working progress. Last question, if I may, my colleague John Mason talked about what we can do sanctuary. It seems to me that a lot of, I've been speaking about culture, the culture of the patient, how to change the culture of using any, for example, or using maybe too early or too much care homes. Really, that needs to be addressed sanctuary. Maybe there should be some funding authority allocated to have a central message to try to promote not only the outcome, but the way, as well as the different way you are working across the nation and making sure that we have a single message trying to tell people, all the people, the same, the same message. How would you go about that, if not centrally? Within North Lanarkshire, one of the things that we did in terms of message and communication, one of the things that we did with reshaping caramannys was to appoint a communications officer who actually came from the media, came from working for one of the national papers. He has had tremendous impact in terms of taking all the kinds of stories that I'm talking about this morning and many, many more examples of work that has been happening and ensuring that those messages are actually out there in all the local media fora that we have, including radio and the local newspapers are an important part of that. There is a strong commitment to put in the message across. I think that the message comes from how we engage as services, how we engage, how we make very clear the things that I've been talking about around the role of the third sector, the importance of the small initiative within a community that builds its capacity by putting the funding into that. We're giving a message to the community that this is vital and important. It's not something that we treat as a bolt on. The example that I talked earlier about rehabilitation and the change in the approach to delivering home support. When we began to do that, we anticipated that we would have a lot of real difficulty from the public because their expectation built up over decades was that, when you started with a home support service, you remained with that service for the rest of your life or until you went into a care home. There were many examples of people who went into a hospital who were unwell and had a home support service before they went in because they were waiting for a hip replacement. When they came out, they needed a bit more during their rehabilitation, but the medical opinion was that two months after the hip replacement, they should actually be better than they were before they started using the service. They would continue in the service in a historical model, and that wasn't an effective use of resource. We're going back to the engagement with the public. In our experience, people understood—they really understood—as long as we explained and our staff understood that part of their job was to communicate with the wider public. We had very small numbers of people where there was real difficulty. The anxiety was around people saying, I know that I don't need the home support service for the things that it's meant to come in and do, but this is my contact with the outside world. It's about loneliness, so you have to demonstrate that you're taking that seriously. You are developing the alternative approaches to how you do loneliness. You're not just saying, we're going to reduce the home support service because we've introduced rehabilitation, and we're not concerned with the wider issue that is being addressed. They engage in modelling what we do and explaining that it is absolutely vitally important. It is helped by national-level messages, and that focus is also helpful, but it's not either or. It has to be happening nationally and locally. Christian, you're finishing it. Siobhan, would you like to take over? I'm going to ask about transition services, but Iona, you mentioned in one of your contributions about preventative spend. I just wondered if people understand what that actually means or are we using different definitions across the board. I think that that's coming up anecdotally and a lot of evidence that we're getting, both at committee and otherwise, that maybe our understanding of what preventative spend is may not be what service users believe it is or those who are implementing policies. I was just wondering if you had a definition that you worked to. A lot of the prevention work that we've done, we've kind of split it between prevention and earlier intervention. When we're talking about adult services, a lot of it's more about earlier intervention, so it's about intervening earlier. It's probably joking probably to us, because North Lanarkshire have very well-developed, self-directed support. We've also developed self-directed support, but North Lanarkshire have led the way on that. I think there's a bit about providing services at an earlier point so that you're preventing people becoming sicker, becoming more frail. If we think about the traditional way that local authorities have rationed services is by having eligibility criteria, so you have to be quite in quite a high level of need before you reach that criteria in order to be able to access the service. That's a kind of traditional, and as local authorities have particularly had to deal with reduced budgets, that's been one of the things that's been revisited. I think that what we've begun to do is, through the change fund and through self-directed support, is to look at, can you make smaller payments to people in self-directed support so that they can buy in services that actually will support them better? That reduces their long-term dependence and also gives them much more see-over the care that they have, or can we do things like give people some of the aids, for example, for people with disabilities at an earlier stage rather than wait until they reach a criteria. That's some of the work that we've been doing around older people and people with disability services. In children's services, we're focused particularly around trying to prevent children coming into the social work system because we know that once they're in the social work system, many children have to come into the social work system and should quite rightly be in the social work system, but we're trying to prevent some of the harm that happens to children at an earlier level. We've been doing some examples, in North Ayrshire, of things like a multi-agency team based in Kilmarnock Police Station, which works around domestic abuse. That team basically goes out with police officers the day after there's been a domestic abuse incident. What we've done through that is we've massively reduced the length of time it takes to respond to women. It's mainly women, it's not always women, and their children are very important to their children. We've reduced the number of referrals to the children's reporter. We've reduced the number of requests for further reports and we've got women and children into safety much, much faster. For the first time in many years, we have seen a decrease in the levels of reported domestic violence in North Ayrshire. That's one example. We're doing other things like working around the early years centres and putting in money advice and putting in social workers as well. It's about focusing particularly there around families who are on the edge of the system and trying to assist them so that they don't actually have to get to that terrible point of need or where a family breakdown or where there's something happens to a child. We tend to badge them all as prevention and early intervention, but clearly they have a different focus. I'm glad of all the great work that's been happening, but I think the phrase that you used was intervening earlier. I think that that brings me then to transition services because we've heard an evidence about young people falling through the gap, older people maybe not being prioritised in the group that they wish. Therefore, if they had been identified earlier, those things may not happen. I'm just wondering then how a transition approach, a better financial approach, can be supported in the new integration framework that we have. Do you see room for improvement there? What are the types of things that we should be looking for across the border? I know that there are different areas of work in different ways, but I represent three local authority areas. I don't want to see a young person getting a better service just because they live a few miles away from someone else. What should we be looking for as we look at the budget? In terms of prevention, your question was about definition of prevention. I see prevention as supporting people to live as full lives as possible within their capabilities and capacities and avoiding the need for a more intensive level of service intervention. I think that one example or one area that we are focused on is how we can use new technologies. One of the things that we know in terms of older people is that people will often come too late and will come looking for assistance when it's too late. They come to our attention without the person coming to us, so a serious fall often happens after we know from research that the person has had several falls already. No one outside the person's family may know about that fall, and sometimes people will conceal the fact that they are having the fall because they think that as soon as we open that up, there is going to be a massive level of intervention and I might have to go into care. What we are trying to do in technology is to develop a website that allows people to access information without having to go to a service. Many of us will know from our own direct experience of having an older relative who will say, I think that it's time that you got some help. I'm sure that there are things that we can do to help you. No, I don't want to be referred to social work. However, that's a dialogue, a conversation happening with people who are on one side of the conversation and are very internet capable. They say, let's have a look on a website and see what is there in the local authority area. They will come to a website that says, here's information about falls prevention, here's information about small aids and adaptations that we can order online and get delivered without ever making that referral into formal service. That's an area where we see great potential for prevention and the person not having to come into the formal service or delaying the point where they have to come into the formal service. That is more acceptable to many people themselves because some of the issue around not being identified is that people don't want to be identified in the existing service configuration. Again, just back to how you identify those services so that people don't fall through the gap. I understand the example that you gave Joe, but if you're not competent on a computer or you don't have a supportive family, you're on your own, you don't want to bother anybody, you don't want to tell people you're fallen. Where do you go there? How are those people identified? How is a young person who has gone to school? For instance, in primary school and it's all on one level and everything's wonderful for them and they get the support there and then they find themselves in high school and it's on three levels. No one really understood that because they weren't doing home economics or technical studies that they would have a problem when they got there. How are those young people identified and how does the integration that we're now seeing, be it the public body's bill, whatever that may be, how does that then support young people and older people who are in those circumstances? We've put in children's services into the partnership, so children's services and criminal justice are within. For the reasons that you're talking about, because of that issue about transitions, we can plan better for children. We know that children with disabilities are coming through the system, so it's about better planning and knowing who those children are. The big idea is that, in terms of the strategic approach for children, it's very much about how do we build a multidisciplinary approach around children, teams around children, in early years in primary and secondary and for children who are out of school, so that we actually do pick kids up and that we're doing some work just now with Duttonton Social Research Company, which will identify what children are seeing in each of the school cluster areas. For adults it's very much about, I think, about attaching ourselves to general practice and building the pathways around general practice and integrating the services, because that's where most people will go, is to see their GP or their GP will likely be the first person that gets involved, and I think we need to recognise that and then basically do what we need to do around facilitating the services around GPs and being able to move people through and into the right part of the system, and to take some of the burden off the GPs and to work hand in hand with them to deliver it. To mention, an example of that is a project that myself and colleagues are evaluating, called the Deep End Link Worker project, which the Cabinet Secretary announced funding for the next two to three years, and this is exactly for the situation where there could be a lot of community support in an area, but there's people who are isolated and the GPs themselves will often not know what's out in the community, particularly in deprived areas, because they don't live there. So the Link Worker is a fairly highly skilled person, often from a community development background, and they're actually physically in the GP's practices, taking the fell, so if an GP sees a patient and picks up actually, I think this person is isolated, they can refer to the Link Worker who will see them next day and then go through what's available locally. There's a system called ALICE, which can be localised for all sorts of things, including somebody might run a lunch group or somebody might run a walking group or so on. So we're just at the very start of this, it's being done in seven practices in Glasgow, but the good thing about it, from my point of view, I would say is there's a reasonable amount of money going into re-evaluation, and it's being done as a randomised control trial. So there's 15 practices where half of them are getting the intervention, half not, and we can then compare, does it actually work? Is it cost effective? How many people get this service? Will it actually do what we think it's going to do? I think there's lots of examples of good local projects, but very often we don't evaluate them and then nobody really pulls this together. For me that's a frustration because we do the high-level academic stuff, big numbers and so on, and there's brilliant stuff happening on the ground, and I think we've got to bring those two worlds together, so I think the evaluation of that's really important. But that's one example, so Link Workers who are not medically qualified, they don't need to be, they've got a totally different set of skills, but working very closely with health, with statutory services and third sector, I would see that as potentially a model for the future. It's based on, Professor Mercer, it's just about the money that's allocated, everyone can say they want more money, so I'm not expecting that answer because that's always the answer, but 173.5 million's been set aside in the draft budget for the integration fund. Is that reasonable? I mean, I know you spoke about your own local authority earlier about what that means in the grand scheme of things. Can you do all the things that you wish to do with that money? Is that a reasonable task of you given the current climate or isn't it? Not understand, as I said, we all want more money, but is it a reasonable? But it depends who we use it, and if we use it to change service, so we and Ayrshire would want to use it to make the changes so that we integrate the health and social care components so that we're making the best use of the resource we've got and that we do something very similar to what Professor Mercer has described there with the GPs. I think that that will begin to make some of the changes. It's not enough to make the big shift, as we've talked about earlier, but we need to use it to begin to make in-nose and to make in the big shift. It's not enough, and because we've only been guaranteed it and we understand why for a year, it's not enough to set up a whole lot of new services. It's about changing the way that we currently use the services, and our proposals are similar to the ones that Professor Mercer has talked about. Thank you. Can I just check, John Finnie? Do you want to ask any questions? Have they been covered? They've been covered, thank you for being here. Okay, thank you. Alex, are you happy to ask him? There was a subject that Professor Mercer mentioned earlier on. It was the issue of the distribution of primary care and how it tends to be fairly even across the country and doesn't reflect demand. I wanted to ask you if the planning aspects of the integration of health and social care are taken proper account of that. To the best of my knowledge, no, I don't think that that is taken into account. This is this flat distribution. Again, it's historic. GP numbers are really distributed in terms of largely population count numbers of people, and there's some inflation given for working in deprived areas and so on. But no, I haven't heard of anything that takes that into account. Now, last week, I think the Cabinet Secretary announced, I think, the 43 million pounds over a year of the next year, part of which will go into deprived areas and general practice in deprived areas. So that's very welcome. We don't know yet how that would be spent. It's only for one year, so it won't solve the fundamental problem, but it's certainly a step in the right direction. But I haven't seen, I don't know of anything that will reverse the inverse care law. So, are GPs being properly taken into the integration process? Well, I think the inclusion of the GPs in locality planning and so on is very welcome. I mean, I think that the GPs need to be involved in that. I don't know how uniform that is across Scotland. It tends to be piecemeal, I think. But there's not, in terms of the health inequalities and deprivation, then it's still a kind of a level playing field. And in the face of a relative decrease in the spend on GPs over the years. So, I don't think it's going to fundamentally change than what I've seen. In terms of GP involvement, it's absolutely fundamental that they are involved in the integration process because they're part of the solution here and we can't deliver what we need to deliver without them. So we have been engaging with them directly and they are represented, certainly in Asia, they will be represented on the integration joint boards, they're currently on the shadow board. We've got a job to do with GPs because I think that they feel quite disenfranchised from what's gone before from the community health partnerships. Now, that will vary across the country, but I know that's the case in Asia. So it's very much about talking to them and engaging with them. So we are meeting with them on a regular basis and I think that we are saying very clearly that they need to be part of the solution because we can't resolve all of these issues unless GPs are absolutely at the heart of it and we would plan also to have GP leadership within our management team as well. In terms of outcomes for older people, will self-directed support have any effect on changing the balance? Yeah, self-directed support, it will support the continued focus on balance of care, it will give some people choices and options to manage their own support in a way that they didn't perhaps feel was available to them before we had the legislation. It's certainly a big part of moving into the future in terms of balance of care. Clearly, there will be differential uptake of the different options under self-directed support, but we are certainly, in North Lanarkshire, saying that more older people are coming into using the option of taking individual budget. That will not be the case for everybody, everybody won't want that. The final question on that run is, is the budget adequate? I think that you probably know the answer to that question. In terms of the change funds that don't change the fundamentals of the budget, they give an opportunity to reshape, redesign and take a step back and say that Professor Merchys point earlier, if you started with that, to change funds allow us to do a little bit of that and it's very welcome to be able to do that. Certainly delivering within the current budgets is a really big challenge and we know that the coming years are going to be harder still again, but as your colleague was saying, we can't just keep coming and saying that we want more money because we know what the answer to that is. We have to find different ways of working and we have to work with some of the principles that have been set out very clearly in the Christy report to say how we can reshape what we do within the financial realities that we work in. I think that John Finnie may want to come in on that. Thank you, convener. Just a couple of very brief questions. One regarding what the specific purpose of integrated care funding will be, what uses will it be put to? The way that we've approached it in North Ayrshire and, in fact, I think that the other two Ayrshers have done the same thing is that we're looking at what needs to be, what the legacy is of reshaping care of older people, what bits of that that we would want to perhaps sustain and change over the next 12 months and that won't be the major part of it. We're looking at around about a third to look at how we change what we're doing. How we integrate, for example, we've got two mental health teams. We've got a social and mental health team and an NHS mental health team. We've got an NHS learning disability team and a social learning disability team. We've got a number of areas for older people. We've got some separate services. One of the things that we're going to focus on is putting those together, reducing duplication and having those multidisciplinary teams. By the end of the 12 months, we should have the multidisciplinary teams. The other focus is how do we attach it? Sorry, can I interrupt? Some people might assume that that would bring savings rather than acquire costs, but... Yes, some people might. Especially my director of finance. There will be some savings. Ultimately there will be savings? Ultimately there will be savings because we will reduce and we will reduce already because we've already set up a partnership management team. It's one management team that manages all the resources, including the whole of mental health. There are savings there in terms of management structures. There will be savings because we will not do things two or three times, as we currently do. We'll do them once. It will take a bit of time to get to that. I think that the demand increases are what's challenging all of us because the demand has continued to increase as the budget has decreased. Currently, just now in North Ayrshire, we have about £2.5 million worth of overspending older people services related to care at home and care homes. That's not meeting the totality of the need. That's the challenge for us, is how do we manage to do this and stay within budget or within an acceptable level for our elected members. However, the other part of it is how do we attach to primary care and particularly to general practice. That's the bit of the model that we want to work through. It's very much about the things that Professor Mercer talked about, but we can organise services differently. The third part of the budget is an innovation fund that has been organised by our third sector colleagues. They are running that to look at what innovative approaches the third and independent sector might want to come up. Probably smaller schemes, but they are focused around some of the issues that Jo was raising there in terms of some of those services and providing support to people. One of the problems in reshaping care for older people was that it was quite strict and it had to be focused on over 65. As we have discussed already today, particularly in areas that are urban in the three towns, people who are in their 40s and 50s are just as sick. That was one of the problems. That's partly what we need to look at. What did we learn from the reshaping care that was good, that we would want to extend, but what else do we want to do that's new and work hand in hand with the third sector to get their best ideas generated as well? Can I pose a very quick question to the Professor? Professor Mercer, you raised the sum of the £43 million. Last week I represented the Highlands Islands and I asked the largest health board there had any intimation of how that cost would be spent. A lot of the discussion has been about urban deprivation. You'll be aware that rural deprivation, when it's compounded with issues of geography, is significant. It's enough attention being paid to that in the budget formula. To rural areas, as you know, there are particular challenges getting medical services and innovative ways of trying to deliver them, not least connected with the GP contracts. I'm not too sure the detail on that, but in general terms, the issue in the little areas of the ageing population is worse. The Highlands Islands are ageing faster than the urban areas. Again, the problems will accelerate, but I'm not sure if enough has been done. I don't know what my colleagues would have done. I think that I don't know what time for that, but thank you very much. Running out of time, Marko would like to ask some questions now, thanks. I've heard a lot about how well things are working with the third sector in North Lanarkshire. Is it working as well in the other 31 local authorities? Well, I think that it's working quite well in North Ayrshire, but I would say that I think that certainly in Ayrshire, the third sector has been very much engaged in the work that we've done to set up the health and social care partnership. We've been working on this for nearly two years now. Our council agreed about 18 months ago about what model we would look at and all the services that we would be putting in. We've been working in partnership across the three years and with the health board to create the structures and the third sector to be involved all the way along. Would you say that your experience is… I'm seeing shaking of head from next to you, so maybe I won't finish that question. I'll just pass over. I think it's from the point of view of integration between the third sector and, say, primary care and general practice. It's at a very early stage. Some areas have got historically much better links. For example, in Cregmuller, at Edinburgh, a high deprivation area, they've got 20, 30 years of having good relationships between the general practice and the local organisations such as the Fistle Foundation. You've got an equally deprived part of Glasgow and you just don't have that. It's not the same across the piece. We finished a project recently with the Royal College of General Practitioners called Improving Links in Primary Care. This is exactly the aim of the project. We looked at four different practices and we worked with them for about two years. What was clear that one model doesn't fit each area, so the policy is good. Each local area has to do with it in their own way. For example, in one of the practices we worked with, it was in a very affluent area. There was a lot of elderly people and a lot of commuters. Their needs were very different from the needs in Cregmuller in terms of the types of linkage required. In the more affluent patch, they didn't need link workers because actually people were quite able to look at a directory and so on, but they did need the communication with the practice. For my part of you as a primary care practitioner and researcher, it's at a very early stage. The Alliance for Health and Social Care, of course, is a big player in this and is doing really good work, but we shouldn't think that this can be rolled out as one size fits all. It's going to evolve over time. The deep end link worker is one example, but that model may not work across the piece. I think this is going to take five years before we really know how to do this well. Is it the case then that you could have third sector providers working quite well at the strategic level for the board and possibly delivering services almost in parallel in certain areas and having communication, but maybe not connecting at the GP line unless there's a history of it and taking times? I think that's entirely possible. That's what I'm taking from that. It's important to note that I can see why that happens because it's about the history of and who holds the contracts but the partnership will hold the contracts. If you look at the social care budget for North Ayrshire, which is about £95 million, half of that is spent in the third and independent sector. The approach that we've taken is that they are our key partners going into this partnership along with everybody else, so that should, if it works properly, bring those relationships that Professor Mercer is talking about as we tie in the third sector as well. Final question. Is there enough financial emphasis coming from the centre and recognisable funding streams coming from the centre to support the need to develop working with the third sector? Is that me, yes? Whoever would like it, yes? I think not. As I said, I think it's at an early stage. The deep end link worker project has been well funded and well supported but it is only six practices and there is a question as to whether that level of funding would actually be, if it's a big success, would actually be rolled out or would it be too costly. That's why we need good evaluation including health economic evaluation because if you can show these sorts of interventions to be cost effective then of course it takes on a very different slant. I think it's early days and I think from a general practice point of view the answer would almost certainly be no. We're just starting on this journey. Sorry, a quick yes or no. Is that project, is that funded directly from Central Scottish Government or from the relevant board? Yes. Scottish Government, as far as I know. Thank you. Through the Alliance. Could I ask if any members have got any final questions they'd like to ask before we finish up? No, okay. I thank the witnesses for coming along this morning. It's been very, very informative and I'm sure that we could have gone on for another two or three years or more. But that unfortunately concludes today's meeting and our next meeting will take place on Thursday 20 November. Thank you again for coming along. Thank you.