 Welcome everyone to the 29th meeting of the Health, Social Care and Sport Committee in 2022. I've received apologies for today's meeting from Emma Harper, but she is substituted by our colleague James Dornan and he is joining us online. The first item on our agenda today is a presentation from Dr Urena Cohnan, who undertook commission research to the committee for the international models of social care for our consideration ahead of our scrutiny of the national care service bill. I invite Dr Cohnan to give our presentation no more than 20 minutes and then we'll ask you some questions afterwards. Over to you. Hi, I'm Dr Urena Cohnan and I'm going to talk to you today about the rapid review that I did looking at comparing the international models of social care. So the aims of this presentation are to provide an overview of the rapid literature review that I conducted and to outline, particularly to outline the key findings of the review. So the main features of the different models, key similarities and differences between each of the models and then also to outline some important considerations when thinking about the transferability of the models. And from this have a look at some of this evidence informed recommendations for decision makers. So the literature review of international models of social care. So the purpose is to very much to provide a descriptive and comparative overview of the literature available and the types of evidence. So the review is structured around six particular research questions. So how social care structure delivered and funded and governed, the benefits and limitations of each model, impacts on population health outcomes, but also as well healthcare delivery, which is also important. And looking at the enablers and barriers to the effective implementation delivery of each model, especially around integration reforms, what other countries have done here. And then looking at the enablers and barriers to the long term sustainability of each model, especially with financial sustainability. And then thinking about the points that we need to consider when thinking about the transferability of the models, particularly in Scotland. So the questions that we had were answered for each of the countries which were Australia, New Zealand, Japan, the US, Alaska, Switzerland, Canada, the Nordic countries, the EU countries, particularly focusing on Germany, the Netherlands and France, and all four of the UK countries. So the review that we did combined systematic narrative and Delfi method techniques to review the existing literature. And that was very much both the academic literature and the grey literature. The data collection process looked at the interdisciplinary materials available, so it covered a very broad range. And the findings were verified via the project advisory group to verify the findings. So the final sample consisted of 166 articles and documents which were coded for and subject to detailed scrutiny. Now, the findings, which is a key thing. So the findings for the first question, how is social care funded, structured and governed? So we looked at these for the different countries. So as you can see here, I've got a sample of some of the countries too. And the key details will be available in the summary sheet that was given to you. So we can see the key similarities in delivery and mix between public and private providers in Australia and Canada, but also the differences in funding. Or here we can see as well in Japan and the EU placed high levels of expectations on informal care compared to Switzerland. And we can also see we've got some similarities between the German system and the Japanese system, both being funded through compulsory social insurance schemes. But we can also see how they diverge in terms of their delivery. Or we have the Nordic models and New Zealand systems, which are quite similar to the UK in a number of ways, but very different in others. So particularly with the extent of integration with the New Zealand system and the amount of for-profit provider provision we have compared to the Nordic countries, although this has been increasing in recent decades too. Now what I would like to draw your attention to is a slide here, which has the key differences between the countries in terms of funding and key aspects of governance and delivery. So we've got a number of countries funded through central taxation, or in the case of the EU through compulsory insurance schemes, which are organised centrally. Big differences here are in the Alaskan models, which are funded through the Alaska state's own version of Medicare. And in France, the social insurance scheme is funded both centrally and regionally via taxation. In Japan, its insurance scheme is funded on a regional basis. And Canada is a particularly interesting example, because the arrangement is done on a provincial basis, with powers transferred to the provinces via federal and central legislation. So a locus of control, we can see key differences here. In Australia comes under federal control, but the responsibilities between federal and state aren't particularly clear, which has caused problems. And in Switzerland, although it's funded centrally, the municipals have control over governance. And in the Nordic countries, I've put largely central, because although the districts have the power to make arrangements, it's supported by strong national level legislation concerning eligibility and quality of care, which places limits on these powers. So again, it's similar to New Zealand, where regional authorities have control, but within national legislative limits. For eligibility, we have a broad range and very strict conditions to broad coverage. And this is also linked to the final column of informal care, where the expectation is that that will plug the gap. So in Australia, we've got it determined by needs and a means tested basis, where the expectation for informal care is low. And in Japan, the criteria is actually very strict that the coverage is broad for those who do qualify, but it's meant to plug the gaps in informal care provision. In the EU countries, it's based on legibility, but the criteria has become much stricter in recent years, particularly in the Netherlands. And in these countries, there's also still a high level of expectation on informal care. And in Germany, it's in the past, it was legislated that family members, you know, should contribute to the costs of care for family members. And there were higher premiums to pay for those without children too, which was very, very controversial. It's a very contentious issue. In Alaska in the US, it's means tested, but the service provision is very low. So what ends up happening here is that families plug the gaps regardless of any cultural expectations like in Japan to do so. And then last but is the integration of social care with healthcare, which is important as it affects the provision. In Australia, separated in the US and Alaska, social care isn't covered by Medicaid unless it's part of residential healthcare services or rehabilitation services. So a lot of what we have here in Scotland that comes under aged care and social care isn't provided for like general assistance in the home under the system. In Canada comes under extended healthcare, which is broader than the US and Alaska, although the majority of care for older people is still provided in residential settings. Coverage for home care is substantially poorer. In Switzerland, they're linked in terms of service provision, but not integrated in the same way as in New Zealand or Northern Ireland. And of course, in the other UK countries has seen a greater move towards integration. So we also looked at the strengths and weaknesses of the different models. So with the Australian system, the opening of care provision to private providers has led to a lot of concerns about increasing inequalities and the lack of integration impacts care delivery for those with very complex needs. But as I said before, we have a reduced need for informal care. In the US, the key problem overarching all the other issues are the inequalities and access to aged care and the exacerbation of social economic and racial health inequalities. Alaska is different to other states in that the models that were provided for Indigenous people are aimed at aging in place. So a lot less emphasis on residential care. And there is potential for reducing inequalities and outcomes because these models are built on diversity, built upon a diversity of worldview, different conceptualisations of health and wellbeing. So it moves beyond simply recognising cultural diversity towards building a system based upon it. But it's also primarily health focused. So the amount of social care provisions still remains limited. Again, in Canada, the majority of care is provided in residential institutions and there are big differences in provincial arrangements, which can create inequalities and accesses between provinces. But what we have found in Canada is that some of the strict regulations they have for licensing of care home helps private for profit providers meet care delivery standards. In Japan, it's very much based on a paternalistic medical model. High levels of informal care is particularly concerning as a gender equality issue with women who are the ones who carry out the majority of care. But access to care is standardised and coverage is good if you qualify. In the EU countries, the system provides the basic levels of care only with the risk expected to be covered by informal provision. Another downside is that single sourced insurance schemes can be vulnerable to macroeconomic fluctuations, but also contribution systems have been said to be associated with the reduced need for political bargaining, where, as in Canada, some of the short political cycles have been said to limit the effectiveness of reforms. In Switzerland, the system ranks very well internationally, but the fragmentation of governance and delivery between the federal, municipal and local authorities in terms of delivering governance has been associated with increased risk of sub-optimal quality of care. The Nordic countries often consider best practice by international standards, providing universal coverage supported by national level legislation, which ensures equality in levels of care provided and the quality of services. In the literature here, a lot of it will discuss how marketisation has challenged the principle of universalism because there is an introduction to pay for add-on or top-up services. The New Zealand model integration helps to meet the care needs of those with particularly complex needs. The emphasis is on overall wellbeing, and it is well integrated. A lot of it is focused around addressing existing health and social inequalities. The UK countries have Scotland where increasing integration has potential for a more holistic approach, but what has been happening is that health can emerge as the dominant partner. Public expectation for social care provision is high and eligibility for Scotland is relatively high. In Northern Ireland, where we have had an integrated system for decades, the multiple layers of decision making and the unclear lines of accountability can mean that there has been quite a few issues here, and care user choices can be limited. England has a slightly greater alliance on for-profit providers than Scotland, but here the key challenge for integration is a lack of statutory basis, and satisfaction with social care in England has also been decreasing in recent years. In Wales, the biggest concerns are over accessibility, care quality and co-ordination, but it has been found that pooled budgets will help facilitate data sharing and commissioning. The answer to the third research question, which was about the impact of each system on population health outcomes, needs to be considered when thinking about the pros and cons of each model. Some conclusions that we can draw are that poor integration between health and social care can negatively impact those with complex needs such as in Australia, especially when we compare it to say Japan, where the system is positive because although limited in terms of eligibility, it will cover a large range of services for those with the most complex disabilities and needs. A limited coverage in the US is very much linked with widening socioeconomic and racial health inequalities. In Alaska, where there is a bit more provision for care services for Indigenous people, it is associated with greater preventative health outcomes as well as better treatment for chronic disease and lower hospital admission rates. In Canada, differences in the provincial arrangements do result in national level inequalities in access to care and health outcomes. The marketisation of social care has in all countries been linked to growing health inequalities in terms of health outcomes. However, the impacts can be somewhat mitigated by national level legislation concerning the quality of care and the amount that providers can charge, such as seen in the Nordic countries and, to an extent, in Switzerland. Integrated care provision is associated with better quality of life outcomes overall, which affects health outcomes and is helpful for reducing pre-existing inequalities. In the UK, so far, there has been little evidence that attempts to increase integration have affected health outcomes to date, but the longer-term effects and impacts are not really known. It will take several decades before we really start to see the impact of this. Again, just have a little thought before I detail the findings to the other questions. Underpinning questions about integrated care are questions about how health related care relates to social care. What I would encourage you to consider is how social care needs reflect health care needs or quality of life and broader well-being needs. Where is the demand now and where will it be in the future? With this in mind, think about which models you might be in favour of. In an ideal world, because obviously it may be limited by questions about funding and ability to deliver, but I think what we need to think about is what do you think should be coming under the rubric of social care? Is it about extended health care needs with wider well-being being part of something else such as community, or should broader well-being come under what you think should come under social care? That is really the fundamental question at the base of these models. Findings with the barriers and enablers to the success of different models of integrated care. We had a look through what the different countries said about what were the successes and barriers. In particular, here was a New Zealand approach about having a clear vision of a one system, one budget, really helps to achieve positive outcomes. In the EU countries and in Canada, I will ask in the United States, particularly in Canada, the amalgamation of the district health authorities into a single provincial health authority helped to improve outcomes. Also, another important lesson that we can take from this is how frameworks and standards can help to facilitate successful integration. In the Nordic countries, the key lesson is that marketisation can challenge quality of access, but if funded care services remain comprehensive enough that very few demands for top-up services are made, it would not impair the provision of universality. Challenges to the financial sustainability of the models. We need to think about how likely each of these models can be sustained. All are affected and challenged by the challenges of an ageing population, which place rising demands on care. The Nordic models, while the gold standards are coming under pressure across the ability to provide universal care in the future oing to the ageing population. But another challenge in Australia and Canada and also in the UK countries are changing patterns of care needs, the move towards care at home, which you need to be able to fund and also provide the workforce for it too. But at the same time, if you take the US with its low state spending, it's coming under pressure from rising inequalities in health with people requiring care at younger ages and often for more complex needs. So reduced spending in this case is unlikely to solve the problems alone. All contribution-based systems funded through central taxation are affected by economic fluctuations so they're not completely stable. The integrated system in New Zealand is dependent on increased spending on community care to sustain it and avoid some of the problems that we have seen recently in Scotland where health spending has emerged as more dominant. Lastly, we looked at factors that we need to consider when thinking about transferring one social care model to a different context. If something works, can we uplift it and implement it somewhere else? From the very limited number of studies that explored transferring models to different contexts, we found in practice that it can be very difficult. The abilities of it to succeed financially is very much dependent on the wider economy so timing here is important and there is a need to consider the fundamental principles that underpin a country's model of care in how it compares with a recipient country. So if we take the Nordic model underpinned by the principle of universality, which is widely accepted publicly, and implement the US system which is embedded on principles of freedom and responsibility, resistance is likely to be high and vice versa if we do the same with the Nordic model. Likewise, there is a strong cultural value in Japan still to provide informal care so to implement this model with expectations in the Nordic or Australian countries where there is a wider emphasis on supporting a dual earner model is likely to be a lot of resistance. It's about thinking about the core concepts and values that underpin a model and seeing where they fit with the social cultural values and expectations of the recipient country. We also find other factors to consider such as the rate of population ageing in both countries. While the Japanese system is coming under pressure from the ageing population, we need to keep in mind that its rise is much more rapid than in Scotland and other countries. So might that be more likely to be sustained here? Perhaps? Other things, population geography and governance structures. So if we take Canada, we've got a huge geographic area with differences in population dynamics in each province. And while we might say regional governance can add layers of complications, when you have an area as large as this and as diverse as this, there is a strong case against the one size fits all model. And also we have to think about population diversity. So you can have a universal system which works in some contexts or you can have a system that recognises diversity increasingly like in New Zealand which is helpful for addressing existing inequalities or a system like the Alaskan models for indigenous people that's based on diversity in how we understand health and wellbeing. So the conclusion, what can we learn from the review? So all systems are facing pressure due to population ageing. There is not a perfect single model. Integration can help to deliver more holistic approaches to care, but strategies need to be put in place to ensure social care does not end up in a subordinate position to that of primary health care. Increased for-profit provider provision can enhance inequalities, but it can be somewhat mitigated by higher level national legislation and ensuring that care services remain high enough so that demands for extra services are low. And again, particularly from a lot of the case studies in Canada, delivering savings should not be adopted as an immediate objective of integration. Strict demands for eligibility, risk increasing reliance on informal care and widening inequalities in health and quality of life, not just for those who care recipients but also for those who are providing care. So from the findings we came up with 10 recommendations for decision makers each which is available at the end of the report that you have too. So just to read a couple of these out to you as well, care services should be provided on a consistent basis across geographic areas to avoid geographic inequalities in terms of provision and outcomes. A clear one system one budget approach can reduce complexity and eligibility for access to care should remain high to prevent rising inequalities on met needs and increase dependency on informal care providers. Lesson from Northern Ireland, standardised definition of what personalisation of care would be helpful for the care user as well as for those responsible for delivering care. And mechanisms that address cultural differences between locally accountable social care services and centralised health services can help improve integration but financial savings shouldn't be viewed as an immediate objective of integration. Budgets intended to support integrated care should not be used to offset overspends in acute care. And when thinking about facing the challenge of the ageing population forward planning and significant investment are required to meet future care needs, but the challenge of the ageing population is something that is posing a challenge to the sustainability of all the models that we examined. Thank you, Dr Conan. I'll let you catch your breath for a bit. Listening to you there and the point that you ended on about ageing population is a worldwide concern for every country. One of the other concerns for, I imagine, most countries is attracting people into the care sector. We are obviously facing that in Scotland. One of the objectives of the bill that we've got here is to make it attractive, a career, parity of esteem with our health sector. Is that something that—I saw it mentioned when you were talking about New Zealand that that came up. In the New Zealand model, because of what they've done, are they finding that they are having less of a problem in attracting people into the profession of care? Are there any of the other models that you can point to where that's actually been a good outcome in terms of the reforms that have been made? One is the Nordic models, particularly in Sweden, where they have standards for professional accreditation of professionals and for service delivery, too, which has made it more attractive to attract people to the profession to do that as well. In New Zealand, yes, it is the case, too, about having it in terms of standards, but again, something in the wider literature, which was focusing on Japan, it was around low wages, low payments for those involved in social care, and discussing that within the idea of the emotional labour side, that caring social care is often very undervalued because it is assumed that caring is a natural thing that people can do without particular training, and that is something or an idea that has prevailed over the decades and still influences this lack of funding towards social care, but that is increasingly being challenged, yes, in New Zealand, also to some extent in Australia, and also in the Nordic countries, particularly in Sweden. Just to follow up before I let my colleague come in, in terms of, I mean, that was obviously the accreditation, but you mentioned the remuneration of people working here. In the Nordic country, was that something that was addressed as well? Yes, it was. Okay, yes. Sandesh, go on, you've got some questions on that, then. I've just got the one, Camila. Thank you very much for your presentation, all the work that you've done in there. My question is about your methodology, to look a little bit into that. So you excluded papers that were published in languages other than English. Yes. Now, that would present a problem because Japanese is obviously the dominant language for Japan, and French in for France, and German being for Germany, and we could keep going like that. So my question is how many papers were excluded on this basis, and if you've excluded papers and how much per language, and if you've excluded that many papers, how can we say that your research on those particular countries is robust? Okay, first of all, the numbers detailed in the reports, there weren't that many that we actually ended up excluding, which weren't in English. And these are academic articles. Now, the standard, there are some journal articles that are published in, say, French or German or in Japanese, but the international academic, the majority of the high-level, high-ranking international journals, the publications are in English. So people who are working in Japan conducting high-level quality research publishing in the highest quality journals are publishing in English, or the same as in France. In Canada, because of the bilingual requirements for journals, it will be often the case that a paper will be published in English and in French, so we can access it that way too. But, yeah, we're talking about high-ranking international journals, which contain the information that the researchers have conducted in France and in Japan and verified by international experts, peer reviewers. To be published. Sorry, but how many were excluded? I couldn't see that. And the exact number, it says in the report, I'm not sure if I can't remember off the top of the head what the exact number was that were excluded, but it wasn't very many, but it's detailed in the reports. Come to Paul, then I'll come to Gillian. Oh, no, Gillian, you don't want. Paul. I wonder if I could ask about social work in this, because obviously it's challenging, I would imagine, in the preparation of this to try and compare like with like, because I suppose we're not, in a sense, and the scope of the bill, which we will be scrutinising, goes beyond just that really practical delivery of social care, I suppose. Northern Ireland's perhaps a good example, because social work is delivered slightly differently in Northern Ireland via more of a health board model. I wonder if you find any international examples where elements of social work, as a profession, were put into this kind of more national structure around social care. Yes, in New Zealand, also in Japan as well, in Australia to a certain extent, and in the Nordic countries too. And just to maybe expand on that, if I can, convener, did that involve criminal justice, children and young people services as well as just older people services or learning disability, for example? Absolutely, particularly around disability services. In New Zealand and in Japan, it was particularly around disability. Also children's services came into it, criminal justice, addiction services and other rehabilitation services too. Any other colleagues want to ask a question or else I'll just keep going because I've got a couple more questions. I'm looking to my colleagues. One of the things that you mentioned, in particular, we're talking about the countries where there is an expectation of, presumably, family care. I'm interested in the countries that have more of a reliance, more of a culture. Do those countries give any kind of financial support the same way that we have the care there's allowance? Is it just a case of those families that are expected just to get on without any variation? There is a variation there, but largely if we're talking about the Japanese model in particular, it's very much a reliance on informal care. That's the expectation. With the social care, it's to plug the gaps in informal care provision. It's round the other way there. There is for carers, particularly in the Netherlands, is a good example here, where there are allowances available for those providing informal care to help cover some of the costs, but again it is extremely limited. It also means tested and it is very much, you could say, is a last resort to. The expectations for informal care, it is long-standing cultural expectations that is behind this. Funding is to support that rather than funding being used to develop that, shall we say. Without presuming, because I don't want to presume, but certainly in this country that expectation tends to fall to women. Is that the case in those other countries as well? It is very much the case there and it is very much related to the earner models that we have there too, whereas we have the Nordic countries in Australia, also Canada placing particular emphasis on dual earner models more broadly, but then we have in the Netherlands, which is still very much, even now, still largely dominated by the breadwinner model in terms of how these cultural norms are embedded within the systems there too. It is very much the case that where informal care is provided in all countries, it is very much falls to women. That does have an all-con effect on things like other measures of wellbeing society, like a gender pay gap as well. It is linked to gender pay gap, also lack of opportunities for women to progress, but also increasing levels of stress in those who provide informal care and poorer quality of life, especially when we take Japan, for example, where people are living longer and we will have people of working age who are providing care for two generations, for their parents and the grandparents as well. It is linked to lower quality of life outcomes for those providing informal care. That is really helpful. Can I bring in James Dornan, who is joining us online, James? Thank you, convener. Thanks very much for the presentation, Doctor. That was very helpful. Can I just ask a couple of questions? One of them is around eligibility and you seem to suggest that there is a balancing act here, that we either make the eligibility criteria higher and then give a better service or we make it more than the optimum and get more people in it. What are your thoughts on that and where do you see the balancing line, if you like? There is a balance there and there are a lot of lessons to be learned from the Netherlands and also from Japan, where they set particular standards for eligibility, for qualifying, and the demand was a lot higher than anticipated, so they had to increase the criteria to be able to access care. That was very much the case in the Netherlands and even increasing it, they had long waiting lists and there were gaps in terms of care provision and in Japan what they did, what they have done is where demand was higher than what they expected, they upped the level of criteria and there is a balancing act there, but the difficulty is that if you cover only a very basic level of care that is funded through a system and you have people who are then paying for additional top-up services, that has been associated with rising inequalities and wellbeing in terms of access to care, but also increasing health inequalities more broadly too, so there is a balancing act. My recommendation would be that the eligibility would need to be fairly broad rather than too strict so that a lot of people can qualify and that a lot of services can be provided to reduce that reliance on informal care and ensure that there are as few inequalities in terms of access and care as there can be. A good answer, but I think that it will be quite a difficult balance to achieve when it comes to practicalities of it. Can I ask just one more question, convener? Of course. In findings 3, you talk about for the UK countries increasing integration that has a relatively limited effect on reducing existing health inequalities today and that is pretty clear. Do you think that that is a case of different systems across the UK, to some extent, the different funding or lack of funding going into it or is it just a case of, for example, in Scotland that it has not been running long enough? I think that it is a combination of both, particularly in Scotland. It has not been long enough. I think that to really see the impact that this will have, you are talking about 15 years, a couple of decades to be able to see that generational impact that it is going to have in terms of its effectiveness, but also the lack of, if you compare satisfaction, some of the outcomes in Scotland and England, the lack of funding for social care is a problem too. I think that another reason is that there have been teething problems so far with health emerging as a more dominant partner that has been issued so far. That needs to be addressed before the system can really reduce a lot of the inequalities because there are quite underlying health inequalities in Scotland, which an integrated system has the potential to reduce if we get it right. Thank you very much. If you have time, can I ask one more question? It is just a small question. It is about informal care expectations. How did you get to figure out how you see ohai mix, etc? In the UK countries, you say that it is low, which means that, I am taking it, it means that there is not an expectation that your family will be looking after you, right? We all know of cases where families are looking after people. We all know of cases and I am sure that many people here, many people will be providing care for older people, but the system is set up in a way that anyone who needs care should be able to access it. It is based primarily on need, not who you know, who you have supporting you to do so. Whereas if you go to the system in Japan or in the Netherlands, it will ask who provides care, who do you know, who are your family, that will be included in your care needs assessment in that way. The expectation is that, although informal care is provided, people who have the need for care to access these services are able to do so. I am going to come to Tess White, so I will recognise Tess online that I have seen that you want to come in. I will go to Tess first. I would like to ask you about something that you said towards the end of your concluding remarks about Canada. You said that there is a strong argument against a one-size-fits-all model based in Canada due to the geographical variation. I feel that Scotland has a significant geographical variation, so how does that statement fit with recommendation one and recommendation three? One is about care services being provided on a consistent basis and three being a clear one-system on-budget approach to the comment that you made about Canada. Canada has spread over such a large geographic landmass, and there are various differences in terms of transport accessibility between the provinces, the territories and the north, big mix between remote, very remote rural areas, large distance to high density urban areas. There is a high indigenous population with a lot of health inequalities there, too. On that basis, there is an argument against a one-size-fits-all model and the evidence in Canada where they have had various projects in all the different provinces to try to integrate health and social care more have said that by amalgamating at the local level within the provinces has worked, having centralised centralisation in the provinces has worked, but not across the different provinces because the needs are very diverse. Yet in Scotland, because that's the in Canada we're talking about the geographic diversity, but if we have high geographic diversity over a smaller space like in Scotland we have the highlands and islands remote areas and also high density urban areas, we do have a particular mix as well which would need to consider you know, would a one-size model work here or not. Now in New Zealand it's about having a clear one system, one budget, that's very much about funding and delivery being controlled more centrally tied together, but at the same time you also need to tailor approaches to a particular place, not something that Wales was looking at as well, to ensure that care needs particularly in a lot of the remote areas, people have equal access to care where there can be difficulties in finding the workforce to be able to do it, but rather than having different budgets or different ways different ways of governing like in Switzerland where you have three levels of governance in different provinces that can raise problems, it's tying together the governance mechanisms centralising it but still allowing enough flexibility to be able to provide for geographic differences, population diversity within that region. Can you hear me? I think it's an excellent piece of work, Dr Conan, what you've done, a very complex piece of work. Can I just ask one question in terms of funding models? I think it was Japan, so talk about differentiating healthcare from social care. In the Japanese model or other models are there salary deductions from a certain age for health and social care separately? Is it just Japan or are there other countries such as Singapore or that you know of? Thank you. In Japan it's the deductions for the social insurance scheme, it is separate to the health insurance scheme, so the funding is the same as in the Netherlands which also has the social insurance scheme separate and in Germany as well, so these are funded through contributions at a certain age. In Japan there's a level of, one level of contribution is made when a person reaches a certain age but there's also a lower level of contribution starting at an early age and at one point it was proposed that this should be lowered again but there was resistance to that, to that too, but yeah the contribution systems are separate to the compulsory but they are separate to the health social insurance scheme. And thank you so it's Japan that's mainly the model there and you say Germany and the Netherlands? I would say Japan and the Netherlands are the two big models there about Germany too to an extent but if you're looking for the clarity over how it's funded and what the barriers are to the funding I would suggest looking at the Netherlands and Japan. Thank you and sorry just a quick one. In terms of percentage differential would you actually say that let's say healthcare is the social care is 50% deductions of healthcare or is it difficult to say is it on par deductions from salary equivalent? It's difficult to say but it has previously been very unequal to begin with it was very unequal although salary deductions now are in Japan I think they're slightly lower than for health but they are standardized in Japan. Okay we have two members with with late beds for questions but I'm only going to be able to take two other questions because we are running out of time. If I can go to Carol first then then Stephanie and we'll need to wrap up. Hi thanks so much for your time and I'm interested in two things and I know they're big things but just quickly I'm interested in the reporting of the quality of care that you get as an individual and you feel as a family and I'm also interested in the the staff that provide that care and the kind of quality and linking those two together I'm interested to know you know about local accountability and healthcare we talk a lot about the closer the decisions are made to that person the better the outcomes and I just wondered if there was any sense of that in any of the models. Closer you mean the closer to the sort of accountability and the sort of setting up of services and the managing of services. Are there any of these models reported on that? Yes yes they did particularly again in Northern Ireland in particular that particularly around Northern Ireland with the idea of personalisation and care that a lot of people didn't really know what it meant and that people were older people themselves who were relying on care were more anything something that was new there were more reluctant to engage with particularly you know terminology as well in the Nordic countries and in the Netherlands as well were the standards increasing standards of care having these the frameworks for accountability same in Canada where there were frameworks for accountability for carers were associated with more positive outcomes but a particular challenge something that was reported heavily on in the Australian literature was high level of staff turnover particularly due to low wages which has an impact on the quality of life for the person receiving care. Thanks very much Stephanie. Thank you. You're very much focused on wellbeing and it seemed to be something like the data across all the countries seemed to be something that everybody kind of struggled with was measuring the success and I'm wondering if there's any where in particular that kind of stands out is is doing some good work around that that we should maybe be taking a look at and incorporating into what we're doing. Around wellbeing in particular yes okay the New Zealand model because it is focused on wellbeing it's departed from we have healthcare on one hand social care on the other hand we have wellbeing the New Zealand model and the Alaskan models which are models for improving care for Indigenous people but they're founded on Indigenous worldviews and their ideas about health and wellbeing so they're more focused on wellbeing without the separation between health physical health they don't have the same separation between we think of in terms of physical health or mental health they have this idea of of wellbeing to see Alaskan Indigenous models and the New Zealand models are the ones that are focused on wellbeing. In Japan it's very much the opposite where we have a very medical model of health that is dominating the social care eligibility criteria. Thank you. I want to thank Dr Conan for the power of work that he's put into this report and for spending so much time with us this morning and answering our questions and it's been a very useful start to our scrutiny so we're going to take a 10 minute break till our panel to change over. Thank you Dr Conan. Welcome back. The second item on our agenda is our first evidence session on the national care service Scotland bill and I'll run through who we have on our panel starting with those in the room. I welcome to the committee Sir Harry Burns, the professor of practice and special advisor at the University of Strathclyde and Nick Kemp, the convener of the care reform group of the common wheel. On line we have Professor John Glassby, Professor of health and social care at the University of Birmingham, Professor Catherine Hennessy, Professor of ageing at the University of Stirling and Professor Catherine Needham, Professor of public policy and public management at the University of Birmingham and the ESCR Centre for Care. Welcome to you all this morning. I'm going to go round everyone to get their initial thoughts on the bill before us. I've just maybe mentioned to colleagues though we will not have time for every single person to answer every single question so if my colleagues can maybe direct their questions to individuals as in like don't follow my lead or else we will quickly run out of time and not get through all of our themes. I'd like to go round the committee and ask the key high-level question of the national care service bill that is before us. Do you think that the framework bill adequately meets the objectives of having better health outcomes for those, or that there's the potential for better health outcomes for those receiving care and I guess with an add-on of families that need assistance with care of a family member? I'll take our online contributors first and I'll go to Professor Hennessy first. Yes, thank you very much. In conception I would say yes and very much underlining what Dr Lin said in respect to her review of the evidence about systems that provide a kind of overarching integrative structure and lines of accountability and mechanisms for financial integration, quality assurance performance review and service delivery. What I think would strengthen the bill actually and I'm not about changing the language of it as it is but somewhere in there I think what could be made stronger is an explicit statement of a life-force approach to health because essentially, as America read through the whole policy document that accompanied the bill, it went step-by-step through the various parts of the system that were going to be tied together and joined up but I think a stronger sense of the fact that risks to health are accrued and protections for health are conferred right along the life course so from in utero really through to late old age all these all these risks and protections are joined up and and that would really I think provide a kind of underpinning for the rationale for what the bill is proposing but I think in essence to answer your question in essence what Dr Conan was emphasising about a kind of overarching integrative structure accompanied by the ability to be flexible at a local level and to tailor services and provision at a local level are definitely within the bill. Thank you. Can I go to Professor Needham next please? Thank you. I guess my question on my kind of understanding of the bill is that improving health outcomes isn't necessarily the measure of success where we know that this has worked that kinds of things that the bill is trying to achieve is realisation of human rights, supporting people to thrive, ensuring communities that prosper and so health outcomes of course will be a part of that but it's located within that much bigger wellbeing piece and I think that kind of the key question to be asking around that then is what's the theory of change here? Why would centralising accountability and creating new care boards achieve those goals around thriving and wellbeing? The research of four nations comparative research that we've done looking at the four nations over the last 20 years in the UK found that we've had a series of disappointing pieces of legislation that haven't achieved their goals despite being really strong, well-supported, well-grounded pieces of legislation so that would include the self-directed support act in Scotland, the social services and wellbeing act in Wales, the care act in England so I think it's about how do we learn from what's not worked so well in the past around kind of the implementation of good legislation and I guess I would say around that there's maybe a few things to think about would be to pay more attention to the policy mix or the interaction between different parts of the policy so for example self-directed support may not sit very well with integration that's been some of the learning from Scotland we need to think about whether centralisation what kind of message centralisation sends there's a risk I think it sends a kind of low trust message to the rest of the system the kind of spirit of well I might as well do it myself kind of of message of I can't trust other parts of the system to get this right and I think that's problematic so I think it's about how we see this not about getting more care packages in place it's about the culture change that's needed and what some of the kind of who we need in the system and what kind of structures will really build that culture change yeah and that should maybe clarify I do I do mean health and wellbeing I did I did miss out wellbeing but I did in my head that's what I mean I'm not just talking about health outcomes I'm talking about the general wellbeing outcomes as well can I go to Professor John Glassby thank you yes looking in from from a different health and social care system our experience over time and our experience of the evidence is that when there's a major national change or a major structural change the risk is that that structural change can become an end in itself in the short term rather than just a means to an end so it can distract attention from improving services on the front line it can increase a sense of a lack of role clarity and can harm morale locally and if you manage it well in our experience it can take 18 months to two years after the change in order to get back to roughly where you were before so there's something about planning for the long term recognising that some things may get worse rather than better in the short term as changes work through being clear as Catherine said about the outcomes that we're trying to achieve and being clear that this way of designing this way of reforming is the best way of trying to deliver those kinds of outcomes and that the things getting worse before they get back to where they were before and then hopefully getting better in the future period is worth it for the the outcomes that you're striving to achieve I think the second thing we often see around health and social care integration is that it's very easy for a more medical and acute led model to dominate social care and wellbeing priorities how you would run specialist health services is potentially very different from the kind of care and support that people might need in their own home and in the community to lead chosen lifestyles and trying to do both at the same time with equal focus on health and on social care has proved difficult not impossible but the medical and the acute often dominates particularly in a crisis and then thirdly there's quite a famous article on the five laws of integration one of which is that your integration is my fragmentation whenever we change our boundaries we inevitably create new boundaries elsewhere so there's always something that you gain and something that you potentially have to work harder at to maintain and as I understand it here just as an example there are still some answered unanswered questions being worked through about the relationships with children's and adult safeguarding around the relationship with children's services more generally around the relationship with justice as an example so a set of organisational changes that make that on paper should make some relationships easier could also make other relationships harder so there's some pros and cons to weigh up in the design thank you and welcome to our colleagues in the room if we go to Sir Harry Barnes first of all yeah I would like to emphasise some of the points that were made there and earlier on we talked about wellbeing and so on and that really is what I have since I gave up being a surgeon I which was a great many years ago I have focused on how we create wellbeing in our society we're operating on people in the east end of Glasgow made me very much aware of the fact that what they did not need was more surgery what they needed was more wellbeing and what worries me about this bill as it worries me about any bill that comes forward for the effects of the health service and so on is that it will be very top down that it will have targets and indicators and all that kind of thing to go along with it there's no question that the way in which you get effective change happening is to ask frontline staff what's needed give them capacity to make things happen themselves and this question of of wellbeing in people I've looked at lots and lots of projects international projects all over the world not necessarily on social care but in terms of improving wellbeing and the critical thing is not telling people what they need to do but asking them asking them what matters to them you know and then helping them achieve that and in doing that they feel empowered and they begin to make changes in other aspects of their lives so a critical part of this I think is that engagement with the individual who is in social care and I feel very strongly about the social care of young people children taken into care have been taken into care because they have had very bad experiences and those bad experiences we know will have profound effects on them throughout their lives and they will end up many of them in in jail in hospital and so on recently in association with a colleague in Wales who recently published a paper in which he calculated the cost of adverse childhood experiences in 28 different countries he didn't include Scotland in that but using his method adverse childhood experiences in Scotland cost the Scottish economy £5.4 billion a year because those children experiencing chaotic upbringing end up in care they end up in jail often they don't do well at school we often don't attend school they don't get jobs they never pay taxes and so on so if you add all of that together it's a huge burden on the Scottish economy so we need to be thinking about care not as a system that we impose on the population but and I accept that we're going to have to have some kind of regulatory framework and so on for it but we have to empower frontline staff to support the people that they are caring for and asking them what they need what matters to them how can I help you make a change to your lives um so that theory of change Scotland has already done this through the earliest collaborative to patient safety programme and all that kind of thing what do you want to change by how much by when and by what method collected data and this this is another point that is very important to me the data has to be collected the general data protection regulations get in the way of all sorts of important data being collected um you know I embarked on a project in which I asked community nurses which families they were caring for that they were worried about we then asked the local A&E department you know do you recognise any of these names yes we asked the local police community policeman you know yeah I recognise all of them and then you went to the NHS and he said well how often are you treating these people and he said oh we can't tell you that so it gets in the way of identifying people who need care who need support and you know we should build into this some kind of system of data collection that shows just how well people are responding to the care that they're getting so I should stop there and but it's I think it's really important it's central to creating enhanced wellbeing across Scotland but it's got to be done in a way that allows frontline staff to shape what what is delivered and not be imposed from the top down thank you and can I come to Nick Kemp thank you you've asked a very general question and my initial response and our response we set out a vision for a a national care service and caring for all which I hope's been sent round all MSPs but that partly came out of the Covid crisis and if you ask me whether this bill will solve all the deficiencies in the care system that were created by the I know right appreciate that but I wouldn't say it's a silver bill I'm saying does it provide the framework for potentially but would it provide the framework for dealing with a similar crisis I would say no and where I think we need to start and the big lack and to pick up what Harry said is about care there is no definition of care wasn't a definition of care in the feely review now care is integral to our lives right and it's it's a reciprocal relationship based thing which underpins the whole of society it runs from the very smallest of things like the way we acknowledge you'll say hello each day all the way to how children are brought up care is fundamental for us to developing into adults and so on so it is very very important is what holds society together the other thing that happens with care is it goes wrong right and it goes wrong and this is everything from the tiny things we all have our off days through to systems where parents under various pressures it's influenced by social things right can't cope with their children so children get harmed and they suffer and it goes through to a position where people actually just stop caring for each other at all and everyone starts going out for themselves so care is absolutely fundamental to what we do and I think that has big implications for the national care service and the national care service bill because it's in because it's integral to everyday life it's got implications about it isn't actually something that you can necessarily decide from the top and I would support what Sir Harry says about it needs to be focused it needs to be bottom up rather than top down so that's one thing about the bill where we would say where a very good thing about the bill which are absolutely behind we haven't mentioned is there is central government funding this was if you like it's the failing in the 1940s five Labour government and so on and setting up a welfare state was care was always left on one side was left discretionary compared to health service health service need was to come before a source and we need absolutely the same for care and actually the bill does give the potential for that and but what it lacks at the moment is there is no mechanism to create data on unmet need so in order to decide what finance is needed for a care service we need step what needs to be added to the bill is some mechanism to measure unmet need thank you i'm going to pass over to my colleague tess white tess thank you convener my question is pleased to um in terms of is to professor kemp so in relation to care um this is about quality versus so during the consultation um Aberdeen city council said that whilst the bill may improve consistency of services it wouldn't necessarily necessarily improve quality of care do you have any thoughts on that yes sorry i'm not a professor i think i'm the only person here who's not a professor um in terms of quality of care i think that the absolute vital thing is that quality of care depends on the relationships it depends on relationships between the staff both social workers who are organising care and care staff they need to have time to have a relationships with the people they're caring for the problem with the current and that comes as to resource because the problem with the current system and we've got a lot of time and task based commissioning where home helps and so on have to be in into houses really rushed stuff in care homes and so on don't have time to care for people and that leads to huge frustrations it doesn't lead to good relationships and that i would say is the single biggest thing that would make a big difference to the quality of care and for that to happen and it comes back you need to devolve decision making to the front line the front line staff need to be able to negotiate those relationships so i've said care goes wrong right relationships can be very difficult if you're working with a very um i'm a social worker if you were working with a very disturbed child or whatever i mean the relationship's very difficult right they're not going to necessarily like you to begin with you've got to hang in there it's very very difficult working with someone with dementia right who keeps repeating the same thing a hundred times to have the patience to deal with that and to try and get through to them and form that relationship is extremely challenging so we need to resource staff to do that and that also means because of the challenging side we need to have a comprehensive training programme for staff what shocks me at the moment you can walk into a care job and be going sent to somebody's house to work with someone with challenging behaviour and you've had no training no preparation no understanding about what their health problems or whatever might be causing them to act in the way they are thank you thank you tess um sandesh you wanted to come in on this yes thank you um so my question is for sir harry um you're speaking about data and one of the things i'm very frustrated by is is the is data or the lack of it and what i feel we should have is we need to find out what we have now to find the data then we need to identify the change you're going to make and what change you'd see in the data and then robustly collect the data and i know that you said you're going to stop there but i'd like to hear a bit more about this so i've spoken to people in all sorts of different sectors you know social housing sector where they have data on windows that get broken and that doors that get kicked in and so on and when i speak to the education folk and ask them well to children from these homes attend school or whatever we can't tell you that you know this kind of thing um the health service do young people from that home how many of them attend A&E with drugs overdoses or alcohol or whatever all of this data which we hold in different silos brought together could form a picture of families that are desperately in need of support and particularly the children in those families who are the the problem of the future we could do it but it's very very difficult to you know when i spoke to a group of educational psychologists and said have you got data on what kids get excluded from school they said uh well we collect the data well where is it we don't know we're not allowed to put it on the computer so where is it it's probably in a cardboard box below someone's desk you know i think you know this is dreadful we could bring this data together um we could identify individuals who need support and particularly their children and we could make a huge difference to outcomes and i speaking to this colleague in Wales who'd done the financial calculations um why don't we go back five years look at the data as it was in five years ago then look at those families now and see if things have changed go and ask them what changed what made you better and then scale that up i a couple of years ago i was president of the british medical association and i say something to add that that's not a political position i wasn't allowed to be involved in bma politics but what they did was they allowed me to ask questions to a doctor so asked primary care doctors across the UK what project have you seen that has transformed the well-being of families that you're dealing with and have collected 30 40 different projects so if we were to start testing some of these and following that data we would transform it and we would reduce demand on the care system my worry is that if we don't do this we're going to create a care system just like we did with the nhs that you know purchaser provider and so on and targets and indicators and so on at the moment the nhs has run off its feet trying to catch up with the problems associated with covid and waiting times and all that kind of stuff because the targets are there they're petrified at failing on the targets if we were able to change the way that frontline staff were able to deal with patients we would get better outcomes so it's there's it's partly about empowering frontline staff but having the data that lets them see that what they are doing is making a positive difference in their communities and scaling that up and we transform our society thank you can i bring in James Dornan i agree with everything you've said data's the important issue here we need to collate it so that we know what it is we're facing and how we can improve it but one of the things we must be fighting against is we saw in the named person legislation that people are very unwilling for others to get the necessary data that's required how do we overcome that if we and you know i'm not saying we need the data just for the sake of having the data we need the data to help people to identify the individuals in need of support and if we can do it in a that very supportive fashion implement the change people will see that their society is improving they will see that there's less you know less social problems in their communities and younger people are doing better at school they'll leave school with qualifications they'll get jobs and so on and all of that kind of thing will make society better we're not looking at data in order to blameful we're looking at data in order to to support them and give them better lives the critical thing i mean i'll vividly remember one man whose story made me decide to leave surgery and go into public health and he was a man who had he was in for the third or fourth time was acute pancreatitis which was caused by alcohol and i said to him if you keep on drinking you're going to die and the response was i know i'm not stupid but life is really rubbish and the only pleasure i've got is the booze so i'm going to keep on drinking and i realised you know we can't it's morally unacceptable to me to sit and let that man suffer like that so that should that should be the case for all of us and you identify individuals like that and support them i appreciate that you don't mind me coming back in and i agree completely but that was what the previous legislation was meant to be about and the opposition towards that was so great that we couldn't move forward because you're right without that you can't help that man without that information you can't help people like that man the thing is five billion pounds a year no matter where you are on the spectrum the political spectrum five billion pounds a year that could be saved what's not to like and we have Professor Hennessy wants to come in and this before we move on to talking about definitions of care if i can bring in Professor Hennessy yes and this relates to Sir Harry's point about data and i just wanted to give an example of the importance i think of collecting the right data and in relation to the kind of outcomes that we that we wish to see um back in the 1970s and 80s in the united states there was huge government investment in alternative models of long-term care provision for older people there were 30 federally and state funded long-term care demonstration experiments and i did a review of of the kind of core 13 of these looking at for example what what their aims were what the outcomes were and in particular what kind of data they collected on on outcomes all these experiments and some of which were national so covered a huge number of states and as i said represented a huge investment in federal spending had as their primary aim to keep real older people out of residential care out of nursing homes and and to keep them in the community with support services typically under case management um teams what what the what the evidence across all these projects showed was in fact um these projects that these models of care provision cost as much or slightly more than institutional nursing home care but what where the real benefits were shown were in terms of increases in wellbeing and health related quality of life or for the participants and also in family caregiver satisfaction but when i looked at what the across these um a couple of dozen projects what actually was measured where the projects showed their greatest impact so wellbeing and also in family care satisfaction not only some of the projects even measured those things so going back to um going back to dr conan's point i think number nine about initially not being so fixated on financial savings i think that's a real point to make uh because the real benefits of these uh projects projects were realized in in other domains as well um so yeah that's essentially what i wanted to say so yeah collecting the understanding what outcomes we're going for and also what data is relevant to that and making sure that data collection is not governed by the kind of law of the the easily measurable okay thank you um move on to talking about definitions of care questions led by david torrance if our other colleagues want to come in just let me know thank you convener and good morning everyone um in our number of submissions the raised issues on how care should be defined for example where does healthcare end and social care begin um so how how would the panel members define social care and support and i'll go to sachari bynns first ask people what they need and help them achieve that whether that be in health or social care or wherever um you know give you an example of a very significant project that i saw that took place in the south of england where a community community in falmouth um where that all the men lost their jobs when the naval dockyard closed and that place turned into a war zone literally fire bombing and gang fighting and so on two health visitors turned it around after a really nasty incident they put letters through 50 doors inviting local residents to come to a meeting five people turned up and they said what would make a difference uh the place looks at it let's tidy up the gardens and paint the houses and they did that five years later the whole place was completely transformed the people employment went up something like 70% and all that kind of thing um health improved dramatically so i don't think you can define health or social care or whatever it's so interrelated it's what people what you can do to people that gives them a sense of self-esteem and a sense of self-worth and self-control that's that's the thing that's important david i'm just wondering if any other panel members would like to come in if any other panel members want to come in who are online you just have to put an hour in a chat box and there we go so i think that's professor it's that professor needom i maybe should let let people know that i'm seeing professor kathryn and we have two professor kathrons so if i do mix the two of you up i do apologise it's just not coming up but i think it's professor needom thank you yeah i think it's really important to remember the point in the feely report about social care being the means to an end and not an end in itself um there's a definition that the social movement social care future use which i really like which is that we all want to live in a place we call home with people we love in communities where we look out for one another doing the things that matter to us and i think that's absolutely what what it's about i really agree with sarahary about the only way to know that is to ask people and let people know produce and design the supports that they want but only some of that will be about health a lot of that will be about people's housing their education their employment their broader relationships so i think it's that much more expansive definition for me and can i bring in professor glassby yes i was going to say exactly the same as kathryn with the social care future definition for me the aim of a social care system is to ensure that frail and disabled people have the same choice and control over their lives as non-disabled people i run the UK wide evidence centre called impact and our mission or our belief is that good care isn't just about services it's about having a life and that plays out in terms of the ethos of care and supports but it also links to the previous question about about data and about setting outcomes and monitoring outcomes and number of years ago i've been involved in evaluating a mental health collaborative programme in england where mental health services would come together and set a series of improvement targets and then challenge and support each other to try and deliver those targets and i was rung up shortly afterwards by by another nation it wasn't um it wasn't scotland to say that they were thinking of doing something similar and did we have any advice and the improvement target that they were thinking of setting was increasing the percentage of people who had assigned copy of their care plan from 20% to 35% and something like that and did we think that that was a good target to set and i remember trying to say well there's a couple of things first of all everybody should have had a signed copy of their care plan since we introduced these reforms in the 1990s so i mean leaving that aside if i had a choice between having a signed copy of my care plan and not having a signed copy i'd properly want a signed copy and i get that having a signed copy of your care plan is indicative of a broader cultural change and set of relationships within services but i remember saying most of the people with mental health problems that i've spent time with say that they want three things they want to live somewhere of their choosing they want a job that they enjoy and they want more friends than they've currently got why don't you run this nationwide collaborative programme and set us the three aspirations people living somewhere that they like people who like their jobs and the number of friends that people say they have and those dead silence at the other end of the phone for what felt like an age before the person said do you know what i'm not sure nation x is quite ready for that yet and so i think there's something really important about the definition that we adopt but then the outcomes that we try to support people to to achieve and those have to be self-directed if people are going to have the same kind of choice and control over their lives as non-disabled people and the difficulty with some of the service structures that we create around that is that some of our other public services aren't really set up to try and deliver those kind of aspirations for people's lives so it becomes quite difficult to join services up culturally because of a lack of fit in terms of desired outcomes and i don't know if it nick hemp wants to come in i've said a little bit about what the definition of care but just following from that and there's a huge overlap with health but there are different knowledge and practices required for health as compared to care to care i mean health is more science-based and it varies but it is more science-based whereas care is actually an understanding about that and making care workers about relationships and so on so there's completely different practices there and staff and in the middle of it there are people like gbs who actually end up doing a lot probably what social workers should be doing if they are allowed they do that sort of relationship work based with people so i'm not trying to say there are two totally different systems but i think me to recognise that people are bringing and the professionals involved in it and the care staff are expected to do different tasks and therefore require different training and so on so it's important to see a distinction between care and health whatever the overlap David i don't disagree with what it just said but the health bit of it yes there's a science to health and well-being and all that kind of stuff but you know simply telling someone who smokes that it's bad for them is absolutely no good if they don't feel in control of their likes if they don't feel that they want to be healthy i mean this this suggestion that we put calorie counts on menus and restaurants and so on really does anyone believe that's going to make any change happen it if you feel a sense of self-esteem and a sense of control then you will want to go out running in the morning and do all of these things anyway so health you know what as a as a medical student and as a doctor for a practicing clinician for 15 years i never once heard the term salutogenesis it was always pathogenesis the causes of disease salutogenesis salus was the roman goddess of well-being and safety and it was the Scandinavians that taught me about salutogenesis and that's what we're talking about creating well-being and you create well-being and you also reduce risk of ill health so it's quite important to know that there's a crossover here i have actually just from the previous presentation one of the recommendations i'm going to ask how important it is is a standard definition of what personalisation of care means should be developed and can i go to professor at a young last way please so i think the risk is that that we develop some of these concepts and they become quite complicated and for me personalisation self directed support is fundamentally simple they're about having choice and control over your care and support so that you have more choice and control over your life and they're about trying to get decisions that really matter to people made as close as possible to the person that those decisions affect ideally it will be a decision by the person themselves or if it can't be for some reason it will be a person that really knows them and really cares about them in that sense it's little more than sensible delegation as the the architect of the personalisation agenda in england Simon Duffy once once described it so we have quite a lot of complicated concepts but actually for me this is about independent living about choice and about control and the risk we've seen in some parts of england i think it's fair to say where i live is that we've sometimes paid lip service to those those concepts but really allowed the old system to carry on the way it always carried on rather than more more genuinely rebalancing power imbalances if you like and genuinely promoting choice and control and again as with integration the the means has sometimes come an end and become an end in itself so if i had 400 direct payments in my council and you had 300 direct payments i'd automatically be doing much better than you irrespectively of whether either of us were actually doing anything to to increase choice and control for disabled people in our local area and alongside direct payments there's a hundred and one of the things that we could and should be doing to increase choice and control so i worry that we make it more complicated than it needs to be and really these are just words for people having choice and control over their lives and and their subsequent ability to lead chosen lifestyles. David are you happy for me to move on? Yes. We want to talk about what i mean a very key theme that came up when we were hearing from Dr Conan about the future demand for social care and demographics and led by Gillian Mackay. Thanks convener and good morning to the panel. What factors need to be considered in addressing demographic changes? Not only an ageing population but a large population of people living into very old age, the potential as we heard from Dr Conan earlier for people to be unpaid carers for multiple generations or for people to be carers into old age as well as a declining birth rate and could i go to Professor Hennessy please? Yes, all the trends that you've just mentioned will are projected to be exacerbated in the next couple of decades in particular so i mean these are definitely things that should be right in front you know right in the forefront of our thinking about the implications of this bill and the and the impact of of this restructuring and again i go back to my my comments about a you know the kind of the kind of framework of of health across the life course that's implicit in the bill but that you know what what comes out of you know at the far end of the life course in in later life in older age is is a product of everything that's happened before and the kinds of supports or lack of support for individuals at all stages of life that we provide so what i see in this bill is an acknowledgement that integrating systems of of care for individuals across the various stages of life and the different kinds of needs that they have not just for healthcare is is very much part of that thinking and will affect the kinds of kinds of outcomes that you're talking about in terms of how we're able to deal with these trends and not just the financial impact of and not just the financial impact of some of these demographic changes and trends julian thanks convener what actions should the government take in addressing the urgent challenges presented by the workforce demographics with the workforce comprising predominantly older women who have caring responsibilities of their own and also in the interests of time convener if i can i'll combine questions and also ask anybody contributing to cover what they believe needs to be done to ensure caring as a career is given parity to nhs colleagues as well and could i go to professor glassby first please yeah so there are some major structural issues that that that affect this i did a session recently for the archbishops commission on reimagining care and i did a normal exercise just for a one life with the commission where i looked online to see what jobs are available in the area of Birmingham where i live and you could be a home carer for minimum wage or you could be a dog walker for 15 pounds an hour so there are some social choices that that we make about the things that we value and until those change it's difficult to see how care could become a different kind of career opportunity for for people in practice there's lots of things that we can be doing in the meantime things like direct payments and people hiring their own personal assistance potentially open up different routes into thinking about the nature and the makeup of the social care workforce things like values based recruitment allow us to recruit people with the right attitudes and values rather than necessarily prior experience and that might broaden the pool of people that we can recruit from at the centre that i lead impact we'll hopefully be doing some work next year on how we can recruit from men to think about the nature of care work and masculinity about 80 percent of the workforce is female and 20 percent of the workforce is male at the moment that's a rule of thumb so because of our social attitudes around the nature of caring we're automatically confining who we can recruit from to to half the population straight up so there's something really fundamental about the nature of care and about masculinity but the advantages of a national system maybe that we can do something in terms of pay and conditions that where there is greater parity with the nhs i've never understood why we have separate systems of pay and rates of pay within health and social care given that people often move across those different boundaries in terms of their their career and actually if you're a home carer working on your own in the community in lots of different people's homes that the complexity of the work that you're doing you know unsupervised and autonomously is often much higher actually than the work that you might do as a healthcare assistant in a hospital where you have lots of support and lots of supervision and lots of systems and processes and colleagues around you so so if it was me i would take the opportunity of a national debate about these issues to have a unified framework in which parity is built into the design and i think Harry Burns you wanted to come in i saw you nodding along to Gillian's question I agree very much with that that comment that series of comments having seen a close relative be receive home care and so on the level of responsibility that they had the carers had was very significant and they were on their own they didn't have other folk to help them out or whatever if there was any difficult issue arise and i come back to this point about asking front line staff you know give them responsibility and support that with appropriate rates of pay the home carers certainly seem to me to be well worth NHS rates of pay for sure and Nick hemp just come on the demographics it isn't an age is the main related the main determinant of care right i suppose for the bulk of you know the biggest group of people needing carers older people but age isn't the only determinant there are other factors there are social factors in there but as you pointed out there's also what's happening to carers right and actually what wasn't really picked up i think in the international evidence is there's 860 000 people providing informal care in scotland there's 25 hours of informal care provided for every one hour of paid care so there's a huge amount of informal care being provided what happens to those informal carers affects the whole need for care in the care system right so and at the moment the particular the economic and social crisis at the moment things like i mean there are over 60s like myself we you know we're involved in doing care you have to work till you're 70 and you've suddenly got rid of a whole lot of those people who are doing informal care so there's a huge amount it's much more complicated than just democrat demographics the second on the workforce i totally agree about pay the national care service should be an opportunity to introduce national paying conditions i think the government said that it wants to do that it's just not in the bill right but there are two other crucial points on it one is training the training is a may in the bill it's not a must we can't have a workforce that's not trained properly it has to be must but the last thing that no one's picked up in the moment is it is a demanding job as i've said because you're often you're working in very difficult circumstances harrys picked up so workers need time for support right that means peer support we have lots of home helps at the moment who work out of the back of the car being ordered to go to places right by someone on a remote app they never get a chance to talk to colleagues let alone their supervisor there's no supervision there's no support people need to be able to go and talk to somebody and get support and deal with the stresses and because there's so little support at the moment a lot of the people who are being recruited to the workforce right they're in wonder who would spend lots of effort on recruitment and they're straight out again because when they come up on the reality they just feel i mean why would you do it if you're just left to get on with it can i bring in professor needle thank you um yeah i mean i think the the demographic projections are such that we're not going to solve this problem just by training and well paying people to deliver care packages it's got to come with a really sophisticated approach to prevention and to thinking about how we keep people in communities without overloading very currently overloaded informal carers but if people are struggling with loneliness and isolation then you know we need to find ways to help those people get back to to the church to the community centre where there's lots of people who can provide bits of informal support for them and give them what they need in a way which isn't potentially much more enriching for them than somebody coming in and popping a microwave meal um in in the in the microwave and they're leaving somebody to eat it by themselves so i think we need to link this to um you know thinking much more about how we uh we address prevention thank you thank you julian um and move on to uh colleagues who want to ask questions around the projecting of future costs of social care led by evelyn tweed evelyn thanks convener good morning panel um the scottish government has committed to increasing investment in social care by 25 to the end of the life of this parliament um do you think that we can really consider and project these costs effectively for the future and to sir harry first please i'm the wrong person to ask about that because yeah i would want you to because i think it's the right thing to do um um but there will be all sorts of other demands that need to be balanced i keep coming back to this five billion pounds that sitting out there that we could be doing something with and saving that would go a long way towards paying for that um so yes i mean in terms of justice looking after people who need care is an important element and i would want the scottish parliament to be leading the way and doing that kind of thing but it's someone else has to do the sums convener could i maybe go to mr kent please yes um projecting costs i think is very very difficult because of all the factors i've said that in effect and you know we're in the moment we've got inflation you know which we didn't expect i mean so projecting costs is is practically impossible but we need to try and do it um that's why i think actually what the bill needs to do is to build in a mechanism by which actually you can track what's going on in terms of care needs what's met what's happening and the resources that are available for it and i'm very much as i said welcome central government funding what the needs to be is a way to have a dialogue with the people delivering the care service and there is bound to be compromises about that that's absolutely inevitable but the other thing i would just say is at the moment we're very much and this is one of the issues with the rights-based approach is that we're very much focused on targeting resources at individuals but if we're going to have the preventative type infrastructure of clubs that professor need mentioned we need to actually also have a collective approach to care and basically we need to find a way of empowering local communities to say what are the sort of services and things that they would have in their area that would make a difference and what i don't see and let's talk about it and there's aspirations in the bill for co-design and co-production but there isn't actually any mechanism at the moment to make that happen instead all the discussions going on at the national level whereas actually what i would like to see is discussions going on at the local level and that feeding up and i want to bring in professor glasby before i come back to you Eveline thank you yes if it's helpful we can send through some long-term projections that we made in england taking the scenarios that we used for health service financing by Derek Wandless when when NHS resources increased so dramatically in the the 2000s and we applied three similar scenarios to future adult social care spending so the methodology may be may be helpful there and i suppose these are projections rather than predictions so they help you to plan and to to think about different scenarios rather than to predict what will actually happen and i think two or three of the unanswered questions that remain in lots of attempts to do this are where we make hypothetical savings in a system can we actually disinvest from that service to free up money to invest elsewhere so often preventative projects will justify their contribution on the number of hospital admissions that they saved now that may well be true but we never get round to closing the bed that that person would have been admitted to we carry on paying for the bed and we fill it with somebody else and then we also pay for the preventative project that that was stopping other people being admitted to that that bed so in one sense we pay for it twice we never quite get round to the stage of disinvesting based on the investment that we've made in in prevention and with care related projects what we tend to see as well is that there is some it's so difficult to access publicly funded social care at the moment and there is so much on mat and under mat need that any attempt to make services better or more outward looking or more inclusive or more approachable or easier to understand tends to bring people more people forward because there's so much on mat need out there now in public policy terms i would have said that was a good thing because that need is there it's just hidden at the moment and we might be meeting it better in the way that several witnesses have spoken about today but if you're the person responsible for that budget and you think that it's going to go down because you've integrated care and then you suddenly find it's gone up because you've brought forward more on mat need that you didn't even even know about beforehand it can be very difficult to manage that individual budget in the short term and then the final thing i'd say if it's helpful is that most of the methodologies tend to focus on service costs when they project forward they don't think about costs for people who draw on care and support for unpaid carers or for communities and different blends of service or different designs of our system have got different implications for what we spend on our public services but also the contributions that people make directly or in kind if they use as carers or local communities as well so if we were looking at it in the round cost of some of our public services might go up but the negative financial consequences for users, carers and communities might go down for example so that the judgment you would make about the effectiveness of that spending might look different if we were looking at things in a holistic way rather than just at public money that we spend on public services which is only one part of the equation. Evelyn? Yeah that would be really useful if that information could be sent through and yeah my final question is in your view where should the Scottish Government focus its investment in social care and if I could maybe put that to Professor Needham? Professor Needham yes. Thank you. I mean we haven't talked much about housing and I think that's a key part of the puzzle here that if we're going to meet the need for care and support of people going forward but also do that in potentially ways that support prevention then people we need to make sure people are living in appropriate housing and that's housing that therefore can support people around issues of loneliness and isolation that we know is so so bad for people's health and wellbeing. So I think it's not necessarily thinking about spending the social care pound always in what looks like social care but thinking about what some of the other forms of support are. Obviously for working-age people with disabilities then affordable housing is also an issue and just thinking about making sure that that provision is appropriate so you know we know that small facilities tend to get better outcomes than larger facilities so I think it's about if we're going to be investing in provision for particularly for older people let's not build massive care homes that look like travel lodges and feel like well maybe at best a travel lodge but are not places of care and love and joy and support let's think about investing in things that feel like community support that feel like places where people can call them home and I think that would be you know thinking about care and housing together would be a really useful way to think about investment. Thank you and we'll now go on to our next theme which we have dipped into throughout it's about the bill on achieving its policy aims and I'll be oh apologies can I just check with Tess White. Tess wanted to ask the question around the financing. I think it should be answered if Professor Glassby can share the figures and the report with us so thank you for that. Thank you very much and apologies again. If I can move on to theme 5 and about the policy aims and how the bill will assist in making some headway in those areas and that's going to be led by Paul O'Kane. Thank you convener and yes I think we've begun to touch on on these areas in terms of what the bill will actually achieve but I wonder if I can reflect perhaps on some of the commentary that there's been since the publication of the bill you know the centre for care has said that there has to be greater clarity about how the reforms are going to achieve their goals and they talk a lot about the theory of change so how are we testing the theory of change and how do we understand whether it will or not have met what we're trying to do here. I think there's been commentary around whether it will fully deliver feeley in terms of the feeley review and we've also seen commentary from trade unions around whether it will do anything to tackle issues around pay terms and conditions. Indeed unison never got as far as to say we should have a pause with the bill so I really came to to get a sense of in that context you know how can the bill achieve the aims that are set out and I wonder if we can start with Nick just to get some clarity on his thoughts. Right well I think the bill has quite a limited purpose I understand which is focused on services on the quality and consistency of services right rather than like what's not done and I think care is wider than that right it's wider than just services as we've explained so I think that that's one limitation but in terms of actually what it's going to do in terms of I have answered question about quality before about workers having time but I think it's worth reflecting a bit about consistency there's a lot of talk about a postcode lottery and we know like in terms of the benefit system that everybody thinks their neighbours getting lots of money but actually there's very strict rules about the benefit system and actually most of the time that's not the case most people haven't got very much and we also know that in terms of consistency in terms of centralised control managing it that there's lots of inconsistency in the NHS there are stories every few weeks about one health board doing one thing and not another but I think the real problem is that until we've gotten it comes back to the data unless there is a mechanism where we can actually collect information on unmet need and so on and who's doing what in terms of what what informal carers are doing we can't actually tell we're not going to be able to tell whether the care service is going to be able to it's going to improve consistency or not so I would see resource allocation as being absolutely key to that and I think a couple of other other points about that if you get the resource allocation right it then allows for local diversity because people can actually and there needs to be some forms of accountability can design different types of services for different areas because what you need we shouldn't be measuring consistency in terms of what a service looks like there isn't a one-size-fit so it's quite obvious that services need to look very different in rural areas to urban areas I wonder if Sir Harry might comment particularly in terms of that test of change I mean obviously you've had experience of testing change and seeing what works so I mean if you if you do what is traditionally being done which is come up with a bill with targets and indicators and structures and all that kind of stuff then everyone will put their effort into the targets you know ticking the boxes what we're talking about here is enhancing wellbeing of people who are struggling and you're absolutely right the data is crucial to all of this and you know normally I would say that for most of the population things like health service data and a range of other social determinants of wellbeing could be brought together for elderly people for families that would work but for care of the elderly it's a bit harder to work out what data would be necessary because you expect the elderly to need a bit of hospital care perhaps and this is this is an area where I think GPs are going to be quite important you know how much effort GPs are putting into their elderly population and so on and it might be that we have to come up with a different data set for for care of the elderly but I come back to the fact that what we're talking about here is support for our fellow citizens and enhancing their sense of wellbeing and their sense of being loved and cared for that's what this is all about really and I don't think the NHS connects data on how much people feel loved to be honest but you're right we need to be thinking about a way in which we can enhance the ability of frontline staff to support individuals and that question what matters to you let me help you achieve that it's the critical thing in all of this thank you yes yes I always get slightly nervous when I hear a debate about consistency versus postcode lottery in the health service equity and equality is such a key principle but we we tend to interpret that as meaning that you should treat everybody the same and if people don't start off equal people or communities don't start off equal and at best all you do is treat everybody the same that then at best all you do is perpetuate the existing inequalities and if you don't quite design your services in the right way you can end up making some of those inequalities worse so I wonder whether we're talking about equality of outcome rather than equality of input necessarily services being the same elsewhere and if we were clear about the outcomes that we were trying to achieve and we were clear on the joint amount of money that was available to spend to meet those outcomes then we could design approaches and services and supports in our local areas that would work best for our local communities co-producing that with local people and involving frontline staff centrally in those in that design so if I were a director and you gave me a series of outcomes to achieve and an amount of money to achieve those outcomes with and then left me with the autonomy to to work out how best to use that money to to move towards those outcomes that would feel the best balance in terms of the local and the and then national and if it descended into a council area has got a such and such a service you need to have a such and such a service then I think we've we started to over prescribe a top-down sort of apparent solution that might look big and look bold but could actually be a distraction for from meeting the the nature of local needs. Yeah follow up because that leads me neatly on to I think the sense I'm getting from those contributions is that this has to be about cultures and not structures but also I think that we have to avoid that sort of that top-down approach indeed reform Scotland said in one of their submissions that there's not been an advocate explanation of why simply removing local government for example from social care would actually lead to implementation of or innovation and delivery so you know would panellists agree that we do need to look at that in a in a more rounded fashion. I think it's worth just saying too here about children services right where we're talking about improving care services in the moment it's not clear where the children services are in but as soon as you put children services in of course there's all these talks and I think it was John said about fragmentation there's all integration you know there's two sides well you've then got a whole lot of further issues there so I think actually there needs to be thought about how you embed all of this how you embed care in local communities, empower professionals to work with each other and that actually comes before top-down structural change. I don't know if anyone else wants wants to come in but I wanted to ask a question around this and a comparison between the approach of the government in implementing the social security system where it effectively went round the country and spoke to people about experiences of social security and the approach that they're doing now where they've actually got a national care forum, was that the first of them in Perth last month where we've got people from third sector and people who are experiencing social care systems throughout Scotland being involved and how is there a comparison that we can draw on the success of that approach with social security to this and how important that that might be as we implement the bill? I think they're slightly different because the social security system is on very prescribed rules right which is about how much income people need and their experience of it and what they need but actually it is it is a very centrally driven system whereas actually for designing care services I've said it's just the variation between where you live and so on it just makes a huge difference what communities you're in, where you are, other or other or it just totally changes things so trying to design care services nationally to design a system with stakeholders about that could be then applied locally right to set out some rules that could then be applied locally and given to it might be when we've only got local authorities at the moment or HSCPs down to then devolve and apply that and come up with services that's one thing but trying to get it just feels to me at the moment as though it's a one size fits all system and I don't think that's going to work because care is very different, it's very different to social security. Anyone else want to come in on that in terms of the approach about actually going out to people with lived experience? That term people with lived experience is extremely prevalent and important when you're discussing early life you know the person who's in jail who's had lived experience of domestic violence and all that kind of thing and hearing from them just how that affected them absolutely changes your view on what they have come through and where they might go in the future. I think that community is really important in this when I've seen you know I'm thinking about conferences have been at one in Australia which looked at which was a rural health conference in Australia where the communities got very much involved in care across the whole system care for the unemployed care for the elderly all that kind of thing and they came up with really clever innovative solutions to their community and I come back to the point that way you see these clever solutions collect the data and scale it up tell other people about it and let them do it and that comes back to the point that we've been making we've been really making which is don't prescribe top-down solutions create an environment where people can develop their own solutions and then share what works so yeah I think the role of community in all of this is is very important and it's something that in when the bill goes through there should be something said about supporting community development in all of this okay thank you um sandesh you have a question on this theme yes thank you convener and I suppose professor glassby would be the person that I'd like to to ask initially um I think consular has repeatedly said that improvements to social care need to be made now and I heard you say earlier that things will likely get worse initially so these changes will only disrupt these improvements being made do you think that more immediate action could be taken to address existing social care issues and do you think the ncs might jeopardise these changes professor glassby yeah thank you um so I don't know enough about the situation in in scotland but but certainly in england i'm really worried about the amounts of financial service and workforce pressure that the social care system is experiencing at the moment and was experiencing um prior to the current cost of living crisis so so I am really worried that without some urgent stabilisation and injection of funding and a further reform the elements of the social care system in england anyway could could fall over this winter or soon afterwards I do think something urgent is needed in the here and now perhaps to buy the time to to have the longer term more fundamental conversations like the conversations that we've been having today so I don't know if that's also true in Scotland but that would be my concern as a private individual in england when there's major structural change as I say the evidence suggests that even though the structural change is often designed to try and deliver different outcomes in future it can become an end in itself rather than a means to an end in the short to the medium term so there's a decline in role clarity there's a decline in morale people reapplying for their own jobs or or kind of jockeying for position in a new structure where harmonising terms and conditions and joining up IT systems and creating new organisational identities and changing the the letterhead and the signage and you know all the things that you have to do when you're creating new machinery and new organisational infrastructures but none of those are things that improve outcomes for people who draw and care and support or patients in the short short term so there is the risk that any major change is a bit of a distraction from the day job in the nicest possible way and that's inevitable with any major change I'm not saying we should never have a major change otherwise nothing would ever change it's just that we need to be ready for the extent of the disruption that the relatively long period of time over which that disruption can last and that we need to be sure that the outcomes that we're trying to achieve are really worth it for the for the upheaval that there will be on route at a more local level I'm guessing there are people on the panel who've experienced a previous merger of a health and social care organisation or maybe two health organisations previously and you can sometimes still see some of the negative after effects of that merger you know five ten years after that the actual change has taken place it could still have been the right thing to do at the time but in organisational development terms you're working with the after effects of the change for many many years afterwards so I think for me those are some of the things to weigh up what are the outcomes we're trying to achieve is this definitely the best way of achieving those outcomes are we ready for the amount of upheaval that there'll be on route and then if social care is faking similar pressures and difficulties in Scotland as it is in England is there anything that we need to do in the short to medium term to support the sector in the here and now whilst we're also working on those longer term system changes I could see Sir Harry nodding along as I don't know if there's anything that you want to add you know just to support Professor Glasbaenys comments around amalgamation of health and social care partnerships and different changes to health board structures and so on it just diverts people away from the job in hand and it takes a while to get over that so the less upheaval we can get in introducing this and the more consultation with people on the ground and people who are receiving care the better and will come out with a really good solution and a solution that I think at the end of the day will not cost a fortune you know it will actually save me save cost in other sectors thank you we move on to our final theme and that is led by Stephanie Callaghan thank you convener and thanks to the panel for coming along today Sir Harry you said earlier on very early on that the critical thing is asking people about what it is that matters to them and actually helping them achieve that and you've spoken about how that can save costs during the line there so I'm wondering are there any further or what further provisions could the bill include to ensure the focus is on personal centered care rather than based on costs I don't think you can quite legislate for things like that I mean I'm thinking just as an example the patient safety programme I have a slide from a patient safety programme nurses in a ward realised that every day they were writing down aims for the day that they wanted to achieve during the day and the doctor would come in and write down for each patient what he wanted to achieve and they realised that nobody was asking the patient what they wanted to achieve and I've got a photograph of this woman in an intensive care ward with a big hairy dog sitting on top of her bed what she wanted to achieve was could she see her pet puddle or whatever it was and you know and that did her sense of wellbeing and so on no end of good that couldn't be achieved by any kind of legislation or anything like that it's a question of just acting I mean I when I worked in intensive care units if anyone had brought a dog in matron would have had them hung drawn and quartered but the point was this woman felt so much better because someone asked her and I've got hundreds of stories of people who've asked for trivial things and it's made them feel much better so I don't think you can legislate for it I think it just becomes a habit you just have folk do it and other folks see the result of it and it spreads so I think what we have to do I would suggest that what we did was when the bill comes out you make it very plain that this is the kind of approach you want to do a kind of supporting people approach and then we go out we get the medical organisations we get the nurse you know a raw college of nursing and so on and we make it very plain to them that we want we we really want that what matters to you approach to become prevalent across the system and they'll jump at it I'd just be interested convener in whether or not anybody else feels that there is something that we could include in the bill that would help actually centre that if any of the others want to contribute mr camp was mentioned earlier about eligibility criteria right I think we would be better getting rid of eligibility criteria at least in terms of seeing social workers right we spent a lot of time doing things people should be able to go like they go to a GP and ask for help right and and we need to help people who are asking for it I mean that's what person-centred care is about now most of the solutions to that will normally not involve money right they will involve working with people and the carers to work out what happens but actually if we stop trying to stop people coming through the door we're just stacking up problems we're diverting them we're creating problems elsewhere so we need to have an open non an open door service to start with which is based in local communities that people can just go and get involved in now the opposite has been happening you know since I've been in working was in working in social care all the local officers have closed down everything centralised it's more run we've now got a community hub in north east Glasgow for 44 000 people I think it is I mean that's not like going to your local GB surgery it's going totally the other way I don't know quite what the answer is in terms of the bill but I think there should be some sort of principle of subsidiarity and the other point I would just like to make in terms of resources at the moment we tend to the eligibility criteria so you get through and you get x amount of service right in fact some of the best things and the best service I ever commissioned was keeping people in their own homes there was a block a tablock in Glasgow with older people and we had one man and it was meant to keep them out of care homes and there was a 24-hour service with people on alarms and they would go and see people right whenever they needed help it was it was absolutely fantastic and they would have two stories from that which were brilliant one was a man with dementia very challenging behaviour I think had actually been chucked out of a care home because they couldn't manage with him the staff worked with him this is a relationship-based thing they discovered he liked swimming right they took taking this man who'd been violent and stuffed down a public swimming pool right might seem like a very risky thing they got him there and do you know what all he needed was to go swimming once a week and all his other problems disappeared now I was the commissioner I didn't mind we were spending 550 pound a week in theory if we looked at an individual basis and this is why I don't think we should see things individually right we were spending a huge amount of money on but actually we just talked to the provider and they reallocated that resource once they freed it up to people who needed more help and I also spoke to them about it and they took compromises the whole time because in this tablock people had alarms right and what would happen is very important you know someone a woman will want help with her nails or her hair right and with all these things that are really important to people and I'd ask what happens when someone goes out the door with dementia wondering and you have to leave them the alarm goes and they just said well we know the service is there for when we really need it when we have a real emergency like if we're on the floor we know that staff will drop whatever they're doing and come see us now I think what that illustrates is and I think it's so good everything that's a harry has said about local control right local decision making good use of resources was embedded it was embedded in those resources and as a commissioner I had nothing to do with the overall operation you know I asked some questions and it was just sounded brilliant could I ask a question though around something like the ethical commissioning aspect of things is it presumably one of the things that the national care service bill wants to do is ensure that there are fair work principles across you know there are standards across everything and that local decision making would still happen obviously you know that that would happen for all the reasons that you've said today but there would be standards in terms of the the type of care that the standard of care that's been offered to to people but also the the fair work principles and the pay principles and the structure that's akin to that of the NHS is that really what is going to underpin all that local decision making I think so and what will basically the structure of ethical commissioning is it says that it will apply the principles in the national care service bill to to practice right now my view on terms of ethical commissioning is the fundamental thing about this is is and it's in terms of this is for services for people rather than community projects or whatever it is all about staff it's what the staff does right so it's about paying them properly seeing their trained and seeing they get supported and have time to spend with each other so actually what we do need and that's what needs underpin ethical commissioning is national terms and conditions for all staff you would have agreed unit costs so whatever service is getting you would know how much it would cost to have someone's giving you know providing x amount of care it should be the same across the country whether whatever sector people should work with and now that's absolutely fundamental to it but the other part of what I would say in terms of the costs of ethical commissioning is it has to take account of the difference in costs of providing services and again the obvious example is rural areas right if someone is having to drive five miles to get to someone rather than walking around the corner the the costs of those services it has to be built in it's far more expensive so there has to be some discussion about how you do that now I was involved when I worked for a scotland excel we did a care cost calculator we developed for care homes how we could pay a fair cost of care for care home care across the country it was based on a greed wage policy you could put whatever wages in you want you could put training allowance and whatever you can come up with these unit costs right it's not difficult we could apply that to every service in the country and it would it would be the foundation for resource allocations on you could then give it to local communities and say the job of commissioners would then get say right well we've got you've got so much resource how do you deploy the staff talk with the staff is on how do you deploy it in a way to meet mead in this at this area I'm going to bring in two of our panellists and then we are going to have to wrap up I've got professor needs I've been waiting very patiently to come in and then I'm going to bring in professor glassby thank you I think just on the point of kind of getting voice to the to the front line then when we did our research on care in the four nations and we spoke to interviewee's working in scotland they said just implement the self directed support act so you know I whilst I do agree with the comments of the under panelist that you can't always legislate for this it is also looking at what's on the statute books and how this new bill can reinforce and reinvigorate that bill rather than necessarily starting again on ethical commissioning I think there's nine Scottish local authorities that have implemented unison's ethical care charter I haven't seen any evaluation of that done by anyone other than unison but I think that could be really interesting to to see how well that's working in those that are signatories and it's also linking the fair work agenda and ethical commissioning to the kind of the end goal of people flourishing and having a good life and so I think that's got to be about making ethical commissioning commissioning for outcomes and to do good commissioning for outcomes you need to have high trust relationships you need to have flexible services and you need to have very skilled commissioners and there's something here for me really about how we train and skill commissioners as well as other parts of the social care workforce. Thank you and friendly of bringing in Professor Glasby. Thank you yes I agree with everything that's just been said equally there are some situations I think where we where we need a formal care service for somebody but with the principles of self-direction there are lots of situations where we might not need anything that looks like a formal service at all and then there's a danger that some of our rules and regulations can become a barrier to innovation so a young person with very complex physical health needs needing to get to school and back each day in England this situation the local authority could only achieve that by getting a specially adapted mini bus from the day centre and so each day all his friends turned up the school on the school bus and he turned up on a specially adapted bus which had the logo of the day centre over the door and it also tied up a specialist vehicle twice today in Monday to Friday and was really expensive with a personal budget that young man's parents paid some six formers to sit with him on the back of the school bus so you could judge the outcome did he get to school and back safely each day he cost a fraction of what the mini bus cost it was much more socially inclusive because he was with his friends and his peers on the bus rather than in a specially adapted bus segregated from everybody else but nobody criminal record bureau checked the six formers or asked them to register with a some sort of central register of care workers they let the parents design that sort of very practical everyday solution with a personal budget so I agree with what people have said about the the benefits of a national system and the scope that that brings to look at terms and conditions and fair work equally there are some situations where what actually choice and control can can devise solutions that don't look like formal care work or formal care services at all and my fear is that we by integrating some of our services we might move towards the more medical model that makes that that everyday innovation harder because it's even more cancer control in some part of our health systems that then it has been in some parts of our social care systems thank you we have actually run over time I'm going to have to to move on to our next agenda item but before I do that I want to thank all our panellists both online and in person for their time this morning and it's certainly given us a lot of food for thought as we continue our scrutiny of the national care service bill that's before this thank you right the third item on our agenda is consideration of four public petitions which have been referred to the committee and I'll just highlight what they are it's PE01845 and that is a petition to for an agency to advocate for the healthcare needs of rural Scotland PE01890 and that is a petition to find solutions to recruitment and training challenges for rural healthcare in Scotland the third one is PE01915 a petition to reinstate cathness county council and cathness NHS board and the fourth one is PE01924 a petition to complete an emergency in-depth review of women's health services in cathness and Sutherland now the citizens participation and public petitions committee has referred the petitions to us after they've done their own scrutiny of them so that it can be considered as part of our work on the health inequalities if your colleagues will remember that we did a substantial review and inquiry into health inequalities and a lot of these issues around the common theme they're going through all these petitions is rural healthcare which we routinely address in our scrutiny of health service anyway and but particularly came up with during our health inequalities work but we do need to have a discussion about what we do with these petitions some of the petitioners have already met for example with cabinet secretary and we're talking about the final position there on the in-depth review of women's health services and members are aware of the work that the public petitions committee has done in fact we have got a member David Thomas is on that committee and he may want to tell us what some of the work that's been done but before I open it up to colleagues I've got some options that we can discuss about what we want to do and I'll just I'll just go through each one of them we could although we will not be able to do it this side of Christmas because our scrutiny of the national care system service is taking up all our time right up until Christmas but we could invite a selection of rural health boards to give evidence on the issues raised within the petitions and follow this with either a letter to the cabinet secretary or a session with the cabinet secretary that's obviously going to take the most time and we need to decide whether or not we do have time for that. The second option would be to proceed directly to invite the cabinet secretary for health and social care to give evidence on the issues raised within the petitions given that a lot of evidence has already been taken and we've already done quite a lot of our own scrutiny on rural health care and our equalities work and I should point out that the cabinet secretary actually did go to the petitions committee I believe to talk to the petitions as well. We could option three write to rural health boards and the cabinet secretary seeking evidence on the issues and just do it via correspondence or we could close all or some of the petitions. There are four options and I think that we should probably go to David because I think that it would be really helpful to hear from David about some of the scrutiny work and this is not revenge of you actually passing them on to us. I just genuinely want to know what level of scrutiny you experienced as a member of that committee and of our committee. David. Thank you, convener. I'll remember not to pass anyone away. Some of the work that's been done around the petitions that are in front of us is quite intense so I'll look at the recommendations if you'd maybe write to rural health boards then bring the cabinet secretary in and I think that would give them justification. There's one there where there is a petition P1915, Green State, Caithness County Council, Caithness NHS Board. I don't think that that is practical for us to do and I don't think that it's ever going to happen anyway so I'll probably close that petition. I believe that there was only two people in support of that petition where there's the other ones where a lot more substantial and there's quite an awful overlap between the other three petitions in particular in terms of the themes. Gillian, that's very helpful. Thanks, David. Thanks, convener. I also support David's position of writing to the health board. I think the petitioners would probably like to see some action taken on this in the period between now and Christmas and I think through correspondence to the health boards to gather that information and then have the cabinet secretary in after Christmas actually makes the most of the time we have in both ways in terms of gathering information while we're doing other things and ensuring that we have that in person session to make sure we cover the issues. That's very helpful. Thanks, Gillian Sandesh. Thank you, convener. I feel the PE 1890 about solutions to recruitment and training challenges for rural healthcare in Scotland. This is particularly important because if we look at healthcare and we look at GPs, for example, it's very difficult to recruit GPs. We know that nursing provision across Scotland is not uniform. We actually have significant worse recruitment in rural areas than we do in urban areas and I could go on and make have more and more examples. I do feel that PE 1890 as a petition should be brought in front of a health board and that our rural health board should be explaining what they are doing right now and we would then follow that up with a meeting with the cabinet secretary to find out what is happening centrally but I do feel this is a really important area that unfortunately we have not got a grasp on. I should also mention that we are routinely meeting health boards as well and we can factor quite a lot of the issues from PE 1890 and the other petitions. We could be factoring that in our work and we did say that we wanted to do some real targeted work on workforce in particular in rural areas and that's why we're having health boards in. Remember that that's already what I don't want to do is duplicate it and have an additional session. You're preaching to the convertor because I'm a rural MSP and everything that you've mentioned is a situation in Aberdeenshire. In terms of sessions, remember that we will be having health boards in any way so that petition could feed into some of the scrutiny that we're doing then as well. My only concern about that is that I feel that there are health boards that do not come in front of us and there are health boards that I don't want to use the word hide but I will and we need to ensure that rural health boards are coming in front of us and we get all health boards in front of us so that we can have this discussion directly because on a session that we had previously the health boards that appeared were ones that were not under great scrutiny and I feel that that's really important that we get everyone here. I agree with you and that's certainly something that we mentioned in our work programme day as well is we want to be hearing from all health boards and that's something that we're endeavoring to do throughout the year but I agree with your point. Any other comments on an approach to these petitions? David suggested that we close one. Gillian suggested that we write to all the rural health boards and have the cabinet secretary in. Any other thoughts? I think that I would be supportive of Gillian's position to write to the health boards then we've got some information that we couldn't look at and then speak to the cabinet secretary and I'm also I would tend to feel that we should keep all the petitions open. I don't know if there's empty here who covers the Caithness area. I'm not 100% sure because I would like to just speak to somebody about that. I don't know a lot about it but it would give me a chance just to refer to somebody that covers that area and of course what you could do is you could look at the outcomes of the petitions committee as David has said if you look at their recommendations with regard to that. I think that's linked to in your papers. Anyone else? I just forgive me because we've not done this before as a committee but there's obviously an issue in there around local government and the structural local government so I wonder if that's actually an issue for local government committee because we are not with the best well in the world going to be able to make a recommendation around the restructuring of local governance in Scotland. It's just a thought and I'm not sure how the ping-pong works in terms of committees. It was referred to us so maybe it's best that we don't do much more ping-ponging than... Pardon that expression. It's already happened. I think that we need to make a decision because I certainly would agree with David on closing the petition PE01915 for the reasons that David has set out and with the other three keeping them open and using them as a springboard to have that scrutiny of rural healthcare and addressing all the issues that the petitioners have raised and getting the cabinet secretary in and I think Gillian's approach is the one that I favour right into the rural health boards but having in mind what Sandesh has said that we need to be hearing from all rural health boards and when we ask them to come in front of the committee it should not be the same ones that come in front of us it should be all of them. I think there's we can't compel people to come in front of us but I think that everyone should take the opportunity to talk about what they're doing to address these issues Sandesh. I wonder if we might need to publicly say who we've invited and who have declined our invitation. I think that's all in public record anyway is it not? Okay well we can talk about that in private session but I re-agreed Gillian's approach because I think that I'm getting a sense that to Gillian and David's approach there you go ownership okay thank you very much colleagues so that concludes the public part of our meeting today so we'll go into private session.