oach to setting a national rate in our work with providers to reform the approach was recently praised by the competition and markets authority in their care home market study going forward we're building a programme of reform for adult social care which allows us to look at what residential care should look like in the future so in conclusion our approach to ensuring sustainability demands that we move beyond the short-term fix to think about longer-term sustainability it needs all parties to work together to meet that happen we're committed to doing this through integration through working with partners to improve our national care home contract through our reform of adult social care and through the actions in the national workforce plan published the second part of which was published back in December so I welcome the opportunity to discuss this with the committee in more detail thank you very much cabinet secretary and as you rightly say this issue stands in the wider context of integration of health and social care and we've heard this morning from Audit Scotland on some of the aspects of that which have a bearing on care home sustainability one of the things that I think came through strongly from their evidence was that although there is as you described some very good practice in particular parts of the country I think they put it as a need to share learning much better and ensure that we're not simply having good local initiatives but actually joining those up what's your take on that and how far do you believe the health and social care delivery plan addresses that Yes, that is critical I'm a firm believer in what work should be spread and best practice should be spread I suppose the caveat to that is that what might work in a remote and rural area might have to be a bit different from an urban setting just in terms of the availability of workforce and there are particular market conditions I mean if you look at the city of Edinburgh and Lothian there are particular challenges here that are not necessarily the same in Glasgow for example so yes absolutely I think there is the need to share best practice we have the improvement work that's ongoing that Geoff can speak about more to help and nobody should be immune for asking for support in terms of improvement no one has all the answers but without doubt is good practice that would be good to share more widely I think the important thing to recognise in this is that what we're saying is across the country how systems of care are evolving when we look at an area like the area where we're in city of Edinburgh and we think of all the different components of providing older people services we draw a diagram which has got about 47 different boxes including hospital care at home respite, support for carers all of which are a system of care and quite often we focus on one of the components of that rather than seeing the whole story one of the interesting conversations for us at the moment is as you begin to think about the evolution and the development of residential care into more step up, step down palliative end of life maybe some of the people who historically would have been in continuing care in NHS facilities you're beginning to describe what in rural areas you might see within a community hospital and in other areas you might also begin to see things which are in hubs so there's probably some general functions or principles but the construction of how you put the system together is probably going to be quite different from area to area one of the most interesting things is how housing which is not a fully integrated service has been one of the areas which has probably seen the most evolution in terms of supported housing solutions in a number of areas and again you're beginning to see how that but that's something which you can probably do within some property markets and not within other property markets so it's the adaptability but the learning we tend to talk about it as a sort of conscious localism you should know the evidence base and you should find the best solution from your area and that includes learning Thank you very much Miles Briggs Thank you convener and good morning to the panel the cabinet secretary perhaps aware that this morning it was named that renaissance care is to close its home in Musselborough and part of the rationale behind that was factors which are destabilising the sector and I printed off their chairman Robert Kilgar's statement on this apprenticeship levy and what's not being put in place in Scotland and just to quote him directly he says here we currently we currently get absolutely nothing back from the Scottish Government for this jobs tax they're making it very difficult for social care sector to claim any credit back from these new extra payments to spend on apprenticeship or training schemes as was intended and as is happening in England so I just wondered if you had any comment on that specifically Well first of all I think we have taken an approach as I set out in my opening remarks to try to support the sector we have as you'll be aware provided significant resources to pay the living wage for example to all parts of the sector including the independent sector that is something that we felt was important in terms of helping them to recruit and retain staff and we have significantly increased the national care home contract as I set out in my opening remarks I am aware that for the care home that we were talking about they had some particular difficulties not least around the fact that they didn't have on suite facilities and that they were struggling to meet some of the standards that were required so I think it's quite a complex picture that that care home was facing and then the requirement of investment there was obviously a decision that the owners would have to balance in terms of whether or not that is something they wanted to do I think the apprenticeship levy is that as I understand we have obviously that was something that the UK Government has decided to take forward that we have worked with employers to make sure that resources are passed on in terms of what we do here in Scotland so I don't recognise the scenario that has been painted there regarding the apprenticeship levy I think there are many issues impacting on the care home sector that is certainly not one that has been highlighted one that has been highlighted mainly to me not least by Scottish care is the impact of the loss of nursing staff through Brexit and the inability of them to be able to recruit nurses into the sector of which of course a large percentage were coming through EU channels and effectively the door has now closed on those recruitment agencies in Europe and that was Scottish care themselves telling me that directly so in all of the issues impacting on the care home sector apprenticeship levy is not one that has been highlighted to me as being a significant issue but I can say that we have made sure that we have translated resources through to support employers as we would expect and I'm happy to write with further detail of that if you'd find that helpful Maybe to add a couple of elements to that so first of all as the cabinet secretary says the apprenticeship levy is a UK levy in terms of the conversations that are going on around the national care home contract and the creation of the cost calculator both the cost of the living wage and the apprenticeship levy are built into that so those are understood as costs that apply as part of the process and the apprenticeship levy was certainly considered as one of the items during the last years negotiations these are also of course both policies, living wage and apprenticeship levy that apply to all care homes which has been applied to this particular care home and so there are a wider range of factors which are not purely about the environment in which care homes operate that we need to take account of and clearly other providers and other homes are able to continue to operate effectively within that framework so I think it's quite easy to identify government policy as the reason but there may also be other reasons that you want to look for In terms of nursing one of the points which was also raised by Scottish Care and some of the evidence we heard which I thought was interesting about 6 per cent of the care home care population and workforce were EU nationals but in terms of future training one of the concerns which is expressed was actually a drive towards the Government's target of just reaching child carers and training child carers and actually a potential loss of adult carers do you have any comment on that and where you're feeding into that system for our college sector specifically to train the people we'll need? So I think Scottish Care had identified nearly 8 per cent of nurses in care homes were EU nationals so I think without a doubt that is going to be a significant challenge around recruiting nurses to the care home sector which is why we are looking at other models we are as I set out in my opening remarks some of the solutions to that I think lie in the workforce that potentially is NHS employed providing locality based solutions to care homes and nursing homes some of that is already happening in some areas and we're testing that further in Dumfries and Galloway not just nurses but HPs and others and I think there is a longer term solution in that direction of travel rather than and of course trying to also meantime promote the benefits of in a nursing career within a care home environment but I think we have to also look at those locality based teams most of your point about child care yes I think there is definitely although it's obviously a good thing the expanded child care provision and therefore the expanded workforce there is a challenge there about it might be the same people who would be attracted which is why in the part 2 of the workforce plan published at the end of the year we were clear that we needed to promote care as a career and it set out the campaign that we would be undertaking this year as one element of that also looking at very clear career opportunities to progress for example on to a regulated profession such as nursing so that if you come in as a care worker you can see a career pathway in front of you that's clear so all of these things are about making care a more attractive career choice not just for young people but for people perhaps in other careers and in other walks of life so a lot of that is set out in the workforce plan about how we intend to do that so that we are minimising the impact of people choosing other choices I think the other thing to add to that is we're conscious of the challenge and so we're doing some cross-government work in other departments or other parts of the Scottish Government to understand the dynamics of that as the cabinet secretary says the second part of the workforce plan also begins to get into using and developing integrated workforce data and better local market analysis because as we go across the country visiting integration authorities we hear very different stories about the availability and again it does take you into the likelihood that you are going to see quite different models of care developing in the context of different available labour forces which is just the reality of where we are Thank you Good morning I often wonder if we have actually even got the words right care home residential care it just doesn't seem right somehow and I'm not going to suggest what it should be called but sometimes that's why it gets what you might call bad press and staff are obviously not living wage in certain aspects and I pick up on Miles Briggs point there as well and obviously the cabinet secretary really you know it should be looked upon as a career because obviously predominantly women low paid so really any care home if that's what we call a provider that can't afford to pay the living wage and the care home contract shouldn't be in the business at all and I'm pleased to see that basically this will be pushed into promotion into other careers as well and I touch on that part because I think it's really important that at the moment we're looking at the changing in care and obviously residents needs are changing greatly and the nursing care is needed too it's greater as well and I will touch on the reason that we had the investigation at the beginning was because of the situation with the bill provision and I would declare an interest in that because relative of mine had stayed in a billed home and got excellent care and I could never fault them for that so I just wonder having went through that and we know the situation with billed small units and communities which worked beautifully and very very well what the Government is doing to alleviate the situation with these care homes obviously that have closed citing the fact that they don't have enough monies in that respect and I just wonder what the Government is doing to alleviate that and what are they putting in place of obviously the situation within the communities that the billed homes are closing Okay well our priority has been to ensure the continuity of care for billed residents and making sure there's no compromise in the quality of care now billed have obviously decided to I suppose go back to their core business that was more focused on housing with care is what they originally did and they see that as the future direction of travel and they had difficulties with the sustainability over a number of years of their diversification into care the care home sector so billed are very clear with me that that decision obviously was a difficult decision but it was based on their desire to go back to providing what they saw as the future direction of travel of housing with care what was important then was to make sure that that transition and the continuity of care for billed residents was the priority officials, Geoff's been involved in this very closely have been meeting with billed on a regular basis along with the the health and care partnerships that are affected to make sure that that happens and that plans are put in place for residents and good progress has been made and there have been a number of new providers that are going to take over some of those care establishments and for others there has been a lot of work put into making sure there is a smooth transition because we know that the important thing here is to minimise the impact of that change for vulnerable elderly people I I mean, Geoff can we talk about the detail of progress being made there but I think there certainly are where they wanted to be in terms of the March position and then the July position and I think they've made the progress that they needed to make perhaps they had another couple of questions first to pick up on me and then we'll get some of the detail on that. Alison Johnstone Thank you, convener. Cabinet Secretary, in opening you spoke about the need for a vision to live independently a home as long as possible and Mr Huggins spoke to about looking at the whole story here and I think we're all aware of the fact that third over the last two decades and more people will be aging in private rented accommodation and often I think when we're discussing this we think about adaptations to local authority housing or social sector housing so I just wondered if there was any discussions that the Government was having with landlords for example because I think involving them in this discussion is really important if we want to lessen future burdens on our care homes with regards to access for carers and any adaptations that are needed out with that social housing model I agree and yes and actually it shouldn't matter what the tenure is the property that the person is living in and it's their care needs that matter rather than the tenure of their rental or whether their own are occupied or whether it's a social landlord or a private landlord actually that shouldn't matter what should matter is what they need in order to remain at home safely and I think the housing component of integration has perhaps been a kind of later addition to being around the table but they are certainly around the table now in terms of engagement directly with landlords I think there's more work to be done on that but essentially so the decisions to put in aids and adaptations to a property should not matter what the tenure of that property is it should be about what the person themselves needs so it's probably fair to say it's something which is less reflected in housing contribution statements in that generally the focus there has been the RSL sector or council or owner occupied it is particularly challenging in the context of the private rented sector because of their desire to be able to rent the residence again so it does take you into some conversations about tenancy as well the discussion around housing over the last 12 months has developed really quite quickly as increasingly people are seeing housing with support as probably over time the replacement for what residential care currently does and the other component which has been quite interesting is the approach to aids and adaptations because historically the approach would be to go and almost do like a health and safety audit and then do everything to the house but when local systems have had the conversation about what the individual feels that they need they tend to ask for a lot less and they tend to believe that they've got more capacity and capability as a consequence of it so actually approaching the issue in a different way and thinking about the potential for rehabilitation and to maintain mobility rather than to adapt is also part of the rethinking from the perspective of the individual but your question is entirely on point and there is no work to be done there Jeff, in your contribution you talked about sort of advising the symptoms of increasing demand rather than having a bigger picture approach and you also referenced Edinburgh and our last panel of discussion I raised the fact that Edinburgh has some 600 fewer residential care beds and it needs right now but that comes jarring against sort of tension with planning I wonder if both yourself and the cabinet secretary can give us an idea of what discussions you are having with potentially Kevin Stewart and other ministers around that kind of whole systems response to our growing care needs Without a doubt there needs to be a bespoke solution for Edinburgh and mobility and there needs more generally because we have a local market here that is very challenging and actually we are already paying well over the national care home rate in order to secure places within a limited availability and we also have a very delayed discharge issue within Lothian that is accounts for a large percentage of the overall delayed discharge and growing so it has to be a bespoke solution there are a number of things being looked at but it has to be a whole system solution so we need to look at more intermediate care so being able because a lot of people can still get home but they need that support on their way home and also looking at some of the changes that are happening with care at home there is more locality based work going on in order to try to secure a more sustainable workforce there in order to keep people in their own homes and then you have the on-going needs of people who are no longer able to remain at home and there is some innovative work looking at you do so for example there is a work going on on a business case around the concept of what's called a training care home it was mentioned in the workforce plan and this would be a partnership with universities it's actually a Norwegian model that works very very well in Norway that looks at a very kind of high quality training environment where you would have student nurses and student care workers coming through a training like a teaching hospital but a teaching care home now that's not going to happen next week but it potentially could provide quite an interesting new model of high quality but affordable care that would also have a training and innovative research component to it so what is on going on that to look at how that might progress so there will have to be some short-term work done and we're working very close with the partnership, Geoff spends a lot of his time working with the Lothian partnerships to try and help them to make some short-term progress while these other models of care are developing you're closer to I suppose a couple of items there I'm not entirely sure where the 600 figure is because I guess it's when we benchmark we would say that City of Edinburgh probably has slightly less than residential care home places than elsewhere but not significantly less we do see this as a system of care issue rather than an individual component and I guess one of the reflections I would have on how other similar solutions have been resolved in City of Edinburgh is like some of you may have done this as well I came to university here a number of years ago and was in private rented accommodation if I was to come to university here now I would be in one of the 20 or 30 purpose-built student accommodation so they've resolved one component of the accommodation and land problem so there's really the potential to resolve these but it requires that system solution we do spend quite a lot of our time talking about City of Edinburgh 600 figure came from a rebuttal to anoral deputation I made to Edinburgh City Council planning committee in objection to a particular care home in my constituency because of where it was located, the impact on local health services and the rest of it and that was used as the overriding argument to councillors to reject my objection as it were so that sticks very viscerily with me a very specific question then on that because that was a 64 bed care home in Crammond just off White House Road and one of the reasons I went into bat for the community in opposition to that care home not that I have an ideological objection to the development of new care homes in my constituency but the problem with that was the impact on the Crammond medical centres that they had no capacity to deal with potentially 100 new patients who had high end needs is there specific guidance to new care home developers about patients bringing their doctors with them if they are reasonably close or how local health services can respond to the imposition that some of them feel of a new care home in their area so there's a couple of things on this as part of quite a lot of the dementia work one of the issues that we were looking at in terms of the quality of medical care within care homes was the fact exactly that people did take their doctors with them as they moved and that brought with it particular challenges about access and engagement so our general assessment is it does make sense for there to be practices which are connected to particular care homes but those practices then need to take appropriate of what the requirements are likely to be and I guess the cabinet secretary talked about the nursing component earlier but looking into the future you're looking at AHP physiotherapy, you're looking at social care you're looking at general practice geriatricians and probably some specialist geriatricians in the psychogeriatric sort of space so you're looking to think about that's part of the purpose of integration is to enable you to build that sort of mix of services rather than think for a particular locality rather than think about how many of this and how many of that do I have so I think that is part of the future I guess I just wonder was the particular home that you were objecting to was it also a private home or privately purchased places? Because again that's another component of the Edinburgh story which is the development of an increasing number of homes which are only intended for privately funded occupancing. Thank you, convener, and thanks for coming along to talk to us. Just for clarity the early discussion on the UK apprenticeship levy is that training levy is a reserved and that's a UK levy tax and the Scottish Government doesn't get any additional funding streams as a consequence of that for example to fund modern or foundation apprenticeships is that your understanding? I think there has been some negotiation around that in terms of what would then come to us but it's been quite a difficult set of discussions as I understand it but the point that Jeff was making was that there should be no detriment to the employer because of its inclusion within the national care home contract discussion. My understanding it's sometimes difficult to be an expert in everything all the time because we've had the conversation before is that the benefit of the levy is applied in Scotland whether that's through reserved powers or devolved powers but we would need to write to you to make sure that all that is done is replacing funding that was there through Barnett anyway so that's not additional. So there's no new money exactly. That's clear thank you for clarifying that. I want to talk about the area of the outcome being delayed discharge and it's good to see some numbers out in the late discharge. Some progress is going in the right direction but it was specifically about the area of flexibility around the care home contracts that you've alluded to because clearly you're looking at rough numbers at costs the same I have somebody in an acute bed for a day as it does to have them in a care home for a week so clearly there's a huge disparity there in the more people that can be moved through that process the better and if there are blockages there. It was really to assess how much you feel of that blockage is down to issues round about the amount of money that's paid to care home providers because there could be situations on the margin where a certain service costs a bit more but they're stuck in the acute bed that's costing seven or eight times more because of the blockage and lack of flexibility around the contract. So is there work to be done there to allow some more flexibility so that more delayed discharges can be actioned? The picture on delayed discharge first of all you're right that there's been continual reductions in delayed discharge and they're generally running at 10% below the previous year and 34 out of the last 35 months have seen bed days associated with delay below the equivalent months of the previous year all of which is good however as I alluded to earlier on there are pockets where a smaller and smaller number of partnerships are now accounting for a larger and larger number of the remaining delays and the city of Edinburgh and Lothian is one of those and that's why we need a bespoke solution to resolve that. In terms of the work going on around the cost of care calculators so there will be, there is a negotiation around this year's national care home contract rate which is on-going and will reach a conclusion alongside that is work going on around the cost of care calculator and part of that is around the actual cost of care but recognising within that there will be variation in terms of localities so the cost in Edinburgh is different from the cost somewhere else so it's about building in enough flexibility and then you have a growing complex care need so because people are older and have more complex needs before they go into a residential care home place by definition their needs are going to be greater and that has to be reflected more within the cost of care calculator so all of that is trying to be wrapped up into this quite difficult complex piece of work the other thing we're trying to look at about so do you wrap up the nursing component of that and just include it in the rate or do you provide that in a different way through locality based teams that are NHS employed and that is part of the discussion that is on-going because I think we have to think a bit more innovatively around that and again that would add a bit of complexity to so what does the national care home rate then pay for and what does it not pay for what is provided directly through a staffing component that might be NHS employed but there's obviously a cost that you would expect the care home sector to either meet or deduct from so it is quite complex but I guess in summary what I'm saying to you is this is a critical way of resolving I think over the medium to long term this annual debate around the rate is we need to move away from that and look at more of a framework solution that takes into account palliative care needs complex care needs and local variation in the market as well there's two quite interesting aspects to that which is first of all if we have an inappropriate admission to a care home one that could have been avoided that will probably cost upwards of the basis that people will then be in a care home for an extended so if you're thinking in terms of the financial costs rather than the human costs the costs of an inappropriate referral because somebody once having been referred to the care home will probably stay there are quite significant and also in terms of overall system dynamics the other side which is interesting is that one of the early bits of work that we saw under integration was the work in Glasgow around step time which used residential care as a process by which people would be assessed in respect of their needs and then move on and they've seen a significant reduction in the number of people who having gone through step down have then gone on to residential care so you get the benefit both of better flow but also people are more likely to return home with the capacity and with the support that that means in terms of the human benefit so I think the simple translation for weekly costs to individual it's a really important thing and we have to always have it at the front of our minds but we need to think about it in the bigger picture again Brian Whittle As you alluded to earlier on as we heard in an earlier evidence session the evolution of the services that are happening in the care homes is very quick and that their complex care needs are ever growing and the age in which people are coming into care homes is going up the care homes themselves have a limited flex around the costs how much their income is and what their staffing is and I know that within my own reason we've lost a couple of care homes under the banner that the welcome introduction or the living wage wasn't fully mitigated against and given that the staffing levels are a big percentage of the costs and I wonder if you recognise that strain if that's continued it's unsustainable and without that bed the cost to the NHS of staying within an acute care system is much increased and I wonder if there's something you could comment on Let me address the living wage issue first of all which has been quite a controversial decision for Government to essentially provide public money to private sector to help them pay their staff the living wage it sometimes feels a bit counterintuitive that they would then complain about that maybe it's just me but I think that that has been the right thing to do because it is important to sustain the workforce I don't think they would have been able to deliver that public subsidy we are very clear that money needs to find its way to the front line to the staff and the health and care partnerships are very clear that is part of their negotiation that money has to go where it was intended to go in terms of the figures in 2016-17 we allocated £250 million for social care almost £0.5 billion of front line NHS spend has been invested in social care an integration which also covers the living wage as a component of that and to support that this 1819 we are going to give an additional £66 million for social care again a part of which is to maintain the payment of the living wage and ensure that that continues to benefit the 40,000 people who were previously not getting the living wage on top of that despite what we have said recognising some of the complexity of care costs the national care home contract has increased by over 13% over the last three years which is a significant increase not replicated elsewhere I am not saying that I don't recognise some of the challenges but I also recognise what the Government has done in terms of stepping into that space that is not seen anywhere else in these islands and there are the same pressures elsewhere so whether it is the increase in the national care home contract and we pay a higher level here even before the increase this next year that has been negotiated is paid elsewhere in the UK and we pay also a contribution to the living wage what I am saying to you is I think there are business decisions that are being made within the sector some of which are difficult and it is sometimes as easy as Jeff alluded to earlier on to turn and blame the Government for some of the challenges which I think is not always a fair assessment of the situation I think that it is also important to remember that the national care home contract took account of the living wage changes and in the first year that we undertook it because of the representations that we had about small or rural or single care home owners one of the things that we added to the agreement was that if there were particular challenges to particular providers because of the structure and because of the changes in what was being required that they would be open to local negotiation and reference that and understood that if I could just to clarify Cabinet Secretary, if I wasn't blaming I was merely passing on information that's come from care homes themselves to say that even though you might have put money aside to pay the living wage the suggestion is it's not necessarily making its way to where it should be or indeed it's mitigating against its cost not just in my area but that's a recognition across many areas that's becoming increasingly difficult to maintain the care home system I think that the solution here is around the cost of care calculator bringing a level of transparency to all aspects of this not just in terms of what is paid through the national care home contract but transparency around what is now a reasonable profit level for example for the independent sector to take because there is huge variation there you have over the last few years some where I accept the margins have been very very tight indeed but you have other providers where actually quite a healthy profit has been taken and we need to bring a transparency to all of that so that we can make sure the public contribution we make leading to an improvement in quality of care staff are paid the living wage but there is a reasonable return for the provider where there is a profit element involved which obviously not all providers have so I think that that is the reason the cost of care calculator is so important in bringing transparency to all of these things Thank you very much Thank you, convener I suppose coming back to the future sustainability idea and I guess I'm talking more into medium and long term that clearly we need to do some work around maybe identifying what these innovative new models of care might be and obviously the cabinet secretary has already mentioned one example from Norway which does sound really interesting are there other ideas or pilots projects that are being used in other countries that perhaps Scotland could learn from that? I think that we have been very open to looking at best practice elsewhere so that the boots org model that we've been trialling here around the idea of really empowering the front line staff working in more of a care at home environment that they would manage their case load and be able to make those changes and adjustments to care that enables more rapid changes if someone needs more care or less care so that they essentially can be making more of the front line decisions around care rather than passing it back to three sets of managers and the time that that sometimes takes so we've looked at that in terms of the care home sector I am very taken with the idea as you probably can guess I've probably mentioned it three or four times now of looking at more of a what are the skills needed to support a never more increasing complexity within a care home environment rather than who employs them and I think the reality is even with the promotion of the benefits and the attractiveness of a nursing career within the care home sector I think even with all of that there's going to be challenges because the NHS is a very attractive proposition for nurses because of the career opportunities and diversity of opportunity there and I think therefore the idea of locality based teams not just of nurses but of other skillsets providing that to the care homes and nursing homes within that locality for me is a very strong proposition in terms of a way forward now that's already happening in some areas but I would like us to look at if that is a viable proposition and obviously we're increasing the number of training posts for nurses so we're increasing the workforce overall so we'd have to there are always demands on the nursing workforce so we have to recognise that but I think we could make that quite an attractive proposition for nurses and other allied health professionals as well which would increase quality would bring sustainability and potentially would be a way of avoiding the care home sector having to pay agency nurse rates in one case of £1,200 a night that is not sustainable so we have to recognise that Thank you Good afternoon to you both Can I raise a general point about the improvement hub that was set up almost two years ago by Health Improvement Scotland I mentioned in the last session that I watched the online presentation last night which I thought was the first class on things like sepsis and the new fit procedures for bowel screening but is it the right vehicle to manage change in the sector I think it's probably one factor although you're right it does some really really good work I guess what we would want local partnerships to do is to analyse their own problems if you like so that they know what their local needs are and where they've got challenges where they've got strengths and where they've got weaknesses and to ask for support I think the partnerships that ask for support the most are the ones that are actually getting on and doing the best and perhaps where there's been a reluctance to ask for support is where we've seen most of the challenges and it should never be seen as a weakness to actually ask for support it should be seen as a strength that you've identified where your challenges are and you actually want support in overcoming those and some of our strongest performing partnerships have actually asked and received some quite significant support so... I think it's a good question the frailty work also that the IHUB has done on a pallet basis in Fife has also been really effective and we see it as one of the reasons for the improvement in a number of the indicators there but it goes alongside the data work and the objective of creating capability for change within local partnerships could I add something just to the previous question two or three things which we're saying is greater use of technology looking also across the housing solution, care home solution community hospital solution but also mixed use environments one of the areas that we've become aware of in England that they developed an Italian restaurant as part of a mixed use environment and as part of the overall funding model which apparently made £8,000 during its opening weekend so if you begin to think you don't have to do it the way in which you always did it but you can find different ways to do it and I guess the other component of that is where you locate care do you take it to the outskirts of the town or do you try and put it in locations where people are able to tap into other sorts of facilities as well so there's a lot going on but it will learn but it will also be bespoke thank you very much, Emma thank you convener I just have a quick question we now use the language of models of care that strips off our tongue quite easily it's a common language that we use but I'm wondering has there been a need identified that people don't still understand what changes of care means as far as respite in the home versus respite in a place or it's not just about bricks and mortar it's not about dementia care in a place it's about the wider connectivity to the community and everything so I'm just wondering if there's a role or a further remit required in the engagement and awareness raising regarding the language that we are using for better care models someone mentioned the language earlier on it might have been Sandra I'm not sure and I think there's something in that that rather than compartmentalising this is that actually it should be about the care needs of the person and whether or not where they receive respite it should be tailored to what their needs are and I think we started off by saying that you can't look at one part of the system in isolation you know it has to be you have to look at the whole system so there's definitely something in that I think and perhaps changing some of the language or adapting some of the language I think it's a more general issue as well because we talk about going to the hospital or saying the doctor there's pharmacy in the social care side one of the things which I find really interesting is just how surprised people are often by what they receive and how pleased they are with what they receive and it's a surprise because it's not hadn't been their understanding of what this was so speaking to a colleague whose mother had returned from hospital and lived in a terraced house and had expected to need adaptations but instead got rehab that was six to seven weeks later was able to go up and down the stairs and had the capacity to use the whole house and that was just a mind blowing outcome and that's normal but it's not the dialogue that we have about one of my colleagues about ten years ago suggested we should do a documentary soap to explain but I don't think that the broadcasters would necessarily find that to be a it's really quite hard to get across on that thank you very much colleagues that's been a very full session can I thank the cabinet secretary and Mr Huggins for their attendance and we will now move into private section thank you very much


What's good Josh bull rocks back again with another video? So we just finished watching Monday Night Raw Night 2 of the draft or Monday Night Raw edition of the WWE draft Honestly, that wasn't anything major in my opinion on draft picks and where certain people went a lot of people were stayed on the Shows they were already on certain championships switch to different brands. It kind of just felt kind of lackluster to be honest with you I Know they did say that some people can end up getting drafted to another brand And if you hear some coughing in the background, that's blondie because she's excited right now She just woke up from a nap. So, um, honestly, I don't know what they're gonna do with the Cody Rose situation We will find that out after backlash, which is actually this week this Saturday so this was the go-home show and Nothing really just Progressed any further other than the little interaction we got with Brock Lesnar and Cody Rose I think that's a big major program that everyone is a lot of people are looking forward to seeing we will see how that play out But outside of that for me this Monday Night Raw was not it It just I didn't care for it the show just didn't really interest me You know, there was some okay matches with a lot of these matches or rematches or some type of form of Interjection of matches. We've already seen the one pretty cool interesting thing. They pulled a Eddie Guerrero when Jimmy was going against Matt Riddle and you had Jay on the outside and Sammy Zane and Kevin Owens Kevin Owens is getting in getting into it with Jay and then Kevin Owens just falls he pulled an Eddie Guerrero as Sammy Zane hits gets a steel chair hits the announce table throws it at Jay Uso the ref looks at it and then kicks him out You know, he has to leave ringside and I like that they pulled an Eddie Guerrero That was a cool little little moment and Matt Riddle ends up getting the wind off the distraction or whatnot Hell even at the end of the show, they didn't even have really enough time to show the all-out brawl with all competitors. It's gonna be in that It's That a three-on-three a tag match Well, three-on-three a match that having that a backlash But what I wanted to talk about and I wanted to give praise and I think this is for me one of the highlights of the show Just Renee coming out there, you know talking about what's gonna happen Damian priests talking about what he's gonna do to bad bunny, which I'm actually kind of looking forward to that Street Five match I think it'll be fun Rear Ripley talking about what she's gonna do to Selena Vega We already know Selena's not minute winning that match. So that's kind of you know a mute point But hopefully they can have a good show in and then Dominic Trying to hype up everybody else in the judgment day about their respective matches in the fact that Soon as he picked up the microphone to say something the booze He got Words that it was the loudest reaction of the night outside of the Cody and Brock situation It was the loudest reaction and it just kept getting louder every time he tried to say something It would just get louder and louder. They're booing him.  This is great They have something here in Dominic and we've said this before but just even after WrestleMania even after him losing He's still getting that nuclear heel heat Even though he lost because people still want to see him lose people still want to see him get beat up people still Want to see him, you know get get you know get what's coming to him cuz he's still talking trash and I love it I love it. That was one of the best parts of the show Dominic getting that Mega heel reaction that crowd came alive to boo this man out of the building It was fantastic. I man, they have something with Dominic, bro I hope they can continue that momentum cuz I'm beyond with you and I said this before I Think at this point is it's safe to say Dominic is the biggest heel in WWE Roman doesn't get booze like that Not to that magnitude on a consistent basis It's always gonna be some people that love Roman Reigns, you know saying unless he's doing like some heel like stuff They're gonna love Roman Reigns.  It's not rare. Oh, I mean, it's very rare that you see heels getting so much heel heat Like people are enjoying hating someone. There's always that cool. He'll I rear Ripley? She gets a lot of cheers a lot of mommy chance. She's a heel, but she comes off cool So people rock with her same thing with Roman here with Dominic. No They legitimately booing this man because they just can't stand him and anytime he has a microphone It's just Definite and I love that they literally have something gold here. It's gonna be interesting to see what they do with him The question is do you put a championship on him like a mid-card title on him or maybe Have them end up winning a tag team championships at some point from Kevin Owens and Sami Zayn They can get some real good heat, but they do a feud with I would love to honestly see Dominic Damian Priest at some point you know kind of aligning themselves as a tag team and That would be interesting if they won the tag team titles at some point from Kevin Owens and Sami Zayn because I believe they're on I believe they're on raw as well with the judgment day they had crossed paths Imagine the booze they would get Because right now Sami Zayn is in Kevin Owens. They're mostly because of Sami Zayn They're getting a lot of pops anytime people see them the pops is super large So imagine the booze they would get if they cheated to win and they became the new tag team champs at some point Down the road because Dominic has been a tag team champ with his father, but no one really remembers that title reign much This would be great because now You know I'm saying now you would have something very Substantial here. You know I'm saying they have the tag team goes Rhea has has a championship Maybe Finn Balor ends up becoming a new world heavyweight champion You know I'm saying maybe the whole faction has all gold on raw It could be something interesting. That's something they could do but I do think putting the tag team titles on Damian Priest and Dominic should be the future because now you they have Championships and people are gonna be really invested to see them lose those championships by any means necessary So I think that would be good And it'll be they would get even more heat because they beat some over baby faces as tag team champ So I think that should happen later down the line. Let me know what y'all think about that How did y'all feel about this Monday night raw? Did you guys enjoy it? Did you guys not enjoy it? And what did you guys think about this whole Dominic? Segment of him getting the boo booed out of the building. What was your favorite segment on the show? But I appreciate all of us for you guys shown on channel roll 250 K and I'm still you under speed of YouTube wrestling champion world Appreciate y'all kicking me down


Hi friends, welcome back to my channel and welcome if you're new here. My name is Jen, I'm a certified weight loss and nutrition coach and I am on the MyWW Blue Plan. Today it's another holiday vlogmas video. I have a fantastic gingerbread inspired holiday treat recipe for you today. It is not WW friendly, to put that out up front, now you can make it WW friendly. So in the recipe on my website, I will make some notes of some modifications you can make to help reduce the points and the calories. But we are making it full holiday with all the real butter, real sugar and flour that the recipe calls for. I'm excited for today's video because it's going to again bring in those gingerbread vibes into my holiday. You'll find this recipe on my website. My website is down in the description box below. You'll also find my nutrition coaching website. I have personalized macro and calorie calculation as well as one-on-one coaching in 30 and 60 minute sessions. Definitely, definitely take advantage of macros and calories so you can set yourself up for success for 2021. You'll also find links and discount codes to the items I shared today and all my favorite things.  I have so much fun stuff coming your way for the new year plus a huge announcement was made in that group this last week. So definitely head on over and join us. So we have a holiday gingerbread recipe to make so let's jump in. For today's vlogmas video, today's holiday treat, we are making gingerbread cookie bars with cream, cheese frosting, homemade frosting. Who doesn't love gingerbread during the holidays? So let me show you what's in our recipe. You're going to need baking soda, flour, sugar, brown sugar, molasses. And then the recipe actually calls for nutmeg, cinnamon, cloves, all your traditional gingerbread spices, but I'm using the Dax pumpkin spice in place of that because this contains all of those plus honey, which just puts this over the top when it comes to these types of holiday pumpkin clove nutmeg spices. You can pick Dax up for 10% off and free shipping using my code here on the screen. And there's a link down below. I love Dax, there are no salt, no MSG, nice clean, clean ingredients. And literally they have the best seasonings ever. So definitely check out Dax, but we are going to replace several spices with this one. You're also going to need some vanilla extract, an egg, butter, cream cheese. I'm just using one third less fat cream cheese and powdered sugar. So let's make some gingerbread bars. So to start our gingerbread bars, we're going to add in one half of a cup of melted butter. I just taught that in the microwave for about 30 seconds and it melted it pretty well. We're also adding one third cup of the star of gingerbread and that is molasses. Three quarters of a cup of sugar. And then we're going to put in about a teaspoon of vanilla extract. I never measure that, I just kind of eyeball it. And then last but not least, we have one quarter cup of brown sugar. And then we are going to cream this all together on low speed with a hand mixer. We're going to add in one cracked egg and then just stir with a spoon until combined. You don't want to over stir, just make sure that egg gets mixed in. We're going to put in two teaspoons of a baking soda, two cups of all-purpose flour, then all of your spices or in my case just the Dax pumpkin spice. It wants about two teaspoons of spices. So I'm just going to put in two teaspoons or so of the Dax pumpkin pie and a pinch of salt. And then we are going to stir until fully combined into a greased nine by 13 baking dish. Here is our mixture. I ended up adding about two tablespoons of water. It just was pretty dry. So don't feel bad if you have to add water to your mixture. We're going to add all of this to the baking dish and spread it out in the bottom nice and even. Here are our bars. These look so good, you guys. These are going in a 350 degree oven until they're cooked about 15 to 20 minutes. Definitely do not overcook. The gingerbread cookie bars just came out of the oven. Look at how incredible these look. We are going to whip up the cream cheese frosting while these cool. Make sure they are cooled completely before frosting. To my medium sized bowl, I added my eight ounces of reduced fat cream cheese. You can use reduced fat or regular. I have a quarter of a cup of butter. So I'm going to add that. This is softened butter. It's been sitting out the whole time while we made the rest of the recipe. And then we are going to do a teaspoon of vanilla extract. And with your handheld mixer or stand mixer, we are going to mix this until it is creamed together. And then we will slowly meticulously add in the powdered sugar. Cream cheese frosting. This looks amazing. So we're just going to set this aside until our bars are cooled. The bars are cool. So we are going to frost them with this decadent cream cheese frosting. So go ahead and frost them completely. And then I think for a little added extra holiday pizzazz, we're going to put on some holiday sprinkles. And the final step is I'm going to add some of the green and the red, kind of sanding sugar to the top. How fun. How fun. How festive. And who doesn't love number one gingerbread and number two cream cheese frosting. So these are going to be our gingerbread bars. We're going to taste test these next. So I'll let you know my first impression, taste test of these bars, but these look absolutely incredible. All right, we're going to try the gingerbread bars. Honest first impression of these bars. Wow. Oh my gosh, they're so good. I taste ginger. It's gingerbread. And then that sweetness from the frosting. So good. Oh my gosh, definitely make these for the holidays. Thank you for joining me for today's holiday gingerbread recipe. I hope you are as excited as I am to make this for my family for the upcoming holiday. Again, the recipe is on my website, which is in the description box, along with my nutrition coaching website, links and discount codes to my favorite things. And of course, my Facebook group, come on over and join us. If you love today's video, please do me a favor and give it a big thumbs up. It really helps out my channel and kind of lets me know what content to put out for the rest of Vlogmas. And if you haven't already, again, help me reach my goal of 30,000 subscribers and turn on the notification bell and hit the subscribe button. Thank you guys so much for watching Merry Christmas. Happy, happy Vlogmas and I'll see you tomorrow. Bye.