ST from Work needs to work under the healthcare committee of 2018. I welcome everyone in the room to ensure that mobile phones are switched off or to silent. Welcome to use mobile devices for social media purposes, but please not to record or photograph the session of the committee. We will start this morning with the Scottish health council evidence session, taking Felly, rydw i'r cyffredinol yng Nghymru gyda'r Sgolwyr Cysylltu Llywodraeth. Mae'r cyffredinol i'r sefydliadau ar gyfer y cyfrifio'r teimlo, yn ffac, ar gyfer y llyfr yng Nghymru lleiwyr yn y gyfrifio Llywodraeth. Felly, rydw i'r cyfrifio'r cyfrifio'r cyfrifio'r cysylltu Llywodraeth, pan hynny'r gwybod, yn ddwylo'r Sgolwyr Cysylltu Llywodraeth, ddwylo'r ddwylo'r ddwylo'r sgolwyr Cysylltu Llywodraeth, Llywodraeth, a Llywodraeth, Roddy Persen, ddigon nhw, yn deistafell hynne, croeso, yn maen nhw, i'r sechcyn a'i gwybod i'r cyfrifio'r cysylltu Llywodraeth. Ie ddweud i arbennigol i ddim yn cysylltu'r ddiwheeluio. Felly, mae'n ddwylo'r rhain mae'n gwybod i'r cyfrifio Llywodraeth, ac i gyfrifio Llywodraeth. Rwy'n credu i gwneud y cyfrifio Llywodraeth i'r gei rhaglarion The Scottish Health Council is constituted in legislation as a committee of healthcare improvements Scotland. It is, we can say a bit more about the actual committee of the Scottish health council. The Scottish health council is an entity that is embedded and it is accountable within healthcare improvement Scotland. It is an accountability line that runs from the director of the Scottish health council to the chair of the Scottish health council, and a line of accountability runs from the director of the Scottish Health Council to myself, as a chief executive of Health, Care and Improvement Scotland. It acts as a governance committee of healthcare improvement Scotland. As a result of that, we have a mixed membership of the council. Half of the membership comes from healthcare improvement Scotland and board members, and the other half are separately appointed. At the moment that we are pending the final outcome of the review, we will be considering how we might broaden that wider public membership. That is helpful. In relation to a primary function of the Scottish Health Council in enabling a public participation, a public influence in change within health services, is that role a scrutiny role in terms of scrutinising the efforts of others, or a support role, or is it a combination of both? Convenience is a blend of things. There is a scrutiny, there is a quality assurance role, there is an improvement support, there is an enabling role, and we can maybe say a little bit more about how we would like to strengthen particularly the enabling of capacity and capability in Scotland to engage with communities. As part of the review, you can say a little bit more about that if that would be helpful. We have a blend of things within the Scottish Health Council, and in some ways, convener, it is a microcosm of healthcare improvement Scotland in itself. Healthcare improvement Scotland having a role in quality assurance, a role in improvement support, a role in good practice and dissemination of good practice and evidence, you can see all of that within the Scottish Health Council itself. We might want to say a little bit more about the actual individual parts of it as the evidence session proceeds. I suppose that we have a relatively small team within the Scottish Health Council that specialised in working with boards and more recently with health and social care partnerships in relation to service change. The vast majority of that work is about offering advice on good practice, sharing examples of experience from other areas, sometimes offering a bit of training in capacity building to staff within those bodies. In a small number of changes that are identified as major change, the Scottish Health Council has a quality assurance role, and that means that we work very closely with the NHS boards throughout that process. The boards are required to carry out a minimum of three months consultation, and we have a role in making sure that they follow the requirements and the guidance, the CEL42010 guidance, and to produce a report at the end of that process. Our report goes to the board to help inform its decision making before any proposals would then go forward to the cabinet secretary. We try to do three things in the reports. We first of all set out the process that the board has followed and how that has complied with the guidance. The other thing that we seek to do is to provide a bit of an independent summary of any views and concerns that might have been expressed by communities throughout those processes. The third thing is that we think about recommendations for the board in terms of moving forward, things that we think it should do in terms of next steps in relation to the particular change, but also perhaps areas where we think that they could learn for the future. How far do any of the witnesses feel that the function and the role that you have described at the Scottish Health Council is clear to the general public? Can I give a bit of feedback from the actual consultation that we undertook? There is not as great a clarity as there could be about the role of the Scottish Health Council. In some ways, convener, it would be fair to say that the name gets in the way as well. However, in the broader opportunity that we have within Healthcare Improvement Scotland and the work that we are doing to explain the work of Healthcare Improvement Scotland, there is evidence to this committee in the past around the improvement hub. It is a good demonstration of the work that we do within Healthcare Improvement Scotland. We have work to do, it would be fair to say, to make sure that people understand the role of the Scottish Health Council within the broader responsibilities of Healthcare Improvement Scotland. Equally, there is a role for us to ensure that the Scottish Health Council is fit for purpose in a different landscape. If you go back to when the Scottish Health Council was constituted in 2005, there were 15 territorial health boards that was a principal relationship. We are now in an environment that is more diverse. We have around 70 different bodies that we have to engage with, from local authorities, territorial boards, integration authorities, and that is putting aside where we are in respect of the voluntary sector. There is work to be done in defining clearly the role and contribution of the Scottish Health Council within the broader strategy of Healthcare Improvement Scotland. I want to explore that a wee bit further. Sandy, you have laid out the two things that you are trying to do here and the three outputs from that. I suppose that I just wanted some clarity in the paper that you have submitted. You are talking about having a refocus and maybe going in a different direction and changing what you are doing. I am just trying to understand what it is that you think about what you have described that you are doing at the moment, is that you should or shouldn't be doing and what extra you should or shouldn't be doing in that context? Do you mean specifically in relation to the service change work that we do or more generally? In terms of what you have written here, you said that Healthcare Improvement Scotland believes that a refocus Scottish Health Council and you are saying that there are changes that you are going to have to look at making in terms of what you are doing. What is it that you think you need to change? I suppose that health and social care integration has been really important for people using services for communities across Scotland. It has changed over the last couple of years the way that we have worked, so we do not have a formal role to work with the integration authorities. Our role was a statutory role as we are working with NHS boards, but in light of integration and what that means for communities, we have already started to adjust the ways that we work in light of things such as our voice framework, which was about strengthening people's voices across health and social care services. Gradually, over the past few years, we have been doing more work directly with communities. We have been offering advice on service change to health and social care partnerships informally. That was an opportunity for us to step back and reflect on how the landscape has changed and how we might have to change to adjust and accommodate that. We recognise that that means working with a number of different bodies. It means working in different ways. There are other bodies that have a real interest in that, and we want to make sure that our work is focused in areas where it will make the biggest impact. That was the purpose of understanding your landscape change, so that you do not have to look at social care as well as health. That is clear, but I would be doing what you are doing and expanding it to work with different bodies. I suppose that it is the bit that we have quoted in our papers from Pam Whittle, which says that there are undoubtedly tensions between different aspects of the current role acting as assurance and an emerging call to move to becoming an independent feedback body. I am not quite sure where that is going. I think that the whole issue of independence is quite difficult when it is from an organisation that sits within an organisation, but we do speak as an independent voice. I think that it is that which we have become more assertive in trying to make sure that our view is clearer as we move forward. Nevertheless, it is a complex picture. Do you think that you are not independent?  Do you think that you are not independent of the health board? Well, we are independent of it. Exactly, so I do not understand why he thinks that there is tension. I think that it is a perceived lack of independence from certain people who think that we have thought in the past. It is just us about being clearer about... So it is about communication. It is about communication. It is about rallying and fundamentally changing anything. Correct. I think that that is absolutely right. It is about communicating what we are about. That was something that became quite clear in the progression of the review, the initial review and the subsequent review, that it was not clear to everybody exactly what our role was. Okay, so what you are talking about is not changing the remit or the direction or what you are doing or the way you are doing it. It is about how you communicate that to make it clearer to what is going on. You wanted to come in. Can I just pick up one of the points in terms of what would be different about the Scottish Health Council as we evolve over the next couple of years? So, for instance, a relationship, the primary relationship between the Scottish Health Council and the territorial boards is through our local offices around the country, and that is a really important working relationship at the front line of services out there in Scotland. One of the other things that I would like to see the Scottish Health Council do, though, beyond the local contribution, is to give more of a voice to the bigger national issues facing Scotland. So, this committee has spent a lot of time looking at the quality of care offered to children and adolescents in Scotland. Now, the Scottish Health Council could have a role in giving an overall thematic review of how easy it was for individuals to access, for their families, for children and young people, child and adolescent mental health services from the user perspective. So, I would like to see more of that evolve for us as a Scottish Health Council into the future. Okay. I thank you for that. I have a very practical question to finish up with that you may be able to help to comment on. In my area in East End of Glasgow, we had the situation with the Lightburn site, and that is thankfully put behind us now. I have met with the health board roundabout where we go forward, what goes on that site, what goes on other sites, what they do with services around the area. As part of that, I have got an intention, along with other elected members, to go out and talk to community groups on our own behalf and get some comments, feedback, etc. To then take to the health board and say, this is what we see in the community. So, that kind of engagement process, if you like, but outside something that the health board is doing directly, is that something that you would perhaps be willing to engage with and support us in doing? Absolutely. So, what I would say is that one of the discussions that we have had in the previous meeting of this committee is the concern in some arbitrary position between major and all service change. What we want to be in a position is enabling whether it is NHS boards or integration authorities to do the very best in engaging with their communities and providing the tools, providing the expertise, and that is very much akin to the resource nationally that we are providing for improvement support through our improvement hub. So, I would like to see more of that being taken forward on behalf through the Scottish Health Council by engaging and supporting those bodies that are responsible for engaging with the communities, but doing it in a consistent, high-quality way. I want to touch on integration boards. You mentioned, I think that it was Sandra mentioned, about giving advice informally. To the convener, at the beginning, it is still not very clear exactly what you do to the general public and to me as well, actually, who you are accountable to and the legislation you have, but sticking to the intergenerational social care and health, do you think that your role should be extended to include that? Would it need legislative change for the role of the body to be able to work with the integration boards? You mentioned that you would give advice, but you do not have any legislative clout, as you might call it there. Would you be looking or do you think that legislation needs to change so that you can actually do a job with the health integration that is coming about? So, position is a healthcare improvement Scotland, which the Scottish Health Council, as a constituent part, is already engaging with the integration authority's improvement support. It is a good example around strategic planning, strategic commissioning of services, the work that we already do with the care inspectorate in the joint inspection of adult services, and we have just published a report, for instance, into North Lanarkshire. I do not believe that this is a legislative thing. This is about how we work with a broad range of stakeholders. It includes the care inspectorate, it includes the alliance, it includes COSLA, it includes a whole diverse range of voluntary groups. Within the resources that we have within the Scottish Health Council, we cannot possibly do everything, so it is about how we deploy the expertise and skills that we have got with other agencies to support and enable greater participation and engagement of citizens in the design of their health and social care services. I do not believe that it is a legislative thing. I think that it is important that we can work across organisational boundaries in a way that ultimately delivers better outcomes. That must be the objective. You do not believe that you need legislative change. You are already working with the integration boards. You mentioned in the fact that the groups that you engage with, at the very end, you mentioned public. That is the most important thing about changes. How do you expect to expand your role working with the public to ensure that they are consulted and that they know what the integration is? There are two parts to it. Sandra White might want to say a bit about the national citizens panel, but it is really important to engage with people at a local level. We will say a bit more about that, but can we hear if Sandra White wants to say a bit about engaging with people? I suppose that there are a number of different ways that we look to do that. Engaging people on national issues is something that we do through our citizen panel being one mechanism for doing that. We also use our local offices and their networks to sometimes gather views from people about a number of different issues. You might have some examples of that in the written submission. The citizen panel was set up partly because of a perceived gap in how you get the voice of the general public or the Scottish population into health and social care issues, rather than people who might already be involved and engaged. The panel was set up, and it was recruited from people across Scotland. There is a whole report that sets out the rationale of the thinking as to why we recruited in the way that we did. We went through the electoral register, we did some on-street recruitment, and we did targeted recruitment. The idea was to get a profile that was broadly representative of the Scottish population. We have been quite successful in that. There are one or two categories where it was a bit trickier to get that balance. We have, over the last year, tested working with the panel primarily through surveys. We have asked a number of questions, some of which have come from Scottish Government and policies that they are working on, some have come from other organisations, third sector organisations. We produce and publish the reports, and what we are keen to do is to see that those reports have an impact. We go back to the panel members with the right up of the finding, so they can see what is emerging from that. We also follow up with the people who have an interest in the questions and taking those forward to see what difference that will make, so that we can feed back to panel members on how those views have been used. That is a way of engaging with the broader public. I know that one of my colleagues is going to ask in regards to the consultation process and how many replies you had back. I will not go on in that one, but you have got the citizens panel. Concertation should be done by the health board, with the local people who are affected by it. I do not mean that in a bad way, but do you think that there is still a role for the Scottish Health Council? What you have said, not just to me but to others, is the fact that you give advice informally in regard to integration. That is what you said. Obviously, that is a huge big issue. You speak to the health board, you see if consultations have went out, but that statutory they must do consultations, although, unfortunately, like I have made, you had the same situation in Glasgow with a minor injuries unit, where we had to push them to go forward in a consultation. Do you think that there still is a use? Have you spoken to the Scottish Government about it? In terms of the work that we do around service change, which I think is what you are focusing on, clearly there is still an agenda around service change in terms of the 2020 vision and how we make changes to primary care services, for example. It is really important that people in communities are engaged in co-producing those changes right from the very outset. The ways in which we seek to add value to that process is that, in the vast majority of cases, it is about offering advice and good practice to boards, giving examples of what has worked elsewhere, using our local knowledge and intelligence to suggest perhaps groups that might not have had an opportunity or might not be on the radar of the health boards or the integration authorities to try and make sure that, as many people as possible have a say, sometimes that is also about doing a bit of capacity building with the boards. I am sorry to interrupt you. When you say groups that have not had a say, is this local communities? Yes. Is this patient groups? Yes. Because they are the people who are the most vulnerable and do not tend to get a say. I am not going to get into how many people have replied from you in that group, because I know that it is going to be asked before, but that would be your purpose is to get the had to reach people to come to you. Yes, absolutely. In the case of major change, the changes that are generally regarded as being the most contentious changes, I suppose that the value in our report is that we are providing an independent commentary, hopefully some independent assurance about how the process has been followed and an independent summary of the views and concerns that have been expressed by communities and where we think that the learning is. We hope that that is of value in terms of informing the decision-making process. So in light of the major questions that have arisen from the review regarding the council's existence and its role, can you tell me what material actions and decisions have resulted from that lengthy review? The first thing to say is that we have received that and we are considering it. Over the past two months, we have been taking very much the output from that. If I could say that there are four or five big things that we want to do on the back of this review. Firstly, it is about respecting the fact that we are no longer in a position of 15, as it was in 2005, territorial boards. There is a completely different landscape out there in health and social care. I will not dwell on that any longer, but we need to adjust to that. The second thing to say is that people are looking for us to influence and inform policy at a national level. I touched on children and adolescents in Scotland and how they access services. We know that half of adults in Scotland who have a mental health condition acquired that condition before the age of 14. There is an important role for us in Scotland's healthcare improvement in informing the design of services and in informing best participation and practice in accessing children and adolescent mental health services. That is one example where I would like us to adopt more of a national thematic approach. The third area that has been identified in the consultation is that there is lots of good practice out there. There is lots of evidence and lots of tool kits about participation and engagement, but it is pretty patchy as to how it is implemented. We have a greater role in not only quality assuring but also in giving the tools and enabling the capability to happen in a more consistent way. The other area that has come out of the consultation is around service change. We absolutely need clarity in respect of the role of the Scottish Health Council in that more integrated landscape. We can see a bit more about our thinking and how we convey that. Those are four big themes emerging from it. One of the other messages is a very positive message about the contribution of all our staff in the Scottish Health Council at a local level. The relationship is built up in a supportive way to NHS boards over the past 12 years or so. We also recognise the need to enhance the capability and expertise to allow greater involvement in the design of effective participation. That requires enhancing our skills and resources in the Scottish Health Council and building on the local presence that we have. Those are the resourcing issues that we need to think about how we do that best. Those are four of five. I hope that that gives you a flavour of some of the key messages emerging and how we are anticipating responding. You say that it is how you are anticipating responding, but I took a note of what you were saying. They seem to be more that you have identified that these are areas where you might need to change, but they have not necessarily explained how you will change or how you will take action on that. For instance, you said that you think that you would like to influence policy, but you have not exactly said how you would follow that through. You said that you think that you need to adjust to the different landscape of the health boards, but you have not said exactly how you will do it. Can you enlighten me a little bit on that? That will be a transition and a journey. The Scottish Health Council has been in existence since 2005. That will not be a flick of a switch to achieve all those things. There will be things about resourcing, the workforce, the skills, but it is also something about how we work with a range of partners in delivering it. We have had good work in relationships with the Care Inspectorate, with the Alliance, with COSLA, and it is important that we build on that and take it forward. That will be a two to three-year journey. On the specific point about the thematics, what I mean is that the Scottish Health Council, Healthcare Improvement Scotland, would publish in future a report about access to child and adolescent mental health services, for instance, and about how individuals were at young people, other families, their mums and their dads, and how they were able to access those services, and how easy it was and what the difficulties and what the challenges were, and how we can better inform more effective participation in that example. I suppose just to be described to you a bit about how things have worked and just how that might change for our staff on a day-to-day basis. We have lots of requests coming to us as an organisation locally and nationally for support and to get involved in a range of different things, to provide advice, to perhaps somebody that is reviewing a service, to provide training, etc. We have multiple projects, multiple pieces of activity going on across all of our work. What we think we need to do is to try and focus in on areas where we can make a bigger collective impact so that we join up some of the work that might be happening locally with our evidence function at a national level, with our volunteering programme and thinking about where the role for volunteers might be in a particular activity. What we really want to move to in future is a system where, rather than responding to all of those different demands on us, we are engaging with our stakeholders and we are looking at where are the areas, the priorities for services, where our collective efforts might make the biggest difference. That is what we mean by shifting to a more thematic way of working and doing that in a way that is more about collaborating with our stakeholders to make sure that we are avoiding duplication, that we are adding value and that we are able to demonstrate distinct impact, but that we are looking for opportunities to collaborate with others where our collective efforts might add the biggest benefit. I hope that that helps in terms of articulating what that shift might look like for our staff and what we are delivering each year. One of the interesting developments that we had last year was that I established a programme board for taking forward some of the aspects of our voice that the Scottish Health Council is responsible for. As a result of that, that has brought other people into play in a much closer partnership approach that has demonstrated how we are moving forward jointly with the Alliance and with COSLA. I think that it has been very positive. I think that we want to build on that type of partnership approach, but on a bigger scale. What is the implication, then, if you go to a more national model or way of working? What is the implication for the local engagement to which other colleagues have asked about already? What is crucial is that we do not throw the baby out with the bathwater in here. The local relationships and those local offices at that local level are absolutely important. What we need to do is think about, in the context of 31 integration authorities, 32 local authorities, three emergent regions, and start to think about how we evolve our relationships that go beyond where we have traditionally been on that spine of 14 territorial boards. That will require a different thinking about resources and people and how we use our people to the best effect within that. However, we have a budget of around £2.7 million. We have over 60 people. We have some extremely experienced people in what they have done and the relationships that they have built. We just need to be careful that we do not move from something that is a centralisation. That is not what we are about here, where it is about that balance between local identity, local presence and where we can at a national level add value by doing bigger national things. However, there are choices and priorities to be made within that. Thank you, convener, and good morning to the panel. I wanted to really look at how—I get both Sandra White's question and Ashton Damon's question—how that is actually going to happen in practice. If you are looking back at the last meeting, there was a quote that our former convener read out to you. It was from a constituent of mine that said that she believed that the SHC is a toothless beast with absolutely no power to enforce recommendations. How do you think that your review is going to change that for patients who are trying to put their faith in you as an organisation to speak on their behalf when major service changes take place? Is it time we looked at whether or not there is more of an independent role for you? In healthcare improvement Scotland, it would be fair to say that we do not pull our punches when we do our scrutiny work. We are very direct in how we convey some tough messages. There are some points of learning and reflection that we want to take from the service change process that we think can enhance our contribution from our participation and engagement perspective, and I would like Sandra White to refer to that. I think that that is a good question. We realise that major changes are areas where people feel really passionately about. We know that people can be quite lengthy, protracted processes, and there are people who invest a lot of time and effort because they really care about the services that are being considered. What we have in common with those people is that we want to make sure that their voices are being listened to and that that is evident in the decision making process by NHS boards. I have alluded to the fact that our reports, as well as looking at the process for engagement, seek to provide an independent commentary on the views and concerns that have been expressed by communities and recommendations. We speak to communities directly through those processes. If there are campaign groups that are established, we are keen to make sure that we understand and reflect their views in our reports, but our report is produced prior to the board decision making, and we send that to the board for them to take account of. One of the suggestions that I think was really interesting and one of the consultation responses that was received was whether boards could do more to perhaps more formally respond to our reports and recommendations. I think that that is something that we would welcome. I think that that would probably be welcomed by the communities who take part in those processes, because it would enable a clear articulation of how the boards are taking into account people's views. That might not necessarily mean that the board agrees with the views and concerns of people who have been involved, but they need to be able to respond to them and explain whether they are proposing something that is at odds with what communities want and what the rationale is for that. I think that that bit of the process is really important, getting that bit right. To really get to the nub of this, I was looking back at 2002, Nicola Sturgeon, when she was a member of the health and sport committee. She said that people feel that consultation processes are a sham and health boards go through the motions and then do what they want regardless. I think that that sums up where we have been concerned that your recommendations are just that. Health boards can ignore them and do ignore them, but when you are running a campaign, using you as an organisation to stand up, it is really important for people out there. From what I have heard, how do you think that that has to change? To make sure that your recommendations—maybe not to go forward with service change—are actually heeded by health boards, not just considered? Our role in respect to the Scottish Health Council is to ensure that, when it comes to major service change, the level of engagement and the quality of that engagement and the voice that has been heard. Our role is not to provide a commentary on the overall shape of the clinical model that has been, for instance, advanced, but what Sander has described is a process that would be more transparent about how the board has responded to the recommendations that we are making in the context of a quality assurance around participation. That would be very similar to the role that we already have in Health Improvement Scotland from a scrutiny standpoint about recommendations and requirements on NHS boards. There would be a level of transparency in the responsiveness of NHS boards. Alex Cole-Hamd. Thank you, convener. Good morning to the panel. My question stems from Miles Briggs and touches on some of the granular detail that we have covered lightly in this session so far, and that is about service redesign. Obviously, one of the functions of the Health Council is to consult around major service redesign, but we discussed that last year as well to a set degree. Can you remind the committee the process by which a service redesign is designated as either major or minor, and in the case of a minor service redesign, what your mandate is in terms of consultation of the public? I think that that is over to you, Sander. So, the process is determined and set out in the CEL4 2010 guidance for NHS boards. There is a requirement on boards to consider whether a service change should be major and if they think that it may be to seek advice from the Scottish Government about that. In approaching the Scottish Government, it is required to take account of the guidance on identifying major change, which sets out nine different factors around change, such as what is the impact on on patients, so how many patients are likely to be affected by a change, does it involve a relocation or centralisation of services, does it involve unscheduled or emergency care, is there public concern about the proposal so far based on the engagement that has taken place, what is the impact on other services likely to be, is there a history here around this service, so that guidance is really about making sure that there is full and comprehensive consideration of what a change is like. The board should consider that guidance and reach its own view about whether a change is major or not and then should then approach the Scottish Government, but when they do that, it has become custom and practice really for them to ask for our view to include that when they make their approach to the Scottish Government. We then offer a view, we take into account the board's considerations, we take into account our own knowledge and understanding about the process and the concerns that have been expressed so far. We also look at the precedent around it, so we look at have there been any other similar changes that have been considered in the past and were they considered to be major change or not. All of that then goes to the Scottish Government and ultimately it is the Scottish Government that makes a decision on whether a change is major or not. We think that it is probably unfortunate that it has become perceived as being this very two-tier approach about major versus non-major because, from our perspective, wherever a decision is being made, it is really important that that guidance, the process is clear, that people are involved right from the outset in helping to shape the change, but we appreciate that the status of it being a major change has become very important for some communities. In terms of minor service redesign, if the Government designates something as a minor service change, do you have any role to consult affected communities about that? We do not have a role to consult communities. The role in consulting communities sits with NHS boards. Our role, when it is a major change, is to provide a quality assurance report about how they have done that, and we speak directly to communities to inform our view. When it is not a major change, we still have an advisory role to advise on what changes might be, what engagement might be proportionate, and we do the sharing of practice from other areas about things that we think boards should take into account when planning changes. We would still be encouraging boards to make sure that their communities are having every chance to give their views on these processes, to be involved right from the outset, and that they should also be taking those things into account, but we do not have a formal role in terms of any quality assurance of non-major change. Given that any service change can be very emotive for the patients that it affects, the subjective application of that guidance can be quite troublesome. It worries me that the Scottish Government is the final arbiter of that, particularly when it is facing negative public scrutiny about proposed service redesign. Perhaps that should be taken away from the Scottish Government. The designation of whether it is major or minor should perhaps rest with yourselves or another third party body. Do not think that it is appropriate for me to comment as to whether a change at that level should be taken away from ministers. Ultimately, the national health services and the accountability of ministers is to this Parliament and about major service change, and it should remain with ministers. I am not here to comment on that. I think that what is important for the Scottish Health Council is that whatever the nature of the change is that we are there ensuring that there is best practice, there is effective participation in that. I take very much the point that is made that whatever it is, whether it is major or less than major, it matters to those communities. Thank you very much. Good morning, panel. I just wanted to follow on from Miles Briggs's question, when he is suggesting that HIS reviews and HSC reviews are recommendation, and there is no compunction to take those recommendations forward. Who has an overview of the implementation of those recommendations? It seems to me, as you and I both know, that in an HIS review in 2017, it was almost identical to the one that came out in 2012, the recommendations that came forward that had not been implemented. Should they be policed by yourself, and should that effectiveness of the recommendations be published? At the moment, to me, boards are self-reporting against those recommendations, so should the HIS and the HSC have a bigger independent role in policing that change? I think that it is an important point. What I would like to see, and it is picked at the point that Sandra Mead, is the transparency around the recommendations that arise from major service change. Ensuring that NHS boards do not just add it into the business case and off it goes, there is something about ensuring that there is a closure of a loop here, and when there are concerns, whether it is about communities' access to transport or the distribution of a service that is moving in a different way, those voices are heard and there is an active feedback loop from the issues raised in the recommendations from our work. It is an important part of the role of healthcare improvement Scotland. What is important is the patience at the centre of our work and the voice of citizens in accessing services, whether it is health and social care services needs to be absolutely to the fore. There is a transparency point in ensuring that NHS boards respond to recommendations in a very clear and meaningful way and that it is not about tokenism. In that case, who is reviewing those recommendations? Who is reviewing them and who is publishing them? How are you going to make that more transparent? From what Sandra has described, there is a process whereby we can make recommendations on the basis of a process of engagement and participation, which might be good, suboptimal or poor, but we make recommendations on what we need to ensure is the NHS board responds visibly and publicly to those recommendations in the future. That would be a good step forward in terms of transparency and building a more effective system of responsiveness among NHS boards. I want to implement that. Do you need more legislative power to do that? I do not believe that we need more legislative power. Thank you, convener. Good morning, everybody. I am interested in what has been done differently in the past year from the previous report to engage locally, because you have just looked at the Scottish Health Council's website, there are documents and documents that would take me days to go through, and they are all excellent. I have been a nurse for 30 years and I did not know that the health council existed until joining this committee. I have spoken to former colleagues that would be happy to engage. The question is what have we been doing differently? Sometimes I find that social media action groups are how the local people are informed, instead of boards that might communicate more effectively. Can the Scottish Health Council support boards to engage with local people? That is a key part of our role, to support boards and to encourage them to do more. Some of them are moving forward differently. Methods of communication are changing all the time. I accept your point that, as a worker in the health service, you do not always know, but we have had some very positive social media action. We are quite prolific on Twitter ourselves. It is about raising that visibility, which we accept may not have been quite so clear in the past. One thing that we have done differently, which has been quite a development for us, has been what is called the voices Scotland approach. That is about building capacity with community groups that might have an interest in getting more involved and trying to broaden the reach and diversity of people who are getting involved at local level. It is a flexible, modular approach. It was developed by Chest Heart Stroke Scotland. It is about working with groups to support and enable them to have an understanding about how their local services are structured, how they work, to encourage people to think about their own experiences of services, what matters to them, what might be the things that they might like to see change in their services, and how might they go about having their voices heard locally. That has been quite a new development for us, but our local staff are all trained in the delivery of that approach and have been using it quite flexibly in working with different groups. That is partly about trying to encourage some sort of bottom-up engagement from communities for it to be about encouraging bodies to respond to the issues that matter to people, rather than consulting about the issues that they want to consult with people about. It is about trying to encourage that confidence within communities. It is still a relatively new piece of our work, but it has been pretty positively received by the groups that we have worked with. It takes a long time to push change forward in the national health service, because it is very slow and people have to join together. I am also interested in how you decide how to go out and do consultations, the organ transplantation and tissue donation. There is no input from anybody in NHS and Frees and Galloway or the Borders, but we have input from Ayrshire and Arran. South Scotland is a huge region, so how do you decide who to go and engage with locally? That is what we call our gathering views work. That is usually in response to requests. Sometimes from Scottish Government, sometimes from other bodies. The advantage for us is that we have a national presence with a local reach. We are able to, with the contacts and experience that we have within communities, engage in quite a targeted way with people. It is about having conversations with the people who are asking us to do that work on their behalf. In the case of organ and tissue donation and transplantation, there had already been other work and other engagement planned, but I think that there had been a need identified to engage with particular groups. That was people with learning difficulties and looked after children and young people. That is because when it comes to issues around transplantation and tissue donation, there are particular legal issues around consent for those groups. That was intended to be a very targeted piece of activity. We worked with Bernardo's Scotland, People First, Arran Youth Foundations and others to design a session that would enable us to get the views of people with learning difficulties and looked after children and young people to make sure that their voices are being heard on those important national policy issues. However, how we target that engagement depends very much on what the ask is. Who is the target audience? Who is it that people are looking to reach and who might we work with and collaborate with at local level to enable that to happen? Does that help to clarify? I'm usually Kate Forbes. Two really brief questions. The first one is in a word. Do you think that boards are engaging better or worse with the public? I'm not sure that it's a binary answer. I think that there is good practice around the country in demonstration of good practice of engagement, but there are also examples of pretty poor practice. I think that what we need to be doing within Healthy Improvement Scotland, the Scottish Health Council in particular, is bringing to the surface that really good practice and have equally the transparency about where poor practice is happening. That's when we'll get to a much higher quality level of engagement across the country. Thank you very much. Secondly, if you could identify a specific example that would be useful too, I note that boards in 2016-17 are largely focused on feedback, comments, concerns and complaints when it comes to their engagement, which is very much retrospective. Could you give an example of a board that's done a good job in terms of engaging with the public in a way that's bigger and broader than just reports complaints? We did some work specifically around feedback and complaints using our participation standard, which is about going out and looking at how our boards are responding. There was a bit of a mixed picture around that. Can I just clarify how you're looking for an example, which is about broader engagement? I'm trying to keep it quick, but in terms of how you are identifying generally, when it comes to your reports, how boards are engaging with the public and whether they're meeting the three participation standards, I note that in 2016-17 you were largely focused on complaints, etc. Are you also looking at the other standards in the participation standards, and was there a particular board that stood out in terms of how it was doing that? We only looked during the recent assessment at how they were handling complaints and feedback, and that was on the basis of expectations within the Patients Rights Act a number of years ago, which was about looking at complaints and feedback in a much more holistic way, not treating them as separate things, looking at all of the intelligence, making sure that there's lots of different opportunities for people to give feedback, things like care opinion, for example, making sure that people have access to the patient advice and support service. The participation standard assessment that we did was focused very specifically on that area of board's responsibilities. The process this year showed that some boards had made real improvements since the previous time that we had looked at that a couple of years ago, others less so. There's a national overview report that sets out our findings and pulls out examples of good practice from a number of different boards around it, but it's a really important area for patients and carers as well. Thank you very much. That's been a very full session in a short, compressed period of time, so we're very grateful and we will now adjourn the session. Thank our witnesses very much and we'll adjourn for five minutes and we'll resume just at 11 o'clock for the next session. Colleagues, welcome and we will now resume. The second item on our agenda is an evidence session on the Scottish Government's revised national outcomes. I'm delighted to welcome to the committee today Shona Robison, Cabinet Secretary for Health and Sport, Alison Taylor, the head of integration and Roger Halde, the chief statistician at the Scottish Government, Jerry McLaughlin, the chief executive of NHS Health Scotland, and also Professor Sir Harry Burns, Professor of Global Public Health at the University of Strathclyde, and I understand just a few moments ago a grandfather, so congratulations as well as well. On that cheery note, I'm sure Professor Burns would have many cheerful things to say to us in any case, but I can tell that he's going to have a particularly elated session this morning, but nonetheless there are some serious questions to ask and I would like to start, if I may, with Alison Johnstone. Thank you very much, convener, and good morning. I'd like to ask the witnesses how the national performance framework will address health inequalities, obviously an area of some concern in Scotland. If I could kick off in broad terms, obviously the national performance framework is designed to enable us to see how Scotland is performing against a range of indicators relevant to health inequalities and to make sure that it informs policy making going forward to tackle health inequalities. Wherever possible indicators will be broken down by both protected equalities characteristics and area-based inequalities. As part of the transformation of the Scotland performs website, we're going to report on progress for both of those equality aspects. Obviously, reducing inequalities, as I'm sure you're aware, is already a key feature of much of the Government's policy programme. In smoking, for example, we set targets for health boards to reduce smoking in our least well-off communities as a priority. That's led to greater levels of success in targeting those services and the proportion of people successfully quitting from more deprived communities now far higher than anywhere else. Obviously, today, with minimum unit pricing, again, there's a stark social gradient to alcohol-related harm, and the minimum unit pricing policy will deliver greater benefits to lower-income communities where health harms are disproportionately experienced. It's also probably worth just mentioning that we are also investing heavily in mitigating the impacts of welfare reform and austerity, with £100 million per annum spent in that area. I think that it's worth noting that, across the whole of government, it's not just my portfolio that's important in reducing health inequalities, and it can't just be done by the NHS or, indeed, integrated partnerships. It has to be done across the whole of government, and that provides the opportunity for all the whole of cabinet and the whole of government to focus. I very much appreciate that point, because a Government letter in response to the committee's 2014 inquiry on health inequalities did state that tackling health inequalities isn't a matter for the NHS alone. I would just be very grateful if witnesses per caps touching on that health inequalities being addressed by all portfolios. Could you give a couple of examples of how you think that might be demonstrated? I think that the welfare reform and the £100 million investment per annum is clearly about household incomes, supporting people, and it is clearly a tool in tackling inequality. Lightwise, in education, the attainment fund, again, having that resource for head teachers to be able to support children within schools, particularly in more deprived communities. There will be examples across all portfolios. I guess that where the national performance framework is important is being able to take an overview of that and to ensure that, as we can measure the Scotland's performance against those indicators that we're taking across the Government approach to that. I don't have too much to add to that. I suppose that this is a framework that very much is looking at how we improve the economic, social and environmental wellbeing of people in Scotland, and that's why we've got the purpose of values and a set of outcomes that sets that out. Fundamental to this is the approach that mainstreams equalities throughout Scotland. This time, we've moved from having a situation in which we have a specific outcome on reducing inequalities to being something that's done throughout the framework. We're reporting progress, as the cabinet secretary said, for different equality groups and for area-based inequalities. We're using that information to tell whether we're making progress for the whole of Scotland and for the different communities in Scotland. I could pick up on an example that demonstrates the point that you're raising. Some work was done a couple of years ago around the development of a place standard for local communities, which looks at a range of those outcomes and indicators that are spread in terms of responsibility across public services and looks to create, particularly as we have regeneration within communities or new communities being established, the kinds of conditions that will both improve and indeed create health and wellbeing. At the heart of that is the use of a tool that engages local communities about what's important to them. Clearly, they do not define that within the context of Government portfolios or indeed the responsibilities of individual agencies. From a public health point of view, the extent to which we can influence local community planning in discharging its new responsibilities under the Community Empowerment Act, gives an example of how we draw right across those different national outcomes. Harry Burns? Down the list of indicators and so on, every single section has things that will contribute to narrowing inequality from the economic one about productivity and jobs and so on to things like poverty and those kinds of things. For me, the critical part of this, and I've spoken to the committee before about complex system change, the important bit of this is about how action is going to be taken forward. Who's going to be doing things? What do we want to change by how much by when? Our experience with things like the earlier collaborative and the patient safety programme tells us that the best people to design that action are front-line staff. It's not something that is easily done in offices a long way away from the communities that we're trying to help. You could easily imagine a local authority sitting down and taking some of those indicators and saying, yes, we're going to try and work to change the following five things. What do we want to change by how much, by when and by what method? Once that gets going, we'll see change happening. Do you feel that there's a bit of work to do there then? There is under next steps in the document testing new approaches around delivery of the outcomes, focusing initially on four outcome areas to identify methods to turn broad outcomes and tension into concrete policy options and proposed actions. I think I know what that means, but there is clearly a plan and it's got to get rolling and it's got to be scaled up as quickly as possible to have a significant impact across Scotland as quickly as possible. Can I build on Alison Johnstone's points about health inequalities? I was doing quite an interesting article on evidence from Pickett and Wilkinson in 2009 that said why more equal societies do better. The argument was that we need more emphasis in social economic factors. Why is it the poor die younger than the rich? It was arguing about having a fundamental change in society in the macro level to change the power distribution. That's obviously a wider point than this committee, but I wonder if any of the panel wishes to comment, particularly perhaps Professor Shahari Burns initially. Pickett and Wilkinson's whole theory is based around what Sir Michael Marmot talks about a status syndrome, that inequality per se makes people at the lower end of that scale feel bad about themselves. It's actually more complicated than that and I've had a number of discussions with Richard Wilkinson about this kind of thing. It's entirely possible to narrow inequalities using a whole range of approaches, but the fundamental one is to give people a sense of being in control of their lives. If you're living in bad housing, if you don't have a job, if you don't have a sense of purpose in life, if you're worried about drug pushers getting at your children and so on, you are buffeted by circumstances. If you yourself have had a difficult childhood, then your ability to feel in control is impaired. There's lots of evidence that the way public sector interacts with people can either enhance their ability to be in control or can damage it. I've been arguing for a while about changing the way in which public sector interacts with people living at the lower end of the social scale to enhance their sense of self-efficacy, to enhance their sense of control. Lots of evidence that that improves educational performance in children in those families, reduces the risk of offending, increases the risk of their chances of educational success and so on, and increases their chances of ultimately participating in economic growth. We do a lot of this service by reducing complex problems to a single cause and effect relationship. It's much more complex than that, and we need to adopt complex system approaches in order to be successful. At the end of the day, if you get change, you might never know what it was that you did that produced that change. It might be 10 of the 20 things that you tried that produced that change, but my argument is who cares as long as we make things better. I could perhaps have one final one or two, perhaps the cabinet secretary. Obviously, we've had unanimous decision about MUP, which I think has to be welcomed. What are the next steps for that? Clearly, we all know the damaging effects of alcohol. There are some suggestions—I'm not recommending this, cabinet secretary—but there are some suggestions in the press that we should have health warnings on alcohol a bit like we have secrets. There are also the second issue, as you know, about the social responsibility levy, which I know has been put on hold in the meantime. Can you say a little bit more about the next steps for this? Clearly, alcohol is a major issue in Scotland affecting our health. I'm happy to, given today's importance in taking forward what I think is hugely important public health policy. I'm very pleased that it has cross-party support. You'll be aware that the framework is being refreshed. We've always said that minimum unit pricing doesn't stand alone. It stands with a range of other measures that are being taken. Looking at the issue of advertising and health warnings has been part of the consideration that Eileen Campbell has taken forward around the refreshed framework. There are already some that have the CMO's guidelines on and drink responsibly messaging. I guess what others are calling for is to go further than that in terms of the warnings that would be on the product. I think that some progress has already been made, which is to be welcomed, and we'll certainly give consideration to the further calls. Some of that will be between UK producers or international producers, so there are issues there around advertising and where the responsibility and power to change that would lie. Obviously, those are quite complex matters, given where production would take place, but we are certainly looking at what more can be done in that space. In terms of the next steps, the evaluation will be important in looking at the success of minimum unit pricing and what it will tell us about whether we need to make any further adjustments in the future. That evaluation will start straight away and will run through for the five years to give us a wealth of information at the end of that. As I have said before, we are really happy to keep the committee informed about that, because it will not just be that we start here and we end there. There will be information flowing through the course of that evaluation. We are very happy to keep the committee informed. Anything about the social responsibility level? As we have discussed before, the social responsibility was designed to be a local mechanism to recognise perhaps demands on local resources. It was never really thought of as a national tool to be in response to policy like minimum unit pricing. However, whether it is a social responsibility levy or the public health supplement, we will keep those matters under review. We felt that it was not the right time, given some of the economic circumstances that the country has faced over recent times, to apply the public health supplement again. Obviously, we have done so in the past, but we will keep those matters under review. I encourage colleagues to keep questions and answers in the context of the national outcomes, if we may. Alex Cole-Hamilton Thank you, convener. Good morning, cabinet secretary and officials. Congratulations to Harry on your new arrival. I would like to draw the questioning to the content of the indicators, what is included and, more importantly, what is not included. William Valentine is 96 years old. He is my constituent. His son and daughter came to see me yesterday because William was admitted to hospital at Christmas. He is in the western general. At the start of February, he was declared fit to go home. A social care package was drawn up. It was not a complex package. It was three visits a day that he requires. Nearly 100 days later, he is still in the western general because there has been no provider willing to take up that commission. We know that deficiencies in social care in our communities, particularly for older people, create an interruption in flow throughout the whole of the health service. It means that elective surgical operations are cancelled because there are no beds for people to be admitted to. It is partly responsible for why we have delays in A&E because there are no beds in the wider hospital for people to be put through to. In that context, can I ask why there is no indicator within the performance framework for the provision of social care to older people as an indicator to underlie the health of this outcome? First of all, you raised an important point about delayed discharge. Of course, the trend has been downwards 7 per cent reduction over the course of the year. That is good, however. There are local challenges. You will be aware that, within Lothian, there are particular challenges. There is a new chief operating officer starting within the integrated authority in Edinburgh, who brings a wealth of experience from Aberdeen in terms of mechanisms and policies that are taken forward there. What is important to say in a general nature is that the national performance framework looks at the key indicators that can establish Scotland's performance, but underneath that is a wealth of work that is going on, particularly within integrated authorities. Integrated authorities have been doing huge amounts of work around data collection and developing their own indicators. Tackling delay is one of the key indicators. As you say, it connects to making sure that we can reduce unschedule care and reduce the length of stay. We can avoid admission to hospital in the first place. All of those things are absolutely key around the indicators that integration authorities use. Alison probably knew more of the detail on the work that has been done. Thank you, cabinet secretary. Absolutely. The national performance framework, obviously, sits across the top of Government responsibilities. We are doing a lot of work with the integration authorities, as the cabinet secretary said, to support them to have a core of improvement measures that they share with us, which are common across the country, but to build around those a network of measures that are appropriate to local circumstance. I would expect to see quite a lot of variation in which measures individual partnerships used, particularly where they had obvious recognisable problems of the sort that you describe. For example, I know that in South Lanarkshire there is built up around the partnership a framework, a local framework for improvement, which looks across about 100 measures. It specifically focuses on areas where they know that they need to see improvement and make progress. We have a lot of work under way to reinforce the data that is available to partnerships, so that they are using a common set and there are comparable lessons and evidence to be drawn from that. However, on top of that, as you rightly reflect, there is a need to consider locally what the pressures are that need to be addressed. As the cabinet secretary has indicated, we are supporting colleagues in the Lothian partnerships and particularly Edinburgh around the problems that you describe. Thank you very much, cabinet secretary. You will recall that there was a commitment given in the budget scrutiny that we would receive data regarding integration joint boards by the end of March, and that is still not arrived. I wonder whether you want to comment on that. I think that there is a letter drafted coming to you very soon on that, if my memory serves me right, so we will make sure that you get that as soon as. I just wondered whether it would be helpful to say something in general about the indicators and why we have chosen the set that we have, because you are right that we could have had hundreds of indicators, thousands of indicators, but I am in charge of statisticians around the country that are beavering away, producing some great data. However, we have chosen 79. In other countries that I have seen around the world, they have a maximum of 50 indicators when they are trying to describe economic, social and environmental progress. We did some consultation events with a couple of 100 experts that generated hundreds of ideas, and I knew that I needed to whittle that down. I have done that by some principles, which were that it was important that the indicators that we had measured progress towards each of the 11 outcomes that we had, that they could tell progress across different parts of Scottish society on any quality group, so that the data is technically feasible and so that the underlying data of it allows us to tell whether there is improvement or worsening of measures and that where possible we are aligning the indicators that we have here with the indicators from the UN sustainable development goals. That helped us to decide which of the indicators that we would go with. Thank you, convener. I am not suggesting that these indicators are not worthy. They are quite worthy and quite exciting in some cases. However, even though that process is as you describe it, I am still not persuaded that an indicator that measures the number of visits to the outdoors is more important than the fact that we have nothing in this suite of indicators that measures the health of our social care landscape, which, as we know from much research that this committee has done, is one of the main blockages to an adequate flow through the NHS. Why should we not think that the Government has its head in the sand on social care, because it does not have an indicator to measure provision within our communities for it? As you are well aware, tackling delayed discharge is a key government priority, reflected in the fact that all of the integration authorities have that as a key target. It is local delivery that is going to deliver and is delivering the reduction in delayed discharge. Without that local delivery and the indicators and targets being applied across the integration authorities, we would not have got the reduction in delayed discharge. Sitting with an indicator in the national performance framework is not going to deliver the change locally that partnerships need to make sure that they, because each area is different, need to make sure that their targets are relevant to their area. It is through that sustained work around tackling delay that has led to the reductions. If you look at the City of Glasgow and what it has managed to achieve for the size of its integrated authority, it is absolutely astonishing. We need to recognise that, in Lothian and Edinburgh in particular, they have particular market issues of the ability to recruit social care staff who are well aware of them. We need to help that partnership to overcome some of those particular issues. That is particular to Edinburgh and Lothian, and it has to be shaped in that local context if it is going to be in any way successful. That is why those targets better sit within the integrated authorities. It is working. That is why we have a reduction in delay that I do not believe that we have had if we had not had those that focus through the integrated authorities driving delay down. Sandra Hart. Yes, convener, just a small follow-up from Alex Cole-Hamilton's. We have mentioned before about the framework. It is not just about the negativity, it is about improvements in people's health as well and picking up on the older people's situation. It is a good thing that people are going to be projected to live longer, and I am looking forward to joining them. I am sure that lots of us are as well. It should be celebrated that people are living longer, but hopefully in a better atmosphere, in a better way as well. I was a wee bit concerned that there was no outcome for older people, but I quite understand that there are so many underlying issues in that respect. When we are getting feedback from the various agencies, will there be an outcome for older people at the end of the day? Will it be included in the frameworks or will it be included in all the other groups that are there as well? I just wanted to pick up on that. People are living older, yes, but probably the worst thing for people's health, mostly older people, but not just is loneliness. I am assuming that the strategy for loneliness would be included in that, too. Another thing that I wanted to pick up on was Dave Stewart's point about alcohol and minimum pricing. Although we continually mention younger people, alcohol-focused Scotland did a pretty big, massive survey. Unfortunately, most people who are targeted at the moment, and hopefully minimum pricing will help in that respect, are older people who are lonely and sit at home and are drinking there as well. There are facts and figures to prove that. Will all of that be included in the strategy that will feed in to the national performance framework? I guess that it is like a pyramid. You have the national performance framework with the broad indicators at the top of that, but underneath lies all the work that you have highlighted, Sandra, and all the local delivery that is where change is going to happen. Again, I cannot emphasise enough the role of the integrated authorities because they are the delivery mechanisms for change. They will take all of that, but they will then craft it to be relevant to their local circumstances and to make sure that they are focusing on what the priorities are for their area. You mentioned loneliness, and many of the integration authorities are focusing on reducing social isolation, bringing people out of their homes and making sure that, as we have talked at this committee before, the idea that someone does not see anybody from their care worker on a Friday through to the Monday is not something that we want to see. Tackling loneliness and the involvement of the third sector is crucial. Again, we are encouraging integration authorities to have a focus on that and to reduce social isolation. The work throughout all that is going to, in one way or another, impact on the broad outcomes at the top. Brian Whittle I think that you are probably aware that I have a particular preference for looking at the prevention agenda. I think that we are looking at national outcomes. For me, what comes up is the health of the nation, a measurement against the health of the nation. I think that we would all accept that perhaps we are not doing particularly well in things like mental health, in terms of drinking drugs and obesity. In terms of the health of our healthcare professionals, which I have got to say is fundamental to the delivery of any national outcome. With that in mind, I wonder whether you think that the national outcomes need a stronger focus on the prevention that creates that environment that encourages better and healthier choices. I think that there is a focus on that, in terms of reducing inequalities that we were talking about earlier. A lot of that is around prevention, whether it is in the field of alcohol. Obviously, we would see minimum unit pricing and all the rest of the framework as being about cultural change. It is about trying to change the nature of our relationship with alcohol, which is clearly about preventing alcohol misuse in the next generation and viewing alcohol in a different way. I think that we have made quite big strides forward in public health policies and smoking, for example. You are right to highlight obesity, which is obviously the next challenge. You will be aware of the work that Eileen Campbell has been doing around trying to make sure that we take an evidence-based approach to our public health policies that can begin to make inroads into that area of public health. I think that the new public health body will be able to help in giving a sharper focus to the prevention work, not just what is happening within the health field, but in its support for local government, for example, in being able to help local government and other local decision makers around some of the decisions that they make in the public health arena. I am working on a pace with the new public health body. I think that all of that will help to rightly focus us on the prevention. Harry's point is important here that it is not just about a particular health challenge, but about giving people a chance in life and hope. That has to underlie what we are doing, particularly around children and young people, and making sure that we get that right. That has to be one of the keys to improving the opportunities of the next generation, which impacts directly on their health and wellbeing. That is why we have a particular focus on children and young people. Rather than talking about the health of the nation, I prefer to talk about the wellbeing of the nation in a broad sense, because a healthy population will tend to be a population where they will see low crime, high participation, good social cohesion, productivity. Across the board, we are firing on all cylinders. It tends to be a positive childhood, a nurturing childhood, that takes young people into an environment where they learn, participate and behave well. Coming through in the train today, there is an article in that free newspaper that they gave away talking about how young people who get into trouble, their brains are wired wrongly. We have known that for about 20 years. We have done studies in Glasgow that shows that psychological activity differs in people who have lived in complex situations as children. They learn to be defensive and they have their emotionally labelled or their executive functioning. They do not make good decisions and so on. We can see that. When I talk to teachers, they do not, because they see that in their classes. It is about getting families secure, safe and feeling that they can move forward in life that will make the big change in the future. I think that the suite of indicators is something that contributes to that in every single section, but I come back to the point that there is a huge number of those things. How do we make them work together? How do we get local authorities, health boards, Police Scotland, education authorities and so on to be working together in order to deliver across all of those indicators to make the necessary change? I am very excited by the possibility, but I am in no doubt as to how difficult it is going to be to get this to happen. We need a real open-minded approach to working together and testing things. If they work, do more of them and if they do not work, stop doing them and move on. A really good example of that cross-government approach was the recent event looking at adverse childhood experiences. Every Cabinet Secretary was there at that event to listen to the experiences of people, but it was also important to look at how they could have been prevented in the first place, but also when they occur, how to pick up and have early interventions. When you look at the impact of that on the population and the cases that Harry is referring to, it is huge. We are absolutely taking a cross-government approach. It is not one Cabinet Secretary that can begin to tackle that. It has to be cross-government, and that work is under way, and I think that it is going to be very important. Turning to that preventative approach, you will recall that one of the pillars of the Government's health and social care delivery plan was about the reform of public health in Scotland and a particular relevance to my own organisation, because we will become part of the new national public health organisation. However, there have been some important developments as we pursue that reform. One is that, in the next month, I expect a new suite of public health priorities to be published. They have been developed on a whole system basis right across public services, but with a particularly strong focus from local government. In the course of the discussions, particularly on the oversight board that is looking at those reforms, there has been a contribution from local government about the extent to which the public health voice in local communities needs to be much stronger in informing community planning. It is a real plea that we position public health to support community planning partnerships, because it is within those local communities that plans around transport, planning itself, will then encourage rather than just to exhort people to be more active. It is a good example of that preventative approach. Those priorities that are emerging are entirely aligned with the national outcomes as they are being developed. As you have alluded to, that is not just about your portfolio, it is about a cross-portfolio issue. I want to clarify that the other portfolios are feeding into those national outcomes and are implementing their policy against some national outcomes in health. I gave one example of adverse childhood events, but across the whole development of the framework, it is absolutely across Government. There has been a bit of a change of focus of looking for opportunities to collaborate. For example, you might be aware of the work that I am doing with Michael Matheson and Justice around looking at the prison population and how we can improve the outcomes for prisoners, particularly when they are leaving prison, to reduce the risk of re-offending. That is about making sure not just that they get access to health services to address issues with addiction, but that there is a whole range of other ways of minimising the risk of re-offending. That is one example of collaboration that feeds very much into the framework. There are many others, and I think that there is a real willingness to look and seek out opportunities like that. I wanted to ask how the principles that are espoused in the Government's review of targets and indicators are going to be manifested within the national performance framework. Specifically, the rationale around the review of targets was that NHS staff and managers had expressed frustration at the way targets were affecting their work and their priorities, leading them away from best practice. In terms of empowering our NHS and social care staff, how do you see that happening in the future? When a nurse tells me that they are frustrated at the amount of formfilling that they are asked to do, how is that going to change their lives and empower them to do the job that we want them to do within our health services? We certainly want to reduce bureaucracy in people work generally. The more we use technology, it is an opportunity to do that and to make sure that we maximise the amount of time that health professionals and anybody else has working with people rather than paperwork. Developing the new framework, I think that we are very mindful of the need for coherence with the work that Sir Harry's review has taken forward. I think that the new framework reflects that in a number of ways. It is providing an improved clarity on the aims of the system. It has more of a focus on indicators than targets. It is being shaped through engagement with a range of stakeholders and it looks across the whole system on how they are interconnected. We have sought to incorporate the findings of the review into the work on the framework, but we also recognise that the framework will continue to evolve and that the recommendations from Sir Harry's work can be further incorporated as we take that forward. There are a number of other pieces of work under way, so looking at how we focus more on outcomes rather than necessary targets. There is work already under way around the cancer waiting times. There is work looking at A and E, and the four-hour target is important, but so is the experience of patients across their whole experience of unscheduled care. We are looking at that as well. I think that there is a lot of work that is aligned to this, and some of that will be reported quite soon. I think that you will find that it is in line with what Sir Harry had recommended. The comments that I made in the previous national performance framework, when it was frustrating that the national performance indicators were really only being measured annually, did not seem chymious enough to be able to make any change. If things were going wrong, waiting for another year to measure it would not give you any decent feedback as to whether or not what you were doing was having an impact on them. However, the second thing was that I found that some of the process targets and indicators in healthcare waiting times, four-hour waiting times and so on, are important. However, I was hearing stories of people who were attending their local A and E department 40 or 50 times a year and who were also calling 999 40 or 50 times a year. A four-hour waiting time in A and E is not going to help that individual. There are other things going on in that person's life that need to be addressed. That is where those high-level indicators come in. What I was interested in was, rather than worrying about how quickly people were getting through the system, I was asking why people were going into the system in the first place and where they were going at the end of that system. The NPF indicators will give me the opportunity to manage that broader system and get change happening there that would reduce demand and improve outcomes. It fits with what I was concerned about in the review. When you highlighted that, the whole committee agreed that people should be getting treatment and care from the right professional in the right setting. Empowering our professionals was really my point. I have met nurses who have never met their managers. I know their name, but I have never seen them. It is looking towards how our health service is going to change in the future for a different system. There is lots of speak within this report around main change management, but making that happen in the health service does not know how we will do that. I am interested to hear how you think that that should happen in the future. I agree with you that, where we have seen successful change in things such as the early years, collaborative and so on, it has been through front-line staff being empowered to make change happen. That requires leadership from the top. It requires leaders who will come along and say, You know about this better than me, so I am happy to let you test the change and tell me what happens. Give them permission to do things differently in the hope of finding a better way of doing it. There are any number of examples in industry and so on of that happening, and we have examples in public services in Scotland where it has happened. To spread that is the way to make change happen quickly. One of the best examples in the NHS is the patient safety programme. It has worked on that principle of empowering front-line staff. That is not a memo from a senior manager saying that you need to do it, it is about empowering. That methodology is now being used in other areas of the health service, for example mental health and primary care, and in other parts of the public service and justice, because it is very much about empowering front-line staff. I think that drives cultural change as well. One of the examples of making sure that our finances are spent as well as they possibly can is the empowerment of front-line staff in giving and testing ideas around the way that things are ordered, the way that money is spent. For example, front-line staff within wards have been making changes that they have wanted to make for quite some time, but they have been empowered to do so. It has had a huge financial benefit to that area of the hospital, because they know that processes could be improved. It is about listening to front-line staff, but also empowering them to make changes, whether they are procured through to patient safety through to other areas. That is a big cultural shift. Just to add to that, when managers feel that they are going to get shouted at in the press, or dare I say it in the Parliament, for failing to make a four-hour waiting time, it is understandable that the focus is on that rather than on the big picture. We all need to understand that this is a complex change that is under way. You may not have made your 95 per cent target, but that might mean that there are an awful lot of people coming in the front door, and you should be managing that rather than throwing all the money in effort at the four-hour waiting time. I always enjoy talking about that stuff, because this is what I did for a living before I came into politics, so it reflects the experience that I have had in implementing those kinds of systems across a range of organisations. On the positive side, it is great that we talk about empowerment. It is wonderful that the system is thinking absolutely correct. It is clearly very important that we measure the right things, and there is an understanding there that you need to dig in and understand unintended consequences and make sure that we are focused on the right stuff, and I can see that the thought process is starting to go in that direction. The thing that concerns me, when I was looking at this, is an organisational review of things that I have done in the past. You would say that it is great that you are measuring things, it is great that you are having a conversation about whether we are measuring the right stuff, but there is clearly quite a long way to go in terms of the things that we are measuring lined up with each other. Those are the things that are most important for the organisation that we are trying to deliver, and I would really live in and breathe in that stuff and use it to drive process improvement, because I cannot get the feeling that I do not think that you wake up in the morning and the first thing that you think about is the national performance indicators, and the last thing that you think about before you go to bed is the national performance indicators. If you are doing this process properly, that is exactly what you would do, because what is on this piece of paper in front of us would be completely aligned to everything else that is important right across the organisation, and every single thing that was happening in the organisation would understand the linkage from that back to what is on this piece of paper. There are still a lot of ways to go in that journey, which is fine, because the more we go down that journey, the better things we are going to get. The question is if you are looking at what we have in terms of this piece of paper, the national performance indicators, the work that you are doing on indicators, what health boards and integration authorities are doing on local delivery plans, all of that in a perfect world or on a sensible world should all be joined up so that you know what they are doing here, links up with that and we understand that linkage in that relationship and what they are doing on the health board at the local level directly impacts something on this piece of paper. How are we getting on with joining all that up so that it is all linked up? I think that we are. If you look at the work under way with integration authorities with the data working group, that work is very much aligned, I think, with the LDP standards that continue to be important and are being reviewed, and I touched on some of that earlier on. Your point about measuring the right things, so developing Harry's point in that regard, he is absolutely right. It is about why are people ending up at the front door of the hospital and we are understanding that a lot more and the work that integration authorities are doing of explicitly saying that we are going to reduce those unscheduled episodes because we know that a lot of people are in the wrong place for them. That is why you will see integration authorities investing in primary care, keeping people at home, services that do that, so that it delivers that outcome. I think that we are seeing far more of a focus understanding some of the addiction issues and that is why some of the work going on, particularly the Glasgow Royal, where it has identified people who keep coming through that revolving door, so dealing with that and having alternatives for them is the focus of the work. I think that we have understood that a lot more and that is why all of that work is aligned, and to the national performance framework, the success of all that will drive the indicators in the national performance framework in the right way. Get it back to that pyramid, all the work at the bottom of that pyramid is going to drive the indicators at the top in the right direction through making sure that we are focusing on the right things. That is an important example that the cabinet secretary has given about the objective to reduce occupied bed days in hospital that is set out in the delivery plan. We have, for a very long time, quite rightly and improperly focused on delayed discharge. Everyone in local systems tells everyone this, so everybody knows this. If you start thinking about the problem at the point when someone is delayed, you are starting thinking far too late. What we needed to do was get a much more holistic look at the whole pathway of care, the sort of experience that Harry is describing, and look at what is happening before admission. Setting it out as an objective to reduce unscheduled bed occupancy while at one level still looks like quite a narrow definition, narrow enough that we can actually count it, which is important to. At the same time, it is a good signal for what is happening across the system and the relationship that we have with the partnerships, so that they are looking at their current performance. They are establishing a good objective for them to improve to fit into the national aim. I think that that is a good balance. It is a good balance of responsibility and it also signals a good relationship between the national partners and the local partners. I am hopeful that we are measuring better, if you like, and in a better way than we were. Anyone else? Being responsible for one of Scotland's public health bodies, it was interesting that, just over five years ago, we were responsible for health improvement in Scotland at a national level. It was very clear that health inequalities had become a very real focus within the public policy narrative of Scotland. It was to the national outcomes that we looked to almost source the authority for a change of emphasis towards focus on inequalities. That is why our organisational strategy is called a fairer, healthier Scotland. That gave us the opportunity to then look outside of the world of the NHS, within which we operate for most of our business, to work with natural partners. Therefore, it required us to develop a whole different approach to what that partnership looked like. I mentioned earlier on—this is quite a good example—the place standard. That was a piece of work undertaken by our own organisation, Scottish Government planning officials and Architecture and Design Scotland. It was not what you would expect to be natural bedfellows, but it was quite specifically because bringing those people together, on the basis of the evidence that we had looked at, was more likely to create the conditions in which people can be preserved, maintained and, indeed, health and wellbeing can be supported. That is why I also said about the changes of public health that give me a lot of cause for hope. The extent to which Scottish Government has now engaged in a very formal partnership with local government around how we create public health. One of the disadvantages that we have had in Scotland over the past 40 years is that public health has, in many cases, become quite disconnected from local government. That is a real opportunity to put public health right back in the centre of the public sector space between the NHS and local government. That is largely driven by that focus on the national outcomes. The only thing that I would add to that is that, stepping back from this, what I see is that, while we have some on-going challenges about implementing this, the national performance framework has seen internationally as a world leading. The international commentators around the world, Professor Stiglitz, said that. Indeed, many countries have, over the last few years, come to Scotland, taken and adopted this approach. We have some way to go, but we are still quite a long way ahead of other people. Thank you very much, Kate Forbes. On how you empower staff and include staff so that it is on top of their agenda when it comes to doing the daily work, how do you, in terms of improving the ways that they can feed back into the implementation? Talking about trial and error, there will be times where it works and there will be lessons to be learnt as you go ahead with monitoring and reviewing the performance indicators. How do you envisage professionals being able to feed into the process, not just at the beginning of the indicators but also on an on-going basis? We need to look at what the evidence tells us works. With any change, there is a lot of change happening, a lot of reform going on across the public sector generally. We have learned lessons that the worst thing to do is to send a memo down from on high saying, as of next Tuesday, that this is how we are going to be doing it, because that does not create change. The better way to do it is through the improvement methodology that the patient safety programme has shown works. You test the theory of a change in a particular setting with a particular group of staff, wherever they are and whatever they are doing, and you get them to test the method and then they see the benefits and then they become the proponents of why this is a better way to do things. It is not rocket science, but it works. I think that it is making sure that staff are involved in understanding and talking about why this change is necessary, why it is better to do something this way and then the methodology of changes is about making sure that that is tested properly and then they become the promoters of doing that in a different way. If you look at 10 years down the line from the patient safety programme, that is how it started. It started very small in one area, doing something different and has now become a way of developing, delivering change across the public sector. When I was at Western General, some of the folk who were involved in those early days of the patient safety programme, there was a lot of cynicism about, oh, we've heard this before, and why is this going to be any different? Those same people were saying what a difference that made because they could see straight away the benefits to patients. Taking that way of working and applying it, you can apply it in any setting at all and that, as we take reform through our public services, we should be using that methodology as much as possible. Daca drives front-line staff to make changes. Maybe it is recent events that are making me think of bedtime bear, but how do you raise cognitive development in children while one thing is to make sure that they all have bedtime stories? You could write down and say, we're going to have a strategy for bedtime stories. It's not going to work, but if you get front-line staff to say, okay, what can you do with parents who come to collect their children from nurseries that would enhance bedtime reading? You ask the children the next day, did you get a bedtime story? You log it and you do something, and it goes up, and you do more, and it goes up again. Staff become seized with this, and bedtime bear was a classic example of this. One nursery gave out a teddy bear to all the children and said, bedtime bear needs a story before he'll go to sleep at night. When he's going to sleep, you take bedtime bear to mummy or daddy and get them to read your story, so the child gets the story. Small things like that were one of the first tests of change in the early years' collaborative. Suddenly, it went up and East Ayrshire Council tweeted a picture of an A4 sheet with the numbers going up, and everyone started thinking about it. Showing people that what they're doing works encourages them to do more of it, and you share it across the whole of Scotland before you know where you are and you've got a result. As a brief supplementary to that, all the indicators are given equal weighting, which is my understanding, but in terms of filtering down to daily priorities for staff to meet those indicators ultimately, there may well be rural and urban inequalities and how they meet those indicators or those targets or those priorities? There shouldn't be. Patients are patients, whether they're rural or people are people, wherever they are. If you want to enhance handwashing and award, the same principles apply no matter where you are. The critical thing is that staff working in rural settings need to be involved and to be part of it, and they certainly were. I mean that 800 people would get together every six months for the early years' collaborative, very powerful. Jeff Huggins mentioned on a previous committee on this exact same subject that working towards developing a next-stage process is how he framed it. I'm just wondering what is the next step and when can we expect a bit more information on this outcomes-based approach? The work is on-going, as we speak. It's about making sure, going back to Ivan McKee's point, that it's all aligned and everybody can see how it's aligned. The work that the integration authorities are taking forward on the ground, if you like, is that there's a clear line of sight on how that fits with the national performance framework, and that the work that Harry Burns has set us on a track to achieve is about shifting more to outcomes. That work is going on in a number of settings about how we can focus more on the outcomes for people, whether it's them coming through the front door of a hospital or whether it's them receiving, being able to remain at home, tackling social isolation. All of those things are hugely important, but the detail of them will be captured through the work of the integration authorities. That's right. There's a process around that as well. The cabinet secretary has chaired for a number of years a ministerial strategic group for health and community care, which is co-chaired with COSLA, building on that point that Jerry made about true cross-public sector working. It's called the MSG, and that group is receiving regular updates now on the progress that integration authorities are making around some key indicators, which sit at the heart of what their local planning for improvement looks like. The way that we're doing those updates is—it may not sound that novel, but it is—there's a national aspect to it, but then we also asked chief officers from individual areas to come and talk about some of the stuff that they are particularly grappling with. It's all quite new. It's all quite new off the blocks at the moment, but I think that that's a good model to work with, and that will be reflected—the progress that's made will be reflected in the integration authorities annual reports. There will also be a formal published mechanism, so we're building on all of that because a lot of effort and investment has gone into supporting that work on the side of improving the data, on the side of helping to improve skills in local systems. We have analysts on the ground in every partnership area, but we're also learning from some specific improvement activities. Freeson Galloway, for instance, has been doing some very interesting work around dementia indicators, so we're learning from those individual bits of good practice as well, and that's basically the outline of our next stage of development of this. Thank you very much. I thank the witnesses for their evidence today, and we will now move into private session. Thank you very much.