Welcome to the 30th meeting of the Health, Social Care and Sport Committee in 2023. I've received apologies from Emma Harper, and James Dorren will be joining us as a substitute. The first item on our agenda is to decide whether to take items 5 to 8 in private. Our members agree. The second item on our agenda is an evidence session with the Minister for Public Health and Women's Health on the National Health Service General Dental Services Miscellaneous Amendment Scotland Regulations 2023. For this morning's session, I welcome to the meeting Jenny Mintell, Minister for Public Health and Women's Health, Tom Ferris, Chief Dental Officer, Ilza Garland, Principal Legal Officer and Tim MacDonald, Director of Primary Care Scottish Government, and invite the minister to make a brief opening statement. Thank you, convener. Good morning, and thank you for the opportunity to speak about these negative procedure dental regulations. As you've noted, I am supported today by my senior policy officials, Tom Ferris and Tim MacDonald, and legal official Ilza Garland. If I may, I'd like to talk briefly through the purpose of the regulations, as well as the changes we will be making as part of these. As you will be aware, the Scottish Government has been working on NHS dental payment reform for some time now. In my letter to the committee of 18 October, I outlined the key components and benefits of the new payment system, which will be implemented in just over a week, and I will be happy to take any questions on this during the session. In relation to the regulations, however, a number of key changes are required to various existing regulations to support payment reform. Under those changes, we are introducing a single capitation arrangement for all patients, regardless of age, and all treatment items where clinically appropriate will now be available for both adult and child patients. We are also making some changes to support unregistered patients. The system, known as occasional treatment, where unregistered patients can only receive a reduced set of care and treatment, will be removed through the amendments made by those regulations. That means that both registered and unregistered patients are able to access the same comprehensive range of treatments, removing what may be construed as a two-tiered system of care. Those changes also focus on bringing clinical practice up to date. The new single capitation arrangement will rest on managing the oral health of the patient, replacing the requirement to secure and maintain the oral health of the patient. The more achievable aim of managing oral health recognises that self-care is an important determinant in successful oral health outcomes. I can confirm that a quality impact assessment for those regulations report no significant issues and the business regulatory impact assessment reports no adverse consequences. In summary, those regulations are part of the significant work that we have undertaken to prepare for the implementation of payment reform on 1 November 2023. Those changes will support the introduction of the most significant reform to NHS dentistry in a number of years. It is our intention that that will help to sustain and improve patient access to NHS dental services for the long term. I am happy now to take any questions from the committee. Thank you very much Minister for your statement. Can I ask how you intend to evaluate and monitor the effect of the impact of this payment reform? Yes, thank you for your question convener. It is something that we have been very clear about when we started discussions a number of months ago with the BDA specifically and more widely dentists within Scotland. That work will start once the system is bedded in, and we have already started having some very well-attended webinars to ensure that the dentists understand what the changes are and how they will implement them within their practice. However, you are right, the review is something that we will constantly keep in mind. Tom Ferris meets very regularly with dentists, whether through the NHS boards and the directors of dentistry, but also the BDA. It is something that we have been very clear with the BDA that we want to work together with them to ensure that this is the right start for the reforms that we are looking at. Thank you for that answer. You mentioned the BDA on a couple of occasions during your answer. According to them, the criticism was that you did not consider any new models of care or alternative delivery models as part of the payment reform. Can you comment on why the Scottish Government did not do that? Yes, I am aware in my conversations with the BDA that that is something that they have been speaking to me about as well. What we have in Scotland is a blended method, and that is a combination of a capitation payment for the number of people that are in your practice. One of their changes in the regulations is now that adults and children will be treated to the same fee, which I think is positive, but it is also a payment on the actual services that dentists provide. I think that that method works very well for the variety of dental organisations and businesses that we have within Scotland. In fact, just yesterday, Tom Ferris met some academics that I referenced in my letter to the committee on 18 October. They are very supportive of a combined method of paying for our NHS dentistry. They think that that is the right way. What we have been very clear about is that we are building on a foundation that we already have within Scotland that works very well and that practices are built on. The reformed blended message is the right way that we should be moving forward. In that meeting, Tom Ferris discussed the possibility of changing within Scotland. The advice that we got from the academics who were from North America, Europe and Australia was that, if we looked at how dentists' services worked across the world, a simple lift and shift would not necessarily provide a better service. Their view was strongly that we should be modernising a system that is already working. That is what the Scottish Government has endeavoured to do with the changes that we are making through regulations and payment reform. I declare my interests as a registered NHS GP. Has any analysis been done on how much the average patient who is eligible to pay, and not for any free prescriptions, will pay extra? Thank you for your question. The problem is that there is not an average payment of a patient. Everyone in Scotland comes as an individual to see their NHS dentist. What we have endeavoured to do in this, and I am sure that you are the same as me, the letters that I have been getting, is about access to service. That is what people are really pushing for, is that they want to ensure that we improve the access to NHS dentistry. As I have said earlier, is that sustainability of service that we are really aiming to achieve with these changes in regulations and fee structures? Tess White, thank you for coming today. In terms of consideration of other reforms, Minister, was there any consideration made to any other reforms? The current model is focused on a disease-centred piecework, so looking at preventative rather than disease-centred. I thank Tess White for that question. I think that what we are looking at is also a preventative centred dental care service. If we look at child smile, the importance of rolling that out for young children to improve their oral health, I do not think that that is disease-centred. I think that that is very much preventative-centred. The other thing that we are very clear on is, and I go back to the same point, is the sustainability and the ability to access dental services that I think are really important. The change that we made with regard to unregistered patients as well, I think that is important because, again, that moves us into the preventative space as well. I think that the regulations when you bring them all together really show that we are wanting to ensure that there is sustainable access to NHS dental services for the people of Scotland. In terms of reform, if you look at the schools, the places, the university places for graduates have sort of flatlined and those graduates who do qualify tend to, they do not want to go into NHS because of the funding model. Do you think this new model will help attract graduates to the profession? Thank you for that follow-up question. As we know through the pandemic, we lost one cohort of dental students, which is about 160, which is about 5 per cent of the workforce. What I am really pleased to report and be able to let the committee know, and I think that I may have referenced this in my letter as well, is that there are 183 dental students going through dental training this year, which I think is incredibly positive. With regard to the point that you made about dental students not wanting to move into NHS dentistry, I know that you or the Covid Recovery Committee took that evidence. However, evidence that we have had and that the Scottish Government has had and that officials have had do not actually show that. There are many, many students who want to go into the NHS because it gives them such a fantastic training base. I know that my own practice on Islay is one that supports trainees to come in and experience working in a rural practice, which again gives you a wide range of training opportunities to put into practice what you have learned. That is attracting for training, but in terms of the reforms, will they help to retain the bloodletting from dentistry? The intention of the reforms is to ensure that we continue to make NHS dentistry attractive to dentists. In terms of minister, you talked about the single-capitation arrangement. What difference will the single-capitation arrangement make to patient access and treatment options? Also, how will you assess the impact of this change? As I have referenced earlier to the convener's question, we will be working very closely with the dentist to ensure that we get a note and recognition of how those changes have improved accessibility and sustainability of the service. That is an on-going piece of work once it is bedded in. The changes coming in 1 November have caused some confusion and concern among patients, which has been communicated to us. What support is the Scottish Government providing dentists to respond to an influx of concern inquiries? What public messaging and information is being provided to assure people that this change is nothing to be overly concerned about? I thank Mr Sweeney for the question. It is something that we have been very aware of in the planning for this change, which will happen next week. As I referenced earlier, my officials have been having a number of webinars with dentists to explain the new regulations and the way of working. Those have been, as I understand it, extremely well appreciated and extremely well attended. There were about 1,000 at the first meeting and that webinar was oversubscribed. As a result, there is another one being held tomorrow evening to ensure that dentists are across. We are also doing ones on specific subjects, such as periodontistry, to ensure that it is widely known across the profession. Feedback has been incredibly positive. I would like to thank my officials for the work that they have put into this, because I appreciate how important it is for the professionals to absolutely understand the changes that we are making. With regard to public messaging, you are absolutely right. In fact, I walked past a dentist in Glasgow the other day and I thought, oh my goodness, they have their poster out early, but it was a different poster. We are doing a variety of public engagement and messaging, whether it is posters in dental practices, local libraries and such like, but also a multimedia campaign as well, so it will be on the radio and other multimedia outlets. I hope that we have everything covered, but we will clearly be evaluating that as we go on. There is an assuring preventative care, which is mentioned in the policy note. It is concerning that the drumbeat for a routine check-up will slip from six months to a yearly. What modelling have you undertaken to ensure the impact on overall oral health in the population? I thank you for that question. I know that that is something that has been commented on in the media. The year-long review every year is in depth and follows the nice guidelines, but what is really important for everyone to understand is that it is for the dentist to make the decision based on the patient. I reference to Dr Galhany that there is not an average patient and it is important to recognise that if your dentist feels that you need to be seen more regularly, he or she has that ability to choose that. I was disappointed when I was at the dentist to be told that I had to come back in six months because I thought that I was looking after my teeth health pretty well, so I was hoping for a nine-month one. However, it really is focused on the patient and that is what those regulations give us the opportunity to do. I am sure that Mr Sweeney will reflect on that if you were in another area of the health service and you were told that you do not need to come back in six months, it is actually nine months. That would be seen as good news, and I think that that is what we have got to remember as well. It is really based on the patient and the clinical expertise of the dentist as to the regularity of callback. I also wanted to raise a concern that the British Dental Association had raised about wide potential for widening or being sufficient to narrow inequalities. For my own experience, I am trying to get an appointment for a check-up recently in my own practice, which is probably one of the poorer districts of Glasgow. It is very difficult because the permanent dentist has left the practice and they are dealing with locums at the moment. If the change of wording from securing and maintaining a patient's health to managing it could be seen to place more onus on the patient, I know how difficult it is when appointments are cancelled and so on to then rebook it and potentially that could slip. That could potentially be even more complex when people have poor mental health, chaotic lifestyles, etc. Have the Scottish Government anticipated this risk and what plans and measures have been taken to mitigate it? Thank you for that question. I think that, as you will have seen in the BDA response to the regulations, the letter that you wrote to them, they said that this was actually something that they had been looking for. The managing is what they feel is the right level because, as individuals, we have a level of responsibility to look after our own health. I take on board the point that you make about access. If I can just underline yet again that that is what we have sought to improve as a result of those payment reforms that we will be putting in place next week. Minister, you, in the previous answer that you gave to me, spoke of improved access to dental services. With a BDA warning that the SNP were overseeing the end of NHS dentistry in Scotland, are you confident and will you guarantee that those reforms will lead to improvement in access for patients? I have been in this role long enough and as an elected person to know that you it's very difficult to guarantee anything in this life. We know what we have done based on discussions with the dental practitioners in Scotland, taking cognisance of academic research that I referenced earlier, that we believe that this is the right change at this time to ensure that access is maintained for NHS dentistry in Scotland. So, access is maintained, not improved? No, the intention is also to improve access and that's what we've been very clear to improve the sustainability and the access of NHS dentistry in Scotland. To be clear, do you think that these will improve access for patients? That is my hope. One of the big issues that dentists talk to me about when it comes to accessing for patients who want to register is the lifetime registration of a patient. They say that when a patient hasn't engaged with a practice for between three and five years, they feel that they should be able to take that patient off the list to allow space for other people to come on board because they're full, but they say that it's far too difficult to do this. Will you be looking to make what seem like perfectly reasonable reforms and changes when it comes to lifetime registration? I thank Dr Galhany for that question. As I've said, we have been very clear that we will have continual discussions with the BDA with regards to the payment reform that we have introduced. This is lifetime registration of a patient? I specifically said that this was payment reform because that's what we're here talking about just now. We have constant meetings with the BDA and other dentists and I think everything is always on the table when we are in discussion with them.  That's what you said at one of the first questions that I asked you, so this would improve access according to dentists that come to see me. What's the plan when it comes to domiciliary visits to improve access for patients who are unable to go to practice? If you don't mind, I will pass on to Tom Fairless with regards to that question. We have a programme of extended duty dentists whose main focus is going to care homes, and we hope to extend that. It was in a bans over the pandemic and we hope to extend that. We're having further discussions with that group of dentists to ensure that the November 1 reforms help them to fulfil that purpose and those discussions are on-going, but we are absolutely focused on ensuring that people who are resident in care homes have access as well as other citizens to NHS dentistry. Last question, so this is on-going, but this isn't part of the reforms that have been brought in to improve access to domiciliary visits. No, most care homes are either seen by the public dental service, which is the board-managed dental service, or they are seen by those enhanced-skill GTPs. I would prefer if it was enhanced-skill GTPs that took responsibility for that, because it frees up the PDS to do other work for other vulnerable groups in the community. Our focus is about making sure that GTPs feel that working in an enhanced-skill environment in a care home is worth a while and where those are on-going at the moment. It's part of the reform and we're trying to ensure that it works. We're having a conversation with them specifically to say that this is what's on offer and that it does seem as if it's working for you. We've had one meeting already and there's another one in the diary. We've talked already about the shift in language and people taking responsibility for their own auto healthcare. How will the Government support those on low or no incomes to do so? Government has a number of ways that it supports people on low incomes. Between 20 and 25 per cent of adults in Scotland don't have to pay for their NHS treatment. The fact that we have the free examination is important. Highlighting earlier, other initiatives such as Child Smile for getting younger children into the habit of cleaning their teeth have been incredibly helpful. We've just had statistics out today, which shows that in primary 7 age group—I better get this correct—the oral health of primary 7 school children shows that 82 per cent of primary 7 children have no obvious decay. That level of investment that we have put in the preventative side of oral healthcare for children. We know that there's an issue with stalling registrations for very young children, from 0 to 2, which are 25 per cent lower since the pandemic. Obviously, there seems to be a lag in areas of higher deprivation. How can reforms be carried out in a way that minimises health inequalities? How are we going to get on top of that? I think that that's a really important question to raise. Broadly, what we are intending with those reforms is that we maintain that access for NHS dentistry across Scotland. I'll hand over to Tom Ferris. I suppose that registration for 0 to 2-year-olds is the lowest cohort and always has been. It takes particular initiatives to make sure that we improve it. That was primarily through the Child Smile programme. That was in abeyance over the pandemic, and it's only just really got back up to strength. I would see those figures beginning to improve over the next few months and years, but we shouldn't be complacent.  The Child Smile teams, both in nurseries and from practices, kind of work in co-ordination to make it as seamless and as easy as possible, but it has always traditionally been lower. You're right, it's lower than it has been before, but Child Smile should make the difference again. The BDA are concerned that certain aspects of the new determination one may result in unintended consequences, which may result in an increase to oral health inequalities. For example, a single examination fee that doesn't take account of disease experience may favour patients with minimal past dental disease or minimal current dental disease. Do you share those concerns and how will any unintended consequences be monitored? I thank Julie Mackay for the question. What I've said on a number of occasions is that we believed that this was the right reform, building on the foundations of the way that dentistry is funded and provided in Scotland. I think that the other thing that's incredibly important is that we continue the dialogue with our dentists to ensure that we're getting the right changes made, whether that's on governance, whether it's on workforce, whether it's on access, and I think that that's all really important. I know that Tim, you wanted to make some comments about access. Thank you. In response to a question previously, when it comes to access, both sustainment and improvement of access, because in Scotland we have an independent contractor model, it's the confidence of those contractors working in the sector that we have that determines is a critical factor in access. For me, because we've engaged with the profession throughout the development of these regulations and critically the payment system, and because we will keep engaging with them, whether it be through town halls, through my team, through the webinars that the minister has already referenced, that will help us to build confidence in the profession that these payment measures can sustain access because they allow those independent contractors to make good business decisions that can then promote and sustain the overall health of the population to access that critical NHS dentistry. Dentistry is one of those areas where I think patients find it more difficult than others to raise concerns and give feedback on treatment and on-going reforms. Is there a plan in place to ensure that people can have those voices heard and that those ways of giving feedback good or otherwise are advertised for people to be able to input into the system? That's a really good question. The first thing that came into my head was that NHS dentistry was more widely looking at NHS boards. There's care opinion where people can feed in their views. If I'm being honest with regard to the way that high street dentistry, if I may describe it as that, is constructed, it's very much individual businesses, as Tim MacDonald has just referenced, but certainly I would encourage people to use care opinion if they're wanting to feed in to actual NHS dentistry. Good morning Minister and to panel members. Around the reforms, how are we going to assist to retain and recruit new people in NHS dentistry? Thank you David Torrance for the question. It's a very wide question and what we are doing with regard to the changes in fee structure and also regulations is, as I've said before, to maintain and ensure that we have got the sustainability of the service across Scotland. With regard to encouraging people into dentistry, one of the areas that we want to look at is workforce. There has been two pretty big impacts on dentistry. One was Brexit and the more difficulty in getting dentists from out with the UK to come to the UK. With regard to that, I have written to all my counterparts in the four nations and also their CDOs and we're organising a meeting to talk about how we can improve the throughput if dentists wish to come and practice in the United Kingdom, in Scotland specifically, from our perspective. We're also improving the workforce within dentistry. For example, there are some highly skilled dental technicians that we would like to explore giving them more locus to see patients as well, and we're talking around the possibility of doing that. There's not just one silver bullet that's going to solve it, so there's a lot of things that we are working together with. That's why it's so important, as both Tim MacDonald and Tom Ferris have highlighted, is the connection and the discussions that we have with dentists, whether it's through the BDA more widely but also through the NHS dentistry, directors of dentistry. Thank you very much, convener, and thanks for coming along this morning. We know, minister, that dental services have been struggling to recover to pre-bant pandemic levels and that there's been a significant backlog of patients awaiting treatment. I wonder how those reforms will enhance the recovery and sustainability of NHS dentistry in both the short and the long term. I thank Stephanie Callaghan for her question. That's really the nub of what those reforms are, is to ensure that we do sustain NHS dentistry in the long term. I, like you, will have received lots of emails about the sustainability or the access that people have, so we've got those reforms. We also need to remember that the Scottish Government has put other grants in place, for example, the SDAI, which offers £100,000 for a new practice in an area. We have been in discussions with the health boards to ensure that we're targeting those grants in the right areas. We've also got some remote—although I don't like using that term—grant payments, which are really important. The conversations that Tom Ferris and I have with health boards are very important, because they have a responsibility to look at how their dental services are being provided in their jurisdictions. I was really pleased to hear that boards in Freeson, Galloway and Highland are now working together to try and encourage more dentists to come to their areas where perhaps they've had recruitment issues. However, as I referenced to David Torrance, it's also about the breadth of skills within dental surgeries that we need to keep an eye on and ensure that they are supported. Thank you. Are there any concerns about the fact that people who are paying the part of their NHS dentistry treatment, are there any concerns that the increased costs around that, are going to discourage people from seeing their dentist and that that could have an impact on sustainability and early treatments? I think that what we have to remember is that everybody under 26 gets free dentistry and, as I referenced earlier, between 20 and 25 per cent of adults don't pay for their NHS dentistry either. I think that we had to really look at how was the best way to ensure that we sustained the number of dentists and dental practices that we have in Scotland. It was felt that a slight increase in the fees was right. Those are still capped at £384. I think that I've referenced this earlier. The concern that I have been hearing with regard to dentistry is about access. That's what we believe those changes and amendments and regulations are helping us to achieve. Just a very short question there. I do entirely appreciate and understand the logic for that there, but currently with the cost of living crisis happening, etc. Is that something that you will be closely monitoring in case it does throw up any issues? Most definitely. Cost of living is floods through every decision that we are making just now, so it's absolutely something that we will be keeping an eye on. I thank the minister and her officials for their attendance today. We will now move on to the third item on our agenda, which is consideration of two negative instruments. The first instrument is the instrument on which we've just taken evidence from the minister. The national health service general dental services miscellaneous amendments Scotland regulations 2023. The purpose of this instrument is to make specific changes to existing regulations to support payment reform and make miscellaneous changes that the Government intended at the next opportunity of amendment of those existing regulations. The Delegated Powers and Law Reform Committee considered the instrument at its meeting on 12 September 2023 and made no recommendations in relation to the instrument. No motion to annul has been received in relation to this instrument. I ask if members have any comments and I'll pass to Sandesh Gouhani. Thank you and a declaration of interest as a practicing NHS GP. A lot of dentists are still concerned that those changes do not address the root cause of their problems and they do not feel that this will be enough to help sustain, especially in rural areas and deprived areas, and they do not feel that those changes will allow for the Scottish Government manifesto pledge of free dentistry to under-26 to happen. I would like to see evidence over the next year to assess the changes and also what improvement to access there has been following this. Thank you for your comments, Mr Gouhani. They'll obviously be part of the official record now. I propose that the committee does not make any recommendations in relation to this negative instrument. Does any member disagree with that? No, thank you. The second instrument is Health and Care Professions Council, Miscellaneous Amendment Rules Order of Council 2023. The purpose of the instrument is to provide the Health and Care Professions Council with the power to increase fees charged for processing and scrutinising applications for admission to its register, for renewal of registration and for readmission or restoration to the register. It also enables the practice committees and appeals panel to hold remote hearings outside of emergency periods. The policy note states that the health and care professions council fees were previously updated from July 2021. It also states that offering remote hearings alongside in-person hearings will make it easier for some attendees to engage with a process such as those with mobility or mental health conditions. The Delegated Powers and Law Reform Committee considered the instrument at its meeting on 26 September 2023 and made no recommendations in relation to this instrument. No motion to annul has been received in relation to this instrument. I will now pass to Sandesh Gulhane, who I believe has further comments. Thank you, and I'd like to claim my interest as a practicing NHS GP. I'd like to take this opportunity to tell the committee and to also the public that I've received a lot of email and correspondence from members of the Health and Care Professions Council and they are opposed to the increase in fees given the global cost of living crisis and the fact that they feel the increase in fees is not justified. There are a lot of people who are unhappy, though in defence of the council I do understand that this is the first increase in fees for years and they do feel that if they don't increase the fees they might well go bust and this is a very difficult decision that is being taken. Thank you, Sandesh Gulhane. Again, those comments will be part of the official record of this meeting. I propose that the committee does not make any recommendations in relation to this negative instrument. Does any member disagree with this? No. Okay, thank you. We'll now move into private session for a short break to allow panels to change. The fourth item on our agenda is an evidence session on the National Care Service Scotland bill. Today we will hear from representatives of local government and integration joint boards for this morning's session. I welcome to the meeting Eddie Follin, chief officer, health and social care cosla. Eddie Fraser, chief executive, East Ayrshire Council, representing Solace Scotland, and Professor Sue Munson Gupta, director of health and social care south Lanarkshire health and social care partnership, representing health and social care Scotland, chief officers group. We're going to move straight to questions and I'll pass to Tess White. Thank you, convener. Mr Follin, with legal responsibility being shared between the Scottish Government, the NHS and local authorities, does this blur the lines about who is accountable when services are not delivered adequately? Thank you. Thanks very much, Ms White. I think it's probably to go back to where we got to with legal accountability because we're talking about shared accountability. We haven't actually worked through what that will look like yet, so I think that at the moment we're having discussions around that. The intention would be that it shouldn't blur the lines at all, because we're also looking at an escalation framework. At the end of the day, decisions will have to be taken jointly between the NHS, the Scottish Government and ministers in terms of the delivery of social care. From my perspective, although we don't know the detail of it, the way that we would look at it is that it should be clearer about how accountability is delivered. The book would have to stop somewhere? Yes, it would. We'll have to work through that in terms of the legislation. I can understand from a committee perspective how you want to be clear about that when you consider the next iteration of the legislation. We were in a difficult position initially. We had a stand-off between ourselves and the Government in terms of the bill, and I know that the committee heard evidence on that issue. We really had to get to a better place to take that forward. That agreement is between us politically at the moment, and we have a system of shared accountability. As I said, we've not really got to the stage where we've worked that through, and I know that we're working with the Scottish Government on what that will look like and the NHS as well. We would set out with the intention that we know who is responsible for the delivery, and if things go wrong, what do we do about it? How satisfied are COSLA and the local authorities that the new agreement has addressed the issues that the councils have raised? I think that we're in a much better place. Our concern had always been that there was the potential for the transfer of staff and assets and functions away from local authorities. Again, I'll not rehearse all that, because I know that we've probably spoken to most committee members about it. That's not going to happen. There isn't going to be any staff transfer. There's not going to be any transfer of functions, nor is there going to be any transfer of assets. I think that we're in a much better place with Government. We're working in partnership with them and the NHS, which reflects that shared accountability. It also reflects the delivery at a local level as well, because we wanted to make sure that we were replicating the way that decisions were made locally. Those decisions are made locally between the local authority between the NHS and now Government level. I suppose that Government has got out of that. Ministers will be in that accountability, so it will be a joint approach. From our perspective, at the moment, we're pretty content with the direction of travel. A lot of the things that we've said today have not been politically agreed. That does constrain us a wee bit in terms of what we can say around the negotiations, but we've got a system of negotiation in place, and we're working towards making progress. Just one final question. In terms of the accountability and the responsibility, if the assets and the staffing and the budgets stay within the local councils, isn't there a huge concern that there is a difference that one party will be responsible and another will be accountable? Again, those are some of the conundrums that we're grappling with as we move this forward. I don't know if you want to touch on the assets a bit of that from a local authority chief executive perspective. I think that one of the issues here is the complexity with which we're dealing with a lot of those issues. That is a complex area, as you all know, and we're doing that in a really short timescale, which is driven by the primary legislation. For us, we're conscious of that, and we need to be conscious of the fact that we don't want to get this wrong, so we need to deal with issues like that. I think that some of the questions that you raised are absolutely valid around clarity and accountability. Some of the discussions that we're around are about whether you have joint accountability. That then becomes blurred, because you're not sure. That's why, when we talk about shared accountability, there should be a clarity about what is Government responsible for, what is local Government responsible for, and what is NHS responsible for. Although it sounds like a change of word from joint to shared, it's not. As we understand and the advice that we get from the lawyers, that's a very important distinction between them, so that we are all clear and more important. I suppose that people who use services and families are clear about where accountability lies. We've got to, around some of that at a national level and about retention of staff and assets, I think that that is positive. If you're going to retain staff, and I think that, when I was previously at the committee, I was trying to describe if the staff go, then a range of assets, the building they're in goes, then the electric cars they drive go, and those different things there. One follows the other in terms of where we are around that. But where we are just now at a national level only works at a local level if the local arrangements allow that. We've still to see the detail of things like ethical commissioning and the different arrangements that we'll actually see. What does that actually mean at a local level to enable local authorities to continue to provide services and to continue to make sure that social care workers are values and what they're paid to direct divide and deliver their services. So the national is one level to get that in place that that has to be enabled by what we do at the local level as well to make sure that it's actually practically deliverable to. Thank you. Picking up a little bit on that theme, I'm keen to hear the panels using the role of the third and private sector in the governance of social care, given that we know they're responsible for over 75 per cent of provision of the services. So should they have a place in the governance structure of the national care service? Come in on that. It's absolutely crucial that we work with the third sector, you know we know that, and we do, certainly Cosly does and others. We haven't really worked through the national board and how that'll look in its entirety, but I know that the minister, you know, had kind of made a commitment as well to a national advisory group in terms of how that national board will, what will operate. And first we've not, as I said, we've not got a political agreement on these things yet, but you know, if that was to kind of go forward, then you would, you know, certainly our view would be the third sector would be, would be a big part of how that's delivered.  So it's difficult for me to envisage how they would be involved in that kind of relationship back, you know, that's no decision that's been made yet, but certainly, you know, on the national advisory group there needs to be third sector and, you know, wider stakeholder involvement including people who live in space in the development of how that national board will operate. Any of the other panel members want to offer their views on that? Yeah, so I think we should remember already at a local level, you know, every integration joint board has a, required to have a strategic planning group, actually does the planning for health and care and there's a wide range of representation on that in terms of actually doing the plans coming forward. I absolutely understand, you know, where the third and independent sector feel as, you know, second class members of IGIB boards, you know, because they don't have a vote on IGIB boards. I would say, you know, in our own board, you know, in East Ayrshire, we've not had votes because we actually do a lot of work in that strategic planning group and work with consensus, you know, going through. So, but the perception is, you know, it's certainly that there. I think, you know, that we also need to, you know, understand or I certainly understand that our independent and third sector organisations on the whole, you know, employ local people to provide services to local people, and therefore there are huge important parts of our system.  So, if I can give an example, all our care homes in East Ayrshire are actually an independent sector, but it's actually local women on the whole that actually work in them. So, I... We're saying away a bit from what I'm asking here, which is specifically about those organisations being on a governance board. So, I mean, I don't know if you're able to offer an opinion, if whether you think that they should be there. I've heard the importance that you, in the regard that you have for them, but whether or not they should actually be in the room. From our perspective, I think that they should definitely be in the room. You know that the issue comes up again about accountability, you know, in terms of one organisation taking a decision that actually has an impact on, say, the resources of another organisation. But the scale of our partnership with the third and independent sector, I can't actually understand how they couldn't be in the room to actually take, you know, decisions and decisions that are well informed. Simon? Good morning. To add on that point then, so ultimately who's within the room is a matter for elected representatives such as yourself, the Parliament and indeed local elected members and indeed other stakeholders within this. I would, though, concur with Eddie's point that the earlier question around accountability and responsibilities here aren't then just around the delivery element it's as much about the responsibilities and the responsibilities of the individuals who make up whether it be the national board or indeed the local care board or whatever the version of that is going forward. So whoever has a vote within those arrangements, it should also be quite clear to the public as well as staff that this is how they're held to account for decisions that they make collectively as part of those decision making bodies. And provided we've got clarity on that, then we can move forward constructively. Thank you. I'm now going to move to Degard Torrance. Thank you, convener. Good morning to panel members. Why is it local authorities provide and deliver such a low proportion of adult care services? And what would it take for local authorities or health and social care partnerships to increase the proportion of services that are staff delivered directly? And could this be an effective route of ensuring consistent terms and conditions for fair work? That was a bit long winded. I mean, I think when we look at the range of different needs in terms of health and care, often we rely on organisations with quite specific skills to do that. So we do rely on partners who have specific needs in terms of dementia, learning disability, mental health, and we have many partners out there in the third and independent sector who have specific skills in terms of doing that, and they have capacity in terms of doing that across all our local authority areas to do that. So I think you'll find that often when we use organisation partners it's because of the specific skills that the partners have around that. In different areas, different local authorities have looked at the local workforce and they've got different levels in terms of how they deliver through some, have large in-house workforce normally for older people, others don't, and if they commission that workforce in that that's grown up over time, but when you get into some of the specialist areas I think you'll find nearly all local authorities actually rely on third sector partners to actually deliver on that. Thank you for that. Mr Todd, there's a flexibility about the delivery from a third sector perspective as well, and I think third sector organisations as we've said are really valuable partners as are the independent sector because they provide a vast amount of social care as well. I think those decisions will be taken on a local basis and it will take into account, it will take into account costs but it will take into account the ability to deliver the needs of the local population and those decisions will be taken locally, so it's quite a complex picture and some local authorities will provide more than others as well. Can I just add, obviously, that the actual decision about who provides care is actually with individual, you know, under self-directed support, you know, legislation is not for a local authority to decide that they're a sole provider, you know, of that, you know, an individual can either choose to go with a local authority to get it, they can choose to ask the local authority to arrange it for them or they can choose to make their own arrangements of how they do or a mix of them all, so our self-directed support legislation actually gives that flexibility to an individual to make their choices rather than it seems as though from the top down we tell people actually how they need to get their care provided. Thank you for that. How do you see sectoral bargain operating across all sectors of the provision public third sector? The reason that the Scottish Government has pledged £12 an hour, how confident you are no matter who the employer is that that will be given to the worker? I'll take the last bit first, you know, and that is the £12 an hour that will be passed on through local authorities to the individual sectors and organisations as we did with the 1090 uplift as well. In terms of sectoral bargaining, there are a range of discussions going on at the moment around sectoral bargaining. We, you know, in local government we've already got our own sectoral bargaining arrangements, I think that that is something that we, there would be no appetite on our part to pick that apart or take it apart because those are fairly established bargain, but we're really keen to support how you can have that sectoral bargaining in the third and the independent sectors as well, so we're working with CCPS and we're working with Scottish Care around how that can be delivered. So, I mean, I'm not going to put a level of confidence on that because it's not only, I keep talking about complex, but it's not only complex, it's a really sensitive area in terms of pay negotiations as well, but the discussions are taking place, we're absolutely committed to getting to achieving it and local authorities' roles and local government role in supporting that, supporting those arrangements will be really important and we're looking at different ways of doing that. Thank you for that. How confident are you that ethical commissioning and procurement proposals for the NCS will ensure fair work principles are guaranteed for social care staff? Do you want to start? I suppose that's similar to the previous answer that Eddie Gage gave. I think it is important that if we're going to have sustainable social care in the future, therefore commissioning rather than procurement, actually commissioning and understanding the capacity required in social care, we need to understand the workforce required and we need to be able to pay them in respect of that. I think that it's important that we actually see that rather than look at, you know, sometimes look at the terms and conditions of local authority or NHS staff and actually see they're much higher than the independent or third sector, so how do we bring the independent and third sector up to their levels so that the local women that I spoke about earlier are actually getting paid a decent wage to do that. Actually, you know, for me, you know, the ethical commissioning is making sure that the resources that we're putting into this in the wider public sector are actually going to deliver that quality of care and actually that money is flowing through to give the capacity of care and the quality of care for people, so ethical commissioning, for me, is making sure that we have the right capacity of the right type of skills in place and I think that the only way to do that is if we're actually paying people well. Yeah, I would disagree with any of that at all, as you'd imagine. Again, I'm not going to put a level of confidence on it, but, you know, again, the commitment is there to do this.  Is there a frustration on everybody's part that it's probably a bit slower than anybody would like? Absolutely, you know, but I think some of the kind of financial constraints that we face make that difficult as well, some of the kind of sensitivities around pay, you know, and other things make that difficult, but, you know, it's definitely something that we need to do it, you know, and we need to do it, you know, as soon as we possibly can. If I can add to that, good morning, two other elements I'd want to pull out from that. One ties into point A, you just said there, about funding for this, so this is only real if we can pay for it, and, committee members, we've very minded around the real significant challenges we have across social care and detailed care in terms of funding in the moment, as in these of the public sector and on a whole. So we need to make sure that whatever we're promising here, actually, we can follow through from a funding perspective, so that's a, I've suggested, a big challenge for all policy makers at all levels in terms of where we're going within the public sector. And tied into the point around ethical commissioning is that element around standards of care and quality that Eddie's also mentioned earlier when we've selected this. So one of the elements that I do think is really interesting and something we really should be really grasping and embracing in terms of the discussions that we've had with government are around the national agencies here, the national social work agency, and what it can do, how we can work with NES and other colleagues in terms of developing the pipeline for social care staff, social work staff. One of the things that the NHS does well, as you'll be familiar with, it's an area we're constantly working on, but it's got a real tradition around having career structures and pathways for people when they enter at different levels. Now increasingly we're looking to develop portfolio careers within healthcare. It's really important that we develop and strengthen similar arrangements within social care. Ideally we get to a position where actually people are able to move across roles and deploy their skills differently because that's just as important. Paying conditions is one aspect of this, but the other element is actually how we continue to invest and encourage people to move through their careers within health and social care effectively and to do that with a real set of standards that provide reassurance to our communities that the care that they're then experiencing and getting is what they need. I absolutely take on board the issues around funding and things, but I think that there are some elements in terms of culture and other things as well within the system that maybe don't have as many pound signs beside them as some of the other pieces of terms and conditions that we talk about quite regularly. Obviously Eddie said about the the number of employers and that some of them are in better places than others in terms of those terms and conditions and culture and other pieces as well. What works on going at the moment to bring some of those employers who maybe are at the lower end up to the standard of others and what continual work is going on at the moment within local authorities to push on some of those areas of work so that we're not constantly waiting for big pieces of service reform and that we take the staff along with us at the moment who are absolutely slogging their guts out doing their jobs day in, day out? I'll be like Eddie to pick up on some of the actual in-work local authority work. From a national perspective, the culture that you talked about is absolutely crucial. I think that we've had some quite challenging discussions between employers, employer representatives and the sector as well on how that's delivered. But I think that it's a really good point. I think that part of those discussions we'll be looking at, what can we do now? We've got the joint statement of intent and that was signed when the national care service, when the fee-way recommendations first came out and part of that is that commitment to commission. What do we need to do now around the edges of that? I think that part of the frustration has been, and just to reiterate it, is that funding issue? It's at the core, but you're right, we need to probably do more around the edges of that to make sure that that's something that we'll be working with partners to do. Eddie, maybe you could talk a wee bit about what was on local authority specifically. Yeah, I mean, so I suppose there are different levels of earner, so at one level we talk about the role of the caring spectra in terms of any organisation that is in my work, which sector and whether it's local authority, private or independent in terms of making sure that organisations run properly. Part of the joint statement of intent, so with any legislative process, was about improvement in social care, so there is a national improvement board that's been established out with that, that's jointly between local authorities in government and NHS to actually look at improvement in terms of social care and community health services and actually both Eddie and I jointly chair that along with Government. I think there's a recognition that improvement in social care in the community services cannot wait on a legislative programme that can take a number of years, that we have to move forward out with that and actually see that as improvement and support of organisations because again, I don't think that any of the organisations or any individuals are trying to deliver poor quality services, there'll be circumstances that can be supported in terms of that. So I think, you know, that it has to be making sure that we don't almost see improvement kicked into the long grass because there's a legislative programme going on just now that we actually focus on that improvement just now. Thanks, convener. Thank you, and Tis White is a supplementary. Thank you, convener. I can't just register my interest as a fellow of the Chartered Institute of Personnel and Development. My question is to Professor Sengupta. So Professor Sengupta, you said it's only real if you can pay for it. Most staff are employed by private sector providers. In fact, 76 per cent, and the current model outsources to the third sector, and the model focuses on cost and lowest price for those providers. So one of the consequences historically is being that wages are kept low. So if they're competing on price, they keep their wages low. So how does that conflict with fair work and ethical commissioning in your view, and does something significant have to change with the new model? Thank you. Yeah, just waiting. Sorry, mine's going to be red at the moment. Is that okay for me? Sorry. I'll also apologise. I've got a bit of a croaky voice this morning. This is something that we spend quite a lot of time thinking about locally, and I'm sure that that will be the case across all areas of Scotland. Value for money is a key aspect of our procurement processes, so I wouldn't actually characterise it as going for the cheapest one all the time. I can't speak for all areas, but I would say it's about making value for money, and value for money then is about a balance of a number of elements. So absolutely cost is one component of it, but so is clarity of reliability or provision. It's also about the quality and it's about the degree of flexibility depending on the nature of what you're getting. Again, as it's already been talked about today, this is a wide variety of services and sports that we're talking about. It can be highly personal to certain individuals, particularly if you're talking about very complex packages of care that will have sometimes last years and require a high degree of consistency or provision for individual. There are other aspects of it, such as a care home package or whatever, which can actually be done by a range of individuals provided that it's properly unwell organised. For me, as long as we're holding on to making best use of the public pound for the citizen, that is the way that we will continue to ensure that we're making best use of that resource. For me, that ties into your point about ethical commissioning, because again it comes back to making sure that you've got a workforce that are committed, that are where the incentives are in place from to do a good job, that they're paying attention to the needs of an individual in front of them, but also we need to make sure that we're doing that in a way that we can sustain. So again, we can, from a delivery perspective, approach this from any number of angles, but we need the resource in place in order to make sure that the range of service and sports are available to the people who need it. The more resources we've got, the more options we can provide in terms of what the nature of the contracts are that we're offering, the length of contract, something that we get from a lot of providers tied into issues of fair work, is about whether it's a one-year contract or can we not do longer. So if we've got great stability of funding, that allows us to provide them with that sense of certainty, that allows them to provide a greater degree of clarity for their workforce around paying conditions and also other aspects related to fair work. For example, in terms of their environmental sustainability commitment, since we worked towards net zero. So we can't move away from the fact that funding is critical here, both in terms of the money that people get within their pocket, but also about the sustainability of service provision. Does that go some way to answering your question? Let's say, for example, in the previous committee we heard about Shetland, let's say Shetland, and it was mentioned by the minister was a great model. So in terms of if hypothetically Shetland is a great model to go for, and you've got one size fits all under the new national care service, then another local government will be forced to apply the model of another area and then costs will increase. Is that a major concern and how will it be managed? So I'm working on the basis around the position that was agreed, the consensus position that has initially been agreed over the summer, which, as I understand it and has already been articulated, emphasises the need for coming up with local solutions in respect of that. So as I understand it from when the minister gave evidence here, and I don't want to speak for them, but they were highlighting the experience of Shetland, what they weren't proposing that that would be applied across the piece. It's around building on the assets within a particular community, in that case Shetland, saying what the organisational arrangements are in place that can be deployed, critically understanding the needs and priorities of individuals who live there, being realistic about how those assets can be deployed from a logistical perspective and otherwise in terms of that environment, and then moving forward hopefully in a way that it's consensual. Now that's difficult, I mean absolutely that is difficult, that is part of why all of this is difficult. But we keep on coming back to the notion that social care in particular needs to be person led. So that means we need to provide as much flexibility in the system particularly, I would suggest, at local level to ensure that we can come up with arrangements that enable people to get person led services that allows it to be adapted for their particular circumstances, and again that will vary from community, from client group to client group, depending on what the levels of needs are. Don't get me wrong, there's a lot that we need to do within Scotland about sharing of learning, certainly that's something within health and service of Scotland that the chief officer is spending all the awful lot of time engaging with sharing and information bringings because they tell us what they've done and giving it a lot of consideration of how we can reflect upon our own performance to scale it better. The same thing applies across local government, health boards and any other parts of the public sector. We all recognise we need to do better here, but we also do recognise that a challenge we continually get within our local areas from elected representatives such as yourselves from local communities is about how to make sure that the services that we provide are ones which are credible and personalised to the people where they provide services to. Thank you very much, convener, and thanks for joining us this morning. I'm really interested in co-production and regional forums, so I've been interested, I don't know whether any of you have actually been yourselves along to any of the regional forums or whether any of your staff have been along, so it'd be really interesting to hear about any feedback in any learning from that and also what your thoughts are on co-production and co-design and how that can achieve transformational change. Thank you. Our staff have been along to the co-design sessions, it's interesting because one of the things that we were able to move forward with the political agreement that became in June was our involvement in co-design because we were at that point opposed to the approach, so it's been really good to be able to get involved in that. I know that the Government have done a huge amount of work right across, and they had the summer forums as well. I know that the minister was talking to you about that, but certainly from our perspective it's really important that those sessions are taken place locally as well because we'll have a range of voices nationally who will have a view on how things need to progress and what sort of system we need to have and that's absolutely valid, but as far as the co-design sessions go, the aim there was to get voices that were locally, that were getting experiences of the system, how did people feel about how that was delivered now and I think that what will be important about those co-design sessions and what came from them is how that informs the discussions that were having nationally, and that's the crucial bit because I think that, and I absolutely get this, there were people and organisations who saw the bill going in one direction and we took a position on that, but not just as trade unions and others, there was a wide range of views on it, and I think we really welcomed that kind of change of direction in terms of where we got to, but I know that that probably has caused a bit of concern as well amongst people, you know, we lived experience in some of the disabled people's organisations as well, but certainly our commitment is to make sure that whatever system we end up with at the end of this, it's informed by those co-design sessions and by those organisations who represent people who lived experiences, interests and people who lived experience themselves, so that's, you know, we're entirely committed to that, you know, and I think a lot of the stuff that came from the co-design sessions, you know, was really helpful, it reflects a lot of the stuff that we think are prevention, you know, and getting in early and making sure that, you know, the kind of care follows the person that we try to achieve some kind of consistency of outcomes, you know, and if people are moving at care packages, our transfer was one of the big things we heard, so I think all of that, you know, is hugely valuable in terms of how we, you know, how we take our work forward, you know, when we're in discussions with Government and with discussions with other stakeholders as well. So, similarly, I've had staff attend the sessions, I think it's to the credit and the service that they've put such a degree of energy into that within a relatively short space of time. We've had good feedback in terms of what they've been sharing. The proof of the pudding that was in the eating here, which speaks to that point that Eddie has talked about, so we're really critically interested in terms of how the issues that have all been raised through those processes then get factored into the next round of material that comes out in draft from Government. As there are elements of what we've highlighted that we're actually quite reassuring because it demonstrates there's still consensus around the issues that we need to do better on, there are aspects of this though that are also just hard. So, the element around early intervention prevention, for example, all chief officers across Scotland would have absolutely emphasised the importance of us doing better within that space and just redesigning a system to do better in that space. But this committee, individuals around this committee, will be familiar with this, having been talked about for years within Scotland. We could talk about the Christie Commission at length here, which is talked about early intervention and prevention. So, the ability to translate an appetite for working within that space into doing that in practice on a consistent basis and assuring that we've got the funding for doing that and transforming services so that you're able to move upstream, that's the real challenge in respect of that. So, again, I don't envy the task force that we're starting to do that, which is why I think the co-design process continues to be in so important, is we need to recognise that we've got a series of principles here that, broadly speaking, from what I can see, most of the stakeholders can get behind. The challenge is to actually see how you can embed that within a system that delivers it consistently. Thank you very much. Last year, the Scottish Government spoke about how co-design produced a charter of rights, a national complaints process, an electronic healthcare record, but not services. Are you clear at this point which aspects of the national care service are being co-produced or co-designed? Who will be involved and when and how they will be involved? I think that the change of direction has probably had an impact on that aspect of it. We're working with Government on the single-shared record, which is a really important initiative. We're working with a whole range of digital initiatives. From our perspective, what we're trying to do at the moment is to go back to that political agreement, but we're still trying to come to a political agreement on some of the big areas, the big areas that we've talked about, such as commissioning, procurement, funding and other aspects of it as well, such as healthcare boards, the national board and all that, but there are continuing discussions going on around the single-shared record, around the ANS law, and those are areas that we never had an issue with from a local authority perspective initially. We just said, we're not going to do that, we're not going to do any to do with the NCS. We have been working with them on that, and I know that Government has been discussing this through their co-design processes as well, as far as I'm aware. At the moment, the focus for us is to make sure that we can politically get a lot of this over the line in terms of the big stuff. We are fairly limited timescale as well, but the discussions on the other things like ANS law and shared single record have been going on for a while. Fantastic. It's really good to hear that there's that positive commitment now in that shared focus going forward, thank you. Thank you. Professor Singupta, you spoke about how elements of this is going to be very hard, and Eddie Folan, you said earlier that you're dealing with a very short timescale. Is this timescale not arbitrary, seeing as we've already had a delay to stage one? Would it not be better for this all to be ironed out in advance so that we get agreement rather than it be fast? I mean, I guess that we're working with what we have, and I think it's really important that we put every effort in to meet the timescales of the bill, and that's what we're doing. But it is really important that we get it right, and that we make sure that whatever system is at the end of this is effective. Primary legislation is important. There are elements of what we're talking about that's going to require primary legislation. We don't want to lose that opportunity, but you're right. The main thing is that we get this right for people, but we will continue to work in partnership with the Government on the areas that we're working on at the moment. One of the things that you said earlier was about if packages of care get transferred, if people move, and how we could get some standardisation. Do we need a co-design and a process like this? Is this not something that we should be doing right now? I mean, there are a range of constraints on how we deliver at the moment, and I think that everybody is committed to reform. I think that everyone has recognised that we need reform of the social care system. There's no doubt about that. There are things that we don't do well that we need to do well, and I think that what we're in at the moment is a reform process. That includes legislation. There's a legislative element to that, but there's also, as Eddie touched on earlier and Suman, about the statement of intent. There are things that we need to be doing now, absolutely. We don't want to just stand still and say, well, we'll wait for the legislation. That's never been our position. I agree that there are things that we need to do now, but I don't know if anybody wants to add to that. I think that, from a solace perspective, we would be clear that we would have rather had a lot of these conversations before there was a bill. It's so actually understanding whether children's services are in, whether justice services were in. We would rather have had these conversations before, but we accept where we are and we're making progress in terms of discussions in where we are, because it really matters, it really matters to people that get services, it really matters to the people who work in both health and care. We are where we are around that. Understanding what needs to be in primary legislation and making sure that there is a trust that goes on into what's going to be in secondary legislation and guidance is important in terms of where we are just now. In terms of transferability of support, again, these are the types of things that are really important, but again, some of that is doubting what's available in different local areas. One area might have a lot of supported housing available, for instance, and another area doesn't, so the types of support you get in different areas change, but the outcomes for people shouldn't be able to change. People should be able to define what they want in terms of outcomes and then need to use the local infrastructure to deliver that. As I said, when you asked about the time taken for this, I think this will take time. Just now, we're very much in what needs to be taken to primary legislation and then making sure that there is a trust that extends back to the co-design question. I think that we've lost some trust and that people have lost an understanding about as if there are rooms over there making all those decisions that we won't get a say in it. I emphasise to people that that is still at the framework level and that you will still get a say in how that is, but I think that that's an important message that needs to get across to people or else they will lose trust in the whole situation and all of us as partners will not just cover it. Thank you. My final question. Twice now I've heard we are where we are, but we aren't because we've already had a delay, so I fail to see why we can't have another delay to get things right. When it comes to the co-design process, when it comes to the trust, are you happy that there is enough transparency in the co-design process where not only are the things that are said going to be reported but then the transparency of how that's amalgamated and how that's brought in to the general work that goes on afterwards? Well, certainly from our perspective that it has to be brought in to the process, there'd be absolutely no point in doing a whole co-design process and then that doesn't inform what it is that we're going to be doing. Why would we do it in the first place? So certainly from our perspective, and I'm sure that that's why the Government did it, was to get those voices in. I think that because they'd ran a whole series of sessions over the summer as well to try and address some of their issues in the change of direction as well, but as Eddie said, we need to make sure that we can build that trust again because I think that change of direction has people will be like, well, what's happened here? Why were we going this way and now we're going that way? Part again in that trust and rebuilding or if we have to rebuild the trust is to make sure that whatever happens here as part of our negotiations, that we build and make sure that the views that have been put there are reflected in how that looks. The other thing about that as well is that one of our criticisms of the bill, I suppose initially had been that it was a framework bill and a lot of the stuff would be left for secondary legislation, a lot of the detail would be left in secondary legislation. I don't want that to be the same for people who've put their time and their effort into the co-design process that they need to know. This is why we've taken this decision. Some of those decisions may well be taken and it doesn't reflect the views that people have fed in, but there's going to have to be a trade-off for that in some ways, but that needs to be in the backbone of how we design that. What we're trying to do at the moment, as I said before, is to have that kind of framework and get that political agreement so that we can move forward. Previously, we weren't moving forward and you'll know that as a committee. Thank you, convener, and thank you to the panel for their contribution so far. The minister gave evidence to the committee prior to the October recess and our officials confirmed to committee that the co-design process for the charter of rights for the proposed legislation is still on going. Have the panel been involved with a specific example of co-design in relation to the bill? We have been involved in discussions on the charter at an officer level. I don't want to say that I'm pretty sure, but I have to come back and confirm with you. I think that our team were involved in at least sitting in on some of the co-design sessions on the charter as well. I know that there are on-going discussions on the charter of rights at an official level. Do you feel that such an inherent part of the legislation and such a critical part of the ethos of how that will operate should be formed as a product of co-design with local government as a principle? Yes, it's going to have to be. There will be many things in a charter of rights that will only have implications for the delivery of services. Potentially, whether that could be structural or whether that would be financial or whatever, you're never going to realise those rights if you don't have the infrastructure and the resources in place to deliver them. I know that Eddie will have a view on that, but we want to be involved in that. We need to be clear what people's expectations are. We have expectations from the co-design process absolutely rightly, but we also have to make excuses about money and make sure that we deliver on those expectations from people, but we need to have the kind of resources and other things to do that. You've touched on some of it. Clearly, the independent review of adult social care focused a lot on human rights and the discussion with people who use services and family carers again focuses on human rights. I think that the charter has to reflect some of that, so I think that the charter does have to come from what are the regional forums saying and once the regional forums are there, there is a place for local government and national government to say, this is what we've been asked for, how do we turn that round and give it back to people and say, is this really what you're saying to us? Does this really reflect the aspirations in terms of human rights and if some of that is within a framework of what we can do when? That's fair enough, but it's really important when I've spoken about that trust that if we're out asking people in the regional forums and people have aspirations following the independent review of adult social care, then that's what's written down there and people can actually see their aspirations in that charter in terms of what they can expect for that. I do think that there's a role for us in local government in respect to that. I think that it has to be at the right time to make sure that what we're looking at is what people have actually said to us. Add to that, one of the interesting challenges, I use that word a lot, challenges in respect to this is also by that reform piece that we've talked about here, and Eddie's talked about this one particularly when we were talking about packages of care. For me, one of the interesting elements around the charter of rights is to think about that rights in terms of outcomes rather than necessarily activities or processes into some sense structures. That's a big shift and it does talk to that within the independent review around how we move from essentially a system, almost essentially of quasi entitlements, to actually thinking about how we can make people as independent as possible, how we can enable them within their communities, and again some of that does tie into the feedback that's been received through those processes and others, that people wanting to be as independent as possible. So that is also one of the points that we said earlier on was about the culture and the ethos around social care and social work, so it's about how we can bring that ethos and that feedback that we hear continuously from community voices and others into that kind of charter. So it is less about you are entitled to X and Y and Z product and more about we will work together to get you to this level of independence or this level of outcome that you can enjoy within your life. That's again really tricky, but that would strike me as being slap bang in terms of what Chris David is talking about, absolutely in terms of a human rights approach to social care, social work and indeed healthcare and indeed if we're being person led, again a focus on outcomes would be crucial here. Appreciate that and please do keep us updated in terms of your co-design activity and whether you feel it as being as useful and as sufficient. I just also wanted to just ask about the charter of rights. Once it is codified and hopefully to a satisfactory standard, do you feel that that should stand part of the bill itself and be on the face of the bill in principle? I would have to come back to you on that because I would need to go back and check where we are with it to be honest, Mr Sweeney. If we're going to have a charter of rights, and it needs to have the strongest possible effect, it would be my view. Thank you for all your answers so far. It's been illuminating as ever. My first question is to Eddie Fallon. Eddie, you have been very positive about the Government's further engagement, what happened over the summer. Do you feel that the bill is now going in the right direction? Do you feel that now some consensus is being agreed and that we can move on positively? That was the whole point of the agreement that we had on June 30. If you think about where we are, where we were, we weren't moving forward. We genuinely appreciated the change of directives from Government in terms of where we were going. Over the summer period and up to now, we have continued to have fairly intensive negotiations around a whole range of complex issues. That is moving forward. I did say that the timescales are extremely challenging in terms of the complexity of the issues that we are addressing. There is no doubt about that, but we remain committed to moving forward on the timescales that we have at the moment. If I can add Eddie's positivity, if I put my skepticism in a wee bit around that, and this goes back to the first that we saw at the current bill was the day that the bill was published. That involved a huge part of the services that the local government is responsible for and that I am responsible for managing. Although we have worked well in terms of looking at how we can bring forward further proposals for our politicians, both at the local and national government, to consider when we see what that actually is and how much we are engaged in seeing what the reform of the bill is between stage 1 and stage 2. I will feel more certain about that given that. That is back to the fact that we have only seen a bill that had such a big impact on local government. The date that was published does not give a high level of trust. The work that we have done has to rebuild that trust so that the next time we see an iteration of the changes that are coming to the legislation that we feel that we have included in terms of that. I will try to find a middle ground in respect of that. The civil servants certainly have been engaging with the chief officer's group regularly. We appreciate seeing them in respect of that. Eddie's point is still well made in terms of when the timing of some of the announcements are. We are public servants. One of our roles is to be able to provide expert advice, whether to be to members of our IGBs, local elected members of all persuasions, the helpers that we are part of or, indeed, our constituency MSPs on issues such as that. We are available there as a resource, both in terms of our understanding of the running of the services and the needs of our local populations who we have responsibilities for, but also because we, frankly, are experts in different aspects of our field. We are keen to contribute to the process, not just because this is a vital element of legislation and a significant area of reform for Scotland, but also because we want to help to get it right and that we have a massive amount of to contribute to getting it right. I am hopeful and encouraged that our service service colleagues will continue to engage with us on that basis. I look forward to ministers continuing to lean into our advice and expertise alongside all the other voices that they are listening to and paying attention to. Do you have any insight into whether the recent changes in access to funds for unpaid carers have made a difference? I do not have any data or anything to sort whether it makes a difference. To be honest, we need to see significant changes to the funding and to unpaid carers to see it make a difference. We need to support people who use services and unpaid carers to see what their aspirations are. The resources that unpaid carers receive are still at a low level, if I can say in terms of the recognition of the work that they are doing. Obviously, the Scottish Government has additional resources to support and recognise that. We need to make sure that there is a resource going there. I totally welcome the resources that go there for that, but to make them into live-changing resources, we are talking about significant changes in terms of the resources that unpaid carers receive. We certainly get representations from unpaid carers and organisations that represent them, as well, who would absolutely concur with that. There needs to be more resources to support them. We also need to guarantee sufficient capacity in the system to support unpaid carers, because the role that local authorities in helping social care partnerships have got, and I assume that we can talk about that in supporting them, is crucial, but it is also stressed. We absolutely recognise how, without the role that unpaid carers play, it would always have been possible for the system to operate at all, in many respects, because it is that important. However, we need to make sure that we have the capacity to support them, and that comes to things such as rights to brakes. I know that you will be much closer to that than me. I would be happy to pick up the bat in the morning. On the other aspects that I would tease out, one is that point around stretched capacity. Again, as you will be well aware, we have a massive workforce challenge and supply challenge in terms of social care and social work and the infrastructure around it at the moment. To some extent, that also ties into the earlier point that was asked about improvement support in the pens sector. If I look within my area, we are massively stretched in terms of our ability to out-engage in all of those areas.  Some of that is frankly about money. I know that I keep on saying it, but we have massive funding shortfalls to deal with, as you will be familiar with, but also our ability to recruit the staff because in terms of the ability to fill vacancies and then have the time for that staff group to be developed and grow. That is a massive change that we are looking for, taking forward, and that is true across all areas. However, it presents challenges in terms of the kind of support that we are able to provide in the here and now for groups such as carers. Care centres are massively important then, in respect of that. That is why it is so important that we make sure that we have local arrangements in place that make sense for different carers in different communities. Again, one of the points that we said around the Shetland example is that that is why we need to be wary of one-size-fits-all arrangements, that there will be different histories, different sets of assets, different preferences, different geographies that we need to be familiar with. Again, not just around the carers centres, but I would suggest that our third sector interfaces and other key groups help us as a system to work effectively there and to understand better what our local carers need. I accept that there is a whole range of different carers that we are talking about. Again, there are no homogenous groups here. We are increasingly seeing people who are in their older ages caring for elderly relatives. We all need to be very familiar with young carers and they are increasing demands and challenges for them and how we can make sure that we can properly support them at all stages. As our understanding of the sophistication of those issues increases, so then is the challenge on us to be able to have the capacity to come up with the personalised solutions for those monies part of it, but it is also about having the flexibility and, frankly, the time at a local level to engage properly. Principles that I believe strongly apply to how we work with our carers to make sure that we are able to co-design arrangements that, again, are sustainable, that they are realistic in terms of the supports that people know that they can get from us, but also enable carers to support themselves and each other as far as possible. For some individuals who have got care responsibilities, they are looking for a lot of support quite understandably, but there are other carers, as you all know from your constituency work, who maybe just need a bit of a help at a certain point in time and then just need, essentially, the state to back off and let them get on with it. Again, that is why personal conversations and a personalised approach are so important here. Thank you, convener. If I can go back to Professor Sengupta, please. So you said earlier, Professor, that it's only real if you can pay for it, and then we've talked about this balance between one-size-fits-all versus variety. Now, the one-size-fits-all is a lower cost model. When you add variety, you add complexity, and you add cost, you can't have the both and. And I realise it's a dilemma, so we started off with the NTS talking about one-size-fits-all. We've now moved completely to a different model, could say a fudge, but it's like, oh yes, we'll variety, we'll individualise, but that's a huge cost. So what's your question? My question is, you can't have both your point, which is it's not real if you can't pay for it, but then the new model talks about variety, individual needs, compared to the one-size-fits-all, which is a low-cost model. Absolutely. So I would hope that, again, as the Bill progresses in the approach, and I think this is reflecting something that Eddie said, that Eddie Fulham has already said. In effect, what we're looking at is a continuum, and we're looking at a continuum that will vary from different groups that we provide care for. So there'll be some needs that can be met on a fairly standardised approaches. There are others that require a high degree of individualisation. So we need to be much more sophisticated, I was suggesting, about how we're articulating this as we move forward. So we move away from talking about our populations being homogenous, because it's not in the same way that we need to talk about our social care services in terms of the full span of what they deliver, rather than just a single banner headline. But that's the challenge around the world that we live in at the moment, and it would be a challenge going forward about how to get the right balance. And there's debates for, and I don't envy the challenge, for policy makers such as yourselves to actually work out what is the right level of elements that need to be managed and get you best value to national level, what are the elements that are best dealt with at your local level, what are the best areas that could be progressed at a neighbourhood level, and obviously that falls into other aspects of the community empowerment and other legislations that's around. But those are the challenges that I would suggest for any area of public policy development in Scotland at the moment, but particularly in terms of health and social care that we need to actually be more nuanced in our thinking in respect of, rather than a somewhat binary option between one-size-fits-all and flexibility. The other thing that's really important for us to recognise as we do that is that there are clearly areas that have already been alluded to that we are working on that we could see value from being done more nationally. So some of that would be to do with national standard being set and agreed around that. Elements to do with workforce development, the professional support for our social care and social workforce, directed on the standing and recognition of what they do, work around national campaigns. As I'm conscious that one of the big elephants in the room is around our winter pressures, because that goes to the point that was raised earlier about the time aspect here. So we like working and living in a democracy, so we'll work with whatever timescale that the Parliament deems appropriate for this, as in the same way we would approach it within local government. But we're also doing all this work as we stand in the barrel of what's going to be another tough winter, having come out of what was already the worst winter on record, that itself followed what we thought at time was the worst winter on record. So we need to be really thoughtful about where we prioritise our efforts, and if there are areas that we can do better nationally to have the humility to say, you know what, that would make sense to do it at national level. Certainly some areas around procurement that we could look at nationally more through the Scotland Excel model, and I'm sure that if you had conversations with colleagues from Scotland Excel they would talk to you about a range of areas where actually if we had them instruments in place we could do that work better. By the same token though, there are other aspects around our funding, for example, where if we had greater flexibility at a local level, how to use that resource that we could probably act in a much more agile fashion and be again much more personalised for local communities. Thank you. We'll move on to our final theme and Paul Swinney. Thank you, convener. We have had notes that delayed discharge to the national health service last year cost £190 million, so clearly a big opportunity cost and a lot of that is to do with the lack of efficient integration with social care and indeed hospice care. Do you feel that local authorities are receiving sufficient financial resources to deal with social care inefficiencies in the here and now? There are always challenges with the financial package that we've got. We know that many, so we can talk from a health and social care perspective about the deficits that many of them are carrying. From our perspective, and because we have been clear about that, we do need more resource. A lot of the issues around delayed discharge, as we have talked about before, are about the recruitment and retention of staff and what staff get paid. It's not just about social care when it comes to delayed discharge. We need to be thinking about a whole-system approach to tackling that. That's from primary care right through to social care as well. I think that we've been quite clear that the social care system isn't there just to support the health service. It's a whole system of care from GPs right through to care homes and to care at home as well. There are financial issues, there are recruitment and there are retention issues. It's about flow through hospitals. It's about conveyance by ambulance. It's about accessibility in GP and primary care services. It's about making sure that you get your discharge processes in hospitals. Absolutely right. It's about having a planned data discharge and it's about working in and there are a range of issues around discharge without delay. There are other issues as well about we've got adults in capacity. There are lots of people who are stuck because of the arrangements around that. From a cos later in a national perspective we need to work to support local areas in that but we need to make sure that we're absolutely looking at this from a whole-system perspective and not just one end. I know that both next to me have views on that as well. I'll take that up. As Eddie says, delayed discharge is about flow through our system. I'd like to take a step back from that to begin with. Just for avoidance of any confusion or doubt here, we don't want individuals to be delayed unnecessarily within hospitals. It's not good for the individual themselves in terms of deconditioning, in terms of their ability to get back into their lives and be with their families. That is not an attractive proposition for anybody and that is one of the reasons why our systems, our services spend so much time hours and hours and hours every week trying to see how we can get people home at the best time. I would suggest that focusing on delayed discharge as a singular measure of success of our healthcare system is problematic. I feel strongly that we need to think about, as Eddie says, that entire system and in fairness to government and civil service colleagues, the national hospital occupancy and delayed discharge plan does reflect the necessity and totality of approach very much around the principles of discharge without delay. In other words, how do we reduce the length of stay for everyone who is within our hospital? Depending on the year in and I've seen some data around this which I'm happy to share, that over the course of the pandemic, average length of stays within our hospitals went up by one day. If we were to move our length of stay down to the pre-pandemic levels, you would see a massive impact in terms of our occupancy levels across the piece. Those tie into then people turning up at our ED departments. Why is that in a much higher number at various points in time? We need to ask about why. That's to do with the flow through the hospitals themselves to make sure that colleagues within those areas are properly supported to work in different ways but also have sufficient staff on hand. It absolutely is then about the discharge process but also making sure that we're only providing packages of care to those people who need it the most. I feel very strongly, as indeed in my counterparts' notion, of realistic care. The committee will be familiar with that from the chief medical officer's approach to realistic health. The same approach can be provided to care. We shouldn't be providing packages of care to people who don't need it. We should be providing it in such a way that enables them to be as independent with their lives as possible. That's one of the reasons why, for example, the home first approaches that have been rolled out across Scotland are so important because that's about providing wraparound care to those people who need it the most so that you can provide support to them with the core supports that they need but no more than that. The more support you provide, the more deconditioning you potentially provide to that individual but also less resource available for other people, which means that you look after less people. That requires a reformer across that entirety of that process. Again, the lay discharge is a relatively small percentage of the people who move through our hospitals. The vast majority of people who are discharged from our hospitals don't require complex packages of care, and the vast majority of people are discharged effectively. There is a big challenge around thinking about that totality of the system capacity, so we could have a—I'm sure there will be—other times that the committee is met in discussing length around primary care capacity, the capacity of the hospitals, et cetera, so we can look at those issues in isolation. In terms of the messaging that goes out, that speaks to Eddie's last point here, that social care is not there to provide support to healthcare. I say that to somebody who is, if I put aside the hat that I'm wearing here today, who is both an executive director of a territorial board as well as having responsibilities for the council for the delivery of social care as part of an HSCP. My staff, our staff within social work and social care, don't join that group of staff, that profession, to help out hospitals. They do it to help out people who need it within our communities in their homes, and some of whom are in our hospitals. They increasingly work well with our healthcare colleagues, including our colleagues within hospitals. Many of them are based in terms of our hospital-based social work teams. Nonetheless, it's really important that we put a message strongly to our social care and social workforce that they are valued for who they are and valued for what they bring themselves, rather than suggesting that the only credit that they bring to the system is somehow to do with whether a delayed discharge figure has gone down or not. I say that on the basis that we all want to see delayed discharge coming down. However, there are other measures of value within the system that we need to pay attention to. Last thing, though, I would agree with you about the money. We need the resource for doing that, and partly the reason for saying that we need the resource for doing that is because, as I would have at Scotland highlighted, IGBs across the colonies are running significant recurrent deficits. Most of us, to great less extent, are able to balance our books this year and somewhere and are planning to do that into next on the basis of non-recurrent monies. That is not sustainable. We know that that is not sustainable. Our external auditors have told us that that is not sustainable. We are having, then, to all go into processes looking around how we cut our cloth accordingly right now. In addition, to dealing with the winter pressures that are in front of us, we are also having to think about significant service reform that I'm going to take forward given the significant cost increase that we haven't seen because, for example, of inflation and what that means in terms of the actual real terms of resources available to us. That was not a challenge that we had to the same extent last year or the year before, but it is a very real challenge here and now. I appreciate the outline and the complex interfaces between the acute hospitals and social care settings, and I think that that is helpful. Of course, it may be the fixation on the lead discharges because it is a clear metric, as opposed to, say, avoidance of hospital admissions, which is a harder thing to quantify in a firm number, and that is a fair challenge back. What I would highlight back is that Scotland's acute hospital expenditure is probably amongst the highest in the OECD relative to the overall healthcare system. How do we pivot that back towards a more sustainable ratio that is more in line with OECD averages? How will this propose to health and social care integration through the national care service help design processes, improve processes, improve that integration to pivot the system away from the acute hospitals and to the more community settings? I think that if we go back to what we were speaking about earlier about charters of right, so human's right to talk about where we can be just now, but we spoke about the importance previously about prevention. We spoke about the human rights that come out of the independent review of adult social care. Nearly £200 million is spent in the acute hospital. If it was spent within the community to deliver things differently, it could be of much better outcomes for people rather than that. You are absolutely right. What is the trick about how we move that money across? That is something that we have not achieved. That is what the 2014 act is called set aside. Within that, there was always the plan that, if the current IGIBs were able to plan differently for the community, they would be able to draw money down in terms of doing that. That is not really worked, and it is not really worked because the continued pressures that there actually is in delivering in the acute side have never actually been any money to release to come down. The core of that legislation is going to make a difference. If it is going to fall on, not just in terms of the independent review of adult social care, but back to self-directed support and the range of the data is about how to spend money in the right place to get the best effect for people. I was seven years as a chief officer at the IGIB, and I would be totally understanding the day-to-day pressures around that. We all absolutely accept and assume and say that leaving people in hospital for lengthy times that actually sees their health deteriorate is not what anybody wants, so there is a challenge to us all about how do we make sure that money moves to the right place to do that. It is something right from the 2014 act to be quite frank. We have not achieved it at this time. You can say that it is just because there is not enough money overall in the system, which would be one argument around that. You can also challenge us about where is the money in the system and how do we move that as well. I thank the panel for their attendance this morning and for the evidence that they have given committee, which I am sure we will find very helpful. Our meeting next week will be taking further evidence as part of the committee's on-going stage 1 scrutiny of the National Care Service Scotland bill, and that concludes the public part of our meeting today.