Good morning, and welcome to the 17th meeting of the Health and Sport Committee for 2018. Can I ask everyone in the room to please ensure that mobile phones are off or on silent, and please do not record or film the proceedings? The first item on our agenda is an evidence session on pre-budget scrutiny for the Scottish Government budget for financial year 2019-20. This is an area where the Health and Sport Committee has set a bit of a pace in terms of pre-budget scrutiny, and we are keen to ensure that we continue to set that positive pace, so we are taking an early look at the budget for the forthcoming financial year. We have received apologies this morning from Miles Briggs. I welcome to the committee representatives of five health and social care partnerships across Scotland. Judith Proctor, the chief officer of Edinburgh, Eddie Fraser, the director of health and social care at East Ayrshire, Pam Gowens, the chief officer at Murray, Janis Shewet, the chief accountable officer at North Lanarkshire, and Robert McCulloch Graham, the chief officer at the Scottish border.  We have, as a committee, been keen to ensure that we had sight of and that others had sight of full financial information regarding integration authorities, as well as health boards, and we were therefore pleased. I can fairly say when the Scottish Government made that information available earlier this month in the form of a consulted report on integration authority finances. I wonder if we could start perhaps by asking each of the authorities here today how that publication, how helpful that will be for you in your work and whether you will use it in benchmarking in comparison with other integration authorities. Who do we like to start? I am happy to say that. It is really helpful to be able to see it. It is also important that we understand what the fair comparisons are. Because different partnerships have different services within them, we will see them different. Some partnerships have children's services, some partnerships have justice, so it cannot just be a straight-weed across. You need to actually look at a family of partner services that are actually like for like. That being said, you do see trends in them. You see trends in them, it is really good, rather than just looking at what is happening in Ayrshire to be able to see what is happening right across the country and other similar types of board areas, like T-Side or Grampian, when there are several partnerships within one board area. I think that seeing that and seeing that on a regular basis for us is a really helpful tool in our financial planning. Probably just to add, yes. It is what lies beneath in understanding the detail around this and allowing us to ask more questions, because it has stimulated more questions to be considered. I think that it will be very useful. It is a great deal of learning to be had across the 32 partnerships. Any information that is shared is always going to be useful, but to get some benchmarking between us is essential when we are coming into each of the budget rounds. Excellent. I think that that seems to be a shared view across the board, and that is very helpful to understand. Clearly, one of the things that has become clear from that consolidated financial information is that there are issues of overspend in the current financial year and a number of partnerships. Can you ask those partnerships who have that situation what your plans are for addressing that overspend in the course of this financial year? We would be one of the partnerships that indicated that we were heading for an overspend. Again, there are specific reasons and areas where the overspend is. Our overspend in terms of what we would consider the health part of the budget would be almost totally primary care prescribing. In terms of the local authority part of the budget, it is outwith placements for our children's services.  It is some of our services that are very specific to us that are actually overspent in terms of that. In terms of each of those, we work very closely to work at how their change programmes are going to address that. I work very closely with the director of pharmacy, and we are also looking at the new input of resources through the primary care. Our new pharmacists get into GP practices and how that can change some of our prescribing patterns and reduce that spend of that. Some of the increases this year have not been a bit volume of prescribing, it has been a unit cost of prescribing going up, so it is a bit difficult, it is slightly out with our control, but at the same time we need to take control of that. Our children's services are a bit of a wider wellbeing of children. In terms of the services that we deliver to children, we have recently had our joint children services inspection and that has been evaluated very positively in terms of the services we provide. When the children come to us in the partnership, they need their services. Our work has to be around wellbeing, further upstream, to make sure that we give different support to families, different support to communities, so that not as many children need their services that we deliver. We have very clear programmes of planning. Yesterday, we took a strategic plan associated with a financial plan, a workforce plan and a property and asset management strategy to the NHS board to share with them, having already been to the council and the integration joint board. We know where we are going in the future. We know the very specific areas, where there are overspend, and we seek to address them. I am happy to go into one of those areas as well. We have a significant gap still to find from the submission that we have put forward. Some of those bigger pressures are really the same as Eddie has just referred to, but there are some broader themes that are historical. Community hospitals have traditionally had a legacy of what we require to budget for in order to run them at the level that they are at at the moment and does not match the actual budgets that have historically been against them. There are some legacy issues that we are trying to deal with, but certainly out-of-area placements, high-care packages and prescribing are accounting for some of the biggest areas. We have identified just over a million in actual savings that we are absolutely confident that we can make. It looks like our year-end sign-off is going to be better than we thought to the tune of £750,000, but that still leaves about a £3.5 million gap to find. The budget in Murray, the size of Murray, is a small budget. It does not take much shift for us to be in difficulty, so we are very mindful that the decisions that we take now could be legacy. We need to do that in a very considered way. We have already decommissioned some respite facilities, which was very difficult for the few individuals that were using those respite facilities. However, in terms of best value and our ability to deliver on that, with the change in modernisation that is going on through self-directed support, people are choosing not to use those traditional ways of seeking respite, but we have had to manage the small number of people left quite sensitively. Those were, in some ways, difficult for those involved in a quality and family perspective, but easy from a financial perspective, because they did not make good, valuable business, best value sense. We have a huge number of activities going on just now, where we are drilling down with our senior management team into all the services to understand the implications of the gap that we have now. Indeed, the potential gap that we might have next year, particularly in relation to the council's difficulties with its budget. What does that mean for the people of Moray if we have to reduce even further and reprioritise what we do? We are looking to make those decisions with people, with the public and with both the partner agencies that fund us so that we do not have legacy unintended consequences. By June, we are looking to have a reasonable handle on that, but that will be on-going work throughout this year, because this is a three to five-year change programme. On a positive note, one of the other aspects that we are looking at, obviously Dr Gray's, is one of our key district general in Moray, and it accounts for most of our unscheduled care. We are looking at, with NHS Grampian, how we can bolster and support with some capacity around planning that whole system. Again, we want to try and make sensible decisions. We have real recruitment issues and rural aspects to the GP contract and the way that we are running the hospital. There is an opportunity to try and look at that in a more broad systemic sense and hopefully get something that is reasonable and palatable and does not compromise quality. That is what we are trying to do just now. Thank you very much. Dr Gray, do you have anything to add in relation to Edinburgh? I have been in post for this my fourth week, so I have not been very involved in the budget setting up to date in Edinburgh. However, I would absolutely echo some of the challenges that are apparent here. They reflect very similarly those that are experienced in Aberdeen and those that are reflected by my colleagues. Some of the challenging aspects of the budget, those that it is harder to control around prescribing in particular. In terms of our savings plans for this year, there is a lot of focus on prescribing and a lot of focus on the opportunities within the primary care improvement plans and new primary care contracts in supporting that as an area. However, it becomes increasingly difficult to make some of those savings in prescribing in relation to prescribing practice and custom when some of the challenges relate to external factors. One of the issues that I am quite familiar with from my previous role that can drive some of the challenges in Edinburgh is the particular characteristics of the job market in Edinburgh and the make-up of the care home market, where we have a high level of private care homes and a challenge in relation to the capacity of care homes that charge us the national care home rate. In order to address some of our well-known challenges around delayed discharge and access to good services, we need to increasingly look to the private and more costly market to try and secure. That is an on-going challenge for us and one that we definitely need to look at in terms of how we balance our whole offering across Edinburgh. The particular challenges in the borders are about the rurality of the area, and it is difficult to appoint staff there. We have particular challenges around the number of residential beds that we have, and we have the same problems as others of having to use some of the private providers, which are significantly more expensive than others. The bed model that we have within the residential sector at the moment is at saturation, and so we need to be creating more beds in that particular area, particularly to deal with delayed discharges to make sure that there is patient flow within the particular difficulties that we have at the present time. Looking at the savings that the borders have made since the inception of the IGP, there is £6.5 million that has been saved on a permanent basis within the partnerships, so that is good news. However, the last couple of years there have been saving targets that have been met, but they have been met on a non-recurring basis, which means that it is being carried over into the next year. This financial year, the borders are facing a very difficult savings target of just short of £10 million from a budget of £168 million, so it is going to be a very difficult year for us in doing that. The inception of the IGP is to make better use of our community asset, and it is the only way that we are going to make any headway in that. We need to be able to manage the demand on our services, and to do that we need to get access to more of that community asset, so we have been working with the communities in a much better and more efficient way than we have done in the past, so that we can effectively do that shift from acute into community care. All of our strategies and actions are around that, and that is the base of how we are actually moving into the future, but it is a significantly challenging year that we are facing in the borders. Thank you. We are in a very fortunate partnership who have an underspend, and I have to say that prescribing is one of the things like other colleagues that is overspent, but we have created quite a rigorous process around scrutiny of budgets. We have some workforce challenges, so we have vacancies, particularly in areas that, as you know, we sit between the Glasgow and Edinburgh corridors, so sometimes that works for us and sometimes it works against us. Particularly on particular aspects of mental health and some of our mental health workforce, it would be great if we could recruit more to that. However, in light of the underspends, we have been fairly creative around some of the models. This year, we have taken a new home support model through, and as colleagues have said, this is about managing demand in a different way. We are trying to get more with the same amount of money, and we have been quite creative around the use of technology and taking demand out of the system. Equally, we see a huge opportunity for technology, and I think that that is an area that is completely untapped. We would welcome any support in and around that. I think that colleagues have mentioned custom practice behaviours and the expectation of service, and I think that we need to try and manage that over time. However, our home support service is definitely now in a place where we are able to access resources where people need it. We used to have quite rigid workforce patterns, and we have certainly worked with our trade union staff side colleagues. We have been trying to change those views on when workers would work. We have got quite traditional ways of working around Monday to Friday, 9 to 5, and we realise that health and social care is now 24-7, and we need to get appropriate services there. We have taken quite a bit of time out to seriously trying to change resources, but that has not been particularly easy around the things that may seem sensible are not always politically palatable. We have had to really work hard about evidence, about the opportunities for change. Certainly, from our perspective, those have been fairly managed underspends. To date, we are trying to create some of that transformation money so that we can change the balance of care into the community. One final thing for myself on the development of the Monklands redevelopment. We are spending quite a bit of time as we design a new acute facility, what is required in the community. Certainly, from our perspective, health and social care has been very well respected about if we are going to have an effective acute service, the whole system needs to come together. I certainly think that some of that transformational money needs to be invested in health and social care. I have to say that, as well as other colleagues, our independent and third sector are key to all of that. From us, we have a very good relationship with the third sector interface, and that capacity also needs to come from there as well. I am going to focus first of all on some of the evidence that we have received from the Edinburgh submission. Last year, it is fair to say that the committee previously heard about difficulties with the budget setting process, partly due to different timescales for NHS and local authority budget processes, but the fact that local authorities need to present balanced budgets and others do not. Edinburgh has said in its submission that the key challenge in agreeing budgets is the prevailing financial environment facing the public sector and the consequent requirement for a high level of savings in services that face significant growth in demographic-led demand. Your submission suggests that communication is good, but the process has not been too difficult. Do you feel that the major challenge is one of a lack of cash, perhaps? It certainly has not been difficult for me, the budget setting this year, because I have not been involved in it. That aside, it is important to know that relationships work well. I think that, with all the guidance and legislation that we have in place, it drives us to work in a certain way. That is necessary, but more important to that is the relationships and the willingness for integration to work and the budget setting process to go forward in a positive, proactive way. I understand that that is what has happened over previous months in Edinburgh and that it continues to do so. However, one of the things that is very challenging is the wider interface with NHS and the savings that they are required to make and within the local authority and the savings that they are required to make. It involves us, as chief officers and our IJBs, in a very detailed round of conversations and priority setting in terms of what we are required to do for our IJB to ensure the best settlement possible, but also to ensure that we work in good partnership with our colleagues and partners in the NHS and the local authority to help to achieve the savings that are required and the outcomes that they are trying to achieve. Against a generally shrinking financial envelope across Scotland, it involves us all in quite challenging discussions. I would be grateful if others could share your experience about this. Is it your opinion that lack of finance is as big an issue here as different timescales? Do you think that the IJB voice is loud enough? Are you perhaps being too polite, too restrained? Do you think that you are waiting for others to set budgets where you could perhaps be making more of a strident call for what you actually need? I think that there is potentially something in that. I think that we are still maturing. We have really just been in two years or three years in operations, so we are still finding our feet against sitting alongside two organisations that have been around for a long time. Many of us and my colleagues have strived to maintain relationships to try to resolve that together. There is a finite balance between being diverted on to a fight as opposed to getting the right outcomes for people. Are we also asserting the authority and the power that we have at the level that we could? When you are moving forward, you need to be moving forward confidently in a certain power. I will link back to what I said before. There is something about understanding what it is that you are trying to assert so that you do not have unintended consequences that are legacy for the system. We are becoming more assertive. It is a journey. We have had to take time to get our feet into a firm position. However, I still think that relationships are key to success. Therefore, we will always have to balance that. I think that it is fair to say that the IGIV is heard quite loud and clear. We sat fully at the community planning table, our relationships with the NHS board and with the council, and I think that it is open and honest.  If that means that we do not have money out there in housing or education or some of our health improvement services, then all we do is continue to professionalise our services. Our partnership work with the third sector and the independent sector is really strong. It is different from Rob's. We are reducing the number of people in care home beds. We think that a big part of that is the partnership work that we do. We acute, so we bring people out very early at a hospital. More people are going home. Possessions are nine times to the law. People stay at home when we get them home, so our numbers in social care are actually coming down as well in terms of care home places. We only work with the independent sector in terms of care homes, and our partnership work with them and the care inspectorate through my home life leadership programmes, through care about physical activity programmes, is really strong. When you are loud and have an influence over it, it does not mean to say that you want to attract all the money to yourself. It is how you see that money working right across your community planning partnership, not just the council and the health board, and I think that we start to see that making a real difference in some of the work that we do. I would genuinely say that Lanarkshire is committed to a whole system approach. I think that where the differences are versus targets and the expectations of meeting some of those targets, they drive certain behaviours, and it is understandable. Certainly, from our perspective, I think that all four partners—I mean the council, the health board, the IJB and the third and independent sector—want the same thing. We genuinely want great outcomes for people. I mentioned earlier about some of the behaviours of individuals, and I think that there is still a cultural expectation that the state will provide and will provide a variety of services to a level of quality. We need to tackle some of the inequality issues. For me, some of the fairer Scotland duties seem to clash a bit with best value. When you sit in North Lanarkshire, where we have areas of deprivation, one of the things would be to trust partnerships to invest where they think the greatest need is. I realise what the needs are of my population, but often money comes with a tag on it that says that you have to invest it there. We will have to trust partnerships to invest for outcomes for people. To the detriment across the years, we have not invested enough in prevention and early intervention. We have not invested enough in some of the independent community support. For me, your question was, is there enough cash in the system? No, I would want more cash in the system, and I genuinely want that to be given without tags so that we can trust partnerships. Absolutely, I am all up for scrutiny and performance. However, when money comes with tags, it restricts us greatly. More cash, please, but allow us to have the trust locally to identify the needs and invest in those needs. The way that the legislation is set up at the present time relies highly on relationships. If relationships are not working at the senior level within the three main organisations, then it is just not going to work. There is not enough money in the system. You have three independent bodies that are all accountable for their own budgets within that, and at some points they are conflicted within that. That is where it is working together and partnership is necessity to see us through. However, the legislation at the moment is over complicated unless it relies heavily on the relationships between those individuals, and perhaps it relies too much on that. What my colleagues have said about moving towards partnership is the only answer that we have. Getting more into the prevention work in the partnerships that are set up to do that is the only way that we can start to manage the demand in our services. However, there is a balance to be struck. We can take more resources out of the system if we manage that demand, but we have taken a significant amount out already. Looking at the pressures that all of the partnerships are under at present time, I do not think that there is enough money in the system to cover all of that. That leads up nicely to my questions about efficiency savings. Are there particular services that you believe will be harder hit than others going forward looking for efficiency savings? In its written submission, North Lanarkshire noted that it is challenging to continue to protect the budgets supporting preventative and early intervention work. Just be curious as to where your own fears are about what could be hardest hit going forward and how are you intending to mitigate that? I would like to start. That is really a question for everyone, I think. I think that the risk—I am certainly very aware of it—is that when your under pressure, when your budgets are under pressure, you can default to soft targets, as I would describe it. That is maybe not the best term, but that is the one that I will use.  However, there is a real danger that you lose sight of that long-term goal. We often default to support services such as admin, and you get a false economy in terms of what your clinical and practitioner staff are doing versus how they are appropriately supported. I guess that goes back to being able to consider fully what you are trying to achieve. I suppose that strategic plans commit to prevention for good reason. We know that that is a long-term game, and we need to keep going with that. It comes back to some of the things that other people have said. That is not always about the direct budget that is there. The community resilience and the community groups that we have been able to tap into in the third sector that is already thriving are big players in how we have prevention prevailing, and community planning partners are playing a big part in that. When I am thinking about the budgets, I will go back to what Eddie said. We are part of a whole range of partnerships that bring a lot to the table. How do you maximise that to get the prevention end right firm in the middle, because it is critical? For me, that is things such as the Murray growth deal. How do we make sure that, if that is to be successful, we are a key player and contributor and understand what that can bring to communities? Housing has been a massive transformational partner in what we have achieved in Murray. In my submission, I have mentioned a couple of areas that have had impact. All that is prevention, because that is keeping people independent in their home and mentally well rather than languishing somewhere that they do not want to be. I absolutely agree with Pam about the contribution that housing can make. Our strategic housing investment programme has already delivered a number of different projects that directly support wellbeing in the communities. Some of them have been more generally for older people in their communities, people who might be in big tenancies moving to brand new houses and freeing up the big tenancies for families. Others have been about it for people with high levels of need and people with really high quality new housing with tech attacks to it, choosing to go there, so it is not forcing people to go there. We have a number of other projects coming along in the strategic housing investment programme to deliver that. It sees a change from people with maybe ten people all spread across the area, all having 24-hour, one-to-one support to people living in different models of care, where there is still 24-hour cover there on site at hand to them, but they do not all need that individual, one-to-one support, and that is significant savings and also delivers more independence for people. That bit of independence and inclusion is a way that we need to manage demand rather than to talk about cuts. When we have conversations now, we call it our community front door when people first come to us and talk to us about social care services. We very much talk to them about what their priorities are. We talk to them about the things about self-directed support should be about what control and what choice do they want around that. I think that it is the same agenda in nursing to the what matters to you, it is the same agenda in terms of realistic medicine. It is that conversation and different conversation that we are having with people. The output of that for us this year has been against a predicted 3 per cent growth in terms of our social care services, we have a 1 per cent reduction in terms of that, and that has not been about cuts, this has been about different conversations with people. I think that that is the important way we go. We actually talk to people about what is important to them and we make sure that we deliver on that rather than us giving more traditional, oh, you have got this level I need, so you will get three visits a day, seven days a week. That is not the type of support or the conversations that we are having. We are really seeing reward in returns from having the conversations. Again, it is about how we work with other people, it is how we work with people who are coming to us for services, it is how we work with communities and it is how we work with the other providers that are surrounding us, including housing in particular. I again agree with my colleagues that there is a project that has been under way in Edinburgh that is showing some real benefits from just the approach that colleagues have been talking about, where there have been high weights for an assessment where people have come forward with a view to having a need for health or social care and they have had to wait a long time to access that because of some of our challenges with regard to the workforce availability and so on. Just taking that very different approach, which is working with people around what alternatives can we find, what assets are there in your community, what are the third and independent sector, mostly third sector, voluntary sector offerings out there, people have had better outcomes, they have been able to be getting the support that they need, the companionship, the links into their community that is far more beneficial for them in many ways than a statutory intervention. Obviously, those people who have a requirement for a statutory intervention, we have been able to move that one through but we have managed to reduce both waiting lists and the subsequent need for a statutory intervention, and I think that that is really important. We often funnel people into service land as opposed to support them to find the links in their communities. I say that it can often be more rewarding for them. In terms of the question, I think that one of the things that we would strive very, very hard to do is always balance the need for efficiencies with outcomes for people. One of the areas that I think can be a challenge for us to articulate is the transformational potential and the use of transformation funding. One of the difficulties around that is that the transformation programme that we are dealing with is cultural. It is about new models, it is about the use of technology. All those things can take time to really embed and deliver the expected outcomes, including benefits to people and the efficiencies that we will want to see. It is often because that money seems to be sitting spare that we can be under pressure to justify. We need to have well-articulated transformation programmes with the vision of where we are going and a degree of courage and bravery to sit with that and ensure that we hold the line because that is the transformation potential that is really going to deliver sustainable change in our system. You asked what is the hardest hit. Often, the hardest hits are things that do not have targets. Certainly, for me, there is a view that where a target is attached and where there is an expectation to deliver, that drives a set of behaviours. In my own budget, I have only got 46 per cent, which is able to be challenged in and around savings. The rest is fixed. It is quite an incredible amount of money that is already set, and I cannot take anything else from it. Could you go into a bit more detail about the ways in which it cannot be touched? Fixed costs such as care packages that you cannot take care away from folks, and certainly those individuals who are in care homes and packages of care just now. It is quite an interesting analysis when you start to look at how much you are able to take from the edges. Certainly, one of the things for me is that I see my own budget as an integrated budget, and that is not always seen by the two partner bodies as an integrated budget. I would like personally to lose the labels from both of those budgets, so I invest and sometimes I use social care money to invest in a model, sometimes I use health money. At the end of the day, somebody has to do a ledger and a count's back that says that that is what we spent in health and that is what we spent in the council funding and any additional funding, but certainly from my perspective, I consistently see it as an integrated budget. Again, I would like to be able to have the ability to invest where I think we need to. Just in terms of some of the areas of investment, particularly around prevention, the first point of contact that colleagues have mentioned is pretty key. At that particular point, whether they have been known to us in the past or are brand new, that first point of contact is really, really key. At that particular point, we can take a view on folk's financial situations, their need, their supports and certainly direct people into prevention, self-management, information and advice, and we are not doing that well enough at the moment. I think that self-management is something that we really need to explore and invest in. Just to give you an example of some of that in terms of managing demand and the self-management, we have just completed a project in North Lanarkshire, which this week won the local NHS award because it was truly integrated between the workforce of OTs, physios and some of the home support staff. Working together in one team co-located using one system, one had to use the other system, it was difficult and it was challenging, but what we did significantly in that particular project was that we have managed the demand around waiting times. We have not taken a cut, but we are managing more people through the system. That is a growth in itself, so that is really, really key. The aspect of that is that people are getting a good service, but the self-management element of that and the use of technology perhaps in future around physio is that you would have your procedure and you would be given electronic ways of managing, and, certainly from our perspective, that would save visits to the statutory services. Again, for us, just some examples of where we have managed demand. Can I just clarify an earlier point that you made around fixed costs and targets, that where costs are linked to targets, it is harder to find efficiencies there. In terms of the split, I think that it was at 47 per cent that you said was not fixed costs. Does that mean that they do not have targets attached as well? They do, some of them do, in terms of some of the things that we have to provide, and certainly there are clearly more targets in one world that we live in rather than in the other. Sometimes we talk about volumes rather than specific targets, so some of those fixed costs also have targets or expectations of reduced demand or reduced growth. As you are saying that fixed costs, existing care packages cannot be remodeled, I think that we heard something different from any phrase, and I wonder if you would respond to that. I think that they can be remodeled. It is often very challenging when you sit with a family and we have done exceptionally well around learning disability. We have done exceptionally well where we have remodelled the care, but that takes a long time working with families. If we think of overnight support and overnight care, there is a genuine fear from families that we are taking something away as opposed to giving them something better. Indeed, I had a member of staff who sat outside a client's house when we moved to overnight care with technology. It is just that anxious about the first time, and it is that trust that you build up in the whole system that is being able to respond. We can remodel packages, but it is at the margins and often families have to come with us on quite a long journey. Judith Brackle and then Pam Gareth. It was just another example of what we would see as fixed costs that we are unable to influence changes on. It is money that comes in with our budgets that pretty much just goes straight out again, and a good example of that would be the money tied up to GP services. They are largely fixed, and whilst there is transformational potential within how we shift primary care, that is not money that we are actively able to make a saving on, and it is a significant amount to the budget. I just wanted to support some of the statements that Janice has made about the complex packages around people with learning disabilities and mental health. Indeed, working with individuals, a bit like I said around the rest, might help them to understand that there are other ways that they can experience the system. It takes time and takes a lot of confidence building. It is not a quick fix, but it would be quite useful to share with you one of the things that I mentioned in the submission that is feeling really exciting in terms of learning for all of us, and we are having an academic piece of work done around that. In Forrest, which is a small town to the west of Murray, we had a residential care unit for people with extreme autism and challenging behaviour. That was a difficult environment for people to be living in. They were living with people that they chose not to live with. Their families did not have the privacy and the ability to interact in the way that they perhaps wished to. Our recruitment retention was pretty bad, although there was a core group of staff who stuck with that all the way through their dedication. Those staff were really dedicated. Murray Council, before integration, had started to address the basis of two objectives. One was around recruitment retention and one was around quality of life and optimising those individuals right to something better. At the time when they were in the residential service, we were averaging about 70 incidents of assault on staff a month. That is a lot of distress for the individuals involved and for the staff, so that is not a good situation. Last August, we opened brand new build bungalows that are all appropriately built to suit the needs of those individuals—the four individuals that we are moving across in the first instance. Technology-enabled care, they have privacy, and they have the right to family life fulfilled because they have privacy, and their own home and their families can work with them. They are within a community in these lovely, spacious and bright environments, and we have recruited teams specific to their needs to work with them. In the first six months, our incidents went down to one, which was pretty minor. That will be a honeymoon period in the world. We will have peaks and drops in that. Our use of as-required medications—I have the exact figure here, I can get them for you—is 73 per cent reduction in our use of as-required medications, so that is money. Our restraint is 100 per cent reduction in one restraint technique and 93 per cent reduction in another, so it goes on in this very positive. Recruitment has been really successful. We have had one person leave because they went on maternity leave. We are coming up for a year in August, so we will be able to have a really good day to set around that. Since then, and I think that this is important from a budget perspective, because we are all spending out lots of money on out-of-area placements. We have repatriated individuals who could be costing us around £600 to £1 million a year out-of-area down south placement. In a budget my size, that is a scary number. You have not got the connection and you have not got the control over everything that is happening. There are plus for the family that this can be significant travel to try and see them. We have successfully brought people back into those bungalows who have been in those circumstances. Interestingly, we are having positive results in terms of quality of life, no further incidents. All things that actually, from a practitioner perspective, felt very high risk. From a professional perspective, in traditional models, were scary prospects. There was a little bit of boldness there and a little bit of going forward. We are really interested to understand all the factors and, hopefully, for colleagues that will be helpful. I know that others have similar results, but I just think that it can hopefully show a way that you can achieve quality, but you can still have that right to family life and you can still make savings. The average cost now for those people who have their own tenancies, those are their own houses, is about £250,000. Again, making money go further and better quality. There are examples of that that we are starting to understand. Thank you very much. I will give a brief supplementary report towards Edinburgh. You may have touched on this already, but in terms of the budget savings in 2017-18, which were not reported in terms of achievement, will that have serious implications for plan savings this year? We have had, where we will be reporting on balanced budget for the close of last year finance, but that has been as a result of increased investment from both NHS Lothian and City of Edinburgh Council in recognition of some of the pressures and also in support of the wider transformation that we are trying to achieve. The budget forecast efficiency that we are looking for this year is a target of £20.2 million. We have identified £14.9 million of that, so we still have a gap in terms of identified savings. As colleagues have identified, we have a savings programme and scrutiny process in place in relation to the deliverability of savings in year. As you are pointing out, non-delivered savings this year lead to additional pressure next year because we will have savings to make then. If we have unidentified or non-delivered savings, it is of concerns, which is why, from an operational perspective, we apply a lot of scrutiny to that. Additional investment last year won off? I do not have the detail entirely on that one. We have not concluded that there is an element of both recurring and non-recurring in that. I am very interested in what Pam Kerrins has said about the savings and looking at new issues. I wondered how difficult it is to change culture if you have families and, obviously, it is high-cost packages. Is it a reassessment of their needs every year, every two years, whatever it is? Do you want to let me know how you work that out? I am sure that all of us have families come to our constituencies saying that this is not good for my child and that it is a real high-end. How do you make budget savings? Do you reassess every year or every two years what is better for the person involved? We reassess at least every year and, likely, more regularly than that. I think often with some of those transformational changes, it is really no other professionals that folk want to hear from. It is really the families of other folk who have transitioned into different things. I am a carer for a 19-year-old son with autism. If anyone came to me and said that it would be okay, Calum could just spend all night himself. I would just laugh at them. There is the bit about having to see and trust what is happening. That is how we need to work with families. They need to see how it has worked for other people. We have had some of the trailblazers, if you want to call it, who have changed. They have done things differently. People have got a different type of life. They are not sitting. One-to-one support if you are sitting in a house with someone with a paid carer 24 hours a day. When we were learning disability to explain that to me as being with the boss, she said that as someone who was the boss over all the time. She explained to me that she felt she had more freedom when she lived in an NHS facility where she could go to the day room with other patients and sit and watch the telly that nobody had any power over her as a better environment for her than sitting with a paid carer all the time. Actually trying to find somewhere in the middle of that. Some of these housing models that we are doing, people have their own tenancy, they have their own space, but they are also close by all the supports they require. That is the goal that we work with. You are absolutely right in saying how you work with people, how you work trust, and because everyone is aware of the current financial challenges and environment, people think that when you are getting in the door, your purpose in getting in the door is to make cuts. It is a big persuasion about, yes, we want to reduce the cost, but we want to reduce it in a way that gives people at least as much independence and is absolutely a safe way of delivering things. People want control of their own lives, and a lot of the services that we are inputting now contain an element of reablement. If someone has a hospital visit, we want to get them back on their feet as soon as possible, back to the world as much as their normal life. In the borders, we have introduced a discharge to assess policy, so we want to do that assessment in a place that is familiar to them, usually their home or at least a homely environment so that we can find out how they can start cooking again, get out the front door again, start their lives again within that. It is really putting the power and the honest back on the individual to get better within that, rather than taking care of everything and for the state to take care of everything. It is a real cultural shift. We are fortunate in the borders that we have a co-terminosity between the NHS boards, the council and the IGB, of course, within that. We are able to work in very close partnership, and there is a real ownership between all the chief execs and the officers within that of the challenges that are faced right across the whole of the partnership, and the solutions for some of the challenges that we are getting NHS lie within the council and vice versa. We are trying that shift of the balance of care, and one of the things that the borders have been successful at is introducing housing with extra care. Eddie was saying that we have a whole range of facilities that individuals can get into within that, and it is a choice that we are trying to put on. Just one very quick example. Using self-directed support, we have much more flexibility for people as to how they get the care and support that they actually require within that, and we need people to be much more imaginative around what it is that is going to be good for them. An example that I had from a previous role elsewhere was that a social worker was dealing with mental health issues around a middle-aged woman, and she was constantly visiting the GP, getting into depressants, and this was going on for a number of years, but what was the solution to that was actually giving her a puppy, and that she actually started walking the dog, she was getting out the door, she was meeting people, she was joining clubs, and she was out of that isolation. That was a really ingenious move on an individual who had the freedom of a budget that she could use in a different way, and I think that that is what we are all trying to do with the community itself. So, the state does not need to provide everything, we are actually trying to provide opportunities for individuals to look after themselves, and it is a real shift in culture and a real shift in policy, both between councils, NHS and the IGBs themselves. I think that cultural change is significant and long-term, and some part of that we all work with and are supported by tremendous staff across health and social care in the third and independent sector, but sometimes that cultural change needs to sit with our staff who have been trained in a particular methodology, so we need to support them in having those courageous and different conversations, and I think that, as important to that, our IGBs, our governing bodies, our local authorities, our health boards need to have the appropriate risk enablement approaches that enable staff to work in that very, very different way, because sometimes that is the thing when Janice talked about a member of staff nervously sitting outside somebody's house, our staff want to do the right thing, and we need to, through our governance and our culture, ensure that they are able to do that within that new way of working. Thank you very much. Thank you, convener. Good morning to the panel. It has been very interesting hearing from you all so far. I just want to move the conversation on a little bit to the idea of longer-term budget setting. Whether the five-year health and social care financial framework will assist you in that longer-term planning and, if so, if you think it will, what level of detail you think would have to be in the financial framework in order to support you with this meaningful level to support you with that longer-term financial planning? I spoke earlier about having a strategic plan, a financial plan, a workforce plan and a property asset manager. If you do not know what your financial plan is over the forthcoming years, it is very difficult to have a workforce plan. It is very difficult to say what you want to invest in in terms of not just buildings but also in tech, in terms of where you want to go. For us, having a three to five-year forward look in terms of what our budget is, we estimate it just now in our strategic plans, but it is purely an estimate because it is annual budgeting that we are getting. To really be able to do that and say, how will we do this differently? How can we plan a different thing about how many different types of workers that we will have in three years' time? How does the universities and colleges know how many of each type of profession to train unless we can collectively have that workforce plan to do it? The other part that it gives us is when working with the third sector to be able to give them more surety. Again, if we are getting financial planning on an annual basis, often we will see fairly short-term contracts with third sector. In terms of the longer-term financial surety that we have, we can give longer-term surety such as some of the really effective preventative things that we can do. It is about joining these different things together. I want to say that we cannot do strategic planning just now because the reality is that our budgets will only move by a few per cent every year. You know 95 per cent plus what you are going to get every year, but really, they are big budgets. That last 5 per cent is quite a lot of money. You can do financial planning, strategic planning, but you cannot do it to the level of surety that you would want to give all the partners unless you have a longer-term financial plan. If I ask anything, it is to implore for guaranteed approximates. If you can guarantee, I think that Eddie has hit upon it, we overall know roughly what we are getting. It is that what you have to save and the pain that you have to go through politically and with families, trade unions and staff. If that is guaranteed, that can be a very managed transition. That managed transition makes it far easier to have negotiations with trade unions and staff for greater conversations with families and local politicians who will have to manage the expectations as well. I thank all of that together. A five-year assured approximate would be really great for us. We talked about workforce, we talked about skill mix, we talked about the time that it takes to train doctors, to train EHPs, to train new skills into workforce. That is three to five years. Every year, I am trying to work out how many nurses I can afford, how many social workers I can afford. If I have that on a managed basis and strategically plan it, that would have a huge difference to health and social care. It is related, but it is not completely to the point of the question, but it was really to pick up—both my colleagues have mentioned—the issue of the workforce and workforce planning has been really key to that and to the wider transformation. I think that one of the other things that can be incredibly helpful, although the focus on individual IGB areas and localism is really, really important, is that there are some things that we can be doing at a regional basis or, indeed, at a national basis to support the development of the workforce. I think that that is really important. I think that one of those areas where we could be working at a higher level is around the delivery of the numbers of new roles that we need as a result of the national workforce plans. We would be able to do that as a group of health and social care partnerships across Scotland. The balance, then, of how we are able to attract them to our individual areas would be up to local areas. However, if we know that we are needing to train additional pharmacists to manage that shift in the balance, I think that the negotiations and the influence to achieve that end result is far greater if it is done on a national or, certainly, a level higher than individual IGBs. I think that that is where we will see real traction, and that would go across all specialisms and professions. I think that the biggest gain of going over a longer term, three years or five years, is that you can plan your savings over that length of time. You know the pressures that you are going to be hitting over the five years, so you can stagger when you are going to take the biggest hit on the budget or when you are going to pass it off until next year. It is just being able to forward plan. I echo what others have said. It is about confidence and decision making. For me, it is the critical conversations that you have when you are out with communities in terms of having a real conversation about, well, here is the kind of trajectory that we are on, here is the system that we need to try and redesign. We have been able to do that with some confidence around clear parameters, because I have certainly found myself on a couple of occasions holding my nerve in terms of whether to move ahead with something, a decision that is difficult or not on the basis of whether we really need to make that decision or if we have got longer to have the right conversations. I think that certainty gives confidence. Good morning. I ask around the linkages between budgets and outcomes. Integrated authorities are not expected to contribute to those nine national health and wellbeing outcomes. In fact, it is a legislative requirement that you report against those outcomes. In previous reports, the committee has had concerns around the awareness of those reporting requirements and the lack of progress towards that. I was struck by, in the submission from North Lanarkshire, that apparent tension. If I may quote, saying that linking expenditure directly to one specific outcome does not capture the fact that the budget supports a range of outcomes and attempting to allocate specific funding to each outcome may be notional and therefore less meaningful. I think that we want to get, obviously, that it is a legislative requirement. We want to have that meaningful reporting. I wonder what progress is being made in linking budgets to outcomes and complying with that legislative requirement in that particular area. I would like to start. Taffi to answer. In terms of a partnership such as our own, which has children and justice in it, as well as nine outcomes for wellbeing, we also have three for children and three for justice, and they are right up front on our strategic plan saying that that is what we are trying to do. We then translate them across into what is our priorities in terms of doing that and mapping them against the national outcomes. For us, it is giving our children the best start in life, it is making sure that we provide healthy living and health improvement, we give good services, good access to services and we address inequalities, particularly health inequalities. So we take the national outcomes and we talk to local communities about how we map them across and then we work on them in terms of how we map them across. I think that what Janice said earlier is one of the distractions at times. If you get something that is very high focus to us, like for instance delayed discharge or whatever, then that can become a distraction for you to be able to deliver others. You are challenged to us and I am in a good position around us. If you reach a page place where you are very much in control of hospital discharge when people come out early, then you can start to focus on the other things. I think that the focus on the other things and the wellbeing agenda, which is very much the core of the outcomes, is where you really get into partnership work with communities. It is not how we work together with people. I think that you are aware of some of the vibrant communities teams that we have in East Ayrshire and some of the work that we do there, some of the work that we do and some of the opportunity services to give people the opportunities, and it is actually there that you see the real outcomes and then come back. I think that you are right in terms of saying, do we then write down for us the overall 15 last and the outcomes and actually map against all that? We likely do not do that clearly enough. I think that what we do is in terms of our planning, and you can actually see it going through that, but I think that there is something in that that we do not actually map directly across to do that. Brief comment. We seem to trust numbers, but we do not trust narrative. There are some great stories out there about the interventions that health and social care has made. Why do we trust numbers? At times, where some of those targets are processed targets, they are absolutely not about the outcomes. So why do we trust numbers and we do not trust narrative? Fair question. Judith Proctor and then Punggowns. Yes, I think that it is important that we actually demonstrate outcomes both through the numbers and the targets, but I think that Chris Janis has just touched on the experience, the lived experience of people and improved lives for communities and individuals. I think that it is possible to track that. It talks to the point of the challenge around balancing the transformation potential and what we are trying to do in the longer term and the efficiencies that we must make now. If we are able to demonstrate the new ways of working and the changes that we are putting in place will significantly improve our ability to achieve those outcomes with people, we have a good, solid argument for investing in that and preserving. Certainly, in my previous role, we had our transformation programme tracked against delivery against those outcomes. In the business case process, there had to be a clear demonstration of alignment to the IJB's strategic plan and achievement of those nine outcomes or a number of them. The measures of success that sit underneath that gives far persuasion in relation to the board in drawing in new funding and preserving transformation programmes if we are demonstrating the ability to shift the balance in that way. It is really important, but I absolutely agree that we have to be drawing more and more on the stories of how from a narrative perspective people experience services differently. That gives people confidence that, for example, new technology can be an improvement rather than seen as a substitute for a service. I think that they are both really important. It is really timely again in terms of learning how to do that well. We have annual performance reports that I will be due out again this year. Certainly, from a money perspective, the dialogue that we are having is what we published last year and tried to put a lot of stories in it. I think that most people did the same. In fact, we took our learning from Eddie. We looked at what had been done in Ayrshire and tried to learn from that. We are again looking at how we can improve on that and how we can absolutely start to demonstrate something that brings to life what we are trying to do for people in a meaningful way, whilst not acknowledging that we are not getting everything right and that we still have to learn in those cases where we have not done as good a job or where people have not had that experience, what the difference is that we need to make to optimize. I think that our annual performance reports and how we articulate those are our vehicle. We are still trying to work out the best way to make that meaningful, but again with us it has been stories that people seem to have appreciated. I understood the question correctly and I may not have. It is very difficult to allocate a specific budget to a specific action that has a specific outcome within that. All of our actions hit all of the outcomes in the majority of the cases. That is a quick example on the borders. We have introduced community hubs and they operate within the major towns and the borders. It gives access to a whole range of services within health, wellbeing and social services, but it is wider than housing in the voluntary sector. It hits a huge number of outcomes. If I was to allocate the funding specifically for that and divide it up into the outcomes, I am not sure of the value in that, but it is important that we are scrutinised against the outcomes and we demonstrate how we are actually meeting them and working towards them, but I do not think that allocating specific aspects of funding to a specific outcome is going to be that helpful. I think that the cabinet secretary quite fairly recognised to the committee the challenges that are faced in trying to do exactly what you said. Given that legislative imperative that we do report there, I was wondering what support you are getting from the Scottish Government. Is it enough in terms of developing a reporting structure that allows that process to be much more transparent? I think that our dealings with the Scottish Government are across a number of different parts of health, to be honest. Our relationships with the integration support team tends to be strong and different chief officers take a lead across Scotland in different things. I do some of the lead in primary care. Again, I am linked into the primary care teams. We have mental health teams, and we have some of the performance teams that are engaged with us around the lead discharge in the four-hour A&E. The specific area that gives us the support around that is the integration team in terms of the Scottish Government. Throughout the whole process, there has been a huge support to us in terms of what we do. If there are any difficulties at all in local areas, the willingness to come out and talk with us is either as groups or IGIBs or we are brokers or we are health boards. The relationship that we have there is positive and strong in terms of the work that we have to do. I thank the panel for a very interesting discussion this morning. I want to focus on shifting the balance of care. We have touched on that to some extent already. I suppose that it is just to take it up a level and have a look from where you are sitting, from where you see the numbers. Is there a shift in terms of spend? Is that happening? Can you see it happening? Is it difficult to see flowing through? We have been giving some data here, and we have got integration authority budgets chunked into four groups. I do not know if that is something that you would recognise in terms of the way that it is broken up, but it is social care, family health services and prescribing, community healthcare and hospital. That is just IA, so the hospitals, I am assuming, would not include what the health boards on their own are spending on hospitals. When we look at that, the one that would be acute, I would imagine, would be the hospitals. We would actually see that going up. Social care we see coming down, family health we see coming down, community healthcare we see going up. It is in some ways almost the opposite direction to what we would have expected. I am interested to know at your local level what you are seeing in terms of the way in which the budgets are shifting. I think that there are some areas in Edinburgh where there has been quite a demonstrable shift in the balance of care in relation to the balance around mental health and learning disabilities. That will have built on a number of years of the direction of travel where we are trying to support people out of institutional settings and into the kind of homely tendencies that Pam and others have described. That has seen us being able to close acute sector beds. Our ability, however, to take the change in investment and reinvest that in the community has been challenging across Scotland in everything that we do. We may see the models shift, but the challenge that we are often presented with from colleagues in our acute sector, hospital sector and NHS side is that the costs of acute provision are largely seen to be rising. That is part of the challenge with what is known as the large set-aside budget, where a shift has been made in relation to the balance of the care and support in the models. We are not always able to release the notional cash and reinvest that in the community. To that end, there is a national integration finance development group that is looking at supporting that discussion and conversation across Scotland. Is the health inflation in the acute sector higher than it is in the community sector? It is for a whole host of factors, including elements of managing rotas, to ensure that they are fully compliant in regard to working time directive, costs of overheads within the acute sector, costs of new drugs and so on. We have also talked about it, so it is wrapped up in a range of complexities. However, there are some very productive conversations happening. The group is chaired by Christine McLaughlin. It is looking at unpacking some of that complexity so that we can really understand it and begin to think about how we can be supported to achieve that shift in the balance of care. If we are able to deliver those new models that are safe and effective in the community, how do we manage that release? I was just reflecting on what Judith said. We have completed our third year fully operational as an IGIB when we map our numbers against the ministerial strategic group indicators. We can show reductions in unscheduled care, bed uses in acute hospitals and mental health facilities, and geriatric long-stay significant reductions in the last two. However, there is no money released to come across from acute towards us in relation to that, because our hospitals are still very busy. The committee knows that there are additional beds open in areas that are in order to meet some of the demand around that. Although we are seeing a reduction there, if we work in an abhorred area where there are a number of partnerships, not just one partnership feeds into an acute hospital, the hospital is still busy and, in fact, it is too busy. That is the work that we are doing around that. Although we are starting to see a shift, it is not of the scale yet that releases resource. I think that it is fair to say that reflected across will likely see more of a shift in terms of that geriatric long-stay and some of the mental health that is actually over within our control rather than against the set-aside budgets. Some of those areas will be able to really make a shift on it rather than shift to the acute side. Are you saying that you are doing your bit, but the other IAs in the board are not doing their bit, or are you saying that the demand is such regardless across the whole area that if our beds are free up, I will get filled because that demand is flowing through? As I fall up to that, are you saying that we are chasing our tail here and it is a bit of an unachievable goal to say that we can shift to balancing care? I think that we need to be realistic. I think that we can shift to balancing care, and I think that we are already shifting to balancing care. I have worked in East Ayrshire for 20 years now. When I first came to East Ayrshire, we had three community hospitals predominantly full with real older people. We had 150 more older people in care homes and we have just now, at that time, delayed discharge in East Ayrshire with how many people we had over six weeks and we had over 100 over six weeks. We have now not had anyone who has been a delayed discharge over two weeks for eight years or whatever. We now have one community hospital as I say, we have 150 less people in care homes. We have shifted to balancing care. Showing that? The financials are showing it in terms of the overall investment over that period that you have in the community, the pressure on our hospitals, because many of the older people are now living at home and they do it unwell. They need to go in and they need to access and out the hospital. Our challenge and its purpose is integration joint boards is to make sure that we are able to establish the right type of community services that both our GPs and our local families and acute have trust that people can be supported in a different way. Just now, the numbers around the number of people and the pressure on the acute hospital are not such that there is a resource to be released out of that. I know that the committee knows, for Ayrshire and Arran, our first thing is to bring that into financial balance before we can move on to start saying how do you start to shift your role at money around. We are seeing the activity change right across Scotland if you look at the numbers of similar patterns across Scotland, but actually getting that shift of money out of acute hospital. I am sorry that I drilled it behind this important point. Is it the reality that if we are not doing all the things that we are doing to work towards integration, things would be going backwards and just by the virtue of the fact that you are standing still you are actually making progress? Sometimes we work hard to mitigate some of the demands that come towards us and actually it is where we bend the curve so the demand on acute would be much steeper if we were not doing what we were doing, but it gets us into almost a false conflict between community and acute. Both sides are really busy and on the whole both sides are doing appropriate things, but we can change it. Some of the change has to be that medium to longer terms. They are big public health priorities so the health of our populations are stronger and again that is where IGIB sometimes we can get drawn into talking about the services part of the budget all the time. Really some of the biggest gains that you will get out of IGIB is when we are working up there and if I can call it the health improvement public health part actually supporting communities, being involved in communities. Some of the things are encouraging through participatory budget and allotments, clubs and things like that that we will be able to do as we start to see a change in the health of the population that for the future will reduce demand. Probably just making a few points that echo what Eddie said. I looked back over the last 10 years in Murray and we have had a 20 per cent reduction in the bed base in acute and a 10 per cent increase in over 65 populations. We have generally maintained quite a really good performance in terms of admissions and the delayed discharges that we have been struggling about in the past year. It has been peaks and troughs but we are trying to work through what is causing that at the moment, but generally a really good performance against that kind of stat. What we have tried to be and others have done the same is in a sense that idea that you are going to move the cash is quite challenging and that it is good that we are trying to work through and see if there is a different way to approach that. However, we can still have the right conversations that perhaps change the way that we all work together and most of us will have examples of that where, for frail elderly, your geriatric medicine, your old age psychiatry resource both in and out of hospital can come out into the community and again confidence and decision making, more prompt decision making, that if you do not have that level of expertise around, it will not happen and it will keep people in hospital. You are maybe not moving the cash but you are moving the resource and you are making a more streamlined community hospital service. I think that that is absolutely doable in a whole host of things but we could look back in the past 10, 15 years in primary care through the local enhanced services and number of activities that were traditionally delivered in acute hospital settings that happen in general practice now is immense. We have loads of stats on that but that was through a particular investment route that was not immediately taken money out of acute but it was shifting that activity. However, the activity has continued to rise that goes in through acute as well so it is challenging but there are possibilities and hopefully we have given you a flavour of some of those. The hospitals equally have more demands on them just now, the increase in more elective, the reducing the number of bed days, the turnaround. So we are equally working with a system where there are demands on the acute side as well with the expectation of shifting the balance of care. Certainly for me one of our biggest challenges, Eddie has already mentioned the two words trust and scale for me. I think that the real opportunity of integration for me is that understanding now where the hospitals know what is available and have that trust with either primary care or within the community care sector that they can let individuals go and they will be treated with respect and have the due care in the community. There is still some anxiety about letting individuals go with not having a full package of care in place. Is it going to be safe? Is Mrs Smith, Mrs Jones going to be looked after as well as? So some of that cultural changes with some of our very, very experienced consultants and nurses but I think as we shift some of the workforce changes, we have got an investment in advanced practice nurses, they are making a significant difference, the investment in treatment rooms locally and those services being known to the community. Our biggest challenge going forward is unschedule care and colleagues have mentioned that and where we can invest in hospital at home or where we can invest in community resources with social work staff, physio staff, HPs and nurses all working collectively as a team. We will absolutely manage that unschedule care but that is the next challenge because a lot of that front door activity is determining what happens in the hospital as well. Scale for me and trust are the two things, so you mentioned scale and that trust to let go and let the community look after people where they want to be. I think that we have seen a shift, an increase in the number of people who have been cared in the community right across the whole of the country within that but we have also seen an increase in demand in the hospitals. Just to give you an insight to the level of the increase, by 2032 in the borders we expect the number of over 65-year-olds to go up by 62 per cent. The number of 75-year-olds by 2032 will go up by 120 per cent. You just have to extrapolate that back and year on year we are getting increased pressure on our whole system within there. I think that what you are chasing the tail is the comment that you made. We will never catch the tail because the pressure is on both. Without the work of the partnerships, I think that the hospitals would have fallen over by now and the work that we are actually doing about shifting people into the community and caring for where they want to be cared for is the right thing to do and I think that we have demonstrated that in bucket loads over the past three years of doing it. That shared endeavour between the councils and the local health boards is clearly demonstrable now. If you go around the country, you will see many, many examples of where councillors and non-executive directors are sharing the same agenda and making a significant difference. Just an example on the eastern region, we have my own chief exec in the council who has taken a lead role on combating diabetes 2 across the whole of the region. That is the council chief exec taking that lead role, because most of the services that are about healthy lifestyles are held within the council, so ledger services, education, access to good housing. Those are all council services, and here we have an example where the IGB has given a platform and an agenda that can be shared between those two. If you are going to share, you are going to get efficiencies and you are going to improve quality and you are going to get a better outcome for the residents. Some of it is almost like we are talking about shifting the balance of care, but it is almost like we should better describe it as maintaining the balance of care. It sounds like a better way of describing it. Indeed. Thank you very much. Thank you very much, convener. Good morning, as you said earlier on. I have my key questions neatly bringing me on to obviously integration, which is really, really important. I was quite amazed at some of the comments about trust, particularly by hospitals and consultants, trusting to go over to community services as well. There is still a perception out there, perhaps even a professional, apart from the public, that you have funding in a budget that is health, and you get funding in a budget that is social care, and neither the two will meet. In fact, I think that Janice, your council, North Lanarkshire, said that the current system encourages the funding to work through both local authority ledgers and the health board ledger. The funding does not therefore lose its identity and was intended, as was intended, by the legislation. Would you agree with that in that respect? I know that you have mentioned about changing it, but would you agree with that that that is actually what is happening? I think that when you are talking about acute care, it seems to be that the IGBs are doing a great job, and they do not envy the job that you have. They are doing a great job, but, as you said previously, they are getting people out into community care. You are not getting the funding from the health board budget to help your budget. I said earlier that I would reinforce that health and social care is only going to become successful when you cannot see the lines between the budget that came with a health ticket and lost its identity. At the end of the day, someone will do the accounting and the ledgers at the end. Let us put that resource as an integrated budget. We will only become successful when you cannot see the lines in the workforce. So, ditch the lanyards that say NHS and the council because we are absolutely skill-mixing beyond anything that anybody understood. Some of the challenges are around us using technology. Some of the challenges are still around the organisational differences, and some of that resentment is still there. We have to acknowledge that from staff and trade union sides as well, but success will only come when you cannot see the lines between the money, the workforce, the organisation and the strategic planning. That is across the whole system. I think that when you really see the resources working best, that is when they have almost come to us in a joint way. You start to see some of that being used right out in the third sector. We have got the integrated care fund. We have always had resource transfer, so in my own area, I have always been getting £10 million off the health board that is spending social care services for other hospital beds that have closed. The new monies for social care, whether they have come through health or the local authority, have come to the integration joint board with new monies to look at. A particular success for us has been the alcohol and drug partnership money that we see sitting under community planning. Although I lead on it, it is a wider money. For me, it is about £1.6 million. We sit and have an overall discussion with all the partners on how we do it. I see good steps being taken forward and the new monies coming forward in relation to primary care in terms of how we work with local GPs and the wider system. It has been quite hard to move some of the established budgets across. Traditionally, both within the council and within the health board, people still think of them and they still have an ownership of them. It is not a bad thing. They actually have an ownership of them, and I have just not been able to let go, but when new monies have come to us, that is when we have been able to be innovative and think of things differently on how we do it. Even though our integration schemes are written, ours is written to say that both partner bodies will take account of demographic challenges. While they think of that in their own heads about demographic challenges, it is not that it all gets thrown into a pot. If the council thinks that we have this real demand coming for social care, it will be £2 million that we will give across to the IJB. If they suddenly see me putting more district nurses out for it, they will not be that happy because of the decisions. Is that a bit about new monies coming to us? Will we be able to be more innovative around some of the established budgets that it is harder to do the change on? Again, I agree with everything that has been said. What is really important is that it comes back in some ways to the vision thing. What is it that we are all signing up to do here? What are we all trying to achieve? Largly, we are all trying to achieve the same thing for our populations, for people and for communities. If we can demonstrate that the investment of whichever bit of money it is is going to achieve that outcome for people, that creates the persuasive argument that it does not matter and the accountancy bit happens behind the issues of two ledgers and so on, that happens behind. However, if we can agree that the best approach is to take NHS money and to fund different housing models that are provided by the third sector, and it is going to deliver an outcome that we are all signed up to that would improve pressure on the whole system, that self-evidently is the right thing to be doing, the issue of the money shouldn't matter. I think that that is part of the challenge for us and our roles, which are great jobs, is to create that narrative and that vision and that exact influence. With new money—slightly controversial to what Eddie says—with new money, do not give it a label. I know that you want certain things done, but do not give it a label because I know my communities, I know where I need to invest. In terms of alcohol and drug money, I know that I have particular issues against needs. With new money, although sometimes it is helpful to have a label, I am possibly standing out here just to say, do not label new money. I would probably echo everything that everybody else has said. We are on a journey, we are on a trajectory of improvement. Like Eddie said, with new monies we have all got good examples of where, when you have brought the integrated team together and said, go away and think about how we might try and deliver that collectively differently in a better way with the third sector. We will have examples of how we have done that, including primary care money, going to the third sector. All of us have examples of that in order to assist GPs. I think that the real possibility with the existing budgets is that we have some real workforce challenges. One of the conversations that is a really helpful lever in terms of shift in existing ways of working is that, as people try and push forward with what they have traditionally done and what they have kept doing, it does not bring the same result in that they cannot recruit to the existing model or it gives a real platform for that kind of. If you always do what you have always done, you will get what you have got. Again, another opportunity to bring people together and say, come on, there are a range of different ways in which we could think about that. Let's be a little bit bold and go out there. There are ways to facilitate those discussions with staff, with staff side, with unions in order to think differently, but it is something that you are having to almost coach people along and help them to feel safe and secure, because people go into the professions and go in because that is a profession that they want to do and it is scary when they think that they are going to be asked to do something different. Thank you very much. You are all excited about the new monies that you mentioned. I will just throw something into the mix. Do you think that the boards should get direct funding on their own? Would that help, if not what would help, apart from just the new monies? I am always hesitant on that one, albeit that I jumped in to answer the question, because when we talk about this a lot, we are very active as a group of chief officers nationally in Health and Social Care Scotland. There is something that is very challenging about the way that the budget comes to us, undoubtedly. However, there is something that we need to analyse more perhaps, which is the creative tension that exists in the sorts of conversations that we get into, because all partners absolutely have to be signed up to this. I think that a lot of that is touched on. The sort of conversation that you can have with a local authority about the significant contribution of housing and housing models in that community planning arena is hugely important. I genuinely do not know if we would get the same traction and discussion about those different ways of working if we were not all involved in the kinds of challenging conversations, but the ones that, when the tension is right, they can be creative tensions rather than ones that detract us from the ultimate goal. Robert McCulloch, you are able to pump prime, so you are not stopping something to start something else, so it is always easier with new money. You do get an increased level of debate from all of the parties, because there is a greater degree of freedom than what you can use that funding for. All of the parties are conflicted in deciding on the budget, and there are allocations from councils, from NHS, and then there is a smattering of free money, if you like, in between that. There is a concern from NHS and from council bodies around the value that they get on the back of the money that has gone in. There is bound to be a good thing in that, but it is a difficult negotiation that has to take place at the IGB as to how you are actually going to make that spend. There are a number of masters over this funding and trying to keep everybody on the same page is quite a difficult, challenging, enjoyable job for us all to do here. I think that there is more that we could do to simplify the money in the way that the budgets are delegated to the IGBs. I think that there is more work that we could do with that. Good morning, everybody. It is interesting to hear about labelling new money or not labelling it. For me, I love what you said, Jan is about ditching the lanyards between NHS and council. I am interested in focusing on set-aside money, because I find it all really complicated in where the set-aside money is supposed to be the integrated joint board share of the budgets for delegated acute services provided by large hospitals on behalf of the IGB. It seems that there are different approaches to set-aside budgets, and some health boards delegate the hospital budgets as payments to the IGB, which have no separately identified set-aside budgets. It is very complicated. It would be good to hear some kind of simplified response about set-aside budgets. How could it work better? Are there problems with it? In our submission, it says that North Lanarkshire has transferred the community assessment and rehabilitation service from acute sector to the localities as an example of a shift in the resources. You are using some of the set-aside money for social care. It would be really great to hear some kind of simple approach to set-aside. If I try to say a simple approach to set-aside, when IGBs were established, there were 10 different specialities in scheduled care that were deemed that different types of work in the community could change the volume going through the hospital. The looked at it said, what does that cost going through the hospital? For us in East Asia, it is approximately £20 million. It should be that if we are operating effectively in the community, we can reduce specialities. Diabetes might be one and reduce what is happening in the hospital and therefore shift the support to that in the community. The alternative being that if we do not achieve that, we will see that going up. As we discussed earlier, we are doing good work, but it is still floating about in the same position. On how it has come to be reported, I think that in many areas it is just a statistic. What people do is look at the end of the financial year and they say, in the 10 specialities, how many beds converted into money did East Asia use and then they give me a figure. In the first few years of us operating, it has been a reporting position rather than a levered position. I think that we are at the stage of three years in. We are moving into our second strategic plan. We have set targets, trajectories against the ministerial strategic group indicators to bring down spend in those areas. When we bring down spend in those areas, that is where we should see release off of the set-aside budget. If we are sitting here, and we are all chief officers of the VIGIBs rather than acute directors, the acute director would say that he will see if I see whole wards closing, because we have just been shut in one bed and they do not actually say anything. You need to be at the scale of shutting a whole ward. They will get into a conversation about whether that is okay and we will move that across. However, it has to be done in a scale that not only meets demand and then goes past meeting demand to reduce that. I think that set-aside is a good indicator of usage against unscheduled care, but we are not reaching a stage where it is like the previous question. We have seen it fall below where it would release that across to us. The set-aside always feels like an exam question. It is highly complex. I often come back to what can be helpful in my thinking about the intent of why that was in the legislation. Why do we have responsibility sitting with the integration joint boards to plan those services? That is largely about how we create a community-focused service in order to support people better in communities as far as we can and to support the management across our service, which is under pressure in a far more managed way to address some of the issues around unscheduled care and so on. Part of the challenge around it is that we do quite naturally focus on the funding in the set-aside, but it is the activity of doing the strategic planning that some of us as IJBs with our NHS-acute partners have been slow to get started. I think that thinking about my own experience around this is largely because of the intense focus of our early doors on developing our IJBs and our strategic plan. The intense focus was on the transformation within the creation of the health and social care partnerships. Increasingly, working as groups of IJBs in health and social care partnerships, where there is more than one working with a board, the opportunity is to think about doing that planning at a population level. For us in Lothian, what did a population level make a difference in how we plan A&E services that support more people to come home rather than to be admitted into the hospital? How would we deliver respiratory services in a way that was far more focused on preventing acute exacerbations of respiratory illness, and what could we do from a community perspective to help people who have respiratory illness to be as well as possible for as long as possible and deliver as little of that care in a hospital is required, so it is the highly specialist stuff that we are still to do. I think that thinking about that intent and seeing it as our planning responsibility is really important. However, I think that part of the challenge around that is the capacity that we had at the time to do that bit of strategic planning, because it is very different from what we have done before. To date, Judith has described the process that we should be taking forward from a strategic perspective. That budget is generally referred to as a notional budget, so it has a budget with potential, but it is certainly not in any size an actual budget that we are able to take and invest to make change. There is the potential if we can achieve the reductions in unscheduled care to a particular level that we would then technically have to invest and support our developments in the community. However, at the moment, the word to date for us has been described as a notional budget, so it is on our ledger, but it comes in and doesn't go anywhere. Just if I may refer you to North Lanarkshire submission on paragraphs 3.2 and 3.3 of page 4, because I certainly would encourage committee at the very last sentence on 3.3. It says that, at a national level, there is a delay in accessing the current activity levels with the current prices. That might give you some understanding. In paragraph 3.2, we set out the change in hospital capacity. The resource consequentials will be determined through that process. However, if we can look at the data in terms of that activity shift, we would see what notionally could be moved. I think that it has gone back to Eddie's point just about scale. Prevention of acute admission for respiratory illness. I know about this because I am the cross-party group lung health convener. If we keep folk out of hospital by pulmonary rehab investment, that will be a way to use some of that money that is notional or for emergencies or unscheduled admissions, which is set aside. If we put our money into pulmonary rehab, that will ultimately prevent acute admissions. Pam said earlier that some of the shift that we are seeing just now is some of the specialist resources. Those specialist respiratory nurses are some of the specialist cardiac nurses, etc. They are outworking with us in the community. They have come across and worked with us, and that is the type of support. Actually reducing that is really important. I do not think that any of us have really mentioned palliative and end-of-life care, but a high proportion of that is that people get in and out of hospital in the last six months of life. If we can actually provide better services around palliative and end-of-life care, we will see a significant improvement, first of all, in the quality of life for people, and secondly, we see that reduced demand in the hospital. We talk about that a bit as if it is notional, etc. It is really close to all our hearts. Actually, if we get that right, we will see that shift. We will all be able to evidence with the number, whether the overall demands and communities are going up, but some of the ministerial strategic group indicators that are at the very end of the list about where people spend the last six months of their life are really important, not just in terms of quality, but also in terms of the cost that is associated with that. Can I move on to the area of mental health spending? You will know that, across the parliamentary divide, there is lots of interest in this particular area. On a simplistic view, there is a sense that mental health has been a bit of the poor relation compared to physical health. Could you perhaps give descriptions of how you spent additional funding on mental health services in your own particular areas? I am happy to share an example of existing funding merged with some new funding in order to support wellbeing. In Murray Wheel, we produced a strategy two years ago that was good work mental health for all in Murray with a very strong wellbeing focus. As a result of that, we had a tricky path to follow. We decommissioned a service that had been in existence for 30 years and with a small number of clients that were receiving a really good service, but in terms of us looking forward and where we were looking to try to make some shifts and modernise, there was an opportunity to work with those individuals to the right resolution for them longer term but to release that money to recommission something that was going to be fit for going forward. We also had, like others, modernised and primary care funds and had done some tests around link workers and creating environments where people could be diverted away from medical interventions, not as a medical intervention but more community-based and making connections and having good mental health. We commissioned a third sector provider to provide good self-management, good anxiety management and good interventions around depression and those broader issues that people experience, both in group settings and in individual settings with the link workers as part of that model in a hub-and-spoke outreach model into primary care across Murray. That is coming to a point where we will be getting a bit of an evaluation in on how that is gone. I know that they have seen lots of people and have some good success stories and that that has been well received generally across the area. Interestingly, perhaps even more impressive, is that we have had some community activists who have worked really hard to create a hub, a wellbeing hub and develop champions in peer support. Different paid services versus volunteers have been working very close together and that has been extremely successful in how that has changed people's lives and added to others. There is a reference made to the reprevision of beds from the Royal Edinburgh Hospital into community settings. That is definitely to be welcomed in terms of people who have experienced in patient care and who we can support in more intense, albeit more private accommodation in the community. We did agree that the integration joint board has agreed a number of outline strategic commissioning plans to which we will focus on mental health provision in the longer term and another on learning disability. That will look at a blind of the kinds of provisions in community for individuals who have those needs. Increasingly, we need to think about the promotion of good mental health and wellbeing and how we support particularly primary care practitioners, our GPs and our primary care practices in relation to first-line support and the creation of good mental wellbeing and the work that we are beginning to outline around the link worker programme in support of that and in support of primary care being an area that is able to support people appropriately who first attend. It is the entire spectrum across mental health that we need to look at, primary prevention, good mental wellbeing and the support of people who have maybe got low mental health problems and all the way through to those people who have long-term and enduring mental health problems. Learning disability, we want to be looking for those of us in partnerships that do not have children's services and how we invest in good transitions and support young people into the kind of life that they would be looking for, increasingly using self-directed support as a means for doing that. I think that that is such an important area. With some of the resources that we have had already, we have worked very closely with localities around GP practices and they have told us that counselling for young people etc has been the important thing for this, so we will be able to invest there. Other areas have been the community connector model. Again, in Ayrsirlaran, we have had the benefit of recently having a new hospital, Woodland View and moving over from the Ayrsir campus. That has been fantastic. I was doing a leadership walk round of the rehabilitation wards and the opportunities for people to be rehabilitated in a more homely environment and step back across into, and I know that I am stuck in this, into good housing options. Going back into the community and transitioning there is really important. I think that we look forward to the investment in primary care. Again, we have command of prison on our patch and support in the prison, support at the emergency department, these investments and support right in the GP practice. I was speaking to one of our practices recently and they have 1,000 people on antidepressants. They look forward to when they have attached mental health work and pharmacists. It is about how we do reviews of these, how we just become repeat prescriptions and how we make sure we change people's lives. That is the type of investment in primary care that I think can start to make a difference around us. The investment that is proposed to come to us there is really important and it is how we make sure that that works alongside our existing teams. Our existing mental health teams tend to be dealing with very much, I would say, a more acute end rather than a preventive end. Just now, I think that some of the investment has to come in and support us at that lower level of preventive things, what we would normally call primary mental health rather than acute mental health. At that end, I think that it is where we are seeing the benefits just now. Thank you, convener. In North Lanarkshire, what we have decided to do is a truly integrated teams on three things. Children and families, mental health, learning, disability, justice and addictions, and long-term conditions and frailty. Those are three themes. We are forgetting the labels on any of the practitioners where you work, who you work for and those teams will truly come together. We have talked about the connections with justice services and it was the staff who decided that those groupings would be most effective. If you take those Venn Diagram circles, they interface with each other. Children and families sometimes have families with addiction problems, mental health problems, if you take older people with dementia and that connect with mental health services. Those three teams will absolutely not work in isolation. They will work together as three teams, sharing all the knowledge and experience and also the data around some of those families, because it is really important to do so. On the spectrum of mental health from forensic, we have had quite a programme of out-of-area placements back into locality. The in-patient programme and making that service better, the out-of-area and the community placements have been a huge focus for us and the community supports around that. If I was to leave one legacy in integration as I left the building, it would be in our children's wellbeing and mental health. Please, please, please invest in our children's wellbeing. The referrals that we have had in CAMHS services have risen in tier 3 and severe by 23 per cent. There is something not right. We are not doing right with families or children. I am not quite sure that we are using the evidence to know what works around children, but part of the challenge is the workforce challenge around that. I have said previously that investment in the right practitioners is not a range of practitioners. We need to make sure that that is a proper investment. On mental health from children's wellbeing through to forensic, let us get that right. I do not want to take anything away from what Janice just said. I do not think that there is anything more important than the statement that she just said. The demand on our children at the moment is increasing at a terrifying right, particularly around transition for all of us. Between children's services and adult services is a real problem that we have to face up to now, and it is something that we need to grapple with and get a solution to it. There is something happening there that is not right and we need to put a fix to it. Just one last thing on primary care. We need to make sure that we have a different approach to mental health that is everybody's business. There are a number of practitioners who should be involved in mental health that are perhaps not involved as much as they should be. I had one practice in the previous post of a GP where 50 per cent of his consultations were about mental health, and all he was able to do was refer on.  We need to make sure that when we are developing primary care clusters and community work, we get those link workers that we refer to that can deal with some of the lower issues in mental health that often lead into others. However, I do not want to take away anything that Janice said. I encourage this committee and others to have a real focus on children at the moment in mental health. I think that the answers have been very helpful and convenient. Can I just ask a follow-up on how you measure the effectiveness, particularly if you have additional resources? Is it genuinely all-additional or is there some substitution? In other words, is there any element of stealing from Peter to pay Paul in additional funding that comes to you on mental health services? It depends on the approach from the partner bodies on how you are funded. If somebody comes and says that you are getting 2 per cent cash-release efficiency savings, IGIBs on the whole do not have the back-office functions. We do not manage property, we do not manage the HR department, we do not manage the finance department. If somebody asks me for 2 per cent cash-release efficiency savings, it is only out-of-frontline services that I have. I do not have other services. What we always try to do, as was said before, is to be innovative and manage demand, etc. We have not been at the stage where we have taken the new money and had it away somewhere and done that. We have actually up-front done things with local communities to try and reduce demand and cost in the other services, so that we can make them. We use the new money as a driver to save over there at some of the traditional savings that we have had today. We try to be transparent to everything that we do in terms of doing that. We do not try and cost substituting that way. Good morning to the panel. Thank you for coming to see us today. Before I ask my question, I just want to associate myself with the remarks of Janice Hewitt and, indeed, Robin McCleillor Graham in respect of child and adolescent mental health. That aligns with what we are hearing from stakeholders, what we are hearing in our constituency surgeries and is now fast becoming the imperative under which this whole Parliament must move on pain of anguish suffered by some of Scotland's most vulnerable children. I want to ask a similar question to what I asked in the session last year, this time last year. I asked specifically about funding for drug and alcohol services. We learned this morning that treatment times are outshipping by a country mile what we had anticipated or thought they were, particularly as people are being seen for consultations, but they are not receiving the sort of prescription support that they need for several months after that. Over the past two to three years, we have had a dip in funding towards ADPs of some 23 per cent, and that was then measured out in the highest drug-related deaths in the whole of Europe last summer. Whilst there has been an increase of £20 million, it strikes me that that does not close the gap that we have encountered. It does not restart services that were lost to us or bring back that lost organisational memory. Can I ask the panel how much more do we need to spend in this area before we are back to where we were and what does success look like in terms of a fully funded drug and alcohol service model? Who would like to start? There has been a reduction in ADP services. I am reluctant to say give it just for ADP, having said take the labels off things. We have had this conflict locally about accounting, so the ADP funding is mainstreamed for me. The labels off it, which was a huge help, believe it or not. Conversely, you are talking about the performance that you have associated with that cut and the performance target that is going up somewhere else. For me, the association between children and family services, learning disability, mental health, addictions and justice, because some of those individuals are the same and some of them are fathers and grandfathers and kinship care, all of those of our children. For me, I do not mind that the labels have gone and I just want to use it in a different way. Where we see trends or differences in performance, we need to react to that. From my perspective, I am putting a set of different services around and using the money in a slightly different way. If the consequences of that for North Lanarkshire are the drug-related deaths, I need to review what has happened there, but since the labels have come off it, I know that you still want me to report on that, which is interesting because I have taken the label back off and we are still asked to report on it. I have a little bit of a conflict around that. In East Ayrshire, we have not seen a reduction in our funding to the ADP. For us, it is funding to the ADP rather than funding for overall addiction services, which are two different things. Our ADP has an independent chair and a £1.6 million goes to it and it has a discussion on a community planning basis about where the right place to invest is. We have done some innovative investment and we have invested with Barnardo's and Barnardo's have been able to bring the exact same money to the table, so we have doubled their money in effect. We have invested with the Scottish Drugs Forum, which has done some work around getting people into work. We have done some work with ADACTION, which has helped people in recovery. That funding is slightly different from Janus's, so we give it to our body, which we call the ADP, and last year, even though there was a reduction in funding, Ayrshire and Arran covered that reduction and maintained our level of funding. We have continued to work with the partners to do things differently. This is about treatment, and the numbers of people that we get through treatment into recovery are still too small. The numbers of people who are long-term on substitute prescribing are still too many. Just last week, I was with Ayrshire churches and homelessness group, and the local churches are working with a whole range of people who have complex issues that go from alcohol and drug addiction right through into homelessness. We can do the treatment stuff and we can invest in treatment, but if we are going to see a difference in this, we need to get back and be looking at why some of the individuals are harmed and that self-medicating in that type of way to take themselves away from society. There is a whole range of different reasons for people. For us, it is about investing. I think that the role of the ADP is a positive role in thinking more widely than just about treatment services, thinking right into prevention and investing in alcohol co-ordinator for our schools. The types of things that they have been able to invest in are really positive. I would go to everything that Erie said. The approach here is absolutely about a whole partnership and community approach. That is no different to how it is needed to be for years now. In terms of our position, we are very similar to what Eddie has described in Murray, in accessing services. We have a good integrated service operating with the third sector in Murray. It is interesting from my perspective that my background is mental health nursing and was an addiction nurse. I managed addiction services years ago in a context in which drug-related deaths were a real issue. Understanding what was contributing to that was important before we jumped in with the solutions. We need to understand that from a care and treatment perspective. By far, we are back to Janice's statement that the greatest investment that we can have is where we start with children and how we prevent them from getting into that position in the first place. In my experience of working with people, it is a very challenging task. People do not choose generally to be in the position that they are in. They are generally not very happy in the position that they are in, but their confidence and ability to change is usually pretty depleted. Methodo and substitute prescribing are a tool. The more dominant they are, the less effective they will be in getting into a recovery model. They have to be seen as a tool, but that recovery model and supporting individuals is a big task to help them to remove themselves from their day-to-day environment. Confidence is probably the biggest inhibitor, but we really need to understand what we are responding to before we are sure that it is a money issue. I had lots of money when I was managing that. There were not the same strict stringent issues with money that there is now. Money was not the solution, it was culture, it was understanding, it was resilience to work in very challenging conditions and hope that those individuals could achieve. I get that. I absolutely do, but I will take, for example, Edinburgh. I would like to hear from Judith Proctor, if I may, after this. Last year, that 23 per cent cut to ADP funding across the board was manifest in a £1.3 million reduction in our nation's capital, which has to have some kind of impact. If you are not paying workers anymore, they are disappearing to other jobs, so that the footprint of provision is reduced, and that must have a tangible effect. I accept what you say about culture. I am afraid that I will not be able to give you a very full answer on that one, given my relative newness in post, but I am more than happy to have a conversation on that as we begin to understand it. One thing that I have been made aware of is the elevation of the work of the ADP within the IJB. I think that that can only be a good thing that has been seen in the context of that partnership, but I am afraid that I cannot give you the detail that would be useful today. Thank you very much, colleagues. I know that there are other questions that colleagues would wish to ask, but we have already had a very full session. I thank the witnesses for their evidence this morning. We will now take a five-minute break and move into private session when we resume.