Good morning and welcome to the 23rd meeting of the Health and Sport Committee in 2018. Can I ask everyone in the room to ensure that mobile phones are on silent and that mobile devices, although they may be used for purposes of social media, should not be used for purposes of filming or recording. We have apologies this morning from Emma Harper and from Alex Cole-Hamilton. The first item on our agenda is a declaration of interests and I'm in accordance with section 3 of the code of conduct, I invite David Torrance to declare any interest relevant to the remit of the committee. Thank you, convener. I have nothing to declare. Thank you very much. In addition, Bob Doris is attending this morning as a substitute for Emma Harper and may I also invite Bob Doris to declare any interest relevant to the remit of the committee. Good morning. Can you hear me now, nothing to declare? Thank you very much. I welcome David Torrance as I am a new member of the committee bob Doris a'r ddylch yn ddiogelio'r ddeud â'i ddefnyddio'r prosedig. Fodd oedd yn ffordd i ddysgu'r prosesion cyfathodd yng Nghymru a'r ddatblygu yng Nghymru. Mae'r prosesion yn ddondig i ddysgu'r prosesion ar y ddigelio'r ddysgu'r cyffredinol. Fy fawr i ddysgu'r ddysgu'r ddysgu'r cyffredinol Cannan Hedge, ynglyn â'r director honno ynglyn â'r ddysgu'r cyffredinol, Alison Christie, policy and development officer workforce for the Coalition of Care and Support Providers in Scotland, Andrew Strong, assistant director of policy and communications for the health and social care alliance Scotland, Mark Hazelwood, the chief executive of the Scottish partnership for palliative care and Catherine Wainwright, head of human resources, Turning Point Scotland, representing the Scottish Council for Voluntary Organisations. Thank you all very much for joining us this morning. The procedure, as I'm sure you'll be familiar, is that I'll kick off the question session. Other colleagues will ask questions and answer should be through the chair. So can I start by asking all of you a general question around the provisions of the bill and whether, if you like, the issues that the bill may be intended to address and ask whether you believe that staffing in the social care sector currently is adequately covered by the regulation and inspection regimes that we have. Who would like to start? Karen Hitch? Hi there. At this precise moment in time, we already have both the policy context and the legislative context to support social care staffing within the sector. Social Care Scotland has come a long way to begin to create those conditions required for improvement and innovation. You can see this in the health and social care standards introduced earlier this year, the legislation such as the Self-Directed Support Act and in our practice such as the new methods of inspection recently brought in by the care inspectorate. I am proud to represent a never-evolving sector, which retains it as heart and asset-based individualised approach to providing care that is grounded in human rights. As human beings in a society, our wants, needs and wishes change and this means that we need to be able to meet the needs of our older citizens and others who access care and support. We must be flexible to those demands. On top of this, the market itself is ever-changing and we are living longer in terms of austerity. We need to be able to think differently about how care and support is delivered. As the committee will know, the purpose of legislation is to freeze components and my concern is that, by introducing the bill, it will enshrine the use of tools and statutes that could potentially put at risk several things that I can go on to outline later, but at this point in time, the context fits what is required. As I said, I am keen to understand how far the current regimes operate and how far they are adequate. CCPS members believe that the current regulations provide for high quality trained staff to support individuals to achieve their outcomes. We are also aware that the work of the National Health and Social Care Workforce Plan, part 2, is looking to address workforce planning and the Scottish Government and progressing the recommendation to do just that. We have worked quite closely with the bill team and had several discussions with them and we have yet to get clarity on what the benefits are added value that the bill will bring to social services or people using social care. Our perspective is slightly different from other members of the panel, so our response was written in conjunction with our individual members, members of the Health and Social Care Alliance Scotland, to use health and social care services on a regular basis. That was a view that we felt was missing from the debate so far around about the bill. Come back to the question, it is important to see that the bill is a means to an end rather than an end in itself. One of the key things that we heard when we were talking to people was about continuity of care being really critical to them, that they wanted staff to be there, that they knew as far as that was possible, and that great consideration of staffing input is likely to lead to a great possibility of achieving that continuity for them. Many of those people were in favour of the bill, but I would add that in that consultation with our members, we heard experiences of understaffing in health and social care settings that could be improved on by the introduction of appropriate and ambitious tools, but also the resources required to make adhering to those tools possible. There are obviously major issues in terms of workforce across the health and social care sector. Our view is that they are primarily driven by other issues, national workforce planning, affordability for commissioners, and wider issues in the labour market affecting recruitment and retention. The main issues that are around workforce, we do not believe, are primarily caused by deficiencies in workforce planning at a local level or deficiencies or inadequacies of legislative or regulatory frameworks at the moment. We believe that the plans, policies and legislation, the new health and social care standards and the inspection approach is more than adequate at the moment. We see no particular benefit and see that the bill is unnecessary. There is not a focus on the bill in terms of outcomes that is I suppose the way that the sector is thinking at the moment. In short, we do not believe that it is necessary or required. Thank you very much. Can I just come back to Andrew with your particular perspective on the users of services? Is it possible to describe a user perspective that currently exists in relation to staffing issues or is it so dispersed and barely does not allow for such a characterisation? Would your view on behalf of the Alliance be a user perspective on staffing issues and on how they are being addressed or should be addressed? I have come back to the point that people are clear that there has been quite a lot of consultation around the health and social care standards. There has been a lot going on around workforce issues but also about the regulatory framework. I think that people are clear that that is what they are expecting from social care services. I would not say that there was a complete understanding of that. There are differences in our membership about what they think about this bill. Thank you, convener. I thank the panel for the evidence so far. I am really interested in workforce planning, particularly in the care home sector. Obviously, there are different contexts there. There are private sectors, local authority and there is the third sector. Could the panel outline what tools, if any, are used currently for workforce planning in that sector? At this point in time, those who use workforce planning tools often use something called the indicator of relative need or the otherwise known as the iron tool. There were two versions of this tool, an earlier version, which was created around about 15 years ago and then a later version. In itself, it served a purpose as guidance, but in current terms of social care thinking, with terms of having an asset-based approach, it does not meet those current needs of society. Exactly what some of my colleagues in the panel were talking about, that individualised, personalised approach that we need to deliver in social care, in health and social care. At this point in time, it is mostly around the iron. Would you allow me to talk more about the potential? Could you just briefly explain it for those who are not familiar with it? It asks questions and basically assesses what dependency and need is. However, where it is not fit for purposes is around about what we need to think about capability, enablement and prevention, so it is not able to take that into account at this point in time. It is also missing what happens overnight as well, so it is not currently fit for purpose. If tools were to be created, there would need to be a two-stage process, and they would need to be done in such a way that all the other concerns that myself and my colleagues have with the bill are taken into account. However, it would need to be a two-stage process to develop that asset-based model, which can assess, for one of a better word, the needs and outcomes, what a person is able to do and not what their dependency is, as is outlined in the Cairns Spectra submission. There is a bit of a concern there because they have the lead responsibility for producing those tools, so we need to think about how that would work better in a co-produced way if tools were to go ahead because they need to work for the people that are using them on the ground, otherwise they will create additional burden. The second stage of that process would be around about creating an algorithm, and I have absolutely no idea how that works, but I am sure that there are experts in digital who would be able to think about that. They would be taking staffing and skills mix and applying that to the asset-based model, but we would need to think about it very carefully so that we do not want to risk enshrining something that would take away humans that way. Presumably, there is a scale issue involved if you have very small care homes. It must be much more difficult to use the individual web technical tool that you are referring to. Absolutely. The social care sector is very diverse. We have large corporates, we have small individually run providers, and my colleagues also represent other providers, for instance, around about drug and alcohol use. That is Scottish Care. We need to think about how could you apply that tool in different settings, whether or not different tools would be required, there is the training and development that is required around all of that, so many different things that need to be thought of if that is the route that we choose to go down. Other witnesses wish to add on those points. Catherine? As a provider, our two registered care homes are specifically for substance misuse, so I suppose that it is just to highlight that not to make assumptions around it being elderly care and the complexities of the individuals with which we are working is really, really high. The size of the units that we would run are 10 and 12 people that would be supported in those units, so they are fairly small in their capacity and they are supported by other services that are provided, so they do not stand in isolation and there is some enrichment and movement of staff and schools between other services around and about. I suppose that the other part of that is that care homes do not just stand alone, they are part of a greater network within provider units. David, do you have a follow-up? I suppose that the other issues that for many care home owners and all of us in this, all the members here will be visiting care homes across our patches. Certainly when I have been doing visits recently in the Highlands and Islands, one of the issues has certainly been the growth of dementia and the effect that has on staffing. The hard reality, without naming any establishment, is that it is the chronic shortage of staff, which is thrown back to me when I have ever raised that. I cannot speak for the organization that I visited, but having sophisticated tools is all fine and well. From a lunch point of view, that makes a lot of sense, but the hard reality is that trying to fill the rota week in, week out is the main problem that many managers face. Is that clear in your experience as well? Absolutely. At any point, we would be running between a 7 per cent and 11 per cent vacant rate in terms of staffing, and we are pretty good at recruitment. I am talking about turning point Scotland specifically. There is a chronic requirement for staffing, and it feels risky to make that more difficult for us to meet the base requirements. CCPS, along with the HR voluntary sector forum, carries out an annual benchmarking survey, looking at a range of workforce issues and recruitment and retention. The questions are always asked around recruitment and retention, and the 2017-18 survey showed that 93 per cent of providers stated that recruitment is difficult or very difficult. That is an increase from 87.5 per cent previous year, and it is also supported by the Scottish Government Commission's survey in 2016, looking at the social services workforce in Scotland, which stated that the majority of providers find recruitment challenging either regularly or occasionally. Andrew Strong and then Karen Hitch. I just want to come in on the back of that about a future threat around Brexit in terms of the social care sector. BBC research that came out this morning said that there are 26,000 people working in health, social care or in public administration from the EU. I think that we should see that wider context is really important in terms of the social care sector. A lot of people work in the social care sector. The ability to carry on business as usual beyond March next year could be threatened by that. I think that it is worthwhile having a look at the SCCC workforce data report that was released last month. I will draw your attention to it. It says that, with regards to the recruitment retention crisis that the sector currently faces, the SCCC workforce data report published a stability index of 77.1 per cent. What that means is that about a quarter of staff roles are changing in a year. Our own research at Scottish Care also shows that, within six months, more people leave—of entering the sector, more people leave than enter—put those two together with an increased demand. That is a huge crisis that we are currently facing. You alluded to the vacancy rate in your own services. I also want to highlight that for nurses in particular, the vacancy rate is currently sitting at 32 per cent. It cannot continue, and I do not know if you are aware, but there was last week's headline news for 19 care homes that have closed this year because they cannot recruit nurses. I have Brian Whittle and then Bob Doris. Good morning to the panel. In our evidence that we have heard and in writing, the suggestion that the NHS in the UK and in Scotland is very efficient, but that efficiency in itself is making the system more fragile. Does that apply in the care home sector as well? Are we starting to work right at the boundaries of what we would term safe staffing? That is a challenging question, clearly. How fragile is the care home sector? How robust are staffing arrangements currently? I think that I would merely reiterate the statistics that we have just described. We are really struggling to recruit staff when efficiencies are made. That is often where they are made because we are already at the bottom line in terms of the resource for providing the service. There is nowhere else that we can lose funds. In addition to that, because of the 32 per cent vacancy rate around about nurses, you will see that there has been a growth in agency nurse provision of some 18 per cent in the last year. Now, just because there are more nursing agencies does not mean that there are more nurses. Actually, what it means is that some of our providers will have to spend up to £1,200 a night to get a nurse. Efficiencies are not really the word that I would be using in this context at this point in time. I suppose that what providers are trying to do is be more creative and dynamic. They use multidisciplinary teams, so that is the counterbalance in terms of the crisis around staffing. Mark Isherwood, just to pick up on that. The ambition of the legislation is to try and create a framework that spans diverse settings, multiple professions, integrated services and team working. That is good. I am not clear that we really have the evidence-based approaches to ground that in at this stage. I think that there is a risk that in trying to do that we create rigidities that we end up with a tool that is not sufficiently flexible, that this can potentially become an obstacle to the sort of integration and innovation that Catherine has just mentioned, which are really the responses that the sector has when it is facing the workforce pressures and the recruitment issues that Karen has just described. I think that that is one of the risks and potential unintended consequences of the legislation. I wonder if the panel thinks that the bill will support the sustainability of the sector in terms of quality and safety. I am thinking in terms, as it was alluded to earlier by my colleague Dave Stewart, on the different sizes in the care home sector and are the tools therefore applicable across the whole of the care home sector speaking to the tension between numbers and service? Are we talking about their own thinking? Are we talking about numbers when we should be talking about service? Actually what we should be talking about is the people who access care and support and making sure that we deliver care that is responsive to them and actually is led by them. When we start to think about tools, then what you are doing is applying a prescriptive set of skills around that person, which does not necessarily take into account their individuality. Sorry, there was another aspect to your question. What was it, could you remind me? It is just that the tools are applicable across the care sector as a whole, as it is following on from Dave Stewart's line of questioning. Does that in itself create its own tension? I will take you back to the multidisciplinary teams question and around a bit innovation in their current setting. No, they do not, and that we need to be taken into account. One of the concerns that we had was could there be a standardised tool that would suffice across the diverse range of services? On speaking to the bill team, the answer to that was no, it is unlikely. There will be multiple tools probably have to be developed, which again brings its own challenges. Someone asked about how many people do workforce planning again from our benchmarking survey. Only 23% of respondents use workforce planning tools, so we then have the issues and the challenges of people having to be trained when these tools are developed and not just trained in the use of a single tool, but perhaps multiple tools that will have to be used by the same organisation, which brings us on to the point of, there is no clear indicator of how any training would be resourced. I found it really helpful to understand the concerns that exist around us. Right at the house, I think that Karen Hedge said, the current tool that exists at Ireland tool, and I could actually explain the algorithm around that. There are concerns over the tool that is currently being used, so I would be asked the question in another way. I have listened carefully to all the challenges. Any tool or tools that could be developed would have to be suitably flexible, take into account the very needs and the diversity of the sector, but if we could get it right, would it be a positive thing? All those caveats, I suppose what we are up front to get around, if we could get this right, would this be a positive thing for the sector? There are positivities around having tools in terms of transparency and offering guidance. Scottish Care would support having them for those reasons, but they could not be the be-all and end-all. They would still need to be a human judgment as a significant factor in that, which could override the tools themselves. We also need to bear in mind, as you say, the changing landscape. What we haven't discussed, and I'm not sure that the committee discussed it last week, was around about changes to technology and the opportunities that they offer because it allows our staff to just be. Care homes are not clinical settings, they are somebody's home by the very definition. You start to enter into a great area when you are trying to apply something that was created for a clinical setting into somebody's personal place. Could I just re-word that slightly before Mr Hew's words come out, because it might be helpful? Wood and Cairnhead have just said the constraints on the ground. Even after once you have those diagnostic tools to see what the skills mix and the workload should look like in any place, there has been on-the-ground judgment. If there was a degree of flexibility on the ground with those diagnostic tools about what headcounts should look like, what the skills mix should look like, what the workload would look like, would that be helpful? However, as long as you had on-the-ground, that final judgment had to be made because you know your local care home setting best, for example. Sorry, Mr Hew's words. I will come back to that. Let us assume that we have this series of perfect tools. I think that there are still issues. For any well-managed service, it is obviously a consideration of matching the workforce to the needs of the service. As we have heard particularly increasingly, we are making sure that that is a personalised process, so that we are trying to achieve the individual outcomes for an individual person. That has got to be part of the process of running a good service. I think that there is a question about whether that is best done through making it a statutory requirement. I think that there are issues about the statutory context into which you place such a tool. One of the points that we have made in our submission is that there is a lack of clarity about the duty that is placed on commissioning authorities when they are commissioning services. They have a duty to have regard to the duties and principles placed on care service providers. It is not clear how that will play out in practice when commissioners are trying to achieve a balance of quality, safety and affordability. That takes us back to the wider pressures in the sector that we have talked about, when the IJBs, for example, as commissioners, are under great financial pressure. Even when service providers have a sufficient financial envelope to be able to fund the workforce levels that are required to deliver the service, they are going out into a labour market where they just simply are not the sufficient people to meet the needs. Significant concerns and more likelihood of Brexit proceeds as currently seems to be the case that those pressures will be severely exacerbated. Anyone else got an opinion on those points? Essentially, the point that Bob Dorr has made are tools of themselves that are potentially useful, or are they simply the wrong way to approach the issues that you face? I find it hard to imagine them being particularly helpful in this context. I do not see how they would fit particularly well, and I think that until we are at a position where we are resourcing our availability of nurses and social care workers is much, much improved, I do not see how useful that would be. I think that it is particularly important, given the concerns that were raised, that the power contained within section 3 in the bill is to have the care inspector develop a tool, rather than implement a tool. I think that that is an important distinction to make, because maybe they cannot get it right, but I note that. Given that the issue that Mark Hale would have made in relation to recruitment, retention of staff and car and hedge, he said something similar. I note in section 3 one thing that the Government is not taking the power to do is to report on staffing levels. Does that seem a bit odd? Do you think that it is part of the fact that we are reporting on staffing levels nationally, so that we get a national picture and see what is happening across the sector, across the country? Would that be helpful, or would that just be an administrative difficulty for individual care homes in the sector? Andrew Strong? Well, from our perspective, I think that we would like to see something like that. Whether that works for providers or not is another question. I think that from the people that we have spoken to, they would like more transparency about the pressures that social care and health services are facing at the moment. I just wanted to come in on that, because the SCCC already collects some workforce data as does ourselves and CCPS, so there are other means to getting hold of that data, although a national picture might well be helpful in planning for the future. Thank you very much. Thank you very much, convener, and good morning. Thank you very much for coming in. Can I just go back to the very basics of why we are here? We have had evidence from other professionals, and we are having evidence from ourselves and others as well. The whole point is that it is at the health and care. It is important to mention that at the health and care Scotland Bill, and from what I am hearing from ourselves and others as well, it feels that, basically, we have got so many different aspects of this Bill, and it is really based on RCN nursing, which is at the top, and then it is working its way down. You may not think that, but that is certainly what I have been getting fed back. I think that the complication is that there are so many different sectors here. You have got the private sector, you have got council sector, care homes, etc. I just wondered if you can answer me that honestly, if you have not involved enough in it. However, what I seem to feel is that this Bill applies the same general duties on all the providers, and whilst they provide varying levels of not just care, they are completely different organisations. Do you think that this Bill will actually succeed in coherence in the context of integration, legislation or practice between health and social care? Even if you come stay quite close to that core, as you have described it, of the consistent application of nurse workforce planning tools, there are some challenges and complexities that I think are not reflected in the Bill. For example, a major provider of inpatient specialist pallative care provision in Scotland are the voluntary hospices. Amongst the broad range of services that hospices provide, most of the care that hospices provide is provided in people's homes, but they do provide inpatient services. Several of the healthcare services that are listed, the types that are listed in schedule 121C of the Bill, where the Bill proposes the application of a common method, the locations listed in the same table do not clearly equate to hospices. It seems to be predicated entirely on NHS settings. That is a complexity that we need to understand better even before we get to the wider orbit of the huge diversity of health and care settings that other colleagues here have spoken around. I think that there should not be a blanket assumption that tools that have been primarily developed in and for the NHS can necessarily be applied with adaptation to other healthcare settings, for example the voluntary hospices. In terms of integration, I do not think that the Bill in itself would add anything that there is already work going on around that to develop new models of care. The chief nursing officer's directorate recently had a meeting specifically drawing on examples of local change that has happened in terms of thinking how nurses can potentially work perpetitively, look at enablement programmes and things like that. There is already work going on to do that. If anything, putting the Bill in place might create a barrier between the two sectors because there is a potential for nursing staff in particular to move into the NHS from the independent and third sectors in terms of terms and conditions. We already have workforce in crisis, so that is a problem. We really need to be focusing on those new models of care and linked up career pathways, looking at multidisciplinary teams and other opportunities that we are currently already looking into. Keith Brown While we are at four panel members, I have mentioned the impact of Brexit, especially in relation to recruitment and retention. I think that the vacancy rate at 32 per cent was mentioned, and there has been a substantial increase in the last year. It is stunned to hear that a cost of a raise in nurses is £1,200 a night. I wonder how much of that goes to the nurse. On the issue of Brexit, I know that it is not as simple as those that are from the EU potential leaving and the other impacts. Are any of the panel members raised that they are able to give any idea of EU nationals leaving having contributed to this over the past year or even in the past two years? That is in the context of what is in the bill and the workforce planning. I do not have the statistics in front of me, but I happily submit something after the meeting because I know that there is a growing body of evidence about the impact of the prospect of Brexit. I also think that some of the evidence that has been published by the Government in Westminster in terms of economic projections raise concerns as well. Whether it is due to Brexit or other issues to do with recruitment and retention, is it not possible, bearing in mind what has been said about being able to apply professional judgments, which is possible in terms of current tools used by nurses, that one of the potential benefits could be that, if you are able to point to an objective evidence-based and statutory necessary process to commissioners to say that that is what you require in terms of staff, that might be something that might help in relation to the point that Mark raised about commissioners being aware of their obligations? You could point to those tools and say, we need to have this. Everyone has been in the same boat, so you can take that back to commissioners. Hi, that is one of the reasons that we have been looking at this as part of the national care home contract negotiations. Scottish Care, COSLA, who I am, will be appearing after us. Scotland Excel is involved in that conversation with the provisor that the tools act as a guide. They are not a prescribed formula. We guess that there are advantages, but, as Mark mentioned earlier, that commissioners are not included in the bill. It is a huge oversight. We could see this in the Scottish living wage, where there is a requirement, and absolutely so, we should be paying our staff and valuing our staff. However, if that funding does not come down to the providers, they are putting quite a sticky position of having to then be able to pay that out. I would hate that, if the bill created that same drain and resource—a potential drain and resource—that that would repeat itself. A related point, but it is really that it is going to be really important as this proceeds that there is some really clear linkage between the development of the models and the regulatory framework. That is also where the relationship with the commissioners comes in, because what ends up being very difficult is if there is an expectation on the part of the regulator that the provider will meet a certain set of requirements in terms of workforce, but that, in the commissioning process, there is an adequate resource to meet that. The comeback in that position is very often at the level of the provider. We may suffer through poor ratings from the regulator. That is really what I was talking about when I mentioned this issue about what duties are placed on the commissioning authorities in those circumstances. Alison Christy? To add to that, on average, 77 per cent of their income relates to publicly funded services, so it is a huge concern for CCPS members that there is no duty to be placed on commissioners. I wanted to follow on from Keith Brown's question, because I wanted to look at workforce planning and training with the national workforce plan, which is now turned into three. What feedback have you had with regard to future training and the college sector? It is quite clear that the care crisis and staff crisis that we have did not start with Brexit. It has been over many years now building up. What sort of future projections are you trying to look towards as meeting in terms of staff recruitment? Given the fact that the bill will have two speeds with the care sector in the slow lane in terms of this bill, are you concerned that there are unintended consequences of staff being poached to some extent to fill acute setting problems in the future around the staffing bill as well? Absolutely, yes. It is part of that. One of the risks of the bill is the unintended consequence of being resource driven. If you are trying to meet numbers of staffing, that is where you put all your resource. If the health part of the bill is introduced first, that means that more resource will go towards getting people employed there first, which means that, yes, we are likely to lose staff. That is a real concern, given the figures that I quoted earlier. Just a further concern again for CCPS members. A very small proportion of members have care homes. We are third in line for any resources. If they initially go to health, then to care homes, then services that are delivering community support will be under-resourced as a result. Yes, we would be concerned that we would have to divert staff from one service to another to focus on care homes. Is it fair to say that our college sector is not actually meeting our demands at this moment in time as well? I know that the Scottish Government is currently looking to meet their policy around childcare. I know from conversations that I have had here in Edinburgh, where half of all delayed discharges, that so many new potential students are actually looking and being encouraged to go into childcare. My concern is in regards to adult care, as not being able to meet future demands and actively creating unintended consequences of encouraging people to choose different pathways, which never gets them into an adult care career. Does the panel have any views on that specifically? The difficulties in getting people into adult care are also long-standing. We are quite optimistic that the national health and social care workforce plan, the national campaign for marketing, will address some of those challenges. I think that there is a long way to go to make adult social care attractive to people. CCPS and the voluntary sector have a recruitment working group, and we have been trying since May to get 10 people into an employability programme. It is people who have multiple barriers to employment and are long-term unemployed and they are not seeing care as an attractive career prospect. I think that there are a lot of challenges to be addressed beyond the bill. It is about long-term education around the careers in social care. At the moment, there is just not that approach. That starts at the very beginning from people's view at school, as young people, seeing it as a potential option. Our joint and voluntary sector working group around recruitment has shown how people are not choosing it despite being welcomed, offered that, having all the approaches that they would have to entice folks into it. It is really difficult. My colleagues, Catherine Ross and Paul will be better able to put something in writing in the future. I can tell you that there are concerns about the way that the current training is put in place, whether that be SVQ models or whether that be through an apprenticeship. Partly that is because the majority of the workforce or the median age of the workforce is currently 48. With the changes to regulation and therefore an increased requirement for more qualifications, those people often have come into the sector not having qualifications, or have geocaining commitments. We know that the access training between the hours of 10 o'clock and 1am in the morning is a whole host of concerns about that, which, if you would like, would be helpful for Catherine and Paul to put something in writing. That would be helpful indeed. A number of you have commented on the potential for the bill to skew attention towards resources. Can I ask you, on the other side of the coin, is there any way in which you think the bill assists in increasing focus on outcomes for individuals? If there is not, perhaps we should hear that as well. What is the view of panel members on the outcome focus within the legislation as it stands? Catherine Rennart? I do not see the outcome focus in the legislation as it stands. I think that we already have the health and social care standards, which provide a really nice framework for outcome focus. I agree with that. One of the things that I would like to see in the bill is more of a reference to how people who use social care or use healthcare on a regular basis can be involved and consulted in, adding their voice to that. I think that there is a reference around who is going to be consulted in the development of the tools, but I think that it would be legitimate to extend that to people with long-term conditions to sable people as well. I agree with what everyone said so far. The bill was not outcome focused. Okay, thank you very much, that is clear. David Torrance? I have been heard in good morning panel. With the care inspectorate being both the regulator of registered care services in Scotland and the scrutiny and improvement body for social work, do the panel think that the care inspectorate is the appropriate body to lead on the development of staffing methodologies for care home sector? Obviously, the care inspectorate are very experienced in this area. I absolutely believe that they should be involved. We have a very close working relationship with the care inspectorate. Obviously, we need to. That has resulted in the majority of care homes in Scotland having good or very good ratings, but I do not think that they should be doing it in isolation. So, to collaborate is not the same as to co-produce. The tools need to be fit for purpose. They need to be easy to use. If our staff are running from place to place, given if we think about what the impact of the future projections on staffing shortages, that is a high potential for that to happen. They need to be able to use the tools quickly, easily, etc. If tools were to be produced, the care inspectorate can lead, but it has to be done. They must be co-produced. One of the interesting things—we talked about the national care standards and how they were developed—was very much in co-production with providers, with people who use support and services and with other bodies. I would imagine that the care inspectorate would see the value of doing that and would take it forward in that way, so that we would be supportive, but with the caveat that, again, as Karen said, that would need to be in co-production, particularly with people who use support and services and providers. David Torrance Will the bill change the relationship between the care inspectorate commissioners and providers? Do you think that there will be any conflict interests? What is the potential impact? I previously alluded to the relationship that we have with the care inspectorate, and I would like to see that continue. Concerns arise around the potential risk of creating a resource-driven service in which we have to put all the resource into staffing, as opposed to outcomes-based. I do not see that it would change the relationship in any great sense, because we already co-produce things and work together in an outcomes-based way. In terms of reviewing our submissions, my only concerns—I mentioned this earlier—was that we approached this very much from an asset-based model, but in their submission, they referred to dependency tools. I imagine that this is something that we could explore with them, but that is the only place that I could see us coming up against each other. Annabelle Ewing I think that there is, perhaps, not changing relationships, what there is potential for conflict. If the care inspectorate has developed the tools and are regulating against them, there is no duty on commissioners to meet the requirements of the tools and evidence. That is where the conflict could arise between the care inspectorate, the provider and the commissioner. Mark Isherwood It is not a direct answer to the question, but to raise the issue that for the voluntary hospices, some of them have dual regulation at the moment, so some of their services might be regulated by the care inspectorate, but the bulk of their services are inspected and regulated by Healthcare Improvement Scotland. There is a degree of complexity in a whole area of work around that, because Healthcare Improvement Scotland does not have the same inspecting and regulatory relationship with NHS services, which it does with independent healthcare providers such as hospices. We would need to make sure that, when we come to the detail of how this all works through, that there is an appropriate way of taking whatever models are developed, and some of this is specified in the bill in terms of types of healthcare service and types of setting, and make sure that that does not feed into Healthcare Improvement Scotland regulatory processes in a way that is a hindrance or has negative outcomes for the provision of services by the independent hospices. Mark Isherwood My next question is about recruitment, especially in nurses in the sector. It was mentioned earlier that there is a 32 per cent vacancy rate on 18 per cent growth in agency nurses. Can the bill in any way affect recruitment and retention in nursing staff in the sector? Colin Hedge It is very much well in the sense that, because it will be done in a progressive manner from one sector to the next, so from health into social care, there is a potential for the consequence of social care losing staff into the health sector. Other than that, the bill in itself cannot, and I keep referring to this, it cannot magically create nurses, and as much as there is a whole load of other work going on around that in terms of increasing the number of student nursing places, etc., etc., new models of care and so on, the bill in itself will not create more nurses. Alison Christy There is also the unintended consequence. If you cannot find the staff anywhere that the tools require you to have, what happens to that service? The risk is that the service will have to close? Colin Hedge Is there a risk in all of this that care inspectorate, for example, reports that a particular provider is not delivering against the workforce level set out or deduced from the tool, possibly doing a very good job in every other respect, but therefore at risk of attracting a very negative inspection report with potentially serious consequences? Is that a real risk? Mark Isherwood I think that that might be a risk, and I can imagine a circumstance in which that happens despite the fact that the provider organisation is delivering on outcomes that are important for its clients. Colin Hedge So the bill, having no outcomes focus, will potentially be in conflict with practices or policies within providers that are outcome focus. Is that essentially the point Catherine Reanwick? Catherine Reanwick Yes, that is the point, yes. Colin Hedge We are in a real positive position as well because of the recent changes to the care inspectorate's methodology. It would be really good to see where that takes us because it is creating conditions for innovation and improvement and that real outcomes focused approach to bring this in alongside it just seems completely contradictory. Mark Isherwood Are you on the saying that this is the wrong time? Colin Hedge Maybe, yes. Is it fixing things in statute and freezing them in time as opposed to offering opportunity for innovation and change? Mark Isherwood The financial memorandum, policy memorandum around the bill say that it does not inevitably follow that there will be tools devised for care homes and likewise with hospices and other settings which are not specifically identified here. Is there a logic to the bill itself that will drive the development of those tools to witnesses' feel? Is there a risk there? In other words, you create the mechanism to devise tools that then follow that tools will be devised? Colin Hedge We were already looking at developing some sort of tool under part of the national care home contract very much as a guide and to offer that transparency in terms of commissioning and so on, but absolutely within the context of flexibility and not being burdened on an opt-in basis as well. It does not need statute to make this happen and statute could potentially limit where we go with it. Mark Isherwood But if statute comes forward, would you want to see that tool that is being developed put in place rather than something borrowed from the NHS? Colin Hedge It would need to be developed for the sector and co-produced by those of us who work in the sector. Mark Isherwood Brian Whittle I am just wondering whether you feel that the bill should or could cover all care homes because it seems to me that we are just talking about currently the sector in terms of caring for the elderly. There are much more that has already been indicated to the sector than just that. Can we develop tools that are delivered to that sector? Catherine Maynard I think that you would need to look at multiple tools, so it certainly would not be one. It would have to be a range of options probably and those options would have to be quite flexible as well, so I do not see one tool doing that for the dynamic and range of services delivered. Mark Isherwood Can I just follow on from that? Does that then lead—we are obviously like within the bill—is there scope then for the training that will be required to deliver these tools on the ground because there has to be an application, a cascading of that knowledge into the care sector? Is there room in the bill for that? Catherine Maynard I do not see that in the bill. Any kind of training in a tool would need to be cascaded down through organisations. It would have to be applied correctly for it to work. It could be quite dangerous being applied without the training, so it would certainly be a requirement and we would need to ensure that there was capacity for all of our services to be able to do that. Mark Isherwood Okay. Thank you very much. Mark Isherwood I have a final question from Bob Doris. Bob Doris Quickly. It is self-evident that if this tool does progress, there is going to have to be a huge amount of reassurance, a lot of co-production, a lot of flexibility, a lot of justifiable variation on the ground. That is self-evident based on the evidence that we have had today, but one of the really interesting aspects of the discussions around training of nurses and training of social care staff, if this tool does come in, should it automatically trigger an annual review based on the data that comes out from that tool in relation to training places for nurses, the FE sector. It is not enough to say, here is a diagnostic tool that gives you an indicator of how you deliver workforce on the ground and a skills mix on the ground, is the next step that the Scottish Government would have to use, that data on an annual basis to tweak and develop its nursing training places and its FE provision and its university provision according to whatever that data shows, so should there be a next step to follow from that in terms of the training of it? I know that there are issues to get the people to fill the posts in the first place, but if we can get them, do we have to find ways of having this impact or have we taken forward training in the future? Absolutely. If the tool goes forward and there is valuable data, then we should definitely use the data for national workforce planning as opposed to individual service or regional, I mean, we need to look at the whole picture. It was one point to raise, however, is that it is not so quick. For example, with nurses, although you might see very quickly that we need nurses in the sector, and you might train more nurses, the kind of nurses that would be used in our settings need to be quite experienced, they are not usually straight out of university because it is a very responsible job, if not solo, maybe two nurses may work together, they may work alone, so there will be a time delay, so it is about using the data but also thinking about it in those kind of timescales as well. Okay, well can I say thank you very much to all of our witnesses, that's been a very helpful session and we've certainly gleaned some very useful information. We will adjourn briefly and resume three minutes past in order to hear from our next panel. Thank you very much. We will now resume our meeting and resume with our second panel of witnesses this morning, so it gives me a pleasure to welcome to the committee John Wood, the chief officer for health and social care at COSLA, Stuart Bain, HR business partner for health and social care partnership and Fife Council, representing the Society of Personnel and Development in Scotland. Dr Jane Killock, Head of Social Work Strategy and Development, Social Work Scotland. David Williams, chief officer at Glasgow City Health and Social Care Partnership and Eddie Fraser, the director of East Ayrshire Health and Social Care Partnership. Thank you very much for attending this morning as ever, questions and answers through the chair and we will have about an hour for this evidence session. Can I start with a question that I asked to the witnesses in the previous panel, which is how far witnesses believe that this piece of legislation that we are considering today is focused on outcomes for users of services. Thank you, chair. As is hopefully clear from our evidence, COSLA is not supportive of the legislation as it stands and one of the reasons behind that is because we see the bill very much as being focused on inputs rather than outcomes. Although staffing numbers necessarily are not mentioned or detailed within the legislation, it certainly appears that that is the way in which the legislation would head and the way in which tools would head. I suppose that reflecting on the previous session that I was here for, there is nothing in the bill that we can see nor necessarily in the policy memorandum supporting it to demonstrate that the outcomes are at the heart of the bill or at the heart of the intention of the bill. Okay, thank you very much. Equalling what John Sturgeon just said, our concerns are around the qualitative issues rather than quantitative issues, particularly if you think about the care inspectorate. Auditors, by their very nature, will audit to whatever they are asked to audit to, so if that involves counting heads then that is what they will do. It is probably easier to count heads than it is to measure quality, so there is that kind of imbalance in terms of the objectives that we would like to see, which should be high quality care services and perhaps an excessive focus on simple tools or complex tools to measure capacity that do not always capture the whole picture and actually manage to get down to the quality of outputs that would be of interest. I agree with the previous speakers and those at the earlier session today. In terms of outcomes, we are already in a primary legislative environment that, in terms of integration, partners are working towards more outcome-focused approaches, looking at innovation across the sectors. I think that the sector is adequately regulated currently to allow for scrutiny over our processes and procedures. I do not think that the bill lines itself towards an outcome-based approach in that current integrated context. I think that the Public Bodies Joint Working Scotland Act clearly sets out nine national health and wellbeing outcomes that integration authorities are expected to work towards achieving. I think that the very fact that that piece of legislation explicitly sets out that that legislation is about outcomes for individuals and communities is significant in itself. I think that there is a very real potential that it seems to me with this draft proposal that that actually mitigates against being able to deliver on those outcomes because, as colleagues have indicated, it is very process-orientated. I suppose that, in line with my colleagues, I would echo that the policy directing has been about shifting choice and control to individuals around more self-directed support and more self-management. There is a bit of a concern if we go down a line of regulation, particularly around one profession that will take away from some of the innovation and policy direction that we have been working towards. I also think that the health and social care workforce plan, which is already agreed, between Scottish Government and COSLA, gives a sound basis in terms of the responsibilities of what we need to take forward at this time. I hear a clear view in relation to outcomes. Is there any respect in which the legislation, as it stands, assists with workforce planning either at a local, a service level, or a national level? If not, is there another legislation that might assist with addressing the workforce issues that the services that you represent face? My own view is that there is sufficient framework in place through legislative and policy direction and infrastructure to enable integration authorities and health and social care partnerships that have the substantially lead responsibility for commissioning health and social care provision, not within acute hospital settings but certainly in community and some in-patient provision. That infrastructure and existing framework is already in place and sufficient to enable the level of innovation that my colleague Mr Fraser has hinted and alluded to in relation to why integration of health and social care is in place. It is to transform the planning, delivery, receipt and experience of health and social care services across Scotland. Any legislation that seems to me that is proposed to come forward subsequently, including that legislation, should enable that process rather than make it more challenging. To build on that, we have a number of workforce tools out there, particularly the nursing workforce tool. It is interesting that that was developed by the profession in terms of how that has been brought forward rather than regulated to find that. It is not that anyone is saying that we do not think that there should be a clear focus around safe staffing across what we do, but the bill as it is just now seems to focus on a particular profession rather than on how we in the new integrated world work across that and right outwith the services that we manage into the third sector and into some of the choices that people might want to make through self-directed support. Some of the workforce tools that have been developed in nursing through the profession do give clarity and assurance, but at the same time, it is how we see that across and, again, getting back to the vehicle that can be the health and social care workforce plans. Yes, just pointing out that the Public Bodies Act is still relatively new and the integration joint boards and the health and social care partnerships are feeling their way, I think would be fair to say in this particular context. The focus very much should be around outcomes, around self-direction, working in collaboration with service users to redesign services in an innovative way. It seems to us that the bill as it stands really does not lend itself well to that agenda, that it is at the very least premature in relation to furthering the concept of integration. There are some gaps as well, I think, as has been mentioned earlier on. A lot of the focus is around the NHS services. I think that that has the potential to have an unintended consequence of skewing the focus on to the NHS to the detriment of social care. One of the gaps that Social Work Scotland has found in the bill is that the bill covers regulated social care services and not social work services in the wider context. As the bill stands at the moment, it does not include public protection services that are on the ground working in highly complex situations within communities across Scotland. Our real concern is that, as the bill stands, the resource implications will be focused around health, mainly social care secondary and social work, not at all. I draw attention to the regulatory framework that local authorities, in particular, work under with safeguarding addresses through the prevention and protection of vulnerable groups legislation, which is excellent. The work that the Tribal SCs do in terms of ensuring that workers are properly regulated or properly qualified and have achieved the correct levels of CPD, for example, and the inspection regime under the care inspector, which, in my experience, tends to focus on qualitative issues. Those safeguards should not be ignored. On the specifics of your question as to whether the bill or other pieces of legislation give us what we need with regard to workforce planning, part of the answer to that would be to look towards the national workforce plan, which is co-owned by Caws on the Scottish Government, which is obviously a non-legislative piece of work. If we are talking about strategic workforce planning, we are looking at where pressures in the labour market are, where recruitment and retention are under pressure. I think that it would be safe to say that legislation doesn't offer any clear benefits in that regard, but some of the softer approaches, the benefits that can be brought by that national workforce plan are perhaps where our attention might be best diverted. I thank you very much to follow up Jane Kellogg's response, particularly in regard to social work at David Stewart. Thank you very much, convener. I am particularly interested in raising some issues around social work, not least that was my first job, albeit that was many, many years ago. I am particularly interested in the issue around the exclusion of non-regulated social work staff. Some of them, my question has already been covered, but particularly perhaps to Dr Jane Kellogg, the issue around the Public Bodies Act 2014, which she referred to. Is this issue of being excluded not contrary to the Public Bodies Act of 2014? When we look at integration, we are looking at the potential to have non-regulated social work services. The staff are regulated in terms of the SSC, but the service that they provide is not one of the services that the care inspectorate regulates as a service. What local authorities and NHS are looking at across the board at the moment is where front-line statutory services can come together and work in a more integrated manner in order to improve outcomes for service users. Looking at the bill as it stands, it very much separates out social care from health. There is not a sense there that there is any future proofing around what any new models of support might look like, either at the care side of the equation or at the front-line public protection part of the social work and, indeed, health business. As I said, at the moment, the bill as it stands does not really reflect what the integration authority's role is really about. The fact of what you are saying is that it is a bit of muddled architecture in terms of the legislative hold on what we are talking about in the future. Social Work Scotland has taken quite a nuanced approach to this, opposing, if you like, the legislation as it stands, but taking a pragmatic approach that, if the legislation is to go ahead, we would also wish to see social work services included in the legislation and not excluded per se. Any other panellists that you convener like to contribute? In relation to social work services being included, I think that we need to point out how complex an issue that is in terms of including social work services. Social workers work as part of a team around people, so teams around a child, around a family, around an older person. The context of regulating social work depends on the global context that you work in. If a local social worker does not have a multidiscipline of team around him, he would actually do a lot more of them. If he has adequate teams around a child and teams around communities, he might need less social work. That is where it becomes really difficult. How do you regulate for that? How do you regulate for the local context of where it would be? Again, it is about how we look at the whole team, how we look at the local context, not just social work, not just nursing, but the totality of that. Some of that can be right out with our realm into our teaching colleagues and how they are responding in local communities. Just generally, there are concerns being expressed by panel members, albeit in different ways. There were some hints, I think, from Jane, about how the legislation could be improved. Do the panels have suggestions about that? Obviously, their bill can be amended in future stages. Any suggestions for how the legislation could be improved? Our job is members of the committee. That is a very general question, so succinct answers would be appreciated if there are thoughts on that. David Williams. I will have a go at that one. From my perspective, the less is more, it seems to me is the response to the comments that Mr Fraser has just made in relation to the legislation. I think that the complexity of arrangements that need to be often put in place in order to deliver on protection of children or protection around vulnerable adults or even, dare I say, in relation to MAPA responsibilities, multi-agency public protection arrangements for individuals who present risk in communities are a unique individual complex and therefore it is difficult to legislate in relation to staffing arrangements around that, regardless of the sophistication or otherwise of workforce tools. It strikes me that, if the Parliament is minded to proceed with the legislation, it needs to be a legislation that should absolutely have at its heart the notion of flexibility, responsiveness and professional judgment, as opposed to something that becomes potentially a mechanistic tick box response. Anyone else? The only things that I have added to that would be the focus on quality rather than quantity. I definitely recognise that local conditions are very relevant to staffing decisions and that should be reflected in anything. The final thing that I would say is about ensuring that actual workers are included both in terms of consultation and staffing arrangements and in terms of worker wellbeing, because I think that that is important to you. It is incumbent on me to start off by saying that we did not think that the legislation should cover social care in the first place. It is something that our board members were at pains for me to come and express. I would certainly reiterate the point about professional responsibility not quite being reflected in the bill. If we were to look at improvements, I think that that is an area for attention. I am not necessarily sure what local context refers to in the bill as it is listed as a principle to consider, but I think that it would be really important for the tool, at least that is developed as a result of this bill, to take consideration of the challenges in workforce supply. I know that we have been touching on that this morning and probably will later this morning. However, if there is something that works in isolation of the fact that it is simply difficult to recruit people into those roles and that the tool and the legislation do not take consideration of that, then it is a real challenge at the very first hurdle. Thank you very much, Gira. I wanted to come in on the back of staffing or that. I am really quite concerned about what I have heard. I would say that possibly me and others here or constituency caseload is really social work and care homes and perhaps bed blocking and that type of thing. I just wondered when we heard previous evidence, not this morning but the week before, that it was basic to say that it was nurse led, RCN led, but they wanted to create this tool where they could prevent bed blocking if they were able to see that they needed more nurses in that respect. Do you think that that went far enough? I am obviously listening to what you are saying. That is a good idea if it would work that way, but have social work and social care been involved enough and how that will fall down the actual care that you get in, you know, the community? Have you been involved enough? Coming from the top, it sounds great, you will have this tool if you are short, you can get more nurses there and perhaps prevent bed blocking or reduce it, but has anything been done in the lower aspects of it, which is really where the people are getting cared in the community and care homes as well? If this bill had to go ahead, have you been involved enough in your sector? I suppose that the fundamental point is that, before the bill was laid in Parliament and the policy was announced, we were not aware of there being any appetite for this legislation and that is fundamental to bear in mind. In terms of co-production of the legislation itself, we have had conversations with officials after the announcement of the fact that there would be a safer staffing bill introduced into Parliament, but in terms of the appetite, it was not really there. I think that we have received good reassurances that the tools would be co-produced with the care inspectorate and would certainly hold them to that if the tools come to be produced. In terms of co-producing the notion of the legislation itself, that has not really been there. Thank you, chair. If I went back to the integration agenda and the outset of the legislation, I think that the perceived wisdom was that it was substantially in place to address the issue of bed blocking and delayed discharges. It is a lot more than that and I think that it is proving to be a lot more than that and I would want to stress that really strongly. However, in saying that, the attention that health and social care partnerships across the country have been asked to focus on in relation to the delayed discharge agenda is significant, and partnerships up and down the country are responding differently and verily related to local issues and locality needs in terms of how to expedite an improved position in relation to the delayed discharges. I think that the innovation and creativity that comes within the legislation and the integration arrangements facilitates that and an improved picture. I think that the picture has improved certainly in terms of significant reductions in bed days lost across the country and the acute hospital sector as a consequence of that. If you were to—I think that your question alluded—if we had more of X, Y and Z, would we be able to deliver an improved performance again? Arguably, yes, and certainly in the community, particularly around the increasing levels of frailty and a purity of need of significant numbers of the population in their own homes and how they can be better supported to remain in their own homes. Would that legislation assist that? I do not know that it would, because, as I said before, I think that it comes back to the people's unique circumstances and their own particular individual needs and how the array of support around that individual could be brought to better bear and improve impact and outcomes for that individual. I think that I was going to give an anecdotal experience from my health and social care partnership where the fact that we were able to be flexible has actually reduced a delayed discharge. We are able to shift social workers from a community setting to working in hospitals to help in the identification of need. We are then able to change our focus within some of our care homes so that we have enablement bed arrangements where people move into our care homes for a brief period of time to get them back on their feet and be able to care for themselves. Our focus within care at home has also changed so that we are moving to an enablement model in which a short-term intervention and targeting carers to be able to help people to go back to independent living has meant that we are able to move people out of hospital. That flexibility has allowed us to be quite successful in the past 18 months or so in reducing the amount of delayed discharge that we have been experiencing. That is an illustration of what Dave has just been talking about there. First of all, we are an area that is very successful at taking people home and inappropriate. Delayed discharges such as a huge challenge to us. Our number of people attending hospital and being admitted to hospital is a challenge to us. Our investment over the next couple of years will be very much in the community to prevent people from attending a hospital and being admitted in the first place. We will invest between the money for primary care and additional money for intermediate care and rehabilitation £10 million over the next two years to try to support people at home rather than attend the hospital. The other area that I would point out when you talk about capacity within care homes to support people who might be complex needs to be discharged. It is well known that John and I spoke at an event a few weeks ago about nurses in our care homes. There is a real challenge in that sector in recruiting and retaining nurses in the care homes, so much so to the point where the care inspector at times has had to go in and work bespokely with care homes and work out. What does a nurse have to do and what can senior social care workers contribute to that? Given that level of flexibility is required around some of the issues around staffing within care homes, I think that any legislation would need to be very careful that it does not cut across the flexibility that is having to be exercised just now to make sure that the care homes can continue to operate effectively. I follow up on that because it was interesting when you mentioned about nurses. It is obviously very difficult to get them into care homes. The previous panel had mentioned the fact that most nurses at work in the care homes are over 40, 45, 50, etc., and they are very experienced. However, when we heard from other RCNs and others, it was basically about getting nurses through university and brought into that. How will that affect them? Is it right that they are all 40, 50, and more experienced and it is more difficult to recruit that type in us? The answer is that it tends to be. If you look at our community nursing staff and staff who work within care homes, the work is usually unsupervised and they are working on their own out there, so they need a whole level of experience to be able to do that. Often, on more senior nurses in care homes, they are also the manager of the care home.  We, as a partnership, are about to take nine graduate nurses and try to work with them in partnership between practice nurses and GP practices and our community nurses to see how we can have a development role to have a younger cohort of nurses coming through, so that they are younger as in when they are qualified. However, it is right to say that that is the age profile of not just our care home nurses but our community nursing staff as well. If the take-home message with the last panel of social care providers was the need for flexibility and professionalism and professional judgment making, if there is to be this tool brought in, we have certainly heard from David Williams and Eddie Fraser. A take-home message for me is that it cannot be a banner to innovation, to reform and to restructuring, and Eddie just outlined some of that there. When a lot of my constituents think about safe staffing levels and think about hospital wards and think about care homes for the frail elderly quite often with multimorbidities and Alzheimer's or whatever, I just focus on it. There was a bigger picture, Dr Kil hinted that bigger picture quite clearly, because I just talked about that for a little bit. I did not ask this question to Scottish Care, but it might be a question for Mr Wood or Mr Lyle or Mr Fraser, and I said to Scottish Care are you content that the national care home contract suitably enumerates care homes in the third sector on an equitable basis with care homes that local authorities run in terms of safe staffing levels and all those outcomes that we want to see? Would Scottish Care be happy with that? I am not sure that we should really be asking other people to speak on behalf of Scottish Care since they have just left us. There is a more general question there, I guess. I will ask another way. I think that the point that I think is that I know from local care home providers and other care home providers contacting me over the years that they have got issues with the national care home contract, they do not necessarily believe that it is equitable to third sector providers, they have said that in the past. They believe that there is preferential treatment given to local authority care homes. I do not know whether they are accurate or not when I am told that, there is a negotiation going on between COSLA, the Scottish Government and Scottish Care. On to the idea of the tool. How do we get transparency into a system without some form of diagnostic tool that takes into account the workforce, the skills mix, the workload and the individual circumstances in each care home? I get all that in a way that I, as a politician, can go, yes, we have got that right, the transparency there. We are properly financially remerating the third sector in care homes without a robust, agreed statutory tool. Does anyone want to answer that question? In relation to obviously what is in front of us in the bill, John Wood? I think that the interplay between this and the national care home contract is certainly one that we have been live to, and my colleagues at Scottish Care would say that as well. Questions about the rate that the national care home contract produces, I suppose, are maybe for another day, but I am safe to say that we work really closely with the Scottish Care at the moment to reform the national care home contract and to arrive at a rate certainly from next year onwards that is evidence-based and that we believe is sustainable. We believe that we got a settlement that was along those lines for this year, and that from next year onwards that will be the case as well. That point about bringing transparency to staffing levels and I suppose the funding that follows that, I think that there is a specific question about the national care home contract and rates within that. There has been a discussion about a capacity or capability tool being developed as part of a reform of the national care home contract. That conversation has actually happened in isolation of the legislation that we have in front of us today. I do not think that that necessarily needs to change, but I think that further down the line it is really important that when the care inspector at working with partners across the sector comes to developing those tools, that it is really important that the care home sector and probably the national care home contract further down the line needs to inform what that tool looks like and that the two need to be aware of one another. David Wilder. Drillie, just to reiterate what I said before, which is the legislative and regulatory framework for the provision of care in care home environments in particular. In this instance, it is already in place through the care inspectorate and the standards for care that are set at Parliament. That regulatory framework applies in exactly the same way to the private care home sector, the voluntary care home sector and the provided care home sector within local authorities. There is no difference in that respect. Will the bill make any difference to how commissioners commission care from the different sectors? For example, local authorities, integration authorities, will the bill make any difference to how you commission services? I think that one of the things that has been pointed out in a number of the submissions is that, if we go down a line where part of our nursing workforce and say that adult care homes are regulated around legislation and other parts are not, it can skew our commissioning, because we would have to commission into the areas, and there might be other areas of our business that were not regulated that we could not commission for. That would be a real risk for us, because it might be some of the areas that I spoke about earlier in relation to the prevention agenda and stopping people from needing some of the services. It is the complexity of looking at one part of that. In terms of what we are paying, which John spoke about, the national care home contracts are important. It is also important to continue to reflect on the good work that we are on recently around the Scottish living wage and making jobs within social care, particularly care homes, to be able to recruit and retain into the jobs, because it has been a real challenge for us in terms of continuing to care for the residents, and I think that we have seen a change in that, and I think that that is a positive thing. I think that there is a lot of concern expressed through a number of the submissions around the financial availability, if you like, of viability of providers and provision. If the legislation were to go ahead within sufficient resources, I, either coming through the commissioning bodies or from central government towards funding it, and it strikes me that, if we are tasked in integration authorities to commission innovation and changed and transformed services, we would rather do that as a consequence of something that has been done by design and well thought out and well planned, rather than as a consequence of a business failure. Brian Whittle Good morning, panel. I just wanted to follow on from something that Bob Doris says. In taking evidence in these panels, innovation and flexibility are words that continually be brought to the table, and it didn't take long for those words to arrive here. I think that we are certainly in context of the fact that they are recognising the pressures nationally on the workforce and therefore their alliance on a degree of flexibility in innovation. One of the bill sits in terms of being able to continue to deliver that innovation and flexibility, and I wonder if I could ask specifically about the third sector, because, as SCVO stated, there are 40,500 people within the third sector. They are a huge variety of organisations and different sizes of organisations, so I want to disability that into account and what the possible ramifications of the legislation are on there. It is difficult to see how the legislation could take account of all the different sectors, all the different service provisions across the third sector and the public sector, in any meaningful way that is not already covered by existing legislation. The particular areas of the bill that I present are the nursing workforce and the care homes. I would say that the majority of our third sector operations are out there in the community, so now that it does not encompass a lot of the work that we are certainly commissioning off the third sector. Right now, I do not think that it is doing that. I recognise that there is a third sector organisation that is still in the care home business, but the vast majority of the third sector actually work in the communities with people in their own homes, so I think that it would have a limited impact across the third sector. Bill has the potential to reduce the need for agency staff. It is a key element there. The financial memorandum may take into account the potential requirement for extra staffing in terms of complying with the legislation. Two questions, I think. Will it increase or reduce the need for agency staff and what are the wider financial requirements? Stuart Bain and then John Wood. I think that I would just observe that we try very hard not to use agency staff at the moment, and it is not driven by better workforce planning. It is driven by the fact that cost is more. We do not use agency staff unless we have to. The use of agency staff is driven by two things. One would be local market conditions and the second would be the kind of work that we are able to offer. Local market conditions have been talked about all morning. I do not need to go back into that. In terms of the actual work that we can offer, if we are able to only seek somebody for a couple of shifts or to cover one night shift or something, that is not a job for somebody. We have a pool of casual workers that we can call on. That is quite an insecure form of work, and it does not suit many people. Quite often, what people might be seeking would be to register with an agency where they know that they will be able to pick up work from a whole variety of different providers. That means that they are not available for permanent employment by ourselves or anybody else. That is an inevitable part of the way care is configured. Care is not delivered in nice nine to five packages that suit everybody. It really depends on the needs of the service user. That means that we have to deliver care at different times when it does not necessarily suit people's working patterns. That is what drives the use of agency workers, rather than not being able to plan for the workload per se. Although, as an HR professional, I am keen on workforce planning, so I think that it is a good thing to do. It is not what drives the use of. Casual workers have a bad name in terms of employment practice, and agency workers have a bad name in terms of expense, but we do not use those because we have not thought about it. We use them because the need drives that. On the first part of the question, I reiterate Stewart's point about the fact that agency in and of itself is not necessarily a bad thing. Would the bill reduce our dependence on agency? I think that we do not know, and I do not know if the evidence has been presented that it would have an impact on the use of agency staff. That is not necessarily to shrug at the question. We need to look seriously at whether or not the bill adds value in that regard, and certainly from what we can see, there is no evidence to suggest that it would help to reduce our dependency, if it is a dependency, on agency. On the second part of the question about the financial implications, we were concerned about the financial implications. We had a commitment from the previous cabinet secretary, which was welcome that the Scottish Government would meet any additional financial burdens. For us at the moment, our concern is that we do not know what those are. They are not simply about the fact that the statutory tool might result in a need for more staff, but the fact that there will be a resource demand created by the need to train service managers and workforce planners up on the use of the tool—a significant resource, perhaps, especially if we are talking about the number of providers that are involved. Just that strategic capacity on an on-going basis, once people are trained up in the use of the tools, is something that would bear resource demand on commissioners. I will be repeating what the previous speaker said. It seems pretty clear from Cosa's submission and what has been said today that Cosa opposed the bill and he cannot identify any benefits arising from it. In relation to social work Scotland, again, your responses today suggest that you have a similar position, but your written submission seems to suggest that there are some areas of amendment. Do you think that it can be improved or that it is not worth doing that? Our first point of our position is similar to that of Cosa. We would not support primary legislation in that regard. There is sufficient legislation already in place, as we have said before, in secondary legislation and guidance. There are the new standards and the workforce planning guidance that has come out, all of which supports safe and effective staffing. That is the main position that social work Scotland takes. It would be fair to say that a pragmatic approach should the bill go through and the point that social work Scotland is making in the submission is that the exclusion of social work services from the bill could result in an inequity in terms of resource allocation. That is our main concerns in terms of unintended consequences. The focus goes on staffing up in terms of numbers, the pursuit of tools that may or may not be effective in the context that we are talking about here, including community contexts, and the diversion of focus and activity around that, rather than on pursuing the legislation that we have in place around integration and SDS. All of those things are areas that require our consideration in terms of developing approaches that meet the requirements of those pieces of legislation. It seems to us that the focus on the bill as it stands really crosses over the main purpose of the other pieces of legislation, which seems to us to lend themselves well to us pursuing a more outcome-focused approach and perhaps moving towards more of a community social work type approach along with our partners in the public and independent sectors. In short, you would rather not have the bill, but if the bill was going to happen, you would rather have it even handed. Miles Briggs, thank you convener. Good morning to the panel. In the evidence that you submitted, I was interested by some of the unintended consequences that we have touched upon this morning. Specifically, there was a point raised with regard to if this is the case, implementation would drive savings in areas to move to areas that are covered by the bill. I just wondered if you would like to expand further on that. That was specifically from East Ayrshire. From Glasgow, there was also a second point with regard to concerns that legislation will add another process and pressure on the system. I just wondered if you could expand around how you see those unintended consequences affecting your specific areas. I think that I touched earlier on the specific part. If we are regulated around one particular nursing workforce, then that regulation will require to invest to do that, and that could skew what we are doing in terms of working as a team, in terms of our allied health professions, in terms of our social care staff and in terms of the amount that we might want to invest in the third sector for our community connector type link workers. If you have one part of the business that is regulated and you are required to invest in that, then that is what you do. You do not see it as alternatives across. When we recently went out and done the work in terms of recruitment around our intermediate care and rehabilitation, we were quite flexible. There was a range of different professions that can support people as long as they are working on part of a team. Some of that was around what is the available workforce to make an impact just now. What is the balance between our nurses, physios and occupational therapists, and some of our senior social care workers that we are bringing together? If you have one part regulated or concerned, then you are required to do that, and it reduces the scope to do flexibility in the rest of the multidisciplinary team. That was the specific point that we were trying to make. Just to add to that, I think that there is also something about the emphasis on the legislation being on substantially the high-cost intensive level of provision, which is essentially hospital and residential care. If, as Eddie has just highlighted, the level of investment needs to be in those areas that are counterproductive and counterintuitive in terms of the general direction of travel, the integration authorities are expected to travel, which is to shift the balance of care and support more people in the community. We end up perversely taking money and resources out of more upstream provision in the community in order to continue and sustain high-cost intensive and institutionalised forms of care substantially. To come to the particular reference in relation to the other processes and pressures on the system, inevitably, the experience that we have in the system is that if we are required to do something, we need to be able to demonstrate that we are delivering on that. That would require processes and procedures in place and, probably, resources in order to count the fact that we are not only delivering the required levels of staffing in terms of directly provided provision, whether on health or social care within the council side of the business, but among the commissioned and procured levels of services that we are responsible for as well. That is a bureaucratic burden that we could do without. From what you said to the committee, your belief that what we are trying to do with this legislation could destabilise or go against the spirit of what we are trying to achieve and have built a consensus on around health and social care integration two years into this process. As colleagues have intimated from a range of reasons, there is a potential to stifle innovation and creativity. There is a requirement and expectation that integration authorities will deliver on transformation. That cannot happen. If there is a top-down essentially effect stipulation that we must do X, Y and Z in order to deliver something that is legislatively required to deliver, the previous point in relation to where resource allocation might find its way to being focused on is counterproductive to the general direction of travel. In short, yes, I think is the answer. Just to state our agreement with that position, those are our concerns also in social work. David Williams mentioned the potential to inhibit innovation and flexibility. Would any of the other witnesses wish to come on further on that risk of stifling innovation? Again, when we talk about innovation, I will speak about the care home sector. Some of the joint work that we are doing just now with the care inspectorate around care about physical activity has seen much more integration of the care homes in the communities. It has seen staff and volunteers with residents going out in the communities. One of the concerns that we have around us is that we are going to stifle that? Is that going to be around, looking at the numbers of carers still within the building? Is it going to stop what we are able to do in terms of some of that? We are becoming even in the care home sector much more innovative and thoughtful around self-directed supports, so it is not someone who is just now going to a care home and living out their life there. They are having an active life in that care home and are integrating more in communities. I need to always say that it is not that we do not think that we should be safe staffing in every element of health and social care. It is about on the day that the manager has been able to have control. It is fine for one and one member of staff to go down the street with somebody because the rest of the care home is sitting there and it is stable just now. The early types of things and innovation that is going on in the sector, I think that we need to be careful that any legislation does not cut across. I agree with that. I think that the current legislation that is in place, particularly the Public Bodies Act and the SDS legislation, are long-term matters. Long-term issues fundamental change in what we do within the sector. It needs time to bed in. I would say that we are still in the early days of understanding what those pieces of legislation can afford for us in Scotland, particularly given the very complex conditions that we have at the moment, as was mentioned earlier around the population demographic, the implications of Brexit, the whole availability of workforce, et cetera. I think that this legislation is premature in its placing in terms of what we already have in place in Scotland. With budgets under constant pressure, our anticipated costs associated with the bill and the public bodies of our sector businesses are realistic, especially around tool and method development and staff training. There is an opportunity cost in any activity that it undertakes, so if care home managers are using a tool, they are not doing something else. Equally, if you are asking your admin people or your HR people to do it, that will be taking time away from doing something else, be it working on safeguarding or better recruitment or whatever. Do not underestimate the size of the task. A couple of weeks out of somebody's working year, even just one person, can actually mean that someone else is not getting done. Anybody else on the costings? In the context of care as opposed to health as a final question, is risk a different concept in the care sector? Is there a challenge here? Does the bill do anything to help in terms of supporting appropriate judgment and taking on a risk? Certainly risk is a different concept when you are talking about care. You are talking about different settings. In the NHS, when you are thinking about ward settings, it is very different to think about in the community where people live out their lives and they have to be able to take some level of risk in a managed way. Certainly, as the way that the bill is set out, it really does nothing to reassure that we will be able to do that in any meaningful way. I suppose that when you mention risk in social care, it comes to my mind as risk enablement. How do we support people to actually live out their lives? How do we make sure that the things that they want to do, we actually support them to do? Sometimes that does involve risk. Whether that means in a care home walking across the floor to get your newspaper rather than somebody handing it to you, whether it means someone with dementia living longer in their own home, whether there may be risks rather than a care home, because moving to a care home to a hospital is not risk neutral either in terms of what we do. How do we enable people to take the level of risk that they are capable of doing? I think that it is a risk enablement thing in social care in terms of what we are tasked to do. Does the legislation impact on that in any way in your opinion? Only in the fact that it would be more rigid around what we can do. I am not sure that it does impact on that. I think that we need to be careful with any legislation coming forward that it doesn't create the false expectation that we are removing risk as a consequence of putting potentially more staff in place. The example that Eddie has just given around an elderly person being encouraged to cross the floor to pick up a newspaper, that level of enablement needs to be encouraged and supported, but you may well still have any number of staff and the person may still fall. It is about how you allow people to live their lives. I think that we need to be careful that we are not trying to limit and do away with risk in the provision of legislation. One final supplementary question from David Stewart. Just an arguably simplistic point. Does any of the panel members draw any implications from the fact that, originally, the bill was paraphrased as the safe staffing bill? I see that it is now being removed. I am not sure whether the Government lawyers have had a role in that or not, but is there any implications from the panel, from the change of name? I appreciate the change of name, but the perspective that is out there still is at it and will be considered the safe staffing legislation. There is an element of that already in play, regardless of what the final title might be. We got asked in the last session about the iron tool for working out what staffing would look like and some concerns around that. I take fully on board all the points made about some of the significant concerns that all the witnesses have in relation to aspects of the bill, but there was a feeling that iron tool has got some deficiencies in it. Is there a need for a new diagnostic tool in partnership with care providers and others? Anyway, irrespective of the bill, I am just wondering. Just a very simple anecdotal point. I spoke to our manager who looks after care homes in Fife about how they assess staffing levels in preparation for this session. One of the things that she highlighted was that the tools that they use—one of them is iron and the other is a five-countal tool called CPAC—are good at assessing physical need and addressing staffing levels in terms of that. They are not so good at assessing need in relation to cognitive behaviour. As we are seeing increasingly frail residents coming into our care homes, that is more and more important. The tool is not capturing everything that we need to be concerned about. I do not have a professional view on the iron tool. I am not familiar with it myself, but I know that there are conversations going on between officials to look at either how iron could be improved or something else might be developed, but I do not think that that is necessarily a minute. I think that it would be months or years down the line. Thanks to all of our witnesses for another very helpful session, we will adjourn briefly and resume in a few minutes with the cabinet secretary. Colleagues, we will now resume. The next item on our agenda is consideration of an affirmative instrument. As usual, with the affirmative instruments, we will first take evidence from the cabinet secretary and her officials on the instruments. Once we have had all our questions answered, we will then move to a formal debate on the motion. The instrument that we are looking at today is the public apartments and public bodies etc. Scotland Act 2003, amendment of specified authorities order 2018 in draft. May I welcome the cabinet secretary and her officials? Indeed, may I welcome the cabinet secretary for the first time since her appointment to this committee? Congratulate her on her appointment and look forward to hearing from her. May I also put on record the committee's thanks to her predecessor Shona Robison for her active engagement with the committee over time? And can I welcome Jean Freeman, cabinet secretary, also Michelle Campbell from the Workforce Leadership and Service Transformation Directorate and Kirsten Simonole-Feverer from the Directorate for Legal Services. Can I invite the cabinet secretary to make a brief opening statement? Thank you very much, convener. I thank you for your kind wishes and express my pleasure for the first time at this committee. I am sure that we will meet again on many other occasions. I look forward to those exchanges and to our continued good work together on building on the work of my predecessor. With respect to what is before you this morning, I want to thank you for the opportunity to speak briefly to the committee about this amending order, which seeks to remove both the Scottish Advisory Committee on Distinction Awards, SACDA and NHS Health Scotland from the remit of the Commissioner for Ethical Standards in Public Life. The draft affirmative order applies to those two distinct public bodies. SACDA, as I am sure members know, acts on behalf of Scottish ministers with regard to granting and reviewing distinction awards for NHS consultants. In 2010, in accordance with the Scottish public sector pay policy, we froze the allocation of new distinction awards and, as a result, SACDA's duties have been limited to an annual review of current award holders, which has made membership of the committee less attractive to potential new members. In addition, the pool of potential peer reviewers at the top A plus level has also reduced primarily due to retirement. Those issues, coupled with the fact that other members have completed the maximum term of office, including extensions, has meant that SACDA has reduced its current membership from 14 members to 5. By removing SACDA from the commissioner's remit, we anticipate that a simplified recruitment process can be put in place to establish a board of 7 to 10 members. NHS Health Scotland is a special NHS board set up to improve public health and reduce inequalities. It will cease to exist as an NHS board on the vesting of public health Scotland, which will be achieved by 1 December 2019. NHS Health Scotland currently has a small board of 9 non-executive directors, and it would be very difficult and not necessarily appropriate or proportionate to appoint new members to replace those board members whose terms complete before the end of 2019. By removing NHS Health Scotland from the commissioner's remit, we will be able to retain appropriate membership and better manage the organisation's transition over the next 12 months or so of its existence. It is important, before I conclude, to emphasise that both SACDA and NHS Health Scotland will still operate within the principles and ethics of the commissioner and that this step is being taken only to deal with short-term issues of recruiting committee or retaining board members prior to review of the distinction awards and the abolition of NHS Health Scotland. I am now, of course, happy to take any questions. Thank you very much, cabinet secretary. David Stewart. Thank you, convener. I could also welcome the cabinet secretary to her new person to the committee. In general terms, cabinet secretary, I obviously totally understand the practical reasons you are approaching this issue. I could make some general points. As a cabinet secretary, to be well aware, the commissioner for ethical standards is a parliamentary body independent in state-to-date activities but responsible to the corporate body, which I was on in Sandra White as a current member for pay and rations. I have had some experience of it from the other side, so to speak. In general sense, I think that it is very important that we actually look at increasing the range of ethical standards rather than reducing it. I took to understand some practical issues here, but the first point that I want to clarify is that one of the bodies is going to be concluding in a year's time. I understand that Public Health Scotland will be taking over the new role. Is it your intention for Public Health Scotland to come under the remit of the Ethical Standards Commissioner, which I think is very important, which I would support? The second issue, which I said that I totally appreciate Government has changed and frozen the awards since 2010, you will know that distinction awards had some controversy in the past when they were better known as merit awards. I for one obviously want to thank our hard-working consultants and sell about the work that they do and understand that giving financial awards is one way of doing that. Over the period of subsequent Governments, there was a lot of controversy around merit awards and it was felt that they were not transparent and open. The reason that I am raising some concerns is that removing a body from the remit of the Ethical Standards Commissioner is not one that I would generally support. I would go the reverse. I would be looking to ensure that transparency is there for every public body. I understand the reason that you are going for that. I understand that Parliament will have an opportunity to have its overall say. I just want to put in record the fact that it is very important that parliamentary commissioners are parliamentary and have a strong independent role. I would be concerned in the future if Government sought to remove any other bodies from the remit of the Ethical Standards Commissioner. I completely appreciate the points that you have made and would agree with them. As you say, this is entirely a practical move. On the question of SACDA, their current role, because we have frozen the application of new distinction awards, their current role is to review existing awards. To do that, they need to have A-plus reviewers and we have experienced some difficulty in recruiting those. We have also indicated that we will review the position on distinction awards going forward and have begun discussions with the BMA on what that might look like to remove some of the controversial matters that surrounded the previous system and to see if there can be a future system devised that does give that recognition that you indicate that you would welcome, but is also fair across the whole of our health workforce. As we do that work, we will, of course, keep this committee updated on how that is progressing. Should there be a future system for the application of distinction awards and not just the review of them, then, obviously, we would want to look at the role of SACDA at that point and expect it to be part of the commissioner's remit. The section of the meeting is in relation to questions and answers. Clearly, there will be an opportunity to make debating points once the motion is moved, but if there is a further question. That is just a second point, and I appreciate that this question is very difficult for the cabinet secretary to answer. However, if we assume that the Scottish Association of the Scottish Advantage Committee on distinction awards comes out of the remit of the ethical standards commissioner, and there is some future breach, which would normally be dealt with by the commissioner, who is going to deal with it? We would expect the body to continue to work in line with the standards of the commissioner, and if there was a breach, we would take the opportunity, if we thought it was correct, to refer that to the commissioner for their view. I am pretty sure that this question is going to reveal the extent of my ignorance about this area, because it is not something that I have been involved in previously, but I will ask it nonetheless, and I am sure that it will be schooled in this area. I just wonder if, considering the proposition in relation to SACDA in particular, whether it has also been considered the idea of not having the body, or if that is going to be one of the considerations as you go forward, if it is there just to review these awards and know new awards are being made, is there another way that could be undertaken? I wonder if that is part of the thinking that is going on or not. Part of the very early work that has begun is to have initial discussions with the BMA about the future prospects of an award system that met some of the intention behind the distinction award system, but in a way that is fairer across the whole health workforce, is more transparent and is more evidence-based. That is very early days. Should we reach a conclusion that is satisfactory, there has been a previous consultation on this and nothing happened as a consequence of it because no consensus could be achieved. Should we achieve consensus this time round, then there would need to be a body to undertake the work comparable to SACDA. That may be SACDA, it may be a revision of its role and all of that, of course, this committee would be involved and its views would be sought. At the minute, that is the going forward position. At the minute, the role is simply to continue a review process of those who currently have those awards. Whilst I am not clear, being almost equally new, Mr Brown, I am not clear whether you could disband it. My instinct is why cause additional fuss when you do not need to. Let the body continue to do the job that it is there to do, but give us an opportunity in this practical step to improve the numbers of members that it has on it in order to take forward that work. Thank you for your effort. Good afternoon, cabinet secretary, just for some information. The review is now simply to review. What power does that entail? Is it to review and report to yourself? Or is it to review and recommend, because you review just wondering in terms of the process, what happens with that review? It is to review and report to myself. My colleague Ms Campbell probably has a much better understanding of this than I do, but my understanding is that once you have a distinction award, you have a distinction award. I was wondering in terms of the fact that those distinction awards have been frozen for some time now. What assessment has been made around the impact that that has had on attracting people to the health service? Potentially. We know that this is a global pool of people that we are trying to often attract. In terms of them coming to Scotland to work, we know the current shortages that we have around many specialties. Has that been included in some of the work going forward, especially with the work going forward with the BMA? Do we have a timetable around that review? In terms of whether or not it has an impact, the fact that we have increased the number of consultant positions and are filling those does not indicate to me that it has had an impact. I am sure that the BMA may have a view on that matter. We will bring it to those discussions. The discussions are in very early days, so there is not at this point a timetable for their conclusion. Finally, cabinet secretary, the policy note mentions that SACTA had three concerns themselves that it should continue to be composed of both medical and lay members that new appointments should be submitted for approval by the chair and medical director, and the process should be transparent. Can you confirm that those reassurances were provided and that the commissioner for ethical standards was also consulted? Yes, I can. The commissioner was consulted in September, I believe, last year and has expressed himself content. He was also consulted in terms of Health Scotland and is also content. Thank you very much. If there are no further questions from members, we will now move to agenda item 4, which is the formal debate on the instrument on which we have just taken evidence. I remind members that this is no longer a question session, so there are no longer questions to be put to the cabinet secretary. Officials may not speak in this phase of the meeting, but I invite the cabinet secretary to move the motion S5M-12935. I move that the Health and Sport Committee recommends that the Public Appointments and Public Bodies, etc., Scotland Act 2003, amendment of specified authorities, order 2018, be approved. Are there members who wish to speak in the debate? If not, can I put the question to the committee that the motion be approved? Is that agreed? Thank you very much and thank you to the cabinet secretary and officials for their attendance. We will now move into private session for the concluding part of the meeting.