Good morning, everyone, and welcome to the 19th Meet of the Health and Sport Committee in 2017. I would ask everyone in the room to ensure that mobile phones are on silent. It's acceptable to use mobile devices for social media, but please do not photograph or film precedents. We have apologies this morning from Alison Johnstone and Ross Greer is subbing. Can I invite Ross to make any declaration of interest? Thanks for having me, convener. No relevant interest to declare. Thanks very much, Ross, and very welcome to the committee. The first item on our agenda is subordinate legislation. We have one negative instrument to consider as the national health service free prescriptions and charges for drugs and appliances Scotland amendment regulations 2017. There has been no motion to annul and the delegated powers and law reform committee has not made any comments on the instrument. Could I invite any comments from members? No? Okay, that is agreed. Thank you. Agenda item 2 is on the draft budget 2018-19, and we have two evidence sessions today. Welcome to the committee, Sharon Wearing, chief finance and resources officer, CIPFA, IJB, CFO section. That's a big acronym on that one. Judith Proctor, chief officer, Aberdeen Health and Social Care Partnership, Julie Murray, chief officer, East Wrenfrew, Renfrewshire Health and Social Care Partnership and Councillor Peter Johnson, health and wellbeing spokesperson at COSLA. Welcome to the committee. We're going to move directly to questions. Could I ask you maybe to reflect on the budget situation that partnerships are finding themselves in, if someone would like to begin? If we go alphabetically, I'll maybe stab at that one. It's one of the conversations we were just having when we were outside. I think it's a very varied picture across Scotland. Each of the health and social care partnerships started from different places. Each of the health and social care partnerships have a different configuration of services delegated to them, and obviously they have different local circumstances in which we work. Certainly from an Aberdeen city perspective, we closed the year, we managed to achieve a balanced budget overall and indeed posted a surplus in relation to the transformation funds, which was largely as a result of our ability to spend that funding quickly. However, that funding has all been now allocated towards transformation projects. It's a challenging position that we find ourselves in this year, but we are working hard to achieve a balanced budget by the end of this financial year. I'm happy to go next. East Wrenfrewshire has a long-standing partnership. We have been integrated since 2006, and we made management savings through integration fairly early on. I, as chief officer and previously director, have been responsible for integrated budgets since 2007. Part of our difficulty is that we have made easy savings over the years. The low-hanging fruit is now getting to a stage where it is getting much more difficult. We do project to be on budget for 1718, but we are using around £900,000 of reserves, and, like Judith, it was planned, so that we could have a bit more time to create a transitional fund to redesign and restructure. As I said, the low-hanging fruit has gone, so we are having to look at customer pathways, patient pathways, looking at managing demand in different ways and making savings through restructuring and looking at skill mix. Like Judith, we will manage 2017-18, and we are very concerned about future years, given the parent body's potential budget settlements or what they are projecting. We are managing by the skin of our teeth at the moment, but we are nervous for the future. I am happy to give you an update on overall position across Scotland, very much as Judith has said, but each of the IGIBs have different delegated budgets to them. They are not all consistent. For example, some have children and families and homelessness within the delegated schemes. Others are just looking at adult services within what has been delegated to them. There is a variety of out-turn positions across the country. We have gone from one extreme where one of the partnerships has had to have a loan from the local authority to assist in its financial position, which is due to repay back in future years to others who have planned well and being able to deliver the savings targets and being able to put money into reserves, which they are all required to look at in relation to our reserves policies that we should all have in place. It is very much a mixed picture across Scotland, with us all looking at significant savings and efficiency programmes for the coming year, so that we will maintain our balanced budgets where possible going forward. From a causal perspective, we would firstly argue that if you look at the credibility of the health and care budget, you cannot look at it in isolation. We need to understand the detail of the budget certainly, but we also have to understand the wider context within which it sits. The local government budget, from our perspective, is a key driver of preventative activity that seeks to address inequality and more demand for other services across the system, including vitalising our health and care system. We believe that, from a causal perspective, simply protecting the NHS, for example, while cutting local government budgets, is counterproductive to our overall objectives and as a country to the objectives for health and social care in the longer run and will inevitably lead to more pressures being built up and more problems and more expenditure from the public purse in the longer run. We believe that, ultimately, investment in local government will also reduce demand for our health and care services and we accept that every government, local and national, has faced the same problem of funding the current service level but also the shift in the balance of care that we are so desperate to achieve. We would argue initially that we need to see a far greater focus on investing in services that deliver the best outcomes for our communities. A short-term input-focused budget process is, from our perspective, an inhibitor to genuine reform. We believe that IGBs need to be supported to obtain the maximum flexibility in their use of their budgets to meet the demands of their local communities and we would argue that any new commitments must be fully funded but the core budget needs to be sufficient also. Any funding additionality, while significantly cutting the core, does not work. I think that the COSLA paper is very good and I think that it is a robust paper. If we look at the summary of paragraph 5 as a short-termism centralisation and a lack of evidence-based combined with budget cuts, that seems to me to be the summary, but it is the bottom point that I think and it is the point that Peter has just made that reductions to core local government budgets with no cognisance of the interrelationship between all that local authorities do to reduce inequalities, build capacity and resilience and assets and to decrease demand for services in other parts of the system. That is key because I would just like to hear from the panel as to whether in your area you are seeing the services being provided by the partnerships being impacted by the cuts to the core budget of local government because for me that is where the front line and the fight against inequality is. Is that happening in your area? Are you seeing your services being impacted by that core budget reduction? I will start off coming back in relation to the budget settlement in relation to 1718 and what that impact was across all partnerships. There was an agreement for additional funding going into IGIBs of £107 million, however there was also an agreement of a budget reduction of £80 million across Scotland to the IGIB, so we did see a reduction in our services that we had to find savings and efficiencies to cover. The funding that we were in was for the Scottish living wage for additional funding to waive the financial assessment for war pensions and to help to pre-implementation of the new carers funds, so it was not money that was able to offset the savings challenge of the £80 million that we had to find and that was on the local authority side. In relation to the health side, we had a flat cash budget settlement and we did have a big debate about what flat cash meant, but it was expected to be the budget that we had for 1617 continuing with the IGIBs picking up the inflationary pressures that went along with that, which included staffing pressures, other cost pressures and probably the biggest pressure that we faced was the prescribing budget. We were having to fund the uplift in the prescribing budget, which last year for a lot of the partnerships was around a 5 per cent increase and we actually did a lot of work to try and reduce what across the sixth partnership was a £16 million pressure and we put a lot of spend to save and a lot of work with the pharmacist to actually bring that back so that we are managing it within the existing budget that we had, but yes, there has been new funding went in, but there was also a requirement for partnerships to find significant savings to be redirected to fund pressures that they had in the partnerships. From an Aberdeen perspective, we had to find £5.2 million in terms of inflationary pressures that we absorbed from the budget and Aberdeen City Council took the decision to take the full share of the £80 million that they were able to, which meant that we had a further set of savings to find to the tune of about £3.1 million, so that has been significantly challenging for us to find at the same time as trying to transform our services with the budgets there. For us, of course, our thinking is now going into the budget setting for the coming financial year and what decisions in terms of local government and indeed NHS budgets will mean and the impact of that on the health and social care partnership. We are planning ahead prudently, but until we know the impact on budgets of our partner organisations, we do not know the full extent of the challenges that we face. I suppose that my first response is that councils' core budgets are our core budgets. Our council funds £45 million of our core budget, and that is on front-line services. Again, we had significant savings to make last year, and this year our saving total is £4.2 million. However, I have to say that, in terms of the inequalities and the preventive work that our council has protected an element of money, which was the early years change fund, and that is money that we have been using across the family. That includes the health and social care partnership, the cultural leisure trust and the different council departments to focus on prevention in early years. That is around housing, environment, nursery education and so on.  Do you want to comment here, Peter? From a cause-of-perspective, the major issues in the 17-18 budget are threefold. The quantum is the core budget. Is it sufficient to deliver where we are and current day-to-day services? Is it sufficient to allow us to fund transformation? Do we have the flexibility to make local decisions that are best suited to the needs of local communities? As colleagues have said, the health and care budget is suffering from the same tensions as the local government budget, where there are significant questions over whether the quantum is appropriate to deliver the immediate needs of the day-to-day services. The key question for us is that standing still is not good enough. For us to meet the demographic challenges that are coming in our direction that everybody knows about, we cannot afford to stand still. We have to move forward, we have to innovate, we have to find new ways of delivering services that best meet the needs of our people within the community. That is the major challenge that we have with the budget. Summarize the answer to your own questions. Is it no that it is not sufficient? It is not a case of yes or no. You have to look at the whole thing in the round. I think that we have major concerns about the budget being able to meet the ambitions that we have in health and social care. Maureen Watt, can I ask a question about the way partnerships are funded and how this impacts on some of the challenges that you have commented on, particularly the fact that you are obviously funded by your two main constituent parts, local authorities and health boards? In East Remfashore's evidence, you say that that means that funding is not losing its identity. Can you explain what you mean by that? For the rest of the panel, is that something that you agree with? Clearly, we get funding from our parent bodies. The intention is that funding, when it comes into the IJB, loses its identity. We decide on our strategic priorities and direct it back to the council and the health board. For us, the challenge is that we have to continue reporting the spend through two different reporting systems. At the margins, we have moved budget around. I think that my anxiety—I do not have evidence for that, but my gut feeling is that if we decided to significantly disinvest, for example, in social work and decided that we wanted to invest in physiotherapy, I think that I might have trouble persuading the council the following year to give me some additional funding to meet demographic pressures as they would think that they were subsidising NHS budgets and potentially vice versa. I do not have any evidence for that because we have not really tried it, but it does not feel to me that the funding is losing its identity in the way that it was intended. I do not know of colleagues who have that. I would just like to add to what Julie is saying in that we are working with two ledgers, and we are working with two sources of funding, and we are having to report back through those two arrangements. I think that the best way forward would be for the funding to come in and for it to be operating within one ledger for the IJB, which will then allow the IJB to make better decisions around how it loses its identity and where it is at just now, but the system that we are currently operating in encourages the funding to still work through the local authority ledger and the health board ledger. Therefore, it does not lose its identity the way that the legislation was intended. The way to change that would be to look for one direct funding allocation to IJBs and to remove the two elements that come from the two partners. You support direct funding from central government? We support, and it is in our submission, that we would like to explore further direct allocations of funding to IJBs. We would not be surprised to know that that is not a proposition that the cause of land and Scottish local government would support. We think that an essential ingredient in the success of health and care is the on-going partnership between the NHS and local government and the connection between the health and care bodies, IJBs and local government services is vital because the integration does not just happen within the boundaries of the IJB. For example, in West Lothian, my home council, the chief officer of the IJB is also a deputy chief officer, deputy chief executive of the council, and the IJB is wholly integrated. All the arguments that we have been making about frontline council services being essential to tackling inequality and meeting our preventative issues are all joined up and working together to achieve those aims. That is not just the West Lothian thing that is happening across Scotland. In terms of the budget, I think that there are issues about the timescales. The local government and the NHS prepare the budgets at different timescales. It would be helpful if they could be brought more in line. One of the key elements that is causing concern is the NHS attitude towards sethicide budgets. That is a technical term sethicide budget, but I mean unscheduled care budgets. The law, the Public Bodies Act, states that the money must be transferred to the IJB. There are some issues about that. For us, it is fairly fundamental that the NHS follows the law and transfers the sethicide budgets. We think about what we are about to create an integrated care pathway from the community into the hospital setting and back to the community again. That is what the IJB was created to do. If the NHS at times is unwilling to transfer those budgets into the domain of the IJB, that is hindering integration. That is something that has already been agreed by the Parliament, and we just hope that colleagues here can make sure that that does happen across the country. Technically, there is nothing to stop an IJB making those changes. It seems to be that the legislation is very clear. It appears to be not inventing reasons for not doing something, but it is not an issue around how you are funded from the two constituent partners.  You have the funding pressures that you have already talked about. To make transformational change when you are trying to manage a funding pressure and you are looking for other cuts to transfer that elsewhere is probably a bigger challenge, but it would be correct to say that there is nothing whatsoever stopping you actually making transformational change and changing the way you spend money just because you are funded by two constituent parts. I will echo what I said at the beginning. My anxiety is that, if we substantially change the way in which we fund services or whether there is a substantial shift in resource from a council budget to an NHS budget or vice versa, it might be problematic in terms of the future. I think that the council would very much resist subsidising what it sees as a lack of core NHS budget and, potentially, vice versa when money goes to social care. However, we have not tested that properly, so you might be right that it might not be an issue at all. I suspect that, given my experience, it would be. Can I just ask one technical little question in the presentation of the budget? One of the criticism last year was around an accusation of double counting by the Government when it came to the budget Parliament's independent information service. Spice said that the £107 million that was allocated for social care was effectively already included in the health budget totals, but also alluded to in the section around local governments. Effectively, ministers were using the same £107 million to cite growth in both budgets. The Fraser Valandale Institute actually said that that was highly controversial and frankly not right. Do you think that that was a fair criticism and, just from a presentational point of view in terms of the budget, where should those allocations actually sit? From the finance officer's perspective, the funding was allocated to health. It transferred across to the IGIBs and was spent on the social care side of our budget. Again, we come back to how budgets are allocated and our view is that that funding could have been directly allocated to the IGIBs. That is a different response, however. I think it probably would have been a better reflection on what was intended with that funding and how that funding was to be allocated. What it does is it creates additional challenges and actually brings that money across by having to bill for that funding coming across. I think that that comes back to the point that I was making. We are working within two systems and two ledgers, and we put that money back through two ledgers within the council and within health board ledgers. The funding does not necessarily lose its identity, but what does happen is that you will see that funding as expenditure on the health side, but you will also see that funding as expenditure through the local authority side having been directed back by the IGIB. So, from a public finance point of view, is that not the way it should be done? I think from our perspective, our view is that we need to look at how we allocate funds direct, rather than having quite a convoluted way of funding being allocated to the IGIBs. All the additional work that goes behind it, we are looking to try to improve and be more efficient in how funding is allocated going forward. I am not quite getting to the nub of this as to whether that funding was in two places. Do you agree that that was? My view is that it was in two places because there was expenditure on the health side and there was expenditure on the local authority side as a result of that transfer taking place. It was the same money. Yes, it was a transfer from one to the other. Good morning, panel. I say I am really welcome, Mr Johnson's submission and the COSLA submission. If I could quote paragraph 15 when it says that, given the committee's remit which covers sport as well as health, we would also emphasise the benefits that sport brings to the preventative agenda. Sport brings undoubted health, wellbeing benefits and encouraged healthy active lives, supporting mental as well as physical health and promoting communities. With that in mind, do you think that the current budget allows for effective preventative health planning? Furthermore, how challenging is it to balance planning that spend against potential future savings that is inevitable within a preventable health budget? Shall I start with that? I think that Mr Wthall you make and reinforce the point that is the core to the cause of your argument that we can't simply look at the health and care budget in isolation. There are many things that contribute to health and wellbeing which are not directly within the IGBs or the NHS. The example of sport is well made and I can reinforce that again with a local example. For almost a decade now in West Lothian, if someone goes to their GP suffering with depression, they have been able to be, instead of prescribed drugs, prescribed a six-week course in a local fitness centre run by West Lothian leisure, admittedly an arms worth the body of the council. That is a recognition that physical activity may well be, for some people, a better outcome and a better cure for the illness that is suffering than just being prescribed drugs. I don't think that there is any argument that our healthy and well population requires access to these vital facilities. If core budgets are being cut across local government, the stress of maintaining these facilities is clearly one that is going to be detrimental to the outcome that we are all looking to work together to achieve. That is clearly where we are coming from. In that case, in that particular example, which is a particular pertinent one, there will be a saving to the health service because of the non-prescribing of drugs, but a cost to the council in allowing leisure facilities available to the patient. Is that picture that true? That is very true. Unfortunately, there is no means of accounting for that in the system. We do not get back the cost of what the drugs would have been into providing our health and care facilities, our health and fitness facilities in this case, but it is contributing to the overall outcome, which is what is important. Alex Rowley, you can be here. Good morning to the panel. I am also very interested by the COSLA paper. It is pretty heavy stuff in terms of where the government is going and its approach to budgeting and feeding into the IJP process. I like to particularly quote one line in paragraph 5, which says that there is a disconnect between public narrative around the level of investment in public services versus budget pressures. Above that, there is a continued focus on inputs and not outcomes. Over the summer, we saw one outcome of spending decisions in the fact that drug deaths in this country were led by as much as a third, making us the worst performing country in the European Union in terms of substance-related mortality. That is a weather vein of an outcome that is going wrong. It should be a weather vein for the budgeting process as to where we are deciding to prioritise spending. Where are we broken in that system? Is that the fault of central government? Is that the fact that when central government says, well, we have passed the money to the boards even though there is a cut, they can still deliver outcomes by prioritising? Is it the fault of the boards? Where does the disconnect lie? In terms of the ADP allocations, is that what you are specifically talking about? In terms of the ADP allocations, it is clear that the funding was passed to health boards with a reduction. Health boards were asked to re-prioritise. There are so many different priorities. It is quite difficult to see where funding would come from for that. At the end of the day, our health board did give us the allocation straight through, but that was due to probably the compliance test that was put in place around budgets and settlement. We did make a bit of a local saving. Our drug deaths are low locally. Our demographic is such that our drug deaths are relatively low, but they have risen across Greater Glasgow and Clyde. Different ADPs and health and social care partnerships are targeting their resources in different ways. We target ours in recovery. I know that Glasgow is targeted in slightly different ways, but at the end of the day, the health board did pass on the allocation to us. Use is an example of good practice, where you may do with the money that you are given and prioritise ADP funding to be sure that that service would continue. You are not the... No. It is not to say that we did not make some savings, but we made some savings in a way that we thought were low risk. In Aberdeen, we had the full effect of the cut to that budget, and we have had to focus on how we make efficiencies within that. It is difficult to address the full extent of your question, because it would be hard at this stage to see a straight line correlation between a reduction in those budgets and drug deaths. I would think that experts in that field would consider that to be multifactorial and might be attributable to a number of things, but certainly how we use ADP budgets effectively to meet the priorities that we have with the increasing demand for those services is a significant focus for ADPs. Given that those budgets were allocated to the IJBs, it is obviously a significant focus for them as well. I understand that it is multifactorial, as you suggest. However, I had meetings over the summer with the senior consultant who was compiling the drug death statistic, who pointed to our direct causal relationship between a 23 per cent cut in ADP funding and this increase in drug deaths. I understand that there are many different reasons why people die of overdoses, but if we are withdrawing services that can manage their lifestyles or get them clear of their behaviours, then we can actually address those statistics. I would agree that the challenge in relation to the entirety of that budget is in supporting meeting those priorities, while also finding the reduction in savings to balance that or address that gap from elsewhere in the totality of the budget, which is also under pressure and increasing demand. On the generality of that question, what I take from that is what you are asking, what impact has the integration of health and social care budgets had on meeting local government outcomes? For me, it is clear that, across Scotland, IGBs are making good progress and we are beginning to see tangible changes in service design and the essential strategic commissioning that goes along with that. However, the key question remains to have and deliver the pace and scale of change that we need and to do more to support the integration to focus on reducing demand and prevention and early intervention. That is the challenge that we are facing to get the resource to do that. I think that that needs an acceptance that moving services, for example, from an acute setting to within the community and delivering them differently is not a cut. It is simply an improvement and we have to recognise that reducing hospital beds and investing in our communities is not a bad thing, it is actually the way that we can move ahead and achieve the transformation that we are all looking to deliver. You are saying that it is not. This whole process, there is not an element of cuts within it. Your paper would disagree with you on that. That is not what I said. What I am saying is that the difficulty that we have, looking at the budget as a whole, is meeting the day-to-day service requirements and, at the same time, fund the transformational change that we are all looking to deliver. What I was trying to put into this discussion was that we need to accept that moving services from an acute setting into the community is not necessarily a cut, but it is a change in how we deliver things and it may be a better way of delivering the outcomes that we are looking to achieve and that we need to accept that reduced numbers of hospital beds can deliver better outcomes. That is a good thing. I do not disagree, absolutely, but your own paper states that there are reductions to core local government budgets and no cognitions of the interrelationship between all that local authorities do to reduce inequalities, build community capacity, resilience and assets, and decrease demand for services in other parts of the system, such as health and social care. There is a material reduction in the money component. People, I am simply giving you a specific example. Absolutely. We all know stakeholders and people who work in the sector, organisations that do miracles with next to nothing and are forced to increasingly do miracles with next to nothing. I accept what you say about service redesign and it absolutely has its place, but it is important for the committee to recognise the landscape in which we are operating. Just to follow up on my colleague Brian Whittle's comment with regard to budgets, Peter Johnson said at the start of your submission that you cannot look at the health budget in isolation and you also spoke about prevention and early intervention. In the cost of submission, you said that if we are to achieve a flourishing Scotland, we need to deliver on our joint aim of improving Scotland's mental health and wellbeing. On that point as well, in the Eastrend submission, Julie Murray, you essentially argue for targeting services, for preventative services, including specific waiting times, and CAMHS has given us an example of that. CAMHS is obviously the far end of the system in terms of mental health provision, so to what extent, in terms of budget, there is scope to get out of our silos and work across other areas, for example with education in terms of mental health and also in terms of, I suppose, building resilience. Curriculum for excellence within the education system actually has a whole curriculum area devoted to health and wellbeing. In terms of budget pressures, is there scope then for health to work with education together in terms of that? The first thing I would say is that yes, there is, and it is happening. That was part of the argument from a causal perspective of not looking to directly fund IGBs and miss out the local government and NHS link, remove the parent bodies. That is something that we would see as being very detrimental to that process. I think that what is important from a causal perspective is that our IGBs retain the flexibility, however, to make local decision making, and causal work very closely with the Government in looking to put together the new mental health act and strategy. But within that, we were very critical of the Government's decision, which we see as an input measure, that there would be 800 new mental health workers and telling us, in local government and within IGBs, exactly where they would have to be located. We do not find that helpful. We would welcome the 800 and funding for the 800, but we would like the ability to make a local decision as to where they would be best located to suit the needs of our communities. I would like to say that we work very closely with Education and East Renfrewshire. We have a solid foundation in terms of our children's services planning and the work that we do in early years. I think that what our submission referred to was that we have a huge waiting list for CAMHS, because we are not providing the different sorts of support. We would not invest in CAMHS, we would not invest in something different, and we have some examples of that. We part fund schools counselling, and we are looking at some reinvestment on a one-off basis to see if it works with some of the savings. We have shifted the balance of care from children's residential. We are not sending as many children away to school and to secure accommodation, so we are investing in a service that is built around GP clusters, around some family support that prevents inappropriate referrals to CAMHS. Some of the kids that are being referred to CAMHS do not need that level of support, they need something different. We are trying to be very creative and working with our third sector organisations as children first that are running that service for us. Did you say that you had long waiting times for CAMHS? Our waiting times for CAMHS, we are on target, but it is still a long wait. Can you quantify that? It is an 18-week wait, and our CAMHS service is under pressure, but when we have done an analysis— How many percentage of people are meeting the 18-week wait? I do not have that off the top of my head. I can provide that, certainly. But when we have looked at our waiting list, we thought that a lot of the kids that are on the waiting list probably need something different to CAMHS. Just as a specific ball-up to that intervention, you talked about a tier 2 before they get to the CAMHS waiting list, as it were. I am a Fife MSP, and I know that Fife is one of the five health boards across Scotland who have not met that 18-week target. Do you think that there is scope in terms of the budget to get into schools with the healthcare provision or perhaps with councillors? Do you think that that could alleviate budget pressures if that was to happen and perhaps reduce waiting times as a result? I think that it would, yes. I think that it would, but the challenge for us is that we know that some of those preventive things work well, and the challenge is protecting that budget. When our budgets get reduced and reduced and reduced, you have to look at those at most risk, so it is a real challenge to protect that preventive element. For us, one of the ways of doing that is to partner with other organisations. Who can apply for funding, for example? Just one really quick question. Just as a follow-up, Sharon, you mentioned in terms of having two different reporting bodies. You have local authorities and health boards when you are reporting back. With regard to your budget, do you think that that feeds into a lack of budget transparency because you are reporting back to two different bodies and therefore it is much more difficult to evidence that Government outcomes in terms of health have been met? Do you think that that creates a lack of transparency? Each of the IGIBs have their own budget monitoring arrangements that they take to their IGIB on a regular basis. There is a joint budget report that goes in and goes in on a regular basis to give IGIB members where the budget position is at in each of the IGIBs across the country. They see that collective budget monitoring report, but we still have to operationally feed into the health board and the council side, where you start to see that split of that budget happening. My view is that the joined up one budget would be a better way to help that budget lose its identity going forward. One of the themes to emerge from the written submissions is the cluttered landscape of performance frameworks. It has already been touched on issues of budgets losing their identity, and Councillor Johnson touched on the need for meeting outcomes. I would like to hear the panel's views and if they feel that there is sufficient clarity in the Government's stating priorities for health. That question is yes. There is clarity in the stated outcomes, and I would ask you to recognise how those outcomes are delivered. Again, I want to reinforce that the IGIBs need flexibility to deliver on local outcomes. That is part of the reason that you might be raising the question about clarity, because we have a national outcome, but the ways of achieving that outcome will be different in each locality. That is part of the reason why, for example, the Public Body's working act required the IGIBs not even within their own area to have one locality. It recognised that different localities needed different solutions, but they are all working towards the same outcome. I think that the clarity in terms of those national outcomes is absolutely there, but how we get there, we just need the flexibility to do it differently. I agree with Councillor Johnson's assessment there. I think that there is clarity. We work with a broad range of outcome measures, and that sometimes can be challenging. I would absolutely echo the requirement and the real benefit that we can gain from that local flexibility and working with communities on good outcomes for them, because we work within different geographies, even in a small city such as Aberdein, with different health outcomes and different health inequalities across the city. We need to be able to focus on improvements at a very local population level. There is clarity. We work and have developed our own performance framework through which we seek to demonstrate delivery against our nine national health and wellbeing outcomes, but also underneath that a range of indicators that reflect real local need, local improvement, so that we are able to see the impact that we are making in Aberdein and in communities in Aberdein. I agree with my colleagues. I think that probably the vision is clear. We have clarity in terms of health and social care delivery plan. We have all produced our own performance reports, and because we have children's services and criminal justice included in the partnership that we have brought together, the nine outcomes for children's services and community justice, too. We have reported against those, but I think that the focus should be an outcome and not a prescription around the best way to achieve that outcome. That is very helpful. Another area that has come up is, again, this seems to be perennial dispute over direct funding or continuation of the current mode of funding. Is there a middle ground if direct funding is not an option? What could be done to improve collaboration between health boards and local authorities within IJBs? I think that the first thing that would be helpful would be to try and bring together the timetables within which NHS budgets and council budgets are determined and agreed. That would be a significant step forward. I think that it would also be helpful if moneys that were directed into social care did not have to go through the health board route, but came directly to local government. That would increase transparency and perhaps deal with some of the issues that colleagues were raising earlier. We have a tremendous vision for health and care and an integrated delivery of health and social care. We are making good progress with this, but the key message that I am trying to convey is that, to deliver the transformational change that we need in the timescales that we need it, we need to resource IJBs properly to do that, and we have major concerns currently. They probably have sufficient budget to stand still, but they are not sufficient with having tremendous challenges in trying to deliver the change that is needed at the same time as delivering the services that we need to deliver. That is the key message that I hope we will try to get over to you. Julie, you raise your eyebrows when Peter said that there is sufficient budget to stand still. Do you disagree? I do, actually. To stand still next year, we would need an additional £3 million, and our scenario planning suggests that we will probably get £3 million less. I do not think that we have enough money to stand still. In doing things the way that we have always done them, because we have been on an integration journey for 10 years, we have probably had quite a lot of innovation and creativity in what we have delivered, and we are beginning to get to the end of that line. I think that there is a real challenge for chief officers, because as chief officers of and advisers to integration joint boards, what you might suggest would be good for the integration joint board in terms of protected money and perhaps direct allocation, is not necessarily what your parent bodies would like, and you are line-managed by chief executives from the council and the NHS board, who might have very different views on issues such as set-aside or direct funding. There are real challenges for us. Personally, there are some real attractions to direct funding, but some of the issues would be taken care of by better timing, as Peter says. There would be some disadvantages, because as I say, we very much need to be part of the local community planning family. I have mixed feelings, but I think that if there was a sense that IGB budgets were protected as much as they possibly can be to meet the strategic priorities within a context of parent bodies continuing to fund, that would be fine. Aberdeen, you have developed a local protocol to try and support us over the process of budget setting for three organisations. NHS Grampian has tried very hard to align its budget setting process with that of the council. We have made some real strides in that, and that was really in anticipation of when it is going to get difficult, because relationships across all our organisations in the north-east and in Aberdeen have been really, really good, but as budget pressures hit both organisations and the IGB seeks to make different decisions, obviously they can become strained and put under pressure. The budget protocol sets out expectations, a degree in terms of timeline, how it will work and the opportunity against a difficult fiscal background for the IGB to be making representation to the partner organisations in terms of an increase in budget if we can demonstrate need, demographic pressure and so on. That is not to say that we will get it, but it allows us that, reflecting what is in the legislation. That has been a really, really helpful process. Like my colleague Julie, I have mixed feelings in terms of the direct allocation on the one hand. That seems very straightforward and simple, because it is very time-consuming managing budgets across three organisations and hugely complex. However, I do absolutely recognise the benefit of being part of that family of public sector organisations in an area and the ability that that gives us to be having discussions, particularly with the local authority around how some of their other mainstream budgets, housing budgets, are a good example of that, education, children's services. You have talked about how they can be brought to bear to support the overall ambition around reducing health inequalities, focusing and targeting our effort on communities of particular disadvantage and inequality and so on. That needs to be seen as the overall context in terms of how we get our allocation, but that is not to detract from the complexity of managing, as a chief officer in that, with the various calls on your time and your focus, as well as the regular reporting, as my colleague CFO has mentioned. It is challenging. Ared standstill cost is about £8.7 million with what we have observed. It costs us that to standstill as our forecast. Do you have enough? Do you think that you have enough? We are forecasting some significant pressures on the budget. We have reserves that we have put aside for this, but our ability to use reserves impacts our ability to transform. That is the real conundrum in that. We are very ambitious in Aberdeen to change our services, but we are also very realistic in terms of how long it is going to take us to change in the pace that we can move at. The pressures that we face will definitely impact on our ability to move at the pace that we want to and we will have to continually look at how we adjust our expectations and plans on transformation against our duty, our requirement under the legislation to break even. Sounded a bit like I know there, but we will leave it at that. If you look at the budget settlement last year, there is quite a lot of direction from the Scottish Government about the budget allocation to the IGIBs. It was quite directive about the maximum level of savings that could be taken from the IGIB's budget. That helped a lot of the IGIBs to be protected from potentially wider savings targets that could have been faced in the current financial year. I would just like to add to that that that was one element of it and there was also on the health side there was the flat cash guidance that went out with it as well, which again was given to trying to help and protect the IGIBs going forward. However, it hasn't taken away from quite a lot of long discussions around what budget allocation should be and IGIBs are still in the position this year about to finalise their budget for 2017-18. From a timing perspective, ideally, the IGIBs would want to set their budgets before the end of March, but some of the discussions that we are having around what the budget level should be for the IGIBs has taken those timescales well beyond that period, which is ideal when you are also trying to deliver quite substantial savings targets as well. Is there a final supplementary to Gillet Murray and Richard Rock? You have outlined what you would need to essentially tread water. In an idealised ideal situation, how much do you believe you would require to realise the vision of shifting the balance of care? I think—sorry, personally—I don't have a figure at the top of my head, but I think what we require to really shift the balance of care is probably some transitional bridging funding. I think that there are resources within the system. I think that we, as a host, Greater Glasgow and Clyde, where East Renfrewshire is, is quite a complex system. There are six partnerships. I think that if we work together with the health board and acute services as we are doing, we could release some significant resource locally to develop community services, but we probably need some funding up front to develop the services before hospital beds close. I don't have a figure at the top of my head. I think that in a system like Greater Glasgow and Clyde, I'm thinking probably five years. We've only got about 10 minutes left, and I've got four members who still want to come in, so can people be as short as possible if they're snappy. Thank you, convener. I wanted to look at point 23 from the COSLA paper, which outlined that there are a number of accountability and audit issues that have become evident as the work of IJBs have progressed. I wonder if the panel could outline in some more detail what they have been and what steps you've taken yourselves to address that. A further point was the discussion that we've had around budgeting and the experience in Northern Ireland. Would you support shifting towards a single budgeting situation? I've been short and snappy. It's okay. It was just the last point in that paragraph, which states that accountability and auditing issues have become evident as the work of IJBs have progressed. I wonder if you could outline what you have seen in your own areas, those being, and anything that you've done to try to rectify them, especially around benchmarking of services? I think that around benchmarking of services that can be quite difficult because of the range of different services that some IJBs have, so Julie referred to having children's services, children's social work services within her partnership, but it doesn't sit within ours, so that can create different dynamics. I think that sometimes the length of partnerships have been up and running and the ways of working there also can reflect. I think that my colleague Sharon has addressed some of the issues of accountability and audit in terms of the complexity of the landscape, particularly around audits where we're seeking to be streamlined around audit processes, provide assurance and accountability to partner organisations to do that also within the IJB, but not duplicate some of that audit. Working through that remains a work in progress for us, but we're being very, very clear in trying to do that, but it can be quite complicated to work through. I'm not sure if that was what you were asking. I think that one of the areas that Scotland has highlighted is that there's further work required around the set-aside, which is the unscheduled care aspect of the acute budget. I think that we all recognise that there hasn't been the advance that we would like to see in that area of work, and it's definitely an area where we are doing a lot of work this financial year to try to look at better arrangements around the set-aside budget. That is a key area for us in relation to shifting the balance of care, and as Julie said, it's an area where it would be helpful to have some spend-to-save monies, where we could look at bridging finance to move from the acute system and move services across into community settings. It's a complex area, but it's an area that we need to make progress to show and demonstrate that shift in the balance of care going forward. My final point was on budgeting. In terms of Northern Ireland, how they've actually with integration moved things forward towards single budgeting. Do you think that that's a good idea, given some of the concerns that you've raised this morning? The system in Northern Ireland in a number of years, but when I did look at it, I understand that the structure created a number of single boards. However, in some measures last time I looked, there weren't actually making some of the progress that we had in Scotland over particular elements of resettling people with mental health and learning disability. I think that there are still some challenges in terms of delivering outcomes despite the single structure. As I say, I don't know if that remains the case. It's probably a good three or four years since I last looked, but it could certainly be interesting to look at comparisons where it has worked, where it has made progress against where we are managing to achieve better outcomes for our population. I can only reinforce the point that I made already that COSLA would not support single budgeting if it means removing budgets from local government and the democratic control of local councils and taking that money away and then essentially giving it to a new nationally funded range of IGBs. We think that that would be damaging to the process. It would probably require legislation from top of my head in terms of what's in the public bodies working at, and it's exactly what we should not be contemplating when we're facing the challenges that we are in shifting the balance of care and delivering for our communities. It would be a total distraction. Ross. I'd like to go back to the point around the link between expenditure and outcomes. I know in the past that the committee has found that the boards have found it extremely difficult to provide analysis of this. Cabinet Secretary has acknowledged it. It's in number of the submissions here, including the Stremfordshire submission. I was just wondering what progress has been made on making that link, on being able to provide that data, that information. It is something that we're struggling with, and I think that everyone is struggling with it. I think that we are hoping that some colleagues from Scottish Government who might be behind me and the chief finance officers can start working together to provide a national framework, because the difficulty is that we might all try and do things in a different way, and then it would be difficult to compare. It is complicated because there are many services that we provide and bits of our budget that contribute to a number of the outcomes. I think that we do need some national guidance for that, and I try not to make it a really time-consuming piece of work, because we don't know potentially what value it might have. I think that, taking on Julie's point, if you take, for example, the home care budget, the home care budget actually meets a number of the objectives, so it's very difficult to split that budget on how much of that budget helps to lead discharges, as opposed to how much of that budget actually helps to maintain people in their own home. I think that the challenge is, yes, those budgets are there, we know which objectives they actually support, but it's very difficult to actually split that money across those outcomes that we're actually achieving. I think that a different way may well be to show here are the budgets and here are the outcomes that they do support, and I think that that would be a step in moving that direction, but we do have a lot of budgets that support a number of the outcomes, which is why we've got a challenge with that. Providing that is obviously required by the legislation. It doesn't sound particularly ideal or easy to deliver requirement. Taking Julie's point around the need for frameworks, and I assume also that capacity is a big issue here, what else is required to help to move towards being able to actually deliver that? Capacity is in frameworks. Well, capacity is an issue locally, and I think that if we were able to work together, the chief officers have a strong network, as do the chief finance officers, as do our planners, so perhaps with some Scottish Government colleagues, because I'd wondered whether we had guidance, but we don't actually have that, so we can try and develop something. I just wanted to touch on the preventative agenda, spend agenda, and just to refer back to Christy, who floated some big numbers up to 40 per cent potential savings in public services if resources were focused on prevention rather than symptoms, and obviously the whole IJB agenda is supposed to move us towards that through closer integrated working and particular shift from acute spending into community spending, etc. I suppose that I wanted to explore, and if you think about the process of that, what should happen is that you put resources into prevention, and at some point down the line, we save money because we want to spend money on cure. I suppose that I just wanted to touch on some specific examples. Have we seen anything like that manifest itself in savings? It's the first part of the question, and I'm thinking specifically about Peter Johnston mentioning what happened in West Lothian, where doctors were prescribing fitness classes, and in theory what should happen. If you've been doing that for 10 years by now, we should see some output from that. We should see a reduction in your drugs bill compared to other comparable areas. You should see an improvement in health outcomes. Is there any evidence that supports that? In East Dunbartonshire, you've clearly been said that you were integrated for 10 years, and are there examples of things that you've managed to do in the past five or 10 years where you're seeing outcomes and actually have a beneficial effect on the budget? I suppose that it's a macro level. If you had a blank bit of paper, what would you be spending money on now, and where would you expect to see savings from that? Real savings, five or 10 years down the line? I always get the impression that everybody talks about prevention and the concept is great, everybody talks about we need more money to get us over the funding and do the double funding just now, but when you actually push on, where does that mean that you would save money in five or 10 years? It's a bit more vague. Could the answers be some more specific? It's not easy to give a short answer to that, in terms of do you see immediate benefits in the budget? The answer is probably no, you don't, because we have democratic challenges, the population is changing, the needs of the population is changing, demand is increasing, so at the same time as you make reductions by doing one thing, demand for different services comes in and overflows that. Standing still is not really an option, but in terms of priorities, there is a consensus that we want to move to a more equal society, and all policy proposals should be challenged to the extent that they address and target inequalities. That's certainly the cause of view. We'd want to see more investment in testing and financing new models of social care, simply because we recognise that we cannot go on standing still. I remember seeing, it was a picture of, I spent some time on the Healthcare Improvement Scotland board, and it came up with an example from the 1870s, which was the time that the steam ships came in. Sailing ships adapted to the challenge from the steam ships by putting more masts and more sails on their boats until eventually they turned over and sank. That analogy is stuck with me, because it's very powerful. If we continue to do the same things as we are doing, our healthcare system simply will not cope. We have to find the mechanism for doing things differently, meeting the outcomes that we want, and that requires investment and resources to fund the transformational change. I think that we all agree that that is absolutely necessary. In Glasgow City, there has been a lot of investment into services around intermediate care and round-rablement. We also have a direct ordering of home care that nurses from hospitals can directly order to allow patients to be discharged within four hours. The result of that is that we have actually seen a significant decrease in our unscheduled bed days, lost as a result of that work. That is very much as trying to move from acute back to bringing people into community and then trying to get people back home. We will be looking at how we then focus more on the preventative end, but our first challenge was to try and get people home quickly and safely back into their community. It has produced dividends and the bed days lost in Glasgow has went from 38,152 to 15,557. We have done a lot of work in what investment we have put in. We know from the figures in relation to bed days lost what that unit cost would come back to in relation to an overall figure. I do not have it to hand today, but I can get to that. I understand that I was very care for my question to say that compared to other areas that were not doing the same intervention. Back to the question, is there any evidence of a cost saving that the fact that we are slower than has been prescribing fitness classes rather than medication in financial terms or in health outcomes terms compared to other areas that were not making that intervention? If there is not, we might think that it is the right thing to do, but we have absolutely no evidence to say that it is the right thing to do. If there is not any evidence on that, then it really questions the whole preventive agenda, because if it does not save money, you will really go back and question whether what was in Christie was correct or not. I cannot tell you that on top of the head. In principle, I tried to answer that, but what I am happy to do is to go back and ask my colleagues on Westwood in council for some figures that may or may not answer your question. Brian Whittle, back to me then. I was following on from some of the discussion that I was earlier on. I think that it is Manchester that in terms of budgeting, the education budget and the health budget cross over, and there is the ability to move some of those funds according to needs of education, as my colleague General Gareth said, intervention being important in the health agenda. Obvious challenges are involved in that, but is that something that is worth a consideration? It may not even be health and education, but it may bring in the welfare budget in there as well. Where does that cross over? There is a little bit of movement within funds. I think that it is certainly an area that would be interesting. When we talk about the preventative agenda in a partnership such as mine that has largely services for adults, when we think about prevention, increasingly we need to think about the next generation and children and how we create the fittest possible generation for the future. Effort that goes into supporting children and families to have healthy lifestyles, to be resilient, to make good health choices, ultimately is going to have a significant impact on the sustainability of budgets. I think that it needs to be an area of focus for all of us, how we would achieve that with budgets. I do not know, but I think that it would be a fruitful area to consider closer partnerships with schools. For us, we have taken a real focus in Aberdeen on our locality working and the opportunity and potential of working with clusters of schools and our clusters of health and care services could give us a step into that. I think that what you are describing is community planning and community planning partners coming to the table with resources. I think that it is particularly difficult with education at the moment in this climate because of the protection of teacher numbers, other elements of the budgets are being squeezed a bit, but in terms of the work that we do locally, we come together as community planning partners and look at our resources and look at where we best target our resources. Sharon mentioned that in relation to delayed discharge and bed days, you can put numbers on that. In relation to some of the other areas of your work, where we have heard repeatedly from people that they cannot put numbers against what they are achieving and what is being done through the partnerships, how do you know what we are doing? I think that one of the areas where they are looking at is their annual performance reports. This year, they have produced the first of those reports. What that does within limits is to allow people to look at benchmarking and where they are relative to each other. There is a lot of work going on, probably more than the heads of planning across all the partnerships around that area and looking at areas where we can all improve our performance and relate that to the investment that we are putting into areas and to make sure that it is giving us the outputs and outcomes that we are expecting as a result of that. That is a focus that we all have around how we monitor our transformation programmes. Are we achieving the expectations that we have set for them? If not, what do we do differently to change them? I was going to add that it is in one of the submissions. It would be something that I would absolutely agree with. The opportunity and the role of the various improvement organisations around the patch in Scotland could really support us in that. We are doing some work in the north of Scotland with the iHUB through Healthcare Improvement Scotland to really help us understand where is the best evidence currently of what might work. The evidence base is quite sparse for many of the things that we are trying. Therefore, the ability to demonstrate improvement and how well we are doing against that is quite difficult. Strengthening that through the support of cutting-edge evidence and evaluating some of the tests of change that we are variously putting in place in Scotland could be really helpful. I think that doing that in a very concentrated way, bringing in improvement service and others that are around there, would be really helpful in strengthening our understanding of what works and where savings and sustainability come from applying the evidence base rigorously. Okay, thanks very much. Thanks for your evidence this morning and I will suspend briefly to allow a change of panel. Okay, we move on to our second panel this morning. I welcome to the committee Rachel Cackett, policy adviser at Royal College of Nursing Scotland. Elaine Tate, chief executive officer at Royal College of Physicians of Edinburgh. Jill Vakerman, national director of BMA Scotland. Dave Watson, head of policy and public affairs, Unison Scotland and Dr Miles Mac Chair of the Royal College of General Practice Scotland. We will move directly on to questions and could ask Marie to open up, please. Thank you, chair, and thank you panel. I wonder if we could together explore some of the big picture issues before drilling down into more of the detail. So we all are aware that hospital care can be harmful for some people. So being admitted, we were at the dementia centre at Stirling University at the weekend and they were saying that almost immediately somebody with dementia who's admitted to institutional hospital care deteriorates and they don't really recover that function again.  So there is some harm coming from hospital and yet time and time again when I'm speaking to colleagues out in the community I hear stories that it's much easier in a crisis to admit someone to hospital than it is to put in a package of care that would help them to stay at home. So I'm wondering if we could explore together what would better care look like, what would happen in these crises rather than admission to hospital and how do we get from where we are now to there? We are really pressed for time, so I'm looking at you here, Dave. Be brief on that one. Miles, would you like to go? Thanks very much. This has been a big struggle. Throughout my career there's been moves to move services from hospitals to the community and an expectation that that is the right thing to do. I'm delighted that the Scottish Government has followed that up with 2020 vision which really is on the back of other reports like co-report previously which have given some cause for hope in the past but we've really struggled to deliver that. I think from my colleges point of view the main thing that we really want to do is to ensure that we've got the workforce to do that and the investment in general practice to deliver that because that's patently not being the case. We've seen a fall in percentage funding to general practice over the last years and unfortunately that's been continuing in the last three years that I've been opposed as well despite our loud clamoring to have this tackled without the sort of care that my members are able to provide to look after people at home. I think you're absolutely right with the elder population is the particular challenges to us that our core values statement is about that long-term continuity, the comprehensive care and that it's be able to co-ordinate people's care through the work needs to be absolutely essential so whatever we do we desperately need to invest in general practice and invest in GP numbers and to make sure that we really stick close to those sort of core values that the NHS has had for a long long time but that's we're not in isolation, there's clear evidence that that's just important for district nursing services, Helen Irving's work that I know you've had evidence from her before clearly linked the issue to do with GP and district nursing services despite an overall rise in health and social care budget as not actually being able to provide the sort of changes that we're looking for so I think it's that nuanced approach that we need to and it's basic care in people's communities as we'd probably expect it sounds very traditional but actually it's quite revolutionary to be able to see the investment in the way we want to do to deliver that. First thing I would say is that there are times when hospital is absolutely the right place for people who need hospital based care and we have staff working through hospitals who do an amazing job in Scotland in providing that. What we need to make sure is people are only in hospital at the point when they absolutely have to be and that is a fundamental shift there in backing up what Miles is saying and how we distribute our resource and our thinking about how we deliver services. One of those things is about understanding the complexity of the sort of conditions that people are now presenting with and the location in which we're then providing care support and treatment is changing so we're looking at far more complex care therefore being delivered in the community and that requires decision makers to be in the right place in the community 24-7 to be able to make sure that people are getting the care and treatment that they need in their home or in their care home or wherever it is that they happen to be that's out of the hospital setting that those people have the right access to fellow clinicians within the acute sector to make decisions in the moment to try and keep people at home where that's the appropriate thing to do and to get them out and of course that requires a real rethink of how our workforce is configured. One of those things is the NHS is a people-fuelled economy it doesn't work without the people and actually that really does require us to be investing in the right places so for example this afternoon Miles myself and colleagues from across pharmacy and optometry are meeting with Scottish Government as part of a primary care vision collective to talk to them about how jointly we can really rethink how we develop primary care across all the professions to make that work and bring forward that vision that you're talking about that the government's talking about through the 2020 vision and yet we do this at a backdrop where you know we do have significant vacancies within district nursing alone we're looking at a 5.5% vacancy rate within health fisting it's over 7% you know we do have gaps one of the things that we need to be careful of in terms of numbers is not just talking about how many more but actually going back to my point about complexity what are we asking those people to be doing and what's the volume of work that's coming their way there were discussions this morning around set-aside funds I think that's absolutely key when it comes to thinking about how we transfer resource if that is indeed what we are going to do as complexity gets greater and there is an issue about what our hospitals become as the complexity of need increases and how expensive that hospital care will be to provide but there is an issue for us in thinking through those set-aside funds in what we're talking about if you like is free cash to move and what we're actually talking about in terms of people to move and we need to make sure from our perspective as the Royal College of Nursing that we obviously have the right nursing workforce with far fewer vacancies with people at the right skill level to make those clinical decisions so that people's care can be delivered in the community where that is the most appropriate thing to do Joe sorry yeah thank you very much conscious of your comment about the lack of time neo so I'm not good to reiterate many of the points that Miles and Rachel have made and that members of the BMA consistently tell me very same things so I think there's a huge amount of shared consensus around many of the points that have been made that the thing that I suppose that I would add to that is the role of a new GP contract in the landscape of trying to help to find a way forward and that's around about creating a model for GPs to become an attractive profession for GPs to to come to and to stay in in Scotland to be clear exactly what the role needs to be for GPs going forward and to establish how they're going to work within that wider general practice and primary care team so I think all of the other points are absolutely right and I think there is a real need to make this work and to to pull off a different version of a GP model for the future as well yes I mean some 30 years ago I served on the on the health board and I remember the number one strategy was to shift services from acute to community services so where as they say there's nothing new in politics the same issues come round and I think the reasons for not making as much progress as we probably want to are probably two for one is you need to have the community services in place to do that and we have a real problem there not just in terms of NHS primary care and community services but also particularly in the in the social care sector which is a unlike the NHS is a highly fragmented service for which you know if we think the vacancy rates are high in the NHS you want to see what they are in social care at the moment the sort of turnover rates we're getting people are just not attracted to work in the sector and and and it's a very fragmented in terms of employment etc and the second issue is largely political you know try closing a hospital it's not easy your post bags are all full to the to the brim every time you have to make that that shift so you know what you've got to do is convince people that there are credible services in place and then we have to have that dialogue with communities about the best way of using about bringing communities with you doctors are evidence driven and if we make the arguments evidence driven and we give those that have the responsibility for dealing with community transfer the leadership skills to be confident in saying the evidence is there that the services that are being transferred are being transferred safely and you're not going to be in a position where the services delivered in the community are different they're different but they're not going to be poorer. From our perspective one of the challenges with the lack of transition funding which I think was mentioned by several people in the previous evidence session was to make sure that the services are available in the community to prevent multiple admission or readmission from people who've had some care in a hospital sector been transferred to their college in the community and there's been a problem because the community services are not yet sufficiently well established to prevent their readmission to hospital and that's not a reflection on the ability of our colleagues in the community it's a reflection on the investment in the services that are there at the present time. Thank you. Can I ask just one slightly narrower question in terms of bringing the community with us? Your submission mentions this line care should be taken with technological or pharmaceutical developments which deliver small benefits and I think that one sentence there sort of distills down that tension between you know around evidence based medicine which undoubtedly favours pharmaceutical interventions and there aren't necessarily the same levels of evidence about some of the other interventions that might be there. Is it time for a national conversation with the public about some of these very expensive drugs coming along which deliver very marginal benefits? Very high expectations of pharmaceutical driven care and where the evidence is there to support them then indeed people would expect to have access to those therapies. There is significantly less evidence about other areas of care and that's where we need to put our emphasis we need to encourage and support research into some of these other interventions to be clear that if there is evidence in support of them then that's the direction of travel that policy makers should be going but in the absence of evidence we're experimenting and I don't think that that's anything that we would want to endorse. Thank you convener and thank you to the panel I just want to explore a little bit more about the need for disinvestment I've heard from the panel here talking about shifting of care and resources to community so I wonder whether you would agree that there is a need to identify areas for disinvestment and how this can be best approached? This is obviously a very difficult area because I'm asking you a simple question and I'm giving myself time to think. I think you're absolutely right I think there's been I think some of the issues that we're starting to tackle about realistic medicine start to get to grips with this that I think that our CMO is correct in challenging us about actually are the treatments that we're suggesting actually what people are really wanting and needing now that comes from some very difficult conversations and it needs to have that sort of continuity of care that GPs often need to but we need to be well linked up with our hospital colleagues to be able to make those decisions there's nothing worse than us having complex decisions about someone's end of life care heading off to an oncology clinic and getting a very different message without necessarily the benefit of the discussion that we've had somehow we need to to cross those borders but I'm well aware that actually those individual decisions don't lead to quick disinvestment decisions further down the track I think that's more difficult I think we've got to be extremely careful about how we tackles some of the preventative care agendas that some of the screening is now coming under question about how much benefit and what cost are we going to to get from that that we're beginning to have increasing issues about over diagnosis and over treatment which are causing us great deal of concern and I think it's quite clear that even our profession hasn't quite got a head around what the answer might be to that but I think that when it comes down to it this needs to be a decision where the public is involved with as well although these decisions are very difficult the issues about what we would personally go for for screening compared to what one would suggest for a population can be quite conflicting sometimes. Your question was how to approach this challenge and there are a number of different dimensions to this I think but without question what what we're all saying is that in order to release the kind of additional resources and investment that we need to support transformation and delivery of services into the future we need to find ways of not only doing some things differently looking at additional funds being available we also need to think about stopping doing things as well and that's the territory in where that we're in here and when we've explored this there are a number of things I think that we do need to look really seriously at and the culture that we have of establishing targets to be achieved I think is something which we've all recognised requires review that we're still awaiting the outcome of a review on that but I think there is potential territory in there in terms of understanding what the drivers are that are created by targets that we said and exploring whether or not in fact these are the right ones or whether they're directing activity perhaps in the way that's not best in the best interests of patients and indeed in the best way of spending resources that the other thing I think Miles has touched on this is around about the expectation of public and patients about what they would have access to and what might be best for them and I think we're all clear that being able to have a more open and honest discussion with the public about what is evidence-based and best for their individual circumstances is likely not only to produce better quality care for them but ultimately result in savings and stopping providing particular interventions in certain cases as well. I think my point is I don't screw with anything that colleagues have said already but if I draw your attention to the timeline differences in investment in prevention versus investment in repair and the that we have called for increased investment in preventative activities where you're not going to see the benefit of that for some years down the line and therefore the disinvestment that will will will arise will be naturally delayed in addition to that if you look at the inequalities agenda patients from more economically deprived communities make much higher use of unscheduled care services than others and if we can address investment into there as well so a combination of addressing inequalities addressing deprivation and addressing prevention will help us reduce the burden on the acute hospital and scheduled care services or indeed our colleagues in general practice who take an even larger share of that unscheduled care work so disinvestment may not sit in a nice time zone with investment I know that's not what you want to hear but it's a point I think it's important to remember. Rachel? Building on I think what a lot of colleagues have said and we've been in many conversations over the last three or four years about what sustainability in health and then in health and social care could look like and the RCN published a couple of years ago a piece of work on rethinking targets specifically from conversations we've been having with colleagues around how we define very clearly what it is that we're looking for and building on that last year we put forward a proposal that we should be developing very clear criteria for change and that we need to do those really transparently because we are in a place at the moment where we have the double whammy you were really hearing about earlier on and where there is significant holes in finance at the same time as people are being asked to be radically creative and to rethink and we have to remember going back to my point that the NHS like social care is a people economy there are people at the heart of this who are trying to do both it's not just with moving figures around on a spreadsheet we had an event last week where we were talking about the really big transformation agenda that we have at the moment and someone reminded me of a graph but I hadn't seen for quite some time and I went and dug it out it was in the 2011 spending review which was this I don't know if anyone remembers this particular graph with the great big red hole and really this is where we are at the moment we're really down at the bottom of this red and it feels like it in the service and it will feel like it to some patients as well headlines this morning from the BBC we're highlighting that as well so I agree there has to be a real engagement about this it can't just be about those of us who work in policy making decisions it can't just be about politicians making decisions it can't just be about communities making decisions or indeed staff and that we haven't spoken about staff engagement and change is absolutely key it has to be all of us together because there's no doubt they're going to have to be some very brave choices to be made in how we reframe things to make sure that we are delivering the very best outcomes and that kept coming up this morning and we would support that absolutely for the people of Scotland in the resources that we choose to make available to our health and social care service so criteria we think would be really helpful in helping us assess not only whether change is fitting with policy direction is fitting with where we say we want our society to go and has the support of the people both receiving and delivering services but would also also go back to some of the comments that Ivan was making earlier about evaluation those criteria would help us to evaluate are we making the right choices you're right the medicines are easier and have traditionally been easier to evaluate than many other things on that basis where we are making decisions about how to invest in long-term change we do need to know that we can come back at some point and evaluate whether that change has been the right investment so I think all of those things do come together really clearly and there's clearly a step change that we need to make there. In the previous panel we spoke about transitional change and nod off the head we'll do for that one if you don't mind. Are you all in agreement that unless we have money put in for that transition period from the community then it's impossible to deliver that on the scale that we need? Miles? I'd one more bit about that it's not just about transformation it's actually about better it's not just about new systems it's about better ways of working particularly to do with improving the interface of care this is a particular issue that my college has taken on and I'm really grateful for the support we've had from the Scottish Government and from the academy of Scottish Royal Colleges and faculties because we believe that it's not just a matter as we can change the organisational structures but actually we tend to see the same people doing similar jobs although I understand it may well lead to different ways of giving up budgets but actually the key thing from a patient's point of view is how we all behave it's absolutely crucial that I've got really good experts, obviously specialists, clinical decision support from hospitals and also just as important that I'm able to deliver that to the rest of the primary care team and at present I need to get it from them too and that system is not necessarily functioning. Miles, you want to? I wanted to specifically look at what he would raise around people economy and I think we're all acutely aware of that and some of the problems are health service faces with recruitment. To what extent do you think that that is preventing the IJBs and actually progress being made to move to a community setting the fact that we've not had a workforce plan until recently and do you think that plan is actually going to solve the problems we're facing? Yeah, I mean I think a lot of work and we're pleased as new focus on workforce planning and I think obviously you've seen the first stage of that work. I think it would be fair to say and it's not disparaging it because the first stage is obviously on the NHS which is probably the easiest one where there is at least well-established workforce planning arrangements there and it would be fair to say that the proposals are largely around process so you know what they do is they set up systems to do workforce planning rather than actually come to the solutions. I think the next stage obviously the third one is more in Miles' area but certainly the second stage in the social care area is going to be much more difficult even in process. For the reasons I indicated earlier we're talking about a hugely fragmented workforce yet we're talking well over a thousand adult care providers up to seven thousand in total for a country of you know five million people that's a hugely fragmented to try and and we don't have the institutions all the frameworks at the moment. We have ad hoc ones that we try and sort these things out but we really do need to have some sort of framework to deal with that. The challenges yeah I think we set out and I've referenced our submission in the documents in front of you but I think in terms of workforce planning all of the ones that are there obviously yeah pay is an issue you'd not be surprised to hear hear us say you know there are there are huge issues in terms of of people not coming into the service both in the NHS and and more broadly yeah when you've had a 16 to 17 percent real terms pay cut over over a period of six years then that doesn't make the services attractive as they should be. I think in workforce planning terms we do need to pay more attention issues like Brexit particularly the private and the community sector there's a very big use of EU nationals and frankly they are not registering and others are just leaving. I was talking to a group of our members the other day who said you know I am naturally affirming a French firm that's actually been holding an event in Glasgow and some of them have been at it to give you an indication and also big and much more difficult issues I've just flagged one up gender segregation me and the care sector we have you know ingrained over many years gender segregation if you look at where the new jobs are in Scotland we have essentially got to attract young men in particular into into the care field and that's simply not happening at the moment. I'd also flag up concerns it's I didn't particularly pick up the last one but there are issues concerns in the sector about safe staffing there are concerns about litigation with something we didn't talk about there's also regulation particularly growing into the social care sector and there's a concern it tends to create more caution around around practice and some concerns and the last point I'll flag up is that we did some very detailed research earlier this year on the aging workforce now you might not be surprised in the local authority area including social care that that's becoming a more aging workforce because nine out of 10 jobs have been lost since austerity in local government however we're actually seeing aging workforce NHS which is actually growing its workforce and I think that does open some questions as to why young people in particular are not attracted to these jobs is it is about pay certainly but it's also about the demands on the job both physically and psychologically and I think that's putting people off as well so that's that's about four headings there's a lot more in our paper so the question about workforce planning I would describe the two separate sort of dimensions to this one is thinking about how we understand the demand for the workforce and the other is where is the supply going to come from so in terms of the first part of that which is understanding the demand I think the publication of the workforce planning framework is a start in the right direction it is it is not a full workforce plan for the future and it couldn't possibly be at this stage what we need to do is have a clear understanding of what the future health and social care delivery landscape looks like and we don't have that yet that's something that needs to be developed following the implementation of the health and social care delivery plan and the development of the rather complicated landscape of planning documents which are being produced at the moment for regional planning, national planning, NHS board planning, integrated joint board planning, local authority planning that has to come together and that needs to be made sense of and then we need to understand what does that mean for the future workforce that we need and my colleagues have already described the complexities of what that workforce might be made up of but only then can we then develop a map of how we get from where we are at the moment to where we need to be in the future and I think most of us would agree we don't even know 100% for sure where we are at the moment we don't have complete understanding of the workforce in primary care we don't have figures on specialty doctors for example so there's a lot of work that needs to be done to know where we are there's a lot of work that needs to be done to know where we're going and then we could start to map out how we're going to get from A to B and that is what workforce planning is about so we're a long way away from that once we've done that then we can start to think about how do we attract people into these roles and there's a huge amount of thinking that needs to be done about how we make roles in Scotland more attractive we need to recruit people we need to retain people we need to be looking at the start of the journey for the workforce we need to be keeping people in the middle of their careers as well we're losing them in primary care we're losing them in secondary care we're really struggling to keep a lot of doctors at their end of the career they're leaving early and we need to find ways to address that end of career issue as well and the same kind of picture is playing out in the various other healthcare professions Rachel I mean backing up what most of my colleagues have been saying issues like pay for example clearly a a big issue in terms of recruiting and retaining people in the workforce going back to the issue I was talking about earlier when Marie asked her question at the beginning around complexity one of the issues that we're facing in Jill's last point is that as people are making decisions to leave the workforce and to leave early and we have a huge retirel issue in nursing particularly in community nursing what we end up losing is some of our most experienced nurses a point when our complexity of healthcare required is at its greatest and that gives us a real problem and gives ijb's a real problem as well and I think we also have to think through in that circumstance what the morale of the workforce is in terms of thinking retention and also how attractive that is to come into as a workforce you'll know from our submission that we released some early findings from a very large survey that we completed across the UK on staffing and when describing what had impact on their ability to deliver high quality care a third of respondents in Scotland reported that not enough registered nurses in a quarter not enough healthcare support workers so those vacancies I was talking about earlier have a huge impact when you're expecting the rest of your workforce to pick up and remember when I said this is a people economy this is an economy that people go into because they want to make a difference because they actually want to do some good for people because they want to work alongside people who have health needs and actually therefore if you're going in and coming away every day feeling that you're not really able to quite do what you want because the vacancies are too high because you're too stretched because you haven't got the resources you need that has a direct impact on your ability to feel good about turning up to work every day I think one of the things I would say you know we're in this this great funnel of not having enough money that in those situations quality becomes an issue that's harder to hold on to when money becomes the big driver and I would say I was listening with interest our colleagues before us talking about service redesign and cuts and I do you think we have to have and this goes back to our criteria point a really clear idea of when which is which because some service redesign are cuts and some service redesign are based in really good evidence where the impact on patient outcomes is either equal or better than what they would have had before I think sometimes we're not always being clear on that basis and sometimes we end up with replacement models we end up with downgrading models and actually that isn't a good outcome that does not deliver good outcomes and when finances are all which they are at the moment for people who are starting the year knowing they've got an eight or nine million pounds whole in their budget that becomes a really difficult one to hold on to so I'd go back to our call for criteria we need criteria so that we can be transparent with the public when a service change is genuinely an improvement I wish you would go and speak the chief executives of health boards and ministers because we've been pursuing this for so long and there is the voice of sanity on that story. Elaine? Thank you we often talk about the valuing of world-class workforce and if Scotland's going to achieve the challenge it set itself for a significant transformation in the way in which services are delivered we're going to need that world-class workforce across all the healthcare disciplines but if I speak for a moment particularly about hospital doctors with who are members of our college what drives them is direct patient care it's about contributing to service development it's about contributing to quality improvement initiatives and patient safety initiatives to the research agenda where there are evidence gaps that are so sadly needed to achieve some of the care safely or changes safely that we've already identified and last but by no means least to contributing to the education and training of the next generation of doctors who are going to take over from them so there's a real issue in workforce planning about generating enough space in the work plans of these doctors to enable them to fulfil their patient responsibilities but also the longer term contribution towards the development of health services looking forward and if we don't do that we devalue the job for them and that makes us less attractive as a health economy to retain and recruit doctors into our service so we also said you're looking at hospital doctors working under pressure in exactly the same way as the other professions both in the community and in the hospital sector are functioning but trainees are watching them young doctors coming into the profession at first and they're watching their senior colleagues retire early because of pressure or working in a different way and they're starting to question do I really want to live my life like this if we don't stop that cycle of pressure and difficulty then we will struggle to recruit in the future and then we'll struggle to make the changes that we all need to make. Okay, right, are you okay? Colin? Sorry, sorry, too many males. Too many males, not many of us around. I'm just going to make the point that in 1996 there were 2,600 hospital consultants and 3,400 GPs and in 2014 there were 4,500 hospital consultants and the whole-time equivalent GPs had actually fallen to 3,200 so I think that we have had a fail in the workforce planning for general practice. It's obviously difficult because we're an independent contractor service but in a situation where we are tightly bound by the resources coming in to employ new GPs it's perhaps not surprising that we're in the situation we are and briefly about. It's so interesting to hear comments from the social care side of things. Actually, the idea is about the GP career flow. Actually, we have to think about how we recruit people into profession, how we train them and how we retain them right the way through the career seems to be very relevant to other parts of the profession. We pinched it from rural ideas, it's now seem to be mainstream for general practice but actually I think we really need to be careful about that. I'm really pleased to see the progress that Scott Gems is making in the Graduate Entry Medical School will be training doctors the right way for the future needs of the NHS. I'm looking forward to seeing how the official report reflects. Five members of the panel nodded when your previous question was asked. One of the criticisms when it comes to the health budget is when the Government are challenged about resources it's often a defensive response. It's pointed out that we've got more doctors, more nurses than we've ever had before. I know that frustrates a lot of organisations because the real debate is not how many we have but actually is the numbers and the resources keeping up with demand. How do we move that debate on to the issues from a budget setting process? How do we move it on to that debate about resources meeting demand? Is there something that we can do as part of the budget process to achieve that, for example putting the budget document a figure that actually reflects how much it will cost next year for services just to stand still and compare that to the actual growth in the budget itself? Is there anything that we can do to actually move that debate on to those issues? I would refer at least partly to my answer to the previous question about workforce planning. We do need to understand better what the future demand for healthcare is going to look like, but it's actually not that hard to model on the basis of we know what the population is going to look like in five, ten years' time in terms of its age profile and its morbidity profile. In fact, with the population forecasts that we have we can predict fairly accurately exactly where people are going to be living with various different morbidities and healthcare requirements. On the basis of that, we could make reasonably good estimates of what the cost of delivering healthcare to that population would look like if we don't change anything. I think that there's a really important piece of work that needs to be done, and I know that Scottish Government are talking about it in the context of also thinking about workforce planning and transformation. It's a better understanding of how to model future demand and how to scenario plan on what the cost of alternative models of healthcare might look like, but that must inform the budget setting. We must be absolutely clear and honest about the cost of delivering healthcare with and without transformational change to the population that we know that we're going to have in the relatively short to medium term. David? I think the first word on numbers. Every year I produce my analysis of numbers, which is always different from the Scottish Government's and COSLA's and everybody else's, and we all do this exercise, because I think people do banding numbers around. There are statistics published by through an O&S, but the difficulty with an awful lot of this is that these services are interactive and also there have been lots of transfers between them. One of the reasons that the numbers don't always add up when you do it is that people don't take account of transfers of staff. For example, in Highland, the big shift from local government staff into Heartland health board is rarely taken into account when people claim increased staffing levels in the NHS. I think also I've mentioned the Christy commission before and the Christy commission's big things was about trying to move us away from inputs and more focus on outcomes. There are some difficulties around that, but if we always focus on a thousand nurses or a thousand doctors or a thousand whatever, we're not actually focusing on what we do. I agree that this is about better planning. It's not going to produce some nice little formula, which X over Y to the power of two etc. is going to equal the answer. It isn't like that. We are going to have to make judgments. Of course, part of that is also the political process making big decisions about the future of care in Scotland. All of that has to be focused in before we can do really credible workforce. I think what really irritates staff at the sharp end, however, is that when we start talking about theoretical arrangements, particularly in the social care field, what you get is, oh yes, we're going to produce 500 new care packages to do X. When the staff aren't there, the companies will say that they are offering 100 care packages and they haven't got the staff. It's just simply not there to deliver that level of work. I think that we have to get all of those elements in place but recognise that none of this is going to be the precision which you can monitor and we are going to have to make some broad judgments about the way forward. I guess that it's to answer your question. I think that there's a parallel process that could be very practically looked at by committee and that's the parallel process that we expect for the safe staffing legislation to go through. I think that that will have a direct implication on this in the longer term and I appreciate that that's not for next year's budget because it will be a longer process to see that in but your point about it not just being about raw numbers, but also looking at what people are being expected to do. If you look at what that bill could be and its ability to bring into account determining workforce numbers, skill mix included on the basis of people's dependency, on the basis of their acuity and to come up with a far more sophisticated answer to how many staff do we need to give good quality care and at what levels of experience and knowledge competence, that's the bill I think that as a parallel process this committee will have a real saying in terms of making sure that in future budgets we can then budget according to need in terms of the NHS's biggest resource which is its people. You want to very briefly call? Just touch on one other potential pressure on the budget and that's the current discussions around GMS contract, GP contract. Can I just briefly ask the public question for Miles and Jill is what is it that you want to get from that contract? What does it have to deliver and what impact will that have on the budget? Shall I start, Miles? Fundamentally it has to support a model of general practice which is sustainable into the future and that has to be a model which attracts medical students into a career in general practice. We need to develop a model for the role of the GP through this contract which addresses the challenges that you've been hearing a lot about already during the course of this and now looking at the clock this morning about what it is which is really challenging in the work environment. The contract needs to be clear about what the role of GPs is but also what the role is of the other staff that will work in primary care so getting clarity about exactly what individuals in the different roles do and how many are required is part of the on-going discussion and negotiation as well as understanding that the other factors which make general practice unattractive at the moment for a number of people who are making their choices about their medical career. Additional support and investment in primary care is absolutely unquestionably part of what is required here. More people being attracted into the profession and a model which is sustainable into the future to be able to deal with the types of increasing demands for care in the community that we've been talking about is what we're seeking to achieve. I think that those three things seem to be very much in keeping with where my college would see. The first thing is definitely to ensure that the resources are there for a sustainable future general practice and that's why that question that we need to see a reversal of the falling in funding to make sure that actually it's a sustainable level. The second thing is I'm undoubtedly we're going to need to grow the GP workforce so you're quite right that we need to attract GPs into the profession and we need to make sure that we've got enough GPs to do the work that's there because the transformation itself is going to need others working with others. We're going to need to be providing support for them as well as the other bits of work that we're doing. The third bit is about what sort of a GP is going to be in the future and we've been clear about what we believe the core values of general practice are, which I'm sure the committee wouldn't disagree with. It's about first point of contact, continuity of care. It's being able to co-ordinate the care and to provide the comprehensive care for patients and that's what our patients expect. So it's on those measures that I think we should look at the contracts in the future to see whether it's achieving what we need for the future of the NHS. Okay, Alex. Thank you for having me in the morning everyone. Rachel alluded to the news headlines this morning in a previous answer and those we learned that according to an investigation by the times that 14,000 fewer operations were undertaken in the first quarter of this year than in the same period of last year. For me, that's a critical indicator of an interruption in patient flow through the health service and there are a number of areas where we could point the finger of blame. I'd be very interested in whether the panel thinks that is, if that is a fundamental shortage in social care destinations for patients leaving hospital, whether that's problems in hospital where we're not ring ffencing elective surgical beds, whether that's about the lack of staffing, safe staffing provision in the nursing profession or whether that's at the very start of the journey in terms of the GP sector and the fact that people are having to wait longer for appointments, conditions are getting more acute and necessitating in patient care. It's a big question, I know and you may have different answers depending on your sphere of interest but I'm very keen to hear those answers. Okay, we are really pressed for time now so people need to be very specific. Who would like to go first? Elaine? Briefly then, hospital physicians have a majority of unscheduled care workload, the balance of their workload in hospital is unscheduled and therefore is predictable in terms of pattern but it's not work that can be scheduled or delayed in the way that the surgical procedures may have been but also because of difficulties in community care and a lack of provision in community care it sometimes has meant that physicianally patients, medical patients have taken up resource in hospital that's prevented surgical procedures going ahead and that's one that comes as a surprise to nobody. Our hospital management colleagues have had to manage that pressure, it cannot turn away a sick medical patient out of accident and emergency or from a GP surgery and until such a time as we can achieve this transformational change that's always going to be a pressure that will cause our surgical colleagues difficulties from time to time, so I start with that. Miles? Two bits, we are concerned about the rising in waiting times and this has a direct effect on us as patients come back to us again and again to get symptomatic treatment for while they're awaiting surgery. I think you're absolutely right about saying about the downstream effects on that and unscheduled care is a big issue. I think there is clear evidence from Helen Irvine's work that actually failure to invest in primary care services, particularly GPs and district nurses, puts proportionate pressure for the elderly population into A and E departments and many of those get admitted. So I think there is issues that we need to look at as a whole system. My real concern is that if there are things that can be measured and waiting times is one of those measurable ones but inevitably we may find that we're investing in the wrong place and not actually getting to the root cause, which may well be the aspiration of this committee and of ourselves to actually build capacity in the community. Dave? A lot of work actually people obviously say well are the design solutions here and actually there's a lot of work being done in the NHS in partnership between staff and management in relation to improving flows in hospitals, improving design, doing innovative things. There's plenty of good example of that but clearly there are a lot less operations being done that certainly is down to vacancies. We've talked to you about both doctor, nurse and other staff vacancies in the NHS and that simply leads to in some cases straightforward cancelling of operating lists and the rest of it and then there's the issue of obviously people who are in hospital shouldn't need to be there and obviously progress has been made in a number of those areas but that is largely down to social care. The reason I think the first question that Mary asked was why the reference goes to a hospital and the answer is hospitals don't turn people away. So it is as simple as that that if you're not sure another service is there then you refer to hospital and hospitals have to manage that situation. I'll try to be brief and so won't again reiterate many of the points which I absolutely agree with it. It sounds like a relatively simple question, it's a very complex answer, there are a range of different factors. The one that I would strengthen and add to is obviously we do have a high level of vacancies amongst consultants in hospitals. The latest figures that we've seen is 460 vacancies that's about one in every 14 consultant posts and of those at least half have been vacant for six months or more and that has to have a significant impact on the number of operations that can be performed. Back to the preventable health agenda, there's an inevitable logic about shifting some resource towards the preventable health. I think that there's a reluctance for that move to be made, I think that it's around defining what preventable health agenda actually is because there's a lot of different ideas around that and also therefore there's this almost a requiring of a leap of faith along a preventable health agenda. So how, where are we with quantifying your benefits both financially and socially into this long-term investment in preventable health? I think that the point that was made earlier was flagged up particularly in the Christy commission report and I wasn't advised to that commission. We did look at lots of very practical examples where you could actually even put a consultant on it to show that we did this and we did that. We're probably not very good always at shouting and costing up the benefits to demonstrate them to people like yourselves that actually it does make a difference. That's because it is very complicated and frankly it takes a lot of staff time to start doing all of these things and this sort of reporting. But I think there is very solid evidence right across the world which says that this broader preventive activity, this is why you know there's certain frustration at times when people constantly talk about the NHS as being you know just on that area when we all know that health inequalities require action in education in sport and leisure facilities and and housing and and so much else as well. And there is there's one point I did want to make this morning convener which is because it came after I wrote our submission but you know one thing I would urge the committee to look at very carefully is you will have seen the Barkley report proposals on business rates. One of those recommendations obviously is that the exclusion forms for the trusts and their sports facilities, local authorities have largely moved their sports facilities into into leisure trusts and that will take a big chunk of money out of sport and leisure on that basis. Now I don't actually disagree with the technical recommendation in relation to the business rates but if we don't put the same amount of money back into local authority budgets we are going to see a big cut in sport and leisure facilities of the sort that Peter Johnson and the other identified this morning. So I would urge you to from a health perspective to put some input into whatever recommendations the minister might take from that particular report. I just want to talk from the Scottish Obesity Action Scotland yesterday as part of the Scottish Academy meeting. They were making the point quite clearly that actually one of the issues is that it's not just about having preventative actions but actually having preventive actions which can work across the society. There's no point in having something which just makes the people who are the most wealthy and the most well to do and least likely to suffer real health to get them even fitter. We really need to bring everyone up together. This comes to the key point about continuity of care and about the role of being able to embed the preventative activity into routine treatment. So actually the GP being able to see patients for the long term understand them, understand their community and maybe even understand their family petting so we could potentially even intervene for future generations is an ideal opportunity to get these messages across but particularly getting these messages across in a way which is appropriate to that person who's coming to us. Because for many of them some of our patients who are most needy, actually the idea of living to their 80 or 90 seems like a middle class abstraction to them. It's not something which is on their cards when all they're worrying about is how to pay their bills this week or how to make sure they're rents paid. So we have to work with them where they're coming from and I think we've got a great deal to learn from the deep end group of practices about how we can do that and how the key role of general practice primary care is to deliver that in the context of continuity. Rachel. Back to the convener's question where we almost managed to only nod our heads earlier but we did speak a little which is about the issue of extra funding and I guess your question came about moving funding out of essentially the acute into community sector and I would question whether that's actually possible in the current climate. The NHS remains quite rightly free at the point of need for those who need it. We don't turn people away in the NHS and we still have people who require acute services to be delivered so I think simply removing money and putting it elsewhere when we know we don't have enough is almost going to be impossible. I think we go back to the double funding arrangement that we're going to require to make the sort of step change that we're looking for. I agree with comments that have been made throughout the morning about evaluating what that step change looks like and making sure that investment that new investment goes to the right place. One thing that we've not really touched on this morning is an issue that's been brought up by us and many others which is the issue of long-term financial planning. So at the moment when you're in constant annual cycle to break even you don't actually allow that step change to take to sort of come to fruition over a number of years and I know the order to general among others has talked about potential for three-year planning cycles which we believe would support a much at least the beginning of a longer term approach and finally just to say that Health Scotland published work with ISD over the summer which although I don't like the title I understand why it has the title burden of disease which I thought was some very interesting work looking at where particular conditions in Scotland are having the greatest impact on our population and they're intending to do more work to look at how to do forecasting on that basis. I would suggest a new question about prevention and where we start thinking about directing new investment. That work gives us some really interesting data to start to interrogate about are we actually getting that investment into the right places for the greatest need that we have in our communities. I refer to some of the conversation this morning in answer to this question because a number of people made the point very clearly that the investment that is required in order to tackle this upstream health improvement and prevention agenda is largely the investment that we made outside of the health and social care budget. If we're talking about mental health, obesity, alcohol, drugs, smoking, the majority of the interventions and the actions that need to be invested in need to be funded and resourced from beyond the health and social care budget and there is some very good discussion about the implications of that but it doesn't mean that there are not good things that can be done within the health and social care budget and Miles was talking quite lengthy there about the role of GPs and the potential they can have in terms of positive interventions at various different levels of the family life. So our play would be yes indeed look at the health and social care budget in terms of being clear about what it is that we can do to contribute to that prevention agenda but the majority of it is definitely outside of health and social care. Okay, could I ask a final point on pay? There's been an announcement that the 1% pay cap is going to go. Last year we saw the living wage introduction and then we've still got the hangover from that about sleepovers and how sleepovers money will be paid or not paid or you know that there's all sorts of machinations within that. Does anybody know where the 1% the money to break the 1% is coming from? I think the show answer is no because in fairness there are a couple of factors in terms of addressing that. Obviously one is the UK Government's autumn budget and obviously we can all guess as to how much the Chancellor will jiggle his own targets to create. What we hope is revenue spending by the way, you know in the past there's always been some capital monies being fed in the budget there but actually all things we're talking about pay in particular need revenue funding so obviously we hope that the Chancellor at UK level will free up some resources so there will be a revenue increase to the Scottish Government which it can then use partly for pay and secondly obviously it's the Scottish Government's own decisions about the other half of the budget that it controls in terms of what it's going to do in tax and obviously you know we've heard from the First Minister that there's going to be a discussion paper on tax so I think obviously we're very much welcome the statement of principle to say that 1% cap is not not sustainable that's really good news and we welcome that obviously 1.1 isn't going to be acceptable so we obviously want to see a real increase in pay this year we're going to tackle some of the long-standing issues in terms of attracting people into this we need to do more than pay is absolutely the starting point is the the the basic starting point is sorting out all of the recruitment retention issues but then you have to do the other things around the amount of staff that they're training and so much else but I think pay is absolutely crucial to that so we hope the Scottish Government will have some flexibility to be able to put serious money money in health not just to token the increase above the 1% but but certainly to start to catch up and make health and care in particular an attractive profession for people to come into. In terms of the social care living wage some of that money had to be found internally from the system are we likely to see that again? Well I noticed a question early on and you'll see in my submission I have made point about double counting of living wage monies if it goes through the NHS I often say that with one of our finance members said to me I can't spend the same pound twice Dave so that is a real issue in relation to that. In terms of living wage living wage is largely being being paid for waking day duties and waking night duty we are still in discussions with Government calls on etc about how we will deal with waking night duty and sleeping in in particular one of the problems that we need to recognise is that the historical use of sleeping in is no longer an appropriate model in care the idea that if you're on the sleeping in duty you're going to spend the night kipping in the hope and not been woken up it just doesn't happen so I think we're going to have to bite the bullet and recognise that the difference between sleeping in and waking night duty is now pretty blurred if it exists at all so Minister in Fairness has said that she wants to be paying the Scottish living wage for these hours we think that's right and there are discussions in the moment as to how we might we might get round and do that. No okay thank you very much and we'll now move into private session.