Health and Sport Committee

Meeting date: Tuesday, May 1, 2018

Official Report 496KB pdf

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Revised National Outcomes

Agenda item 2 is an evidence session on the Scottish Government’s revised national outcomes. I am delighted to welcome to the committee Shona Robison, the Cabinet Secretary for Health and Sport; Alison Taylor, head of integration at the Scottish Government; Roger Halliday, the chief statistician; Gerry McLaughlin, chief executive of NHS Health Scotland; and Professor Sir Harry Burns, professor of global public health at the University of Strathclyde—and, I understand, a grandfather, as of a few moments ago, so congratulations as well as welcome to him.

It’s a girl!

I am sure that Professor Burns has many cheerful things to say to us in any case, but I can tell that he is going to have a particularly elated session this morning.

Nonetheless, there are some serious questions to ask. We will start with Alison Johnstone.

Good morning. I would like to ask the witnesses how the national performance framework will address health inequalities, which are obviously an area of some concern in Scotland.

I will kick off with some comments in broad terms. The national performance framework is designed to enable us to see how Scotland is performing against a range of indicators that are relevant to health inequalities and to make sure that it informs policy making to tackle health inequalities. Wherever possible, indicators will be broken down by both protected qualities or characteristics and area-based inequalities. As part of the transformation of the Scotland performs website, we are going to report on progress for both those equalities aspects.

As I am sure you are aware, reducing inequalities is already a key feature of much of the Government’s policy programme. For example, we have set targets for health boards to reduce smoking in our least well-off communities as a priority. That has led to greater levels of success in targeting services, and the proportion of people from more deprived communities who are quitting is now far higher than the proportion anywhere else. There is also a stark social gradient to alcohol-related harm, and minimum unit pricing, which starts today, will deliver greater benefits to lower-income communities, where health harms are disproportionately experienced.

We are also investing heavily in mitigating the impacts of welfare reform and austerity, with a £100 million per annum spend in that area.

I will let Roger Halliday comment, but it is worth noting the work that is being done across Government. It is not just my portfolio that is important in reducing health inequalities, and it cannot be done just by the national health service or integrated partnerships. It has to be done across Government, which provides an opportunity for the whole Cabinet and the whole Government to focus.

I very much appreciate that point, because a Government letter in response to the Health and Sport Committee’s 2014 inquiry into health inequalities stated that tackling health inequalities is not a matter for the NHS alone. I would be grateful if the witnesses could touch on health inequalities being addressed by all portfolios. Will you give a couple of examples of how that might be demonstrated?

The £100 million per annum investment in mitigating the impacts of welfare reform is clearly about household incomes and supporting people, and it is clearly a tool to tackle inequality. Likewise, in education, we have the attainment fund resource for headteachers to be able to support children in schools, particularly in more deprived communities.

There will be examples across all portfolios. I guess that the importance of the national performance framework lies in its ability to take an overview and ensure that, as we measure Scotland’s performance against those indicators, we take a cross-Government approach to that.

I do not have too much to add. The framework looks at how we improve the economic, social and environmental wellbeing of people in Scotland, which is why we have the purpose and values and the set of outcomes that sets that out. Fundamental to this is the approach that mainstreams equalities throughout. This time, we have moved from having a specific outcome on reducing inequalities to that being done throughout the framework. As the cabinet secretary said, we will report on progress in relation to different equalities groups and area-based inequalities, and we will use that information to determine whether we are making progress for the whole of Scotland and for different communities within Scotland.

I will pick up on an example that demonstrates the point that you raise. Work was done a couple of years ago on the development of a place standard for local communities, which looked at a range of outcomes and indicators for which responsibility is spread across public services. As regeneration takes place in communities or as new communities are established, we look to create the conditions that will improve health and wellbeing. At the heart of that is the use of a tool that engages local communities in what is important to them, and they do not define that in the context of Government portfolios or the responsibilities of individual agencies. From a public health point of view, the extent to which we can influence local community planning in discharging its new responsibilities under the Community Empowerment (Scotland) Act 2015 gives an example of how we can draw right across different national outcomes.

As I look down the list of indicators, I see that every single section has things that will contribute to narrowing inequality, from the economic one about productivity and jobs to the indicators on poverty and so on. I have spoken to the committee before about complex system change. For me, the critical part of this is about how action is to be taken, who will be doing things, and what we want to change, by how much and by when. Our experience with such things as the early years collaborative and the patient safety programme tells us that the best people to design that action are front-line staff. It is not easily done in offices a long way away from the communities that we are trying to help. You could imagine a local authority taking some of those indicators and saying, “Yes, we will try to change the following five things. What do we want to change, by how much, by when, and by what method?” Once that gets going, we will see change happening.

Do you feel that there is a bit of work to do there?

Under “Next Steps”, the national outcomes document states:

“We are testing new approaches around delivery of the Outcomes and will be focussing initially on four Outcome areas to identify methods to turn broad Outcome intentions into concrete policy options and proposed actions.”

I think that I know what that means, but there is clearly a plan and it has got to get rolling and be scaled up as quickly as possible if it is to have a significant impact across Scotland.

I will build on Alison Johnstone’s points about health inequalities. I was reading quite an interesting article by Pickett and Wilkinson from 2009 entitled “Why more equal societies do better”. The basic argument was that we need more emphasis on social and economic factors, such as why the poor die younger than the rich. It argued for a fundamental change in society at the macro level to change the power distribution. That is obviously a wider point than this committee is addressing, but I wonder whether any of the panel, in particular Professor Sir Harry Burns, wish to comment.

Pickett and Wilkinson’s whole theory is based around what Sir Michael Marmot describes as status syndrome—the idea that inequality per se makes people at the lower end of the scale feel bad about themselves. It is actually more complicated than that, and I have had a number of discussions with Richard Wilkinson about that kind of thing. It is entirely possible to narrow inequalities using a whole range of approaches, but the fundamental one is to give people a sense of being in control of their lives. If you are living in bad housing and do not have a job or a sense of purpose in life, or if you are worried about drug pushers getting at your children, you are buffeted by circumstances, and if you have had a difficult childhood, your ability to feel in control is impaired.

There is a lot of evidence that the way in which the public sector interacts with people can either enhance or damage their ability to be in control. I have been arguing for a while about changing the way in which the public sector interacts with people living at the lower end of the social scale in order to enhance their sense of self-efficacy and control. There is lots of evidence that that improves the educational performance of children in those families and their chances of educational success, that it reduces the risk of offending and, ultimately, that it increases their chances of participating in economic growth.

We do ourselves a disservice by reducing complex problems to a single cause and effect relationship, as they are much more complex than that. We need to adopt complex system approaches to be successful. At the end of the day, if you get change, you might never know what it was you did that produced that change. It might be 10 of the 20 things that you tried that produced that change, but my argument is: who cares, as long as we make things better?

My final question is for the cabinet secretary. We had a unanimous decision on MUP, which is to be welcomed, but what are the next steps? We all know about the damaging effects of alcohol. There have been suggestions in the press—I am not recommending this—that we should have health warnings on products with alcohol, as we have with cigarettes. Another issue is the social responsibility levy, which has been put on hold. What are the next steps, given that alcohol is a major issue that affects health in Scotland?

I am happy to talk about that, given today’s importance in taking forward what I think is a hugely important public health policy, which I am pleased has cross-party support. You will be aware that the framework for action on alcohol is being refreshed. We have always said that minimum unit pricing does not stand alone; it stands with a range of other measures that are being taken.

The issues of advertising and health warnings have been part of Aileen Campbell’s considerations for the refreshed framework. Some products already have on them the chief medical officer’s guidelines and messaging about drinking responsibly. I guess that some people are calling for us to go further than that in the warnings on products. Progress has been made, which is to be welcomed, and we will certainly give consideration to the further calls. Given that United Kingdom and international producers are involved, issues arise as to where the responsibility and the power to change advertising lie. Obviously, those are complex matters and they depend on where production takes place. However, we are looking at what more can be done in that space.

On next steps more generally, the evaluation will be important in looking at the success of minimum unit pricing and considering whether we need to make further adjustments. The evaluation will start straight away and run for five years, which will give us a wealth of information by the end of the period. As I have said before, I am happy to keep the committee informed about that, because it will not just be about where we have started and where we have ended; information will be flowing through the course of the evaluation.

Do you have anything to add on the social responsibility levy?

As we have discussed previously, the social responsibility levy was designed to be a local mechanism to recognise demands on local resources. It was never really thought of as a national tool or response like the minimum unit pricing policy. However, as ever, whether it is the social responsibility levy or the public health supplement, we will keep those matters under review. Given the economic circumstances that the country has faced in recent times, we felt that it was not the right time to apply the public health supplement again although, obviously, we have applied it in the past. We will keep those matters under review.

I encourage colleagues to keep their questions and answers in the context of the national outcomes.

11:15  

Good morning, cabinet secretary and officials. I congratulate Professor Sir Harry Burns on the new arrival in his family.

I want to draw the questioning towards the content of the indicators in terms of what is included and, more important, what is not. One of my constituents is 95-year-old William Valentine, whose son and daughter came to see me yesterday. William Valentine was admitted to the Western general hospital at Christmas and was declared fit to go home at the start of February. A social care package for him was drawn up, which was not complex and involved him receiving three visits a day. However, nearly 100 days later, he is still in the Western general because there is no provider willing to take up that commission.

We know that deficiencies in social care in our communities, particularly for older people, create an interruption in flow throughout the whole health service that means that, for example, elective surgical operations are cancelled because there are no beds for people to be admitted to; and the interruption in flow is partly responsible for delays in accident and emergency, because there are no beds in the wider hospital for people to be put through to. Given that context, why is there no indicator underlying the health outcome in the performance framework for the provision of social care to older people?

You raise an important point about delayed discharge, but there has been a good, downward trend in that figure, with a 7 per cent reduction over the year. However, there are local challenges. You will be aware that there are particular challenges in Lothian and that a new chief officer is starting in the integration authority in Edinburgh who brings a wealth of experience from Aberdeen about the mechanisms and policies that have been taken forward there.

Generally, the national performance framework looks at the key indicators that can establish Scotland’s performance, but a wealth of work goes on underneath that, particularly in integration authorities, which have been doing huge amounts of work on data collection and developing their own indicators. Tackling delay is one of the key indicators and, as Mr Cole-Hamilton said, it connects to ensuring that we can reduce the level of unscheduled care and the length of stay in hospital, and avoid admission to hospital in the first place for some. All those things are key for the indicators that the integration authorities use. Alison Taylor has more detail about the work that has been done in that regard.

Absolutely. The national performance framework sits across the top of Government responsibilities. We are doing a lot of work with the integration authorities, as the cabinet secretary said, to support them to have a core of improvement measures that they share with us and which are common across the country; and to build around those a network of measures that are appropriate to local circumstance. I would expect to see quite a lot of variation in which measures individual partnerships use, particularly where they have recognisable problems of the sort that Mr Cole-Hamilton described. For example, in South Lanarkshire, a local framework for improvement has been built up around the partnership that looks across about 100 measures but specifically focuses on areas where they know that they need to see improvement and progress.

We therefore have a lot of work under way to reinforce the data that is available to partnerships to ensure that they use a common set and that comparable lessons and evidence can be drawn from that. However, on top of that, as Mr Cole-Hamilton rightly reflected, there is also the need to consider what local pressures need to be addressed. As the cabinet secretary has indicated, we are supporting colleagues in the Lothian partnerships, but particularly Edinburgh, to address the problems that Mr Cole-Hamilton described.

Cabinet secretary, you will recall that a commitment was given during the budget scrutiny that we would receive data on integration joint boards by the end of March, but it has still not arrived. Do you want to comment on that?

If memory serves me right, a letter that has been drafted on that is coming to you soon. We will ensure that you get it as soon as possible.

It might be helpful to say something in general about the indicators and why we have chosen the set that we have. We could have had hundreds or thousands of indicators. I am in charge of statisticians around the country who are beavering away producing some great data. However, we have chosen 79. Among other countries around the world that I have seen, some use a maximum of 50 indicators when they are trying to describe economic, social and environmental progress.

We did some consultation events with a couple of hundred experts that generated literally hundreds of ideas, and I knew that I needed to whittle the number down. I did that according to some principles: it was important that the indicators measured progress towards each of our 11 outcomes, that they could tell us about progress across different parts of Scottish society and equality groups, and that the data was technically feasible—that is, that the underlying data would allow us to tell whether measure were improving or worsening. Where possible, we aligned the proposed indicators with the indicators from the United Nations sustainable development goals. All that has helped us to decide which of the indicators to go with.

I will be brief. I am not suggesting that the indicators are not worthy; they are, and some are quite exciting. However, even though the process is as you have described it, I am not persuaded that an indicator that measures the number of visits to the outdoors is more important than the fact that we have nothing in the suite of indicators that measures the health of our social care landscape. As we know from much research that the committee has done, that is one of the main blockages to adequate flow through the NHS. Why should we not think that the Government has its head in the sand on social care, since it does not have an indicator to measure social care provision in our communities?

As Alex Cole-Hamilton is well aware, tackling delayed discharge is a Government priority, which is reflected in the fact that all the integration authorities have it as a key target. Local delivery is going to deliver—and is delivering—a reduction in delayed discharge. Without that local delivery and the indicators and targets that are being applied across the integration authorities, we would not have the reduction in delayed discharge. An indicator sitting in the national performance framework will not, because each area is different, deliver the change locally that partnerships need in order to ensure that their targets are relevant to their area. Sustained work around tackling delay has led to reductions.

What the city of Glasgow has managed to achieve, given the size of its integrated authority, is absolutely astonishing, and we need all partnerships to be doing that. We recognise that there are in the Lothians and Edinburgh market issues to do with the ability to recruit social care staff. We are well aware of that and have to help the partnerships there to overcome those issues. The issues are particular to Edinburgh and the Lothians, therefore the response has to be shaped in that local context if it is to be in any way successful. That is why the targets sit better with the integration authorities.

The process is working. That is why we have seen a reduction in delays, which I believe we would not have seen had there not been that focus within the integration authorities on driving delayed discharges down.

I have a small follow-up to Alex Cole-Hamilton’s questions. The framework has been mentioned. There is not just negativity—there are improvements in health. On older people, I think that it is quite a good thing that it is projected that people will live longer. I am looking forward to joining them; I am sure that lots of us are. It should be celebrated that people are living longer—and we hope, in a better atmosphere and in a better way.

I was a wee bit concerned that there is no outcome for older people, but I understand that there are many underlying issues in that respect. When we are getting feedback from the various agencies, what would be an outcome for older people? Will one be included in the framework or will that be included in all the other outcomes?

I want to pick up on a couple of other points. People are living longer, but probably the worst thing for people’s health—this applies mostly to older people, but not just to them—is loneliness. Will a strategy for loneliness be included in framework?

I also want to pick up on David Stewart’s point about minimum unit pricing of alcohol. We always mention younger people, but Alcohol Focus Scotland did a massive survey in which it found that unfortunately—I hope that minimum unit pricing will help in this respect—the group that is affected most by alcohol is lonely older people who sit at home and drink. There are facts and figures to prove that. Will that be included in the strategy that will feed into the national performance framework?

Yes. The system is like a pyramid: the broad indicators are at the top of the national performance framework, and underneath lies all the work that Sandra White highlighted. Local delivery is how the change will happen. Again, I cannot emphasise enough the role of the integration authorities, which are the delivery mechanisms for change. They will take all that work and craft it so that it is relevant to local circumstances. The integration authorities will ensure that they focus on the priorities in their local areas.

Sandra White mentioned loneliness. Many integration authorities focus on reducing social isolation and on bringing people out of their homes. We have talked in the committee previously about our not wanting a person to see nobody from when their care worker leaves on Friday through to Monday. The involvement of the third sector is crucial in tackling loneliness, and we are encouraging integration authorities to focus on reducing social isolation.

There is a pyramid, and the work throughout that pyramid will, in one way or another, impact on the very broad outcomes at the top.

Good morning, panel. You are probably aware that I have a particular predilection for looking at the prevention agenda. When looking at national outcomes, I think about the health of the nation; the outcomes are measurements of the health of the nation. I think that we would all accept that we are not doing particularly well in mental health, drink, drugs, obesity and the health of our healthcare professionals, which is fundamental to delivery of any national outcome. With that in mind, do the national outcomes need a stronger focus on prevention in order to create an environment that encourages better and healthier choices?

Yes. There is a focus on prevention, and a lot of the work to reduce inequalities that we talked about earlier is around prevention. On alcohol, minimum unit pricing and the rest of the framework are about culture change—change in the nature of our relationship with alcohol. Clearly, that involves preventing alcohol misuse in the next generation and trying to get people to view alcohol in a different way.

We have made quite big strides forward through public health policies—on smoking, for example. Brian Whittle is right to highlight obesity, which is the next challenge. He will be aware of the work that Aileen Campbell has been doing to ensure that we take an evidence-based approach to our public health policies, so that we can make inroads into the problems.

The new public health body will be able to give a sharper focus to prevention work—not just in healthcare, but in support for local government, for example. The new body will be able to help local government and other local decision makers in the decisions that they will make on public health. Work is going on apace on the new public health body. That will help us to focus, quite rightly, on prevention.

11:30  

Harry Burns’s point is important, too. Our giving people a chance in life and giving them hope has to underlie what we do. It is not just about particular health challenges. Getting it right for children and young people is key to improving opportunities for the next generation through making a direct impact on their health and wellbeing. That is why we focus particularly on children and young people.

Rather than talk about the health of the nation, I prefer to talk about the wellbeing of the nation in a broad sense. A healthy population will tend to have low crime, high participation, good social cohesion and good productivity. It will be firing on all cylinders, across the board. A positive and nurturing childhood gives young people an environment in which they learn, participate and behave well. On the train today, I saw an article in the free newspaper about how young people who get into trouble have brains that are wired wrongly. We have known that for 20 years; studies in Glasgow have shown that psychological activity is different in people who have lived in complex situations as children. They learn to be defensive, are emotionally labile and their executive functioning is such that they do not make good decisions. We can see that; teachers nod when I talk to them, because they see those things in their classes. Making families secure and safe, and feeling that they can move forward in life, will make the big change in the future. Something in every single part of the suite of indicators contributes to that.

I come back to the point that the number of indicators is huge, so how do we make them work together? How do we get local authorities, health boards, Police Scotland, education authorities and so on to work together to deliver across all the indicators and make the necessary change? I am very excited by the possibility, but I am in no doubt about how difficult it will be to make it happen. We will need an open-minded approach to working together and testing things so that, if they work, we do more of them, and if they do not work, we stop doing them and move on.

A good example of the cross-Government approach was the recent event about adverse childhood experiences. Every cabinet secretary was there to listen to people’s experiences and, importantly, to look at how the experiences could have been prevented in the first place and how to make early interventions when the experiences occur. The impact on the population, including cases such as Harry Burns referred to, is huge. One cabinet secretary cannot begin to tackle it; a cross-Government approach to the work is under way and will be very important.

On the preventative approach, members will recall that a pillar of the Government’s health and social care delivery plan was reform of public health. It is particularly relevant to NHS Health Scotland because we will become part of the new national public health organisation. One of the important developments as we pursue reform will be the publication next month of a new suite of public health priorities. They have been developed using a whole-system approach across public services. The discussions, especially at the oversight board that is looking at the reforms, have included a strong focus from local government on there being a much stronger public health voice in communities to inform community planning, and there has been a plea for public health to support community planning partnerships.

It is within communities that plans for transport and planning will encourage, rather than just exhort, people to be more active. That is a good example of the preventative approach. The priorities that are emerging are entirely aligned with the national outcomes, as they have been developed.

The cabinet secretary alluded to the fact that this is not just about her portfolio, but is cross-portfolio. Can you clarify whether the other portfolios are feeding into the national outcomes and implementing their policies according to national outcomes on health?

They are very much doing so. I gave an example relating to adverse childhood events. The development of the framework is a cross-Government process in which there has been a change of focus, towards looking for opportunities to collaborate. Brian Whittle may be aware of work that I am doing with Michael Matheson in justice on the prison population and how we can improve outcomes for prisoners, in particular when they leave prison, in order to reduce the risk of reoffending. That is about making sure not only that they get access to health services to address addiction, for example, but that there is a range of ways to minimise the risk of reoffending. That is one example of collaboration feeding into the framework; there are many others. There is real willingness to seek out such opportunities.

Good morning, panel. How will the principles that are espoused in the Government’s review of targets and indicators be manifested in the national performance framework? The rationale for the review of targets was that NHS staff and managers had expressed frustration at how targets are affecting their work and priorities, and leading them away from best practice. How do you see empowerment of our NHS and social care staff happening in the future? Nurses tell me of their frustration at the amount of form filling that they are asked to do. How will the framework change their lives and empower them to do the job that we want them to in our health service?

We certainly want to reduce bureaucracy and paperwork generally. Increased use of technology offers an opportunity to do that and to ensure that we maximise the amount of time that health professionals and anybody else has for working with people, rather than on paperwork.

In developing the new framework, we were very mindful of the need for coherence with the work that Sir Harry’s review has carried out. The new framework reflects that in a number of ways. It provides improved clarity on the aims of the system, focuses more on indicators and targets, has been shaped through engagement with a range of stakeholders and looks across the whole system at how the parts are interconnected. We have sought to incorporate the findings of the review into the work on the framework, but the framework will continue to evolve and the recommendations from Sir Harry’s work can be further incorporated, as we take it forward.

A number of other pieces of work are under way, looking at how we can focus more on outcomes than on targets. Work is being done on cancer waiting times and accident and emergency departments, where the four-hour target is important. The experience of patients across the whole range of unscheduled care is important, so we are looking at that, as well.

A lot of work that is aligned to the framework is under way, and some of that work will be reported on quite soon. The committee will find that it is very much in line with what Sir Harry recommended.

The comments that I made in the report about the previous national performance framework were that it was frustrating that the national performance indicators were measured only annually, which did not seem to be often enough to enable change. If something were to go wrong, waiting a year to measure what was being done would not give decent feedback on whether it was having an impact.

The second thing is that although some process targets and indicators in healthcare—four-hour waiting times, for example—are important, I was hearing stories about people attending their local A and E department 40 or 50 times a year and calling 999 40 or 50 times a year. A four-hour waiting time in A and E would not help such an individual, because there are other things going on in that person’s life that need to be addressed, which is where the high-level indicators come in.

I was not worried about how quickly people were getting through the system; rather, I was interested in asking why people were going into the system in the first place and where they were going at the end of it. The NPF indicators will give the opportunity to start to manage the broader system and to get change happening that will reduce demand and improve outcomes. That fits with what I was concerned about in the review.

When you highlighted that, the whole committee agreed that people should be getting treatment and care from the right professional in the right setting.

However, my point is about empowering our professionals. I have met nurses who have never met their managers—they know their name but have never seen them. We need to look at how our health service will change in the future with different systems working. There is lots of talk in the report about change management but, from that, I do not know how we will make that happen in the health service. How should that happen in the future?

I agree with you: where we have seen successful change in things such as the early years collaborative, it has been through front-line staff being empowered to make change happen. That requires leadership from the top and leaders who will come along and say, “You know about this better than me, so I am happy to let you test the change and tell me what happens.” They must give staff permission to do things differently in the hope of finding a better way of doing them. There are any number of examples of that happening in industry, and we have examples in public services, too. Spreading this is the way to make change happen quickly.

One of the best examples in the NHS is the patient safety programme, which has worked on the principle of empowering front-line staff rather than having memos from senior managers saying, “You need to do this.”

The methodology is now being used in other areas of the health service—for example, in mental health and primary care and in other parts of the public service such as justice—because it is about empowering front-line staff. It drives cultural change, too. An example of making sure that our finances are spent as well as they possibly can be is the empowerment of front-line staff in testing ideas about the way in which things are ordered and money is spent. For instance, in Raigmore hospital, front-line staff on wards have been making changes that they have wanted to make for quite some time. They have now been empowered to do that, which has brought a huge financial benefit to that area of the hospital, because they knew that processes could be improved.

It is about listening to front-line staff and empowering them to make changes, whether in procurement, patient safety or other areas. It is a big cultural shift.

When managers feel that they will be shouted at in the press or—dare I say it?—the Parliament for failing to meet a four-hour waiting time, it is understandable that their focus is on that rather than on the big picture. We all need to understand that the change that is under way is complex. The 95 per cent target may not have been met, but that might be because a lot of people have come in the front door and hospitals have to manage that situation rather than throw all the money and effort at the four-hour waiting time.

11:45  

Good morning, panel—it is still morning.

I enjoy talking about this subject, because it is what I did for a living before I came into politics and it reflects the experience that I have had in implementing such systems across a range of organisations.

On the positive side, it is great that we talk about empowerment and systems thinking. That is correct. It is clearly important that we measure the right things, and we understand the need to dig in and understand unintended consequences and make sure that we are focused on the right stuff. I can see that the thought processes are starting to go in that direction.

However, what concerns me when I look at this, thinking about organisational review and things that I have done in the past, is the fact that, although it is great that you are measuring things and having a conversation about whether you are measuring the right stuff, there is a long way to go on whether the things that are being measured line up with each other and are measuring what is important to the organisation and on whether you are living and breathing this stuff and using it to drive process improvement.

I do not have the feeling that, when you wake up in the morning, the first thing that you think about is the national performance indicators or that they are the last thing that you think about before you go to bed. If you were following the process properly, that is exactly what you would do, because the indicators on the paper in front of us would be completely aligned with everything else that is important across the organisation and everything that is happening in the organisation. You would understand the linkage between those things and the indicators on the paper. I think that there is still a way to go on that journey, but that is fine because the further we go, the better things are going to get.

In a perfect or sensible world, the national performance indicators, the work that is done on indicators and the work that health boards and integration authorities are doing on local delivery plans should all be joined up so that we know that what is happening in one place links up with what is happening in another and we understand the linkage and relationship.

We must understand that what is happening in a health board at a local level has a direct impact on an indicator on a piece of paper in front of us. How are we getting on with joining all of that up so that it is all linked?

We are joining it up. The work that is under way with integration authorities in the data working group is aligned with the local delivery plan standards. Those continue to be important and are being reviewed, as I touched on earlier.

The point about measuring the right things develops Harry Burns’s point. He is right to ask why people end up at the front door of the hospital, and we understand that issue a lot more now. Integration authorities are explicitly saying that they are going to reduce those unscheduled episodes because they know that hospital is the wrong place for a lot of them. Integration authorities invest in primary care and services that keep people at home in order to deliver that outcome.

We see far more focus on understanding addiction issues. That is the reason for some of the work at Glasgow Royal infirmary, for example, which has identified the people who keep coming through the revolving door. Having alternatives for those people is the focus.

We have understood those issues more. The work is aligned and the success of all that work will drive the indicators in the national performance framework in the right way. It goes back to the pyramid. All the work at the bottom will drive the indicators at the top in the right direction by making sure that we focus on the right things.

The cabinet secretary has given the important example of the objective to reduce occupied bed days in hospital, which is set out in the delivery plan. For a very long time, we have focused on delayed discharge, as is right and proper. However, as everyone knows—everybody in local systems tells everyone this—it is far too late to start thinking about the problem at the point when someone is already delayed. We needed to take a more holistic look at the whole pathway of care and the sort of experience that Harry Burns is describing, including admission and what happens before admission.

An objective to reduce unscheduled bed occupancy is narrow enough in definition that we can actually count it—which is important—but is also a good signal about what is happening across the system and in our relationship with the partnerships. It is important that they are looking at the current performance and are establishing a positive objective for improvement to fit into the national aim. That is a good balance of responsibility and signals a good relationship between national and local partners. I hope that we are measuring better and in a better way than we were.

We I am responsible for NHS Health Scotland, which is one of Scotland’s public health bodies, and, just over five years ago, it was very clear that health inequalities had become a real focus in Scotland's public policy narrative. We looked to the then national outcomes to source the authority for a change of emphasis towards inequalities, which is why our organisational strategy was called a fairer, healthier Scotland. That gave us the opportunity to look outside the world of the NHS, in which we operate for most of our business, and to work with natural partners. That required us to develop a whole different approach to what such a partnership should look like.

I mentioned the place standard tool. That piece of work was undertaken by NHS Health Scotland, Scottish Government planning officials and Architecture and Design Scotland, which are not natural bedfellows. However, on the basis of the evidence that we considered, bringing those specific people together was most likely to create conditions in which people’s health and wellbeing could be preserved, maintained and supported.

The changes in public health give me a lot of cause for hope because of the extent to which the Scottish Government has now engaged in a very formal partnership with local government on how to create public health. One of the disadvantages in Scotland in the past 40 years or so is that public health has become quite disconnected from local government in many cases. This is an opportunity to put public health right back at the centre of the public sector space between the NHS and local government, and it is largely driven by the focus on the national outcomes.

Stepping back, although there are some challenges in implementing the national performance framework, it is considered to be world leading—as international commentators from around the world, such as Professor Stiglitz, have said. Over the past few years, many countries have seen what is happening in Scotland and have adopted our approach. We have some way to go, but we are still quite a long way ahead of other people.

You have discussed how to empower staff and how to include staff to ensure that the framework is at the top of the agenda in their daily work. What about improving the ways in which staff can feed back into the implementation? I am talking about trial and error. There will be times when things work and times when there are lessons to be learned as you monitor and review the performance indicators. How do you envisage professionals being able to feed into the process, not just at the beginning but on an on-going basis?

We need to look at what the evidence tells us works. A lot of change is happening—there is a lot of reform in the public sector generally—and we have learned lessons. The worst thing to do is to send a memo from on high, saying, “As of next Tuesday, this is how we are going to do things.” That does not create change.

The better way to create to change is through the improvement methodology that the patient safety programme has shown works. That approach is to test the theory of a change in a setting, so that you get a group of staff—wherever they are and whatever they are doing—to test the method. When they see the benefits, they become the proponents of the change and tell others why it is a better way of doing things. It is not rocket science, but it works.

We need to make sure that staff are involved in understanding and talking about why a change is necessary and why it is better to do something a certain way. The methodology of change is about making sure that a change is tested properly and that the staff who are involved become the promoters of acting in that different way.

If we look at the patient safety programme 10 years on, we will see that it started small, by doing something different in one area, and has now become a way of developing and delivering change across the public sector.

When I was at the Western general hospital, I was told by folk who were involved in the early days of the programme that there was a lot of cynicism about the programme—they had heard it all before and queried why it would be any different from other approaches—but those same people told me what a difference it had made, because they could see the benefit to patients straight away. That way of working can be applied in any setting and, as we reform our public services, we should use that methodology as much as possible.

Data drives front-line staff to make changes. Recent events are making me think of bedtime bear. How do you raise the level of cognitive development in children? One way is to make sure that they all have bedtime stories. We could say that we will have a strategy for bedtime stories, but such a strategy would not work. However, we could ask front-line staff what they could do with parents who come to collect their children from nurseries that would enhance bedtime reading. The next day, we could ask the children whether they had had a bedtime story, and we could then log the results. If you do something and the figures increase, you do more and they go up again, and staff become seized with it.

Bedtime bear is a classic example of that. A nursery gave a teddy bear to all the children and said to them, “Bedtime bear needs a story before he will go to sleep at night. When he is going to sleep, you take bedtime bear to mummy or daddy and get them to read you a story.” In that way, the child gets a story. That was one of the first tests of change in the early years collaborative, and it is small things like that that make a difference. Suddenly, the numbers went up. East Ayrshire Council tweeted a picture of an A4 sheet with the numbers going up, and everyone started thinking about the approach.

Showing people that what they are doing works encourages them to do more of it. You then share that across Scotland and, before you know where you are, you have a result.

I understand that all the indicators are given equal weighting. Ultimately, meeting those indicators will filter down into staff’s daily priorities. However, there may well be rural and urban inequalities in how they meet those indicators, targets or priorities.

There should not be. Patients are patients, whether they are in a rural or urban setting—people are people, wherever they are. If you want to enhance hand washing on a ward, the same principles apply no matter where you are.

The critical aspect is that staff working in rural settings need to be involved in and part of the change. They certainly were involved—800 people would get together every six months for the early years collaborative, which was very powerful.

12:00  

Geoff Huggins mentioned the same topic at a previous meeting, which he framed as

“working to develop a next-stage process.”—[Official Report, Health and Sport Committee, 9 January 2018; c 52.]

What is the next step? When can we expect a bit more information on this outcomes-based approach?

The work is on-going. To return to Ivan McKee’s point, we need to make sure that everything aligns, that everyone can see how it all aligns, that there is a clear line of sight on how the work that the integration authorities are taking forward on the ground fits with the national performance framework and that the work that Harry Burns has set us on a track to achieve shifts us more to outcomes.

The work on how we focus more on the outcomes for people, whether that relates to their coming through the front door of a hospital or remaining at home or to tackling social isolation, is going on in a number of settings. All those things are hugely important, but their detail will be captured through the work of the integration authorities.

That is right. There is also process related to that work. For a number of years, the cabinet secretary has chaired a ministerial strategic group for health and community care, which is co-chaired with the Convention of Scottish Local Authorities. That builds on Gerry McLaughlin’s point about true cross-public sector working. The group receives regular updates on the progress that integration authorities are making on key indicators that sit at the heart of what their local planning for improvement looks like.

How we are providing those updates may not sound novel, but it is. There is a national aspect to it, but we also ask chief officers from individual areas to come and talk about some of the issues that they are grappling with. It is all new off the blocks, but it is a good model to work with. The progress that is made will be reflected in the integration authorities’ annual reports, so there will also be a formal published mechanism.

We are building on all that work. A lot of effort and investment has gone into supporting it, including to improve the data and the skills in local systems. We have analysts on the ground in every partnership area, and we are learning from specific improvement activities. For example, Dumfries and Galloway NHS Board has been doing interesting work on dementia indicators. Therefore, we are learning from individual good practice, too.

That is, basically, the outline of the next stage in the development of the work.

I thank the witnesses for their evidence today. We now move into private session.

12:02 Meeting continued in private until 13:03.