Health, Social Care and Sport Committee

Meeting date: Tuesday, September 28, 2021

Official Report 711KB pdf

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Health and Social Care Finance Stakeholder Session

Our third agenda item is a round-table session with stakeholders on health and social care finance. The discussion is intended to inform the committee’s future work programme discussions and its approach to pre-budget scrutiny.

I apologise for keeping our panellists waiting; they have been very patient.

I welcome Leigh Johnston, who is a senior manager at Audit Scotland; Professor David Bell, who is a professor of economics at the University of Stirling and who remains with us from the previous panel; Siva Anandaciva, who is chief analyst at the King's Fund; and David Walsh, who is public health programme manager at the Glasgow Centre for Population Health. I thank all of them for joining us to help us with our work programme, and for waiting.

I would like all of you to tell us whether there is greater scope in the landscape to prioritise preventative spend. We are dealing with the aftermath of a pandemic and setting up a national care service but, time and again, we hear that we do not prioritise preventative spend enough. As we heard from the previous panel, preventative spend actually saves money for the future and has better outcomes. However, because of the pandemic, we are in a bit of a crisis moment, and it is difficult to square the circle when you have to deal with immediate concerns.

I will go round all the witnesses to hear their views, starting with Leigh Johnston.

As we have previously reported, integration was intended to help shift resources away from the acute hospital system towards more preventative and community-based services, but achieving that has not been easy. There has been a lack of agreement on whether it is achievable in practice or whether rising demand for hospital care means that more resource is needed across the system. With the huge backlog from the pandemic, the situation requires disinvestment and reinvestment, but that, as I have said, has been very difficult to achieve up to now. That said, the pandemic offers a chance to do things differently, and we need to seize the opportunity to think about different and more sustainable ways of delivering things.

I echo what Leigh Johnston has just said. Part of the difficulty of moving resources towards preventative spend, which the Christie commission advocated several years ago, lies in demonstrating the usefulness of such spend and convincing managers that there are genuine resource savings to be made in allocating more to it. That is a difficult task; it is not easy to make a convincing demonstration in that respect to those who feel that acute services are under pressure and require immediate support.

In the previous evidence session, Henry Simmons talked about how lifestyle changes might reduce the negative effects of Alzheimer’s progression, and that result seems to have been accepted. I am reiterating the same point, but it is difficult to persuade managers that programmes that might not see a successful outcome for years are worth doing. Many countries have tried such an approach, some with more success than we have had, but it is a huge challenge.

First, I should point out that I work for a think tank that is based in England, so an awful lot of what I will say—actually, almost everything—will have an English context.

I want to make five quick observations.

First, the logical—or business—case for greater investment in a preventative approach in public health services has been made.

Secondly, as the other panellists have pointed out, that does not seem to have translated into greater investment. It is a fact that things are held to different standards. A proposal to build a new hospital, for example, will, in most cases, not see a benefit for five to seven years, but I am certain that that business case will get through a lot easier than the case for a transformative increase in preventative spending.

Thirdly, for the first time in England—I think that we are largely following your lead in Scotland—some of the structures are changing to support greater preventative spend. We are forming integrated care systems in which the basis of work is collaboration, not competition for greater elective activity. The contractual frameworks will change, so we will get off the hamster wheel of annual spending and have a three to five-year budget, which will provide us with some headroom to invest in services that pay dividends further down the line. Perhaps more important, our expectation of what it means to be a leader in our healthcare system is subtly changing, from someone who runs a good ship—a good hospital or organisation—to someone who is a system leader and thinks about the health of their population.

11:30  

Having made those optimistic points, I will finish on two slightly more pessimistic points.

Currently, in almost every conversation that I am in, the elective care backlog—the waiting list for planned hospital care—takes up almost all the oxygen in the room. That is for historical reasons and because that is where most of the data and performance targets are measured. There is simply not enough funding available to run two systems in parallel: a system that is focused on tackling that backlog and one that is focused on transformative improvements and preventative spend.

Finally, at present, it is uncertain what the system’s strategic priority will be for the next five years. As one chief executive put it to me, “I work out what my priorities are by thinking about what I would get sacked for, and I can tell you now that, over the next five years, it is more likely that I will get sacked for not tackling the elective backlog than for any other issue.”

There is a mix of some hope and a little bit of pessimism.

Good morning. I should preface my answer by saying that I do research in the area of health inequalities, which is less about health services and more about the broader determinants of health. If we are talking about prevention, we need to understand it in a really wide sense, by thinking about the big social and economic drivers of poor health and health inequalities that exist.

It is really important to look at the context. We talk about Covid and the crisis in the health service, but it is important to understand that we were already in a crisis before Covid. The impact of the UK Government’s austerity measures, in taking out £47 billion across the UK from social security payments, has had a devastating impact on health outcomes everywhere, and in widening inequalities. There has been talk of a stalling of improvement in life expectancy, which is one marker of population health, but we know that that actually masks increasing death rates among the most deprived populations across the UK.

With regard to prevention, it is really important to understand that context. Even before Covid hit, we already had the widest health inequalities in western Europe, but they have become a lot wider on account of the past 10 years. Covid has come and it will go, and we will see the impact through a couple of years of markers such as life expectancy and mortality rates, but, when we look back to pre-Covid rates, we see that—as I said—we were in a crisis already.

Thank you.

David Walsh picked up on some of the other issues that colleagues will come in on, but also highlighted what I was driving at, which is the interdependence of different portfolio areas with regard to Government having an impact on health outcomes. You picked up on the idea of economic inequality having a direct impact; we could say the same for educational inequality.

I will come back to you with another question before I go to colleagues. Last week, one of our witnesses commented that every Government minister is a health minister and that we should view health outcomes through the lens of absolutely everything else that we do. What are your thoughts on that? What could be the impact on health outcomes of a universal basic income, for example?

More generally, on the question whether everything matters and whether all the different Government departments somehow relate to health, that is a fundamental understanding of public health. There are thousands of models of health determinants out there, which contain many factors. They include health services, but that is only one of many factors, and it is not the most important. The most important factors are the social and economic factors that you allude to.

The evidence around the relationships between income, employment and education and health, and the conditions in which people are brought up, is overwhelming. Those relationships go back not just decades, but centuries, so it is important to understand that all those factors ultimately impact on health. On one level, that is public health evidence, but it is also common sense—we know all that.

David Bell referred to health behaviours, which do not emerge in a vacuum—they are about how people respond to the environment that they are in. Social and economic factors are imperative, and income is imperative. It is important to consider a minimum income in relation to health, and work is going on in various areas to try to understand the ways in which we can protect the poor. That is fundamentally what this is about.

To go back to the point about austerity, the impact of the cut in social security has been absolutely calamitous in taking away the safety net for the poorest and most vulnerable people in society. In the context of our rather limited powers in that area, we have to try to do what we can to protect the income, and therefore the health, of the poorest and the most vulnerable using the powers that we have. Obviously, they are very limited for social security.

We will come on to have more in-depth discussions about some of the themes that you have all mentioned. Evelyn Tweed will ask about the strategic context for health and social care finance.

I am interested in some of the early comments that the panel made. How do we give managers the headroom to deal with future and preventative care and to provide an exceptional service, rather than having to deal only with the present conditions and backlog?

Let us take this in reverse order: we will come back to David Walsh first, and I will then go through everyone. For future questions, people who want to come in should put an R in the chat box, as not everyone will be able to respond to every question.

Doing this in reverse order is probably not the best for me. My research is not really about health service spend. I made that point when I was invited to come along, but the committee was keen for me to talk about other things. There are probably others on the panel who could respond better to that question.

My work is more to do with the broader social determinants. Clearly, they are the factors that predict poor health in the first place, as opposed to people encountering the health service when they are already in the situation of having poor health.

If it is okay, I will skip that question and leave others to respond.

I would say three things in response. First, the headroom is for clinicians as well as managerial staff—I think that that was in the question. I honestly cannot tell you the number of clinicians who say, “That’s the first thing that goes.” In this country, we have SPAs, or special programmed activities, which are basically my headroom, where I can think about changing my service. Those are the first thing that goes, because I am back on the backlog.

The answer that I am picking up from some of the things that were said earlier is that, if we do not have the right supply of staff—we certainly do not in England—that headroom is incredibly hard to create. Until we increase the size of the workforce, we will always be in a hole.

Secondly, there is an issue with the technical information and the skills and capabilities that we have. For instance, is there the integrated data to show us where we should be having the greatest impact? In parts of the country such as Greater Manchester, that is the case: there are inverted pyramids over particular groups of the population that are relatively small but account for a large amount of cost. If we were going to invest in more preventative spend, that is who we should be supporting the most. Other parts of the country lag far behind. Part of that technical data bit involves giving people the capability to improve services. We have lost some of the ethos of lean operational thinking.

The third thing, which is probably the hardest one for me to get my head around, but also the most important, is culture and organisational development. What particularly sticks in my head is a conversation with a group of consultant ophthalmologists. I was trying to do the sell for having more preventative investment, with greater integrated thinking. They said that, intellectually, they got it but, for their entire career, they had been trained to focus on throughputs and getting people in and out of hospital and their service as quickly as possible. They wanted to do things such as tackling avoidable blindness and unmet need, but no one had yet told them that that was what their new job description was—they wanted clarity about what behaviour should be rewarded—or how on earth they would do things and what steps 1, 2 and 3 were.

The places that I have been most impressed by—Greater Manchester and parts of Dorset, for example—are the ones that have really invested in organisational development, support and consultants working in a different way.

I reiterate what Siva Anandaciva has just said about metrics. If all the metrics that clinicians and other health professionals are confronted with are effectively to do with short-term, acute issues, which can be easily highlighted by reporters in the press, it will be difficult to switch attention away from acute budgets.

On long-term budgets, we are about to have a spending review, but there has been very little consistency of budgeting. That is really because of the UK Government messing around with the timing of budgets and their time coverage.

I agree with a lot of what David Walsh said, but the Scottish Government’s budget is increasingly dominated by health and sport, which now accounts for more than 40 per cent of the overall budget. There used to be roughly the same level of spend on health as there was on local government. For 2021, health and sport spend is forecast to be £17 billion and local government spend is forecast to be £12.5 billion. There has been a big change, and the opportunities to engage with the preventative activities that David Walsh talked about have been greatly limited.

I agree with the point about data. In the previous session, I made the point that, if we do not have the right data, we cannot take the right actions.

Silos and different ministers or different Government departments being responsible for spending their own money and not seeing that some of the resource that they are using would be better allocated to one of the other departments are a big issue.

Emma Harper has questions on that theme.

In the Health and Sport Committee, we took evidence on shifting the balance of care and moving finances into a social prescribing model. One of the things that I am interested in is the prevention of type 2 diabetes complications. We spend lots of money mitigating or treating complications—£800 million is a lot of money—when those complications are preventable.

What is the value of social prescribing? Should it really be invested in more in order to help to improve health and tackle inequalities? I am interested in that because of the previous committee work on social prescribing. Maybe we should start with David Walsh.

11:45  

There is some emerging local evidence on the effectiveness of social prescribing. On that specific question, and on the bigger question that you have led into of health inequalities more generally, I think that it comes down to balance. GPs’ prescription of social remedies might work in some cases, but if, as I have alluded to, there is a crisis in basic social security funding, social prescribing is not going to address that balance. It depends on individual cases. Clearly, if people have their income taken away and are then told that a walk would be good for them—I am not trying to belittle that, but it depends on how it fits with the individual’s circumstances.

More generally, when it comes to the issue of health inequalities and what we do about them, an important point to note is that we know what to do about them, because the evidence is all out there. The Scottish Government commissioned an international policy review of what works in addressing inequalities, and what does not. That was undertaken by NHS Health Scotland, which is now Public Health Scotland. That is all published—it was published about four or five years ago—so we know that there are different levels at which policies are effective. Those include policies that address the fundamental socioeconomic drivers of health inequalities—the stuff that I have mentioned about redistributing income, protecting the income of the poor and addressing poverty. Others are in what are referred to as more environmental areas, such as housing, pollution and taxation of alcohol. There are also issues that are to do with addressing individuals’ experiences of inequalities. However, the most important thing is to address the fundamental socioeconomic factors that drive health inequalities.

First, the evidence is there about what works, so what is needed is political will and political bravery. However, in the context of devolution, the question that has to be asked is about the powers that Scotland has to bring about such changes and to introduce such policies. To address those more fundamental socioeconomic factors, do we have efficient economic levers? I think that that is questionable. The evidence is there. It comes down to political will and political powers, I think.

I want to follow up what David Walsh said on the role of Public Health Scotland. Obviously, it was set up just at the start of the pandemic and has been at the forefront of dealing with that, but I do not think that it has yet had the opportunity to take the whole-system approach to public health that it was set up for. It would be good to see what it can achieve once it is able to do what it was set up to do.

I also have a comment on the wider approach to the issue. Judith Proctor talked about it in the previous session. As I have said, integration authorities were set up to try to move the funding into the community—to more preventative care. However, we identified in our report on integration a number of areas in relation to how that could be achieved. Some of that has already been talked about. It involves the need for collaborative systems leadership, rather than thinking about the aims of a single organisation; thinking more about the outcomes that they are trying to achieve for their community; and effective strategic planning—linking resources to priorities and being able then to link those to the outcomes that they are achieving.

However, as has also been mentioned, there is a need to have access to good data. Again, we have reported on a number of occasions that there is still a lack of data on what is happening in communities—for example, in primary care and in social care. Being able to show the outcomes of preventative approaches is important.

How best do we determine the level of funding that the NHS and social care need after Covid? I know that the British Medical Association has said that

“short-term boosts won’t be enough to deliver the full recovery”

that services need, and that what is really needed is

“a full review”

of health and social care spending in the context of a national conversation about our expectations. Would the panel support that approach?

As David Bell said, health funding was already a huge proportion of the Scottish Government budget, and it has been increased by spending throughout the Covid pandemic. We said on a number of occasions before the pandemic that the NHS is not sustainable and costs have continued to increase throughout the pandemic.

There is continuing uncertainty about how the NHS will be funded in the future. The Scottish Government has made a number of spending commitments, both in its recovery plan and in the programme for government. There is talk of a 20 per cent increase during this session of Parliament. We need to see a refreshed medium-term financial framework for health and social care.

It is also important that we bring the public along with us in our approach to that. Things will have to be delivered differently as we consider our future recovery and NHS sustainability. We need a culture change from the public, so it is important that we engage with them and that we bring the public and staff along with us as we deliver services differently to ensure the sustainability of the NHS.

Leigh Johnston is right. There must be a refresh of the UK’s medium-term forecast for health and care spending. I have one caveat: I understand the criticisms of tactical, short-term boosts in funding. One finance director compared that to their financial plan moving from a cliff edge to a cliff face, because money comes at short notice and suddenly has to be spent in a value-for-money way.

Leigh mentioned uncertainty. I cannot emphasise enough how hard it is to develop a planned medium-term financial forecast with such uncertainty about demand. That is not only because we still do not know what the path of the disease will be but because we do not know when the demand for routine services will come back, what complexity that demand will present and how it will spread over time. There is a question about when is the best moment to have a medium-term plan. I would suggest that that should be at the start of the next financial year, at the earliest.

Beyond the question of timing, you must consider what you want to plan for. I would segment that. The first part is the direct costs of dealing with the pandemic, such as the test and trace system or PPE. The second bit is tackling the backlog, which is broader than planned elective care and includes things such as mental health services, child and adolescent mental health and community care.

Thirdly, we should also ask what a resilient health and care service would look like. That is not just about being resilient to a pandemic but about being resilient to other threats such as cyberattack. That is a pet concern for me. There is a shift to using digital and virtual consultations as the default mode. What redundancies are being built in? What does that cost?

The fourth and final part of the plan is any business-as-usual growth in healthcare spending. That tends to go up by 3 to 4 per cent per year, due to a combination of factors. You almost have to bake that in before you layer in those other cost pressures.

I agree with Leigh Johnston and Siva Anandaciva. There is an annual 3 to 4 per cent growth in costs. During the earlier panel discussion, I alluded to the fact that part of the problem is the ageing population and the concomitant and largely chronic diseases associated with that.

We really do not know the rate at which unmet need—which was clearly there during the pandemic for non-pandemic-related healthcare—is going to be unwound. That will have an important effect on funding requirements.

The budget for health and sport for 2021-22 is £17 billion, and our receipts from income tax, which is our largest tax, are £12.25 billion. It is important that the Scottish Government addresses that funding issue and the issue of how to engage with the public and with staff on the inevitable growth in demand, which has to be set against the needs of the other areas of the Scottish Government’s responsibility, such as education and local government.

Emma Harper has a quick supplementary question before we move on.

Thanks, Gillian, but I do not actually have a supplementary question—I was just correcting a spelling mistake in the chat box. [Laughter.]

The discussion help us begin to think about the context of coming out of the pandemic and what will happen as we move forward. I am interested in service redesign, which has been touched on in previous answers. I am interested in what we can learn from the pandemic about doing things differently and in ways that bring savings. I am thinking about digital technology in particular. With regard to social care, the use of technology-enabled care is interesting. I want to get a sense of where the opportunities are for some of that.

There are opportunities. As you said, with regard to digital technology, there have been some advances during the pandemic. There has been some redesign of the way in which people access urgent care, such as the A and E system.

However, we have to achieve a balance. There are opportunities there, but there are some potential huge cost increases. The question is how many of those will become recurring costs and some of the witnesses have already talked about some: the vaccination programme, test and protect and the increased infection prevention and control measures, such as PPE, cleaning and social distancing, result in hugely increased costs, which will offset any potential savings. There is also the huge backlog of patients who still need to be seen, and the investment required to progress digital technology will lead to increased costs and investment.

It is also important that we properly evaluate some of the innovations that have happened during the pandemic—obviously, they will not suit everyone—to ensure that they meet the needs of the population and are sustainable in the longer term.

I will make an overarching point. As Leigh Johnston has indicated, it is a largely evidence-free zone. There are a few real-time studies that are collecting real-world evidence, but, to be honest, there is nothing that I would rely on to make massive service changes.

In England, people are looking at three buckets for productivity improvements that were spurred by the pandemic. The first, as Paul O’Kane mentioned, is digital and virtual appointments for primary care and out-patient care. That work is certainly not finished, but the early evidence that I have seen suggests that there is clearly a wider societal benefit from reduced travel times and emissions and the need to take less time off work. The evidence for impacts on NHS productivity is much more equivocal, including the questions whether you can really reduce the number of dropped appointments or appointments that the patients did not attend and improve clinical productivity. There are real questions there that need to be answered.

12:00  

The second area is more operational changes. In this country, we have seen a lot more sharing of, for example, a single clinical rota or equipment, particularly larger equipment such as computed tomography or magnetic resonance imaging scanners, across a wider pool of organisations. It is not much talked about, but that has led to reduced downtime for those assets and, as a result, some productivity improvements.

The third area is broader service reconfiguration—in other words, what services are delivered where. Because of the pandemic, many countries separated out planned routine services, particularly in hospitals, from what we call hot services, which deal with emergencies where things are harder to predict and you might have, say, a patient coming in with trauma through the A and E department. There are productivity benefits to be had in separating out those things, and the pandemic has made that approach possible.

Those are the three train tracks that we are trying to build more evidence around. Finally, though, infection control guidance will, for the next six months at least, be the rate-limiting factor on the amount of productivity that a health system can deliver.

Paul, do you want to come back on any of that?

No, that was helpful. I have some questions on sustainability, but we can move on to that later.

We are just moving on to the issue of financial sustainability. Sue Webber will kick off those questions.

I am sorry, convener, but my question is more generic. What does the panel think of COSLA’s comments that the consultation

“cuts through the heart of governance in Scotland”

and will

“have serious implications for Local Government”.

Perhaps Leigh Johnston from Audit Scotland can respond first.

When you talk about the consultation, are you asking about social care?

I am aware of the time, convener—I was just asking about finance in general.

The finance of what?

I was just seeking the panel’s thoughts on the consultation.

Which consultation? For the national care service?

Yes.

Okay. Does anyone—

If you do not want me to ask the question, I can—

No, that is fine. I thought that it would be more of a general point. If anyone wants to come in on that, please let me know.

I asked Leigh Johnston to respond, although I do not know whether she wants to.

Leigh, did you want to come back on that question? I know that it is not really what we were going to discuss—in fact, it is more a question for the previous panel—but if you want to respond, that is fine.

I think that I have been unmuted anyway.

Obviously, I have to be careful with my comments at this stage, as we are drafting a response to the NCS consultation. As you know, we have said that changes are needed in the provision of social care in Scotland, but the solutions are far from simple. The new models of care that are required will cost more money, and it is not clear how they will be funded.

I will make no comment on the governance arrangements at this stage.

I suppose that I am less constrained than Leigh Johnston. In the previous session, Derek Feeley made a very good case for the national care service, but I worry a little bit about what that leaves for local government. It has already lost the police and fire services, and its functions will be further depleted with the establishment of the national care service.

There is an issue with attracting people—professionals and elected members—into local government. As functions are drawn away, the attractiveness of that route seems to be declining. That needs some further investigation. We are a relatively centralised country, and further centralisation always seems like an issue that ought to be considered very carefully, on democratic grounds.

I invite Sue Webber to come back in on the financial sustainability of NHS boards. It would be helpful if we could focus on that theme.

I will bring that back in. We have spoken about centralisation, but Scotland is very diverse. In trying to identify how we might want to change how NHS boards are allocated their money, we find that one of the current issues with integration is that the money goes from the acute service to primary care and the social sector. What other models are you considering? What might be considered as best practice, looking across other areas?

Who would you like to direct that to first?

Let us ask the King’s Fund. I am sorry—my lenses have gone, and I cannot see anyone’s faces.

I am really sorry, but I lost the second half of the question. I got as far as allocation to acute services getting devolved to primary care. Could I get the second half of the question, please?

What other funding models might be appropriate for a national care service?

Great—thanks for that.

I say this with the caveat that I have never seen one model that is demonstrably better than another. In this country, we are broadly considering three different models. One is a contractual model that binds together health and care organisations broadly for the totality of their services. If we take a patch such as Greater Manchester, the contract might basically say that all the organisations must work together to improve the health and wellbeing of the population of Manchester. There is a single, lump-sum allocation, and the people in the local system must decide how they want to divvy up that allocation to best meet that goal of improving the health and wellbeing of the population.

The second model that we are considering is more structural. It merges organisations, so that a single budget is used. That is not a contract binding different parts of the system together—they are now one organisation. In parts of Birmingham, primary care services are working as part of the acute hospital, together with community services—an integrated provider, basically.

The third model is much more disease specific or patient cohort specific. For example, there was a contract for cancer services in Staffordshire where, rather than binding everything together, people came together to plan how they would improve the health and wellbeing and, essentially, the mortality and morbidity of patients with cancer.

I have seen no evidence that one of those models is better than another. I would give two reasons for that. First, we can do whatever we want, but if we do not have the wider conditions for success, which are enough staff, long-term planning and clarity in the strategic direction of travel, the contract cannot overcome all those issues.

The second element is much less technical and is purely down to leadership. When parts of Tameside and Glossop came together, across the local council and the NHS, to tackle rough sleeping, the contract and the structure came years after leaders came together to acknowledge that their model was broken. People who were sleeping rough were ending up in hospital because services such as bed and breakfast provision were being cut. What if we were to say that there is one Manchester pound, the best way to invest it is to have those preventative services, and the contract can be sorted out afterwards? It was culture before form.

It is worth considering a menu of options, but recognising that that can get you only so far.

The system that is used in Scotland at the moment is the NHS Scotland resource allocation committee—NRAC—formula. Would any of our panellists like to highlight some of the issues with that? This is the crux of the matter. That is the formula that is being used right now, but what else is out there that might address some of the concerns that have been expressed about the formula?

The allocation to health boards is driven by the kind of formula that drives allocations to local government. The formulas are based on estimates of need, which are principally driven by population size, but also by demographic structure, levels of deprivation and so on. I have had a lot of experience with those kinds of formulae and whether they can be fine-tuned to improve their performance.

Clearly, there are areas that feel that they are hard done by; for example, there was a long period in which NHS Grampian felt that it was getting insufficient money, given the issues that it faced. Part of the problem is that a lot of this is hidden and people do not understand how the determinations are made. Bringing it into the general public discourse so that there is some understanding would be useful, but I would hesitate to say that I have a better formula that will result in a reduction in Scotland’s health inequalities in the near future. It is a wider problem than that, and it goes back to our earlier discussion about social and economic circumstances that will not be resolved simply by allocations to health boards.

I will bring Siva back in.

I agree with Professor Bell, and I would like to provide a shorter but better answer to the question than I did before. We use a very similar resource-allocation formula in England, which is broadly weighted capitation. You can tweak the parameters and inputs to change how much weighting is given to deprivation. I have not seen a fundamentally better way of allocating healthcare resources than weighted capitation of the usual components of deprivation and age.

If you want to fundamentally change things, there is as much to be done by changing how money is used once it has been allocated to a health board, as changing how money is centrifugally flung across the country.

David Walsh wants to come in.

To follow briefly on what David Bell said, I agree about the complexity of how these things are measured. The formulas try to take deprivation into account, but it is not measured terribly well in some respects. Also, with regard to the impacts of austerity over the past 10 years, we are not capturing some of those additional levels of poverty. That interacts with some currently pertinent issues, such as the very high rate of drug deaths in areas, such as Dundee, that have measured levels of deprivation similar to other places that do not have those issues.

I am not suggesting that I know a better formula—as has been hinted, it is very complicated—but I think that there are potential tweaks around understanding aspects of deprivation that the current formula might not be picking up.

I certainly hear that point in regard to rural poverty in my area. Sandesh Gulhane has questions about financial sustainability.

I want to ask about the way that the money is used. My understanding is that a board gets its money through its funding, which is then divided into allocations. I always hear clinicians saying that they are not able to use that money, so who is the determiner of how that money is spent? Is it clinicians, or is it managers? Who do you feel it should be?

Who would you like to direct that question to?

Can we start with David, please?

12:15  

David Bell or David Walsh?

I am sorry—David Walsh.

I think that the correct answer was David Bell, because I do not do any research on funding for NHS boards. The other David might be a better bet for that question.

It is not my first-choice subject, either. Clearly, there has to be clinical input to the decisions that are made by health boards, but there also has to be an overall strategic view. Decisions have to reflect the challenges that an area faces. It is not always the case that clinicians have the strategic picture of what is happening, so views need to be brought together before decisions are made. Clearly, clinicians have to be involved, but it is not clear to me that the process should be clinician driven.

Stephanie Callaghan has some questions on the integration of health and social care.

I will direct my questions to Leigh Johnston and Siva Anandaciva, but they can correct me and suggest that someone else answers.

I am an elected councillor in South Lanarkshire. Leigh Johnston spoke about the systems management approach. IJBs and health and social care partnership directors have quite a difficult role in working with chief executives in health and with local councils. Pre-Covid, there was some success in freeing up hospital beds through preventative care, upskilling staff, preventing admissions, discharging people from hospital more quickly and shifting funding into care and treatments that are delivered in patients’ homes. With the NCS’s much bigger scope, how will we achieve a bigger shift from hospital to community care? How should the funding work? How do we get the right culture and ethos in place for that shift to happen?

I recognise what you have said. As you know, South Lanarkshire was one of the case studies in our integration report, with the moving of money and freeing up of hospital beds.

I can refer only to our previous report on integration. It is important that we learn the lessons from the difficulties in health and social care integration. The collaboration and agreement that will be needed for the reforms have been difficult to achieve elsewhere. Again, I go back to the six key areas that we identified, which are still very relevant to the proposed reforms. There must be collaborative leadership, and people should be encouraged to think about outcomes for their community rather than what a single organisation is trying to achieve. There should be good longer-term financial planning, which we have talked about, so that the required disinvestment and reinvestment can be planned and that resources can be shifted from acute hospitals into the community. There should be effective strategic planning, so that priorities are linked to resources and people are clear about the outcomes that they are trying to achieve.

Another area that we identified related to agreed governance, particularly clinical governance, and accountability. We should be clear about where decisions lie and when someone is no longer responsible for something.

The issues around data are still key, too. How can we share data appropriately across the system to ensure that people do not have to repeat their stories? Of course, the other issue is the lack of data to allow us to understand what is going on in community care, social care and primary care. That makes it difficult to understand activity and to plan for what needs to change and the outcomes that you are trying to achieve.

The other issue, which we have already talked about, is the need for on-going, meaningful and sustained engagement with the community, the public and the service users. We need to take them along with us as we reshape services, because that requires culture change in the public as well as in staff.

I will make four very quick points.

First, as Leigh Johnston has said, you need to be absolutely crystal clear with regard to accountability. Are you as a board jointly accountable for the entire pathway? If not, the default will be that, once a patient has been deemed medically fit for discharge and has left the organisation, the clinician’s accountability ends.

Secondly, there is a strong argument for building outwards from particular services or opportunities where there is better evidence that joint working works. Examples would include safe discharge into a new setting, end-of-life care and rough sleeping. I have seen too many instances of health and care organisations coming together either to boil the ocean or to focus on things that are an NHS-specific issue. I vividly remember a councillor saying, “Why am I sitting in three-hour meetings talking about a joint venture on pathology? It has nothing to do with me. If we were talking about end-of-life care, I could absolutely see why we would all need to be in the room.”

Thirdly—[Inaudible.]—been doing any big strategic change programme. They include making sure that you spend time together. There is a group of chief executives in the south-west of England who carve out some time every Friday afternoon to come together to understand each other’s—[Inaudible.] All we need is to trust each other. We do not need to get along with or even like each other, but we do need to trust and understand each other.

Some quite tactical tasks have been set for organisations. For example, everyone in a health and care board might be told, “Right—go away and by the next meeting make one decision that is to the detriment of your organisation but benefits the system.” Moreover, what I have seen time and again is that people who train and learn together work better together, so I suggest that there are opportunities for joint training and working.

My fourth and final point is almost a reality check. Almost every piece of evidence that I have seen has made it quite clear that integrated care can deliver better value and a better-value outcome for the inputs into the health and care system, but the evidence that it saves money is very ropey. If the task that we are setting people is to improve value, that is great, but if it is about taking loads of cash out of the system, that creates the wrong dynamic and tension and just sets people up to fail.

We have come to the end of our time. I thank both panels of witnesses for spending this time with us. Your evidence will be valuable as we think about our work programme and financial scrutiny of the upcoming budget.

At our next meeting, on 5 October, the committee will consider a legislative consent memorandum and discuss its future work programme. That concludes the public part of the meeting.

12:24 Meeting continued in private until 12:40.