Agenda item 3 is our last evidence session on the Public Bodies (Joint Working) (Scotland) Bill at stage 1. We will have a round-table discussion with what I could loosely call regulatory, scrutiny and complaints bodies. As is usual with a round-table session, I will introduce myself and ask everyone to do likewise, although there are many well-kent faces around the table. Many of you have been here before, but it is useful to have that information for the record. I am the convener of the Health and Sport Committee and the MSP for Greenock and Inverclyde.
I am an MSP for Glasgow and the deputy convener of the committee.
I am from Audit Scotland.
I am from the Care Inspectorate.
I am an MSP for Central Scotland.
I am from the Care Inspectorate.
I am the MSP for Clydebank and Milngavie.
I am the chair of Healthcare Improvement Scotland.
I am a Highlands and Islands MSP.
I am the Scottish Public Services Ombudsman.
I am an MSP for South Scotland.
I am director of scrutiny and assurance at Healthcare Improvement Scotland.
I am an MSP for North East Scotland.
I am from the Information Commissioner’s Office.
I am the MSP for Aberdeen Donside.
I am from the office of the Scottish Public Services Ombudsman.
I am the MSP for Edinburgh Northern and Leith.
I thank all our guests for that. Richard Lyle will open up the discussion with the first question. As always, we will give our witnesses preference over the politicians around the table. We want to listen to what you have to say today—it makes a change from having to listen to politicians. We will see if we can keep to that.
I welcome all the panel members. I will begin with the subject of public involvement. The committee has heard extensive evidence about the involvement of key stakeholders such as the third sector and different professional groups. However, the committee has heard less about public involvement. Last week, our witnesses stressed the importance of including the public, patients and carers. How should the bill involve the public, and is it clear about the involvement of the public?
One of the issues that we have with the bill relates to the models that are used. I am thinking specifically about how the public will exercise their rights under the Data Protection Act 1998 should they either wish to make a subject access request or have an issue with the information that is recorded about them. Of the two models of public involvement, we would go for the body corporate model as opposed to the delegation model because we see the latter as being quite confusing for members of the public who want to engage with the organisations concerned regarding the delivery of services.
From a regulatory point of view, we believe that hearing the public voice as part of the evidence for our inspections is really important, and there are a couple of areas in the bill that might help to increase public participation in the inspection process. One of those is the principle of person centredness. We involve laypeople in our inspections, and we take more than 3,000 complaints a year from members of the public specifically about services, which we investigate. That already gives the public a voice. The protection of people’s human rights is also fundamental to the bill, and the public could either come to us with complaints or raise such matters as part of the work that they do in inspections to ensure that those rights are being upheld. We think that there is some potential for us to increase public participation in our inspection regime.
Audit Scotland has long advocated users and carers being at the heart of the way in which services are delivered, and what is coming through strongly is the important role that local professionals such as general practitioners and social work staff play in shaping how services develop over time. However, it is less clear how the public will be involved and, as the bill develops, we are keen to hear more about how their voice will be heard, as it is very important that it is at the heart of service delivery.
I echo what has been said. The Scottish health council, which is part of our organisation, is responsible for delivering the Scottish Government’s national person-centred health and care programme, which will extend out through community services. We also have a statutory duty of user focus and feel that, in addition to what the bill provides, we already have the framework in place for that.
The Scottish health council already has a participation standard that is mandatory for national health service boards. We assess NHS boards against that standard in terms of how they engage with the public and service users. In addition, local authorities have the national community engagement framework standard. We have an opportunity to align the Scottish health council’s participation standard and local authorities’ community engagement framework standard. That would give us an indication of how we could join up and arrive at a common language about engagement with communities and individuals.
Structures can be very easy for administrators to find their way around. The issue that I have is that, whichever structure is in place, it must be easy for the ordinary person to access and get around. When we look at structures, the first thing that we should look at is not how they will be administered but how accessible they will be.
Those were interesting answers. I have a follow-up question: does the bill comply with the Christie vision of services that are designed with and for people and communities?
Do the witnesses think that the bill will make things better? Is it designed around the needs of service users? Is it accountable to those people?
As we said in our submission, we believe that that is what the bill’s principles seek to do, so it has the potential to do that.
Does anybody want to be more enthusiastic? I do not intend that to sound too sarcastic, because I think that what has been said reflects a lot of the evidence that we have already heard. Many MSPs, including members of this committee, are ambitious to make the bill work because what is already in place could be better for service users and others. However, there is much more work to do, between the bill and delivery. Does Robbie Pearson want to come in?
Yes, I just want to develop that. It is about how we engage not just with service users but at a locality level. There is a real opportunity through the bill and locality planning for communities to be more closely engaged than they have been hitherto.
As Annette Bruton said, the bill’s principles are right. One of the biggest obstacles to getting better outcomes for service users is entrenched organisationalism. Anything that we can do to break down the barriers is to be welcomed. Across the Scottish body politic in general, there is consensus on that. Politicians will perhaps disagree about the emphasis in how that is done, but the general direction of travel is to be welcomed. What we are all about is trying to get better outcomes for frail and vulnerable people.
How do we change the culture?
That is the point that I was going to make. There have been lots of attempts to resolve some of the challenges around the lack of integration of health and social care services. We welcome the approach that puts the user at the heart of the changes, which is important. In theory, the bill is about trying to get round artificial divisions between services. There is a real appetite for that to be taken forward at a local level, and we are certainly starting to see signs of the development of partnership work in a much more serious way than we have ever seen in Scotland.
Just to build on that, one of the great opportunities in the bill is the commissioning powers that it will give health and social care partnerships. The commissioning powers will be partly based on standards. Apart from having both health and social care standards, it is important that we have standards and outcomes that are about what people genuinely think about the services that are being delivered. To build on Robbie Pearson’s point, it is about asking people in a locality what they think about the services. I think that we will be able to answer the question in the next couple of years, if commissioners adhere to the standards that have been set and have person-centred outcomes.
On the public interface, Mr Martin said that there needs to be standardisation, which leads us on to issues around the complaints system. NHS Dumfries and Galloway told us that it felt that there was no urgent need for a standardised complaints procedure. However, the ombudsman’s submission states that
I think that that question is directed to you, Mr Martin.
Initially.
It sounds like it.
Does anyone else want to comment?
I absolutely agree with everything that Jim Martin has just said. However, I want to make sure that we protect the level of complaints handling that the public currently enjoy. When we carry out our complaints investigations, we do so on behalf of the complainants and we try to work out with them what they are complaining about and how we can help them to resolve the issue.
You must concede that the number of people round the table is a physical representation of the complexity of the system. In many cases, it is difficult even for elected representatives, with the resources and help that we can get and our experience of casework, to get families through the system, so how much more difficult must it be for others? We have two inspection agencies—Healthcare Improvement Scotland and the Care Inspectorate—and we have all these people round the table. We want seamless services so that, irrespective of where someone is on their journey, they can expect the same quality of care. It seems obvious that we should have a system with one entry point to ensure that people are picked up and supported.
My question is on the scope for standardisation. The bill will not cover all social care and health services—it focuses on adult social care and health services, although obviously there is scope for expansion, depending on the use of ministerial powers. How do you envisage the standardisation approach? Do you see the bill as an opportunity to standardise complaints procedure across the board, even though we perhaps do not have integration across the board? We could end up with a complicated picture if one part of the complaints process is standardised, but individual complaints procedures remain for the rest of the system.
I refer the committee to the work that was done by Lorne Crerar and then by Douglas Sinclair. As I think I have said to the committee before, one of the most frustrating things that I find about the Parliament is that the pace that we go at between taking a decision for change and implementing the change sometimes seems very slow. Lorne Crerar was asked to start his work on standardisation and scrutiny in 2007. We are now in 2013 and we have just begun to implement standardisation across local authorities, housing associations and other bodies. If we are serious about integration, all aspects of integration should be looked at, which should include complaints. It is a matter of some urgency. I would not want a system to be put in place and then have a lag on the complaints side that causes people to become frustrated with the system and begin to lose confidence in it. I urge people to think carefully about that.
We are on the same channel, and we share that frustration. It is 18 months since the committee made what I think were decent recommendations on HIS and the Care Inspectorate working together, and we raised all the issues that have been raised today. We share that frustration with slow progress. Do we have around the table the same scenario that exists on the ground, which is that everybody is for change and working together until it impacts on them? We need to take pretty difficult decisions within organisations to break down those barriers. Is the cultural resistance that we perceive on the ground at the point of delivery reflected right the way up? Are we not all guilty of that?
I do not think that we are culturally resistant. We have a huge opportunity in the integration bill. The Care Inspectorate and Healthcare Improvement Scotland have begun pilots on integrated scrutiny, which have been successful. Also, I do not think that we have issues about feeding in complaints. As organisations, we have started meeting regularly with the Scottish Public Services Ombudsman to look at the pattern of complaints in different areas.
The frustration expressed by Jim Martin and by ourselves is shared by the cabinet secretary. That is why we have the legislation, as Claire Sweeney said. Malcolm Chisholm, who is here today, previously attempted to encourage that change over a long period of time. The legislation has been brought about by frustration at not having been able to change the landscape and focus on people who are using the services. That is why we are here. What is Claire Sweeney’s view on that?
The scale of the challenge becomes clear to us through local audit work looking at how public resources are being spent across Scotland. It is a huge cultural change for people at all levels and there is a need for really strong, clear, local leadership and a shared vision, and for clarity about how resources will be used and to what end. Most important, the thing that has been missing in the past is focus on the impact, on the difference that it is actually making to people, and clarity about what the intended change is supposed to be. Those things will help to move us forward, but the scale of the challenge is significant.
Does anyone else want to respond to that? Does silence indicate agreement?
I am certainly in agreement. A crucial element is ensuring that, when we talk about health and social care integration, we bring together elements such as GPs in local communities. The increasing engagement of GPs in this agenda will be a marker of success in the future, whereas it has not been so robust with the community health partnerships.
We have spoken about complaints, and I note that Audit Scotland’s evidence also mentioned the fact that it was not clear that the different bodies making up the new corporate body would have different audit procedures in place. We also heard previously that there are different statutory procedures in place for such things as staff governance between health and local government. I wonder how a new body gets over that, because we have heard in detail about how messy complaints can be. Once you get into staff governance, audit and the like, how can you ensure that the new body is workable? That is one of the concerns that has been brought to us.
Audit Scotland’s submission raised technical issues and broader issues that we would want to see addressed going forward. There are technical issues around how the body corporate would work in practice, with questions such as whether there would need to be a set of accounts, whether auditors would have to be assigned to the new bodies, and other technical details underpinning how the body corporate process might look.
I want to raise the issue of clinical governance in the new bodies corporate. In Healthcare Improvement Scotland, we currently assure clinical governance throughout the NHS. As far as the body corporate is concerned, it is important to have arrangements around both clinical governance and care governance in order to deliver the quality and safety of services in clinical terms. We are now beginning to have discussions about clinical governance within the body corporate.
Claire Sweeney’s contribution, and her paper, raise two of the central issues: governance arrangements and resources. I suppose that the question of how resources will be determined is a straightforward one. We might wish to discuss that in more detail in a moment.
I refer to our submission, which set out some of our concerns about that lack of clarity and the need to be clearer in future. We know from previous work that we have carried out around community health partnerships, for instance, that clear accountability and a clear sharing of resources are a very powerful combination. The potential is there, but the question is how it can be taken forward in a practical sense, and that will be interesting to see as the bill develops.
From the perspective of the Information Commissioner’s Office, the issue is about who is a legal entity. When it comes to pointing the finger of accountability on behalf of data subjects, the body corporate is easier for us, in a way, as it is a legal entity, and that is what we would pursue for some kind of redress, or to determine whether there had been a breach of a nature that was serious enough to impose a civil monetary penalty. That penalty would come from the legal entity, which is the body corporate.
That is interesting, but one of the concerns is that, if we are to make the system work, we will have to set up a body—an entity on its own—and then reproduce all the functions of the two parent bodies such as audit, staff governance, clinical judgment and so on. How much would that cost and how much would it remove from the services that we are trying to provide? The bill is designed to provide better services to those on the ground, but what if we spend much of the existing budgets on setting up a new service? Will it need to be funded by central Government? Will it need to be a body in its own right? How does that work and what costs will be attached?
I am afraid that I do not have an answer to that. My perspective comes from the Data Protection Act and thinking about individuals and their rights under that act. What I am advocating will not necessarily be the best thing for costs to the Scottish Government. I could not answer that question.
I suppose that it takes us to another question arising from previous evidence about how the organisations here fit in with the health board, the local authority, or three local authorities, the body corporate, or the community health partnerships. How do you all fit in to that? Is it a structure or structures? How does it all fit together with budgets going here and there? Who is accountable? How are the additional ministerial powers to be used if we do not understand the body corporate structure and what we should expect from it? How will we know when it is appropriate that the minister should intervene?
Audit Scotland will clearly take a close interest in any area of the public sector that is going through a time of significant change. Resources are involved and we will be interested in how public money is being used, not least because the risks at that time are greater and significant.
Healthcare Improvement Scotland’s perspective is that, if we start with an older person who ends up in accident and emergency, we are interested in what they are interested in and in quality assuring the pathway that gets them from primary care, through social care, into an accident and emergency department.
To build on the point that Dr Coia has just made, the new inspections that we are developing will be able to be carried out irrespective of the structure and will follow outcomes for people.
It is almost as if we had discussed how to provide a seamless link, because I have been sitting patiently waiting to ask about the inspection process.
I am certain that Robbie Pearson will also want to come in on that question.
There is a real appetite and opportunity to do something imaginative in the joining-up of scrutiny. It would be difficult for us, through scrutiny, to make demands about integration in service delivery but not to demonstrate integration ourselves.
Did those pilots include residential acute settings as well as community settings? What did the pilots examine?
The pilots looked very much at community-based services. Obviously, we have a separate inspection regime for acute hospital settings, but the issues that we identify within acute settings, including the things that bring people into hospital through accident and emergency departments or the things that prevent discharge, have resonance with our wider inspections with the Care Inspectorate.
When will that information be available?
Do you mean information on the joint inspections?
Yes.
We will share the key messages from that in due course. We will not publish reports on the three pilots, but we will learn from them how to apply the methodology.
I add that we should remember what both our organisations need to do in addition to straightforward inspections. In looking at care pathways, it is important for conditions such as asthma or diabetes that the right treatments and facilities are available. The evidence that Healthcare Improvement Scotland uses for that comes from the SIGN—Scottish intercollegiate guidelines network—guidelines and a wide range of standards that we produce. In the same way, the Care Inspectorate has specialist expertise in children’s inspections, with links across to education.
It is also worth mentioning that there are processes whereby inspection agencies come together to share knowledge about their local area, to think about the risks and to consider what those mean for inspections. Post Crerar, a process was established to draw those issues together in a place-based focus, I guess. That is a slightly different cut of the same issue.
I accept that the important thing is that the public have an identified individual who is responsible for the inspection and to whom they can go for information. We also need to keep the expertise behind the scenes, in whatever way that is done most efficiently. However, no one has made specific reference—I do not know whether this omission means that you are supportive of the proposal—to providing quality assurance of the strategic plan for integration. Can we get something on the record about that?
That is a very important point and we missed it out. The Care Inspectorate has certainly been discussing with Healthcare Improvement Scotland what we could bring to strategic commissioning, which we think will be a key part of the plan. Obviously, Audit Scotland will be interested in strategic commissioning from a governance point of view, but we believe that jointly, we could bring quite a lot of assurance and, indeed, could undertake follow-up action if necessary.
Is there anything to stop you from carrying out that assurance now? I think that the HIS submission mentioned sufficient powers or additional powers.
Certainly, there is nothing that cuts across our being able to do that at the moment; the work that we are already testing out with the Care Inspectorate demonstrates that. We would encourage the inclusion of a reference to scrutiny on the face of the bill, through an amendment. We should be working within our existing relationships, not letting structures get in the way, and we should push on with assurance, which is what everybody wants.
To go back to cultural change and what makes it happen, we have just heard from Robbie Pearson that there is really nothing to stop us—we have sufficient powers to carry out that cultural change. I suppose the obvious question is, “Why aren’t we getting on with it?” What is going to drive that cultural change? Will it be the legislation itself? Will it be the ministerial powers? Will it be the shifting of budgets? Will the more focused human rights agenda that is at the heart of the matter help to change the culture?
I will base my answer on my experience, because I am very old.
Not at all.
I have been through this before. I have worked in integrated teams; as you know, psychiatrists have long had integration with community mental health teams. For me, it boils down to leadership. It is about setting the right space. Once you have that and the principles, it is about leadership at local level because it is people and leadership that drive change. The bill gives us a very good framework, within which we have sufficient powers in which to operate.
Do service users have sufficient powers, in terms of their enforceable rights, to change the culture to one with a person-centred focus? That is a change that everyone believes should happen.
It absolutely part of our job in the Care Inspectorate and HIS to be working for the public. We should be held to account for how we involve the public in our quality assurance of services, including how the new community health and care partnerships are involving the public. It is very much part of our role to answer that question.
Our involving people group met last week; it was keen that I say to the committee that one way to hold people to account is to listen equally to the voices of service users and of those who provide the services. The group believes that holding the people who run services to account for the outcomes is how to get integration.
I agree with what has been said—cultural change rather than structural change is the thing. However, I still think that the resource issue will be key to this and there is not really that much in the bill about that. There is scope for great variation in terms of what money is put in and how it is put in.
It is difficult to say how the audit process would follow the money because it is not clear yet how the body corporate—our model—will work in practice. In previous audit reports that we have presented to the Public Audit Committee we have been clear that sharing of resources is very powerful, but there is a need to be clear about what is devolved, who is responsible for what and where the focus will be. We would not comment on the extent to which that should be prescribed, but there is a need for real clarity about what is involved in that sharing of resources and how it will be accounted for. It will be interesting to follow that through the strategic commissioning arrangements and to consider the impact that that shift makes over time. It is a challenge. We are considering services for older people and we can see the scale of the challenge in terms of how resources across both systems are used. It is very difficult.
A question about VAT arose at a meeting that I attended yesterday. Does Audit Scotland have any views on how VAT will be tackled with merging budgets and so on?
That is another issue that we have raised in our submission and which needs clarification. What type of body is the body corporate? That has to be decided. There are different VAT arrangements for the NHS and local government, so we need to understand what type of body it will be. Once that is established, the VAT arrangements should be clear.
Has Audit Scotland been involved in that process? Other issues that have been raised include pension implications, and we have a note from the Finance Committee—it is really for the Cabinet Secretary for Finance, Employment and Sustainable Growth—about the equal pay, pension and VAT risks. Has Audit Scotland done any work on those matters?
There are several strands of work that touch on that process and a lot of local financial audit work deals with those issues, so they have been addressed in the audited accounts and the annual reports for the local bodies. We produce overview reports for the NHS and the local authorities each year, and some of those pressures and risks recur. We have flagged them up over several years and we have been involved in discussions about how they could be resolved.
To link that directly to this legislation, has any correlation been made—
We are keeping a close eye on how those discussions evolve, but we have flagged up the risks around the need to be clear about which type of body corporate it might be. There are implications; there is a raft of issues that need to be resolved.
Is all that on the record?
Yes, it is—through submissions to the committees and discussions with the Scottish Government.
We have heard a lot this morning about the need for good local leadership. I was lucky enough to be in Inverness last week and in West Lothian yesterday where, in their different models, there is good leadership and great enthusiasm, and everyone seems to work well together. What about areas where there is not good leadership at the moment? We know that different organisations are at different stages of this journey towards integration. Will the bill help in the areas where there is no leadership?
Is there any response? There are no takers.
My question is for Maureen Falconer; it is about information sharing. Last week, we heard—from the British Medical Association, I think—concerns about the single shared assessment being shared only in paper form. The view was expressed that if services are to be integrated, information technology needs to be integrated into how information is shared. That is a big challenge, given that we are talking about a body corporate, two different organisations and data protection, especially in a highly sensitive area such as health. Have you had any thoughts about how that could be done?
With great difficulty. It is a challenge now; it will not be the case only when we have whatever body ends up being set up as a result of the bill.
We have covered a number of issues, as we expected to do. We said that we were here to listen—I suppose that there was a bit of tokenism at the end.
Previous
Subordinate Legislation