Item 2 is our second oral evidence session on the draft budget 2012-13 and spending review 2011, which will be a round-table discussion. I welcome our witnesses: Bill Alexander is director of social work at Highland Council; Melanie Hornett is nurse director at NHS Lothian; John Howie is health improvement programme manager for the keep well programme in NHS Health Scotland; Gail Trotter, from the Scottish Government’s child and maternal health division, is family-nurse partnership national implementation lead; Joan Wilson is head of nursing and vulnerable children and families at NHS Tayside; and Rachel Ormston is research director at the Scottish centre for social research. Thank you all for coming. I look forward to an interesting session.
I suggest that preventative spend is doing something quickly, effectively and timeously, to prevent situations from escalating in a way that will need greater intervention and greater spend later. For example, if a child displays difficulties early in their school career, a quick and effective response—perhaps in a multi-agency way—can prevent difficulties from escalating and requiring much more significant intervention at a later stage.
Does anyone else want a stab at defining preventative spend?
From the perspective of the keep well programme, it is about recognising that certain communities and individuals are at risk of early onset of disease and premature death and ensuring that investment is made to tackle the risks that are associated with such difficulties in later life. As Bill Alexander said, such an approach reduces spend later on. Early intervention spend reduces expensive treatment spend later and improves life quality.
Excuse me. Is anyone else having problems hearing, or is it just me? Can the broadcasting staff help, please? Thank you, that is better. I think that I am too loud now—as usual.
We certainly need a clear definition of what we are trying to achieve through preventative spend so that we can measure whether the spend is having the desired impact. Bill Alexander’s definition, which was about the need to prevent problems from arising later on, is probably the right way to go. It is about defining the problems that we want to prevent and focusing spending in that regard.
I understand that, in the discussions about the proposed children’s services bill, consideration is being given to whether it would help if authorities and health boards reported on how much preventative spend they are committed to. If we are to be required to measure and report on preventative spend, we will need a definition that is tangible.
From the perspective of the family-nurse partnership, we know from the evidence that we have on the development of foetuses and the evidence from neuroscience on the development of a baby’s brain that investing in the mother during the antenatal period can have a significant effect on the life-course outcomes for the baby and the mother. Any definition of preventative spend should be linked to the evidence that we have to substantiate the approach.
How do we work out what has the biggest and best impact? We could spread the money thinly or we could focus on certain areas.
The evidence from the United States, where the family-nurse partnership has been developed and evaluated over about 30 years, is that the project has the greatest impact when it works with the most vulnerable mothers and children. I am talking about impact not just in the short term, through reductions in injuries in infancy and better child language and emotional development, but in the longer term, through reduced involvement in antisocial behaviour, crime and promiscuous sexual activity when the child reaches their teens.
We are getting into the important initial debate, which is about universal versus targeted preventative spend.
I do not know whether I can answer your question about what a reasonable screening level is.
Keep well has been a targeted prevention programme since 2006. It uses evidence to identify the target populations, and it focuses on the top 15 per cent most deprived communities in the Scottish index of multiple deprivation. Some additional populations are also recognised to be at risk of the early onset of cardiovascular disease and to require a range of support on social circumstances and lifestyle. That is the evidence that has been used to allow the targeting to happen.
Are the relevant budgets fixed? Are such programmes well or adequately funded? Today’s session is about budgets. Do you have to make bids every year? Initially, the projects were pilots. Have they moved from being pilots to the main stream?
Before we move on to those questions, Richard, Mr Alexander and perhaps others want to respond to your first point.
Dr Simpson talked about Hall 4, which provides welcome, reassuring and evidence-based clarity about targeting.
That implies that we need the integration and co-ordination of agencies but that that is not happening. We may come back to that point.
I want to emphasise Bill Alexander’s point. Lord Laming reminds us, in his Victoria Climbié report, that families have a right to expect that any intervention delivered in the home or to support families should be based on clear evidence. We have to start with that as a premise for good spending. We need evidence for what we are doing in supporting families; they have the right to expect that.
I keep being stimulated into asking questions. Mainstreaming is a central issue. We have been piloting projects with the Paisley midspan studies from the 1980s onwards. We have been fantastic at pilots, but if we are serious about preventive spending and we are to talk to the health boards in the spring about their actual expenditure, we need to know whether your projects are being mainstream funded. The family-nurse partnership is not at the moment—I think that it is still a pilot. Are any bits of the keep well programme now mainstreamed? Have we learned enough in five years to say to every health board what they should be doing and what outcomes they should expect?
The five years have generated a lot of knowledge. The plan is for another three years of investment for keep well—£11 million per year spread across all the boards, with the dominant investment being in Glasgow at nearly 40 per cent.
So, in effect, it is still secondary prevention.
Keep well is primary prevention.
I am glad that we are saying that targeted and universal services are not an either/or. That is a false polarisation: we do both and have done both for a long time.
It is perhaps worth saying a little about the evidence base for FNP in the United Kingdom. FNP has been evaluated for quite a while in the US, and a number of randomised control trials have shown positive short-term outcomes for the child, as well as longer-term outcomes as the child grows up. There have also been positive outcomes for mothers, such as improved employment rates and less dependency on benefits. A randomised control trial is being conducted in England. It involves 18 FNP test sites and it is due to report in 2013. The trial will test how replicable the US outcomes are in a different context with universal health services and health visiting.
Bob Doris raises an important point about the evidence required before any intervention is made. A benefit of FNP is that data is collected for every single intervention—every telephone call, every home visit and every contact with the young clients—so we will have evidence on whether what we do does or does not make a difference.
I reinforce what Gail Trotter has said. Tayside is the second site in Scotland for the family-nurse partnership, and we started properly only in July. Already we are working with more than 100 young women and—even in these very early stages—we are beginning to see the effects that Gail described. Young mothers are engaging with the programme, are really interested in working with the family nurses, and are starting to think about what kind of mothers they want to be. They are hard-to-reach girls in some cases, and it can take considerable time and effort to engage them with universal services—if they engage at all. However, although we are at an early stage in Tayside, we are beginning to see some differences.
Outcome measures are absolutely fascinating. They are very important for the early years, but the effectiveness of early intervention can be seen at all stages and ages. The family-nurse partnership is an obvious model in the early years, but we have worked consistently in Highland to focus on early intervention for eight or nine years now. I believe that that is why, right across the age ranges, we have continuing lower and declining levels of substance misuse in teenagers and continuing lower levels of youth offending at a time when other authorities’ numbers of looked-after children are going up but ours are not. That is demonstrably because of early intervention.
I want to let the discussion flow, but I have a brief observation. I am hearing from what has been said that there is positive evidence that we can quantify some benefits quickly but we should keep the faith and be patient in order to achieve real, long-term benefits. That brings us back to the issue that Richard Simpson talked about, which is how quickly we can have enough evidence about pilot projects in order to start to mainstream them and roll them out. However, I am thankful for the evidence that we have had so far in the discussion.
For obvious voice reasons, I will not say much this morning. However, I am struggling to understand some points. I am with Richard Simpson on the issue of the health visitor versus the family-nurse partnership, but pretty much everyone round the table this morning is for the family-nurse partnership.
I think that some of that question was directed at me—there are a number of issues in it.
I will try to distinguish between health visiting as a universal service and the family-nurse partnership. The family nurses see young women from very early in the pregnancy until the child is two. The child then goes into the care of health visiting and universal services. As we have said, the family nurses target the most vulnerable young women and families at that crucial stage.
Those are health visitors’ words, not mine.
They would not be my words at all. However, the profession has a number of difficulties. It has an ageing workforce, and in NHS Lothian we have an increasing population—it is one of the few areas in Scotland to have that. We therefore have an increasing future workload for health visitors.
Most of us around table know what the family-nurse partnership is about. Our predecessor committee did a report on child and adolescent mental health services. As a result, the Government introduced an additional health check between 24 and 30 months, which we welcomed. However, I have never been clear about what is included in that health check. It has been a bit vague. I ask Bill Alexander what is included in it, given the information that I have provided.
I am afraid that, as a director of social work, I will pass on giving you a response to that question, but other colleagues might be able to give you a more specific answer. As a social worker, I would not want to comment on that health visitor check.
Who is responsible for the check?
The check at 24 to 30 months will involve a full development check for the child to ensure that they are reaching age-appropriate milestones. If they are not, the health visitor will look at what other services need to be involved. The check also involves checking that the child is up to date on immunisations, checking their height and weight and addressing any other concerns that the parent or carer has about the child.
I hear what everyone is saying about preventative spend and the importance of investing in the early years, but there needs to be a period of what could be described as joint spending, to deal with the problems that preventative spend was not in place to prevent. As Bill Alexander said, we must deal with the current problems in teenagers, but we also know that if we spend early we can prevent such problems from happening in future. How is it possible to do that when budgets are being cut, especially in local government?
There was additional funding for children’s services in the early 2000s, and there is no doubt that the authorities and health boards that put that funding into early intervention and early years services are now benefiting from that. We had more money at that time for integrated children’s services and that allowed us to cope with that double spend.
I want to reassure Mary Scanlon and other members that family nursing complements and supports the role of the public health nurse, as she or he is known in Scotland. New learning is emerging from the new way of working and we are starting to share that through the modernising nursing in the community board and the chief nursing officer for Scotland.
Can people around the table comment on their knowledge of the change funds and indicate their involvement in access to them or whether they have been involved in any way to lever money from them and take advantage of the innovation?
The only change fund money sitting in budgets is for older people’s services, so anyone in children’s services will not currently be involved with the change funds. We know, however, that there is a change fund for early years. I understand that local government still has to commit its share to that and that an early years task force is working with local authorities on how the spend will be used.
Would you say that that was £10 million of savings coming out of acute care?
It will be both out of acute care and changing long-term residential care accommodation into intermediate services.
How do you involve in your model the third or voluntary sector, which is very important in delivering change?
The guidance for the change fund for older people emphasised that there had to be a three-way partnership. The chief executives of the health board and the local authority had to sign up to it, along with a representative from the third sector. That is not easy, because the third sector is not one person but a group of agencies of different sizes and with different interests representing a range of different stakeholders. However, the third sector has been built into the process from the outset.
You have spoken very much about your experience regarding the model for the change fund, but how have you overcome the barriers to ensure that the third sector plays a significant role in influencing the use of the change fund in your area?
I would not say that we have overcome the barriers; I would say that we are still wrestling with them. This week, I will speak with about 100 representatives of third-sector organisations who will all want different things to happen with the £3.5 million I referred to earlier. As part of that, we must seek to achieve consensus alongside what we wish to do across NHS Highland and Highland Council. I would not say that that is easy. As Gail Trotter said earlier, part of it is about having an evidence-based approach. We cannot use the change funds as part of a bidding process as we used to do. We used to ask, “Who’s got a good idea and wants to bid into this?” Now there must be a commissioning process that is evidence based and there must be consensus about the approach. I believe that it will be easier when we move towards a more integrated service and have one decision-making structure, one budget and one set of management. Whether it is children’s services or adult services, when there are decision makers in both the council and the health authority, alongside the third sector, decision making takes a lot longer than it needs to.
The third sector is a bit worried that there is a higher test on them to provide evidence on outcomes than there is for health boards or local authorities. There is a big issue regarding who gets access to change funds because at this point a lot of the evidence shows that they are held by health boards and local authorities, so the third sector is fearful that they will not get the use of them.
You are absolutely right. Third sector agencies are anxious about that. The reality is that those agencies can use that funding more effectively and quickly and often with better outcomes. Local authorities and health boards are sometimes slow to respond, whereas third sector agencies can act much more quickly.
Every organisation has its priorities. The reason why I whispered in Bill Alexander’s ear earlier is that everyone says, “We need to do this and that, so we need more resources.” Richard Simpson raised the issue of ring fencing, pilot schemes and more resources. Should your organisations have a budget heading for preventative spend, with funds that can be bid for? We can talk about preventative spend as much as we like, but we cannot do it if we do not have resources. Should there be a separate budget heading?
This is probably not fashionable for somebody from a local authority to say, but if we had not had ring fenced funds for much of the past 10 years, a lot of money would not have gone into preventative spend. The reality is that the money would have gone to other priorities. Ring-fenced funding is not easy to use or manage and it involves doing a lot of work to join various strands. It has many challenges, but if some of the money had not been ring fenced, it would not have gone to the right places. That might not be the fashionable thing to say, but I speak as a manager who had to deploy the funding.
Significant amounts of money are already spent on prevention on a range of issues. I am sorry, but I cannot give you a figure for NHS Lothian off the top of my head. Having ring-fenced funding to set up pilot programmes such as keep well or family-nurse partnerships allows us to establish and develop the work. The hard task is then to mainstream it. That is the bit that we struggle with. We need to decide what we will stop doing so that we can instead do that other thing, because it is a better approach. People have their favourite things to do that have worked well for them and which they are often reluctant to let go. As we become more able to consider programmes across the age ranges with different evidence bases, the challenge is deciding which of them will be the most effective for the population that we serve and how we focus the money on that.
My colleagues in all 14 NHS boards welcome the ring fencing for the keep well programme, as it provides a degree of protection. As I said, the funding will be protected for the next three years, which helps with planning. Although keep well has been with us for the past five years, it is still being introduced to a lot of new areas in our communities, such as Inverness and parts of Glasgow. As we spread the programme more widely across Scotland, there is still a need for the ring fencing. It is welcomed by colleagues across the board.
The committee is considering whether the approach would assist with the focus on preventative spend. The focus on waiting time targets drives how money is spent. Richard Lyle talked about having budget headings and an explanation of what the money is expected to be spent on. Would that approach distort things or would it allow you to identify the shift, identify and evaluate the programmes and examine the outcomes? Does that method allow us to encourage, and push and pull through, a shift in spending in the health service? That approach has helped with other problem areas, and money followed that directive. Does anyone have a comment on that? No? Okay.
It is an important issue, though, because the health improvement, efficiency, access and treatment targets have driven health service managers and the health service. As many will be aware, managers have to meet waiting time targets and they will go to extraordinary lengths to meet them—sometimes even gaming, unfortunately. There is no doubt that waiting lists and waiting times have been driven down since 1997 under both Administrations.
The challenge is the balance between a broad outcome and a particular indicator or target. We do not want people to be delayed in hospital, but is six weeks the right target? We are now re-evaluating that. We want looked-after children to have good educational attainment, but are maths and English standard grades the right target, or is it about a range of vocational qualifications?
We have done that and we have got median targets.
And it is revealing.
I have a family member involved in this at the moment and it took three weeks for a social worker to be allocated to do the assessment. The nurses, doctors and general practitioner had already done nine tenths of the assessment, but there was no joint recording system and no single shared assessment. It is a very poor system in which silos are not working together.
Exactly. There are silos. There is not a system; there are two systems. We have front-line practitioners whose only motivation when they get out of bed and go to work every day is to do a good job. They seek to be as joined-up as possible and to deliver an integrated service, but there are organisational silos that inevitably prevent that by delaying decision making, having separate budgets and all the rest of it. I believe, and I know that there is cross-party support for this, that we should be moving away from organisational silos into truly integrated working, not only at the front line—whether it is getting it right for every child or older people’s services—but in the back-office functions.
We did that with Perth and Kinross in 2001, when there was a pilot for the joint futures programme. There is still a unit in the Scottish Executive called the joint futures unit. I do not know what it does, but it has been there since 2000 to do this. The Perth and Kinross system collapsed. I am sorry for interrupting, convener, but we have been there and we have been saying this for 10 years.
Your apology is accepted, Richard. No one here can answer that question on behalf of the Scottish Executive, but it comes back to the issue that has been identified. Mr Alexander has already placed on the record his enthusiasm about joint co-operation and joint delivery. That point has been made.
Should we really have a single budget or just an aligned budget that people can still make different decisions about? Should we really have single management? Should we really have only one committee that makes decisions? When we have tried to do this before, in various parts of Scotland, there has not been a common understanding of singularity. People sometimes come up with an integrated arrangement, but they have different understandings of where the decisions get made.
And such arrangements are not permanent.
Exactly, and you have to move towards singularity.
Absolutely.
As for incentivising targets, which you mentioned earlier, that can be very difficult because of the very challenges that you highlighted. If you incentivise a six-week target, what about those who are delayed by five weeks and six days? That said, the general outcomes must be incentivised.
That was very interesting.
The discussion in the past five or 10 minutes takes me back to the comments that we heard last week from Professor Deacon and other witnesses about the evidence that you need before you just go ahead and do this. We all seem to agree on the need for a preventative, targeted, integrated approach to the health service and all the age ranges it covers, which suggests that we should move towards reconfiguring the provision of health services to ensure that they are not in silos. Indeed, Mr Alexander might well have been suggesting as much. Do we need to consider some sort of formula in which we start with ring fencing, which leads to pilots, which in turn lead to mainstreaming? That brings us back to the issue of evidence. When do we finally accept that we have the evidence to mainstream all this, end the ring fencing and tell everyone, “This is the way we’re delivering the service”? Could the committee come up with such a formula?
When keep well began in 2006, it had a 10-year range of outcomes. The initial short-term outcomes related to successfully engaging with the target population, inviting individuals to health checks, identifying their needs and successfully referring them to a range of different services that were agreed between the practitioner and the individual. All those things have happened. We have also collected data on individuals; in West Dunbartonshire, for example, 30 per cent of the individuals who have had a health check have a one in five risk of coronary heart disease in the next 10 years. Those needs have been identified. Moreover, referrals to appropriate services have ranged from 15 per cent in the Borders to more than 50 per cent, again in West Dunbartonshire. In short, the first part of the short-term outcomes has been achieved.
Can comparisons be drawn between those areas that have not got keep well and those, such as West Dunbartonshire, that have it? What is the difference in outcomes?
I will probably bring in a research colleague in a minute to describe the flaws—or not—of various research methodologies.
But within that, people who engaged would have got decent advice and so on and harder-to-reach people who did not engage would have carried on their lifestyles. Keep well gives people the opportunity to identify a worry that they already had.
We have not made those comparisons within the programme. We have made a commitment to ensure that all the most deprived communities are targeted, hence the focus on the Castlemilk and Drumchapel areas of Glasgow. Areas in Inverness will also be considered. The ambition is to spread the programme across as many of those communities as possible.
So despite the lack of evidence, we are going to roll the programme out anyway.
As I mentioned, the evidence is there in terms of short and medium-term outcomes. We are engaging and identifying and people are being successfully referred on to services. We are also seeing some returns in terms of clinical change. The evidence is there that the pathway is working successfully.
I apologise for being late. I should not take a phone call before a meeting but it was quite important.
Knowing what I know now, it would certainly have been a significant challenge, but it is always easier with hindsight.
I suppose that my follow-up question to that—
I think that some of the other witnesses might want to respond.
From NHS Tayside’s perspective, our interest was such that we really wanted to be involved in the family-nurse partnership. When we first made approaches, we were not aware that any funding would be available. At that point, we were keen to try it on a very small scale in one postcode area in Dundee. We made a contribution to that from our existing budgets. As we got more involved, we moved on to get the Government funding, but we have made our own contribution.
We know that it works out at approximately £3,000 per year for a client to complete the programme, so it costs about £8,000 in total to deliver it to a family. That is strong and useful evidence. We do not have comparable information for health visiting and the outcomes from health visiting. That is not to say that outcomes are not achieved, but we do not have the evidence. That information on the present cost of the programme is useful for health boards’ future planning and the programme’s sustainability.
You pre-empted my supplementary. That is excellent—thanks very much.
I have been very interested in what a number of the witnesses have said. I would like us to nail down some specifics on the family-nurse partnership. I invite Gail Trotter from the Scottish Government to give us a sense of when we can have sight of the evaluation that has been undertaken and what the cost of rolling out the programme nationally would be.
The evaluation is in three parts. The first part is in the public domain through the Scottish centre for social research, which looked specifically at engagement in the pregnancy part of the programme. The final report is due in 2013.
There will be another two reports next year, as well.
We need to remember that the evaluation is looking just at the transferability of the model to the Scottish context. It is not looking at cause and outcome, although we are seeing some early positive gains.
Over what timescale is that?
It is between now and 2015.
Did you want to come in, Rachel?
I was just going to say briefly that the results of the English RCT, which I think are likely to be of interest to the committee, will also be available in 2013.
Why did the Scottish Government decide not to go down the RCT route, which has been followed in the States and in England?
There are probably several reasons. One is that the Department of Health is doing it for us, at a cost of £5.3 million across 18 primary care trusts. We anticipate that the results will be transferable into the Scottish context. Secondly, the results will be out in the next two to three years and will be useful in shaping how we extend the family-nurse partnership programme in Scotland. There is probably no need for us to spend that money when somebody else is doing it.
Okay. That was helpful clarification. I want to ask Mr Howie about the keep well project—this goes back to something that Bill Alexander said at the outset about preventative spend. Appropriate early interventions can prevent much more significant expenditure later. However, in the evidence that we have taken this morning, I have not heard anything that suggests that we have captured what the cash savings would be or how we would free up time for the health professionals who provide care in the NHS. Mr Howie rightly identified 145,000 health checks and the fact that more people who are at risk of cardiovascular disease receive appropriate and timely interventions. Could that be looked at as part of the evaluation of the keep well project?
The evaluation that is being considered for the next three years has four components: one is around clinical outcomes, one is around patient experience and a third deals with the financial gain from the sort of activity in the keep well project. It is a very complex financial modelling exercise, given that we are looking at the impact that interventions will have decades down the line. The University of Glasgow is putting that together just now. We have had initial discussions—I do not think that Dr Walker is involved in them. It is part of the evaluation that the keep well extension board in the Government is considering. We expect a decision in the last quarter of this financial year.
Will you share with the committee the methodology that is being used in that evaluation? When will we see the outcomes?
The methodology is being worked on just now, so it would be unfair for me to go into the detail—I would not present it very well. We will certainly share it with the committee as soon as it is available.
Bob Doris has a specific point to make on that.
My point is with a nod to our next witness panel. What you said was interesting. You talked about savings further down the line and we are talking about workforce planning further down the line. What consideration have you given to workforce planning? Perhaps you are not involved in that, but are you talking to people who would be involved in it? We are going to see shifts from acute care into the community and so forth. Does that go hand in hand with what you are doing? Have you given that any thought?
We have not had any such discussions. There are significant staff movements and resource savings in moving from acute care to community-based care. We all face that challenge. Until a building actually closes down, it is not possible to realise the savings.
You mentioned short-term gains. To help us to move from considering an abstract concept to something that makes a difference to people’s lives, can you tell us what the short-term gains have been?
As I highlighted earlier, about 145,000 individuals have received a health check who would not necessarily have come forward to the NHS to learn about their current health status. In some cases—I used the example of West Dunbartonshire—30 per cent of the individuals who came for their health check were assessed as having a one in five risk of getting coronary heart disease within the next 10 years. I highlighted the fact that, in response, approximately half of that same population have been referred on to a range of services, including weight management, smoking cessation and stress counselling services. If we accept that those services are effective and that positive outcomes are being delivered for those individuals, the early evidence that we have suggests that people’s health and wellbeing are improving as a consequence of the contribution of keep well.
Screening and raising awareness are all very well and smaller numbers of people are referred on, but how confident are you that the services further down the line have the capacity to make a difference?
The capacity question was initially a concern. We are talking about a fairly large programme. Anything between 30,000 and 40,000 individuals are coming through with a range of new needs being identified. Services are required to refer people on to. As part of the development process, the keep well programmes have to engage with follow-on services to ensure that they have the capacity to deal with the new range of needs that will be introduced to them. There have not been any capacity issues so far. There has not been a bottleneck effect, which is reassuring.
How many of people with weight, smoking or alcohol problems for whom a risk has been identified and who have been referred and passed on have stuck with the programme for a month, two months, three months, six months or a year? How many successful outcomes have there been?
Evaluation of the outcomes, including the patient outcomes, that the services have delivered has been limited. I gave the example of NHS Tayside. Gains have been achieved in cholesterol, weight and blood pressure management. We have small-scale examples.
Remind me what the investment was.
It was £11 million.
This was my question earlier, convener.
Allow me to finish my line of questioning, Richard. The issue takes me back to my original question about what prevention is. Can identifying people, making contact, identifying a problem and referring some of them on be considered prevention, given that it does not necessarily lead to other outcomes? If we do not follow through and create life-changing opportunities, the work does not feed into prevention.
It contributes to those changes after the keep well health check. There is investment of £11 million in the health check, up to the point of the referral on. The responsibility thereafter to support individuals to make the necessary changes and to sustain services comes from a mainstream allocation. We must remember that there are many other factors that determine whether an individual sustains the change. The tobacco legislation, for example, has been an extremely helpful mechanism for supporting people who are going through the smoking cessation programme.
In seeking to identify preventative projects, we can clearly see how the early intervention that we have discussed today is intensive support. It will make a difference in the early years and it will be picked up at the nursery and in mainstream support. We can see a line there, but when that line is broken, it is like getting the big fish out of the water that falls back in—when people say, “I nearly caught one that size.” I am open to persuasion, but can that truly be considered preventative spending?
Professor Barber, who was a professor of general practice at the University of Glasgow, ran a programme on hypertensive screening in 1979, and the results that were published in the British Medical Journal showed that, over a three-year period, 90 per cent of patients who were registered with general practitioners would be seen at their general practice and could be screened. Will the targeted expenditure on the keep well programme and the new programmes that are emerging be sustainable if we do not address the 100 most deprived practices, which are part of what is now known as the deep-end group? They see patients from deprived areas day in, day out, and they will see 90 per cent of them over a three-year period.
I am sorry to talk about the family-nurse partnership programme again, but I reassure you that 75 per cent of clients in the programme are from deprivation categories 4 or 5, so by default we pick up people from the general practices to which Dr Simpson refers.
We do not want to pick out anything, but we are struggling. We have asked other evidence panels what preventative spend is and we have a long list of evidence from retailers and pharmacists as well as from any other group you like that works hard in this field. That evidence states that they are involved in the preventative health agenda. There are many claims for it and we take it seriously, but we are struggling to identify what it really is so that we can ensure that we can support initiatives that meet given criteria.
I agree with you on the role of carers. They already offer us massive support and help through what they do daily, which is often unseen. I also agree about the third sector. There is an issue about the professions because not only do we need to work better with the third sector and carers, but there needs to be some significant change in professional boundaries across the professions to enable the workforce to move forward to deliver on the challenges we face.
I agree. There is a care role for the third sector, particularly with children and families. It can do a lot to provide some of the lower-threshold support that does not need the professional involvement of health visitors or nurses, and it can and does complement the work that is done by professionals. It does many practical things for families: for example, third sector involvement can ensure that children get to school in the morning and it can support families in getting the right food on the table for the children. I have been involved in progressing a Big Lottery bid locally with the third sector and as we have worked through how it can complement the work of professionals, the work has been quite amazing. We need to work on third sector involvement and to consider it seriously, because this is not just about highly paid professionals delivering care.
That is absolutely right. A little bit of money spent on carers goes a long way; kinship care must be one of the most demonstrable examples of that. A child who is supported in kinship care is likely to have much better outcomes than a child who is supported in residential care—and it is cheaper, so it makes good professional sense and good financial sense. Good financial sense and good professional sense often go hand in hand—they are not exclusive. The same applies to other ages and stages. A little more money spent to support communities will mean that those communities can support people for longer and that they will not require formal services.
I thank you all for the valuable time you have given us this morning. I am sure that the evidence and insights that have been given will help our scrutiny of the budget.
I welcome our second witness panel, which comprises Martin Woodrow, who is Scottish secretary to the British Medical Association Scotland; Theresa Fyffe, who is director of the Royal College of Nursing Scotland; and Matt McLaughlin, who is a regional organiser at Unison’s NHS Greater Glasgow and Clyde branch.
I thank the witnesses for joining us. Your submissions highlight two themes—the relatively strong budget settlement for health services, which all the submissions note, and significant challenges that remain, which the submissions quantify. I have no doubt that we will discuss that.
I will separate the two issues that you raise. Our workforce planning dialogue is with boards. I will be straight with you and say that I do not see good evidence of workforce planning in relation to preventative spend. When the Scottish Government pulls together the workforce plans, it would be expected to consider whether those plans support what might be required for preventative spend.
The dialogue on the medical workforce is more at a national level, where there are structures that ensure appropriate discussion of workforce planning. As Theresa Fyffe said, much of that discussion has not explicitly covered preventative spend—there is a disconnect between the two. More broadly, there is discussion about how the workforce needs to move from acute settings into the community. That is part of the preventative spend agenda, but not explicitly so.
First, I do not think that Unison has accepted that the settlement for health spending is strong. NHS Greater Glasgow and Clyde will receive an uplift of less than 1 per cent of what it spends, so there are challenges. That leads into the debate about efficiencies and cash-releasing efficiency savings. For health boards to deliver a service, to deliver preventative intervention and to make workforce planning changes, there has to be investment in change and change needs to run in parallel with the delivery of acute care in hospitals for our aged and ailing population now. The evidence does not stack up to show that we are getting that balance right.
I take from your responses two themes. First, health boards need to do more on any change in workforce planning. We can ask the Government how it is working with health boards to ensure that they raise their game, so that information is useful.
To be honest, we expected more to be provided for the tobacco and alcohol interventions that are required, which flatline in the budget.
Reflecting again on your previous discussion, I think that the issue is what we mean when we talk about preventative spend. As you have heard, there are different views on what it means. Talking in the broadest national policy sense, the BMA has been supportive of preventative spending and has had ideas about the smoking cessation agenda, alcohol policy and so on. To be honest, we have had relatively little involvement in things like the family-nurse partnership model, because it does not directly involve our members. There is an indirect involvement, but we have not been directly involved in discussions on those kinds of things at a local level.
The big challenge is mainstreaming. There are lots of worthwhile projects across health and social care and all the other facets of public service delivery. As we see it, the challenge is that there comes a point at which they become either unsexy or unvalued and something new comes along, and we do not transform something that works well on the ground into something that can work in the main stream. Certainly, that transition can be very difficult.
So, to be clear, there is a welcome for preventative spend, there is a request for more clarification of what the outcome of that spend would be and, more important, there is a call for an effective transition from pilot projects to enduring schemes once we have the evidence base to prove that something works. We have picked up on that last point before. I welcome the support for the direction of policy, but I note that there are challenges around implementation. The organisations that are represented on this panel are vital in helping us to solve those problems, and I thank our witnesses for their time.
On broader co-operation and integration, a recurring theme is that the only way that we will be able to deliver some of the preventative interventions is by having broader approaches and getting out of silos. I note that the RCN’s written evidence draws our attention to the Scottish Government’s overview of first-year proposals, which identifies a clear weakness:
There is a risk that, as we look at previous innovations that we have tried but not implemented as a way of working, such as joint futures work, we say that the only way in which we can do something is by having massive structural change. I am concerned that we could go in that direction because of the feeling that, if we move everybody into one place, we will achieve change. However, silo working can happen in one organisation just as much as it can happen in two organisations. I have seen a lot of evidence of that in my experience of the health system.
I suppose that the challenge to organisations such as yours, which may have vested interests, is to nevertheless bring your significant resources and your minds to bear on the problems. I do not think that it is sufficient for the committee just to hear your criticisms. Perhaps you can advise the committee on alternative ideas.
We have submitted evidence to the cabinet secretary, which we would be happy to make available to the committee, about possible solutions—that is the kind of organisation we are. We do not believe that what is happening is the right way of working, so we have put in significant evidence to say, “We think that these are the solutions.” We did research on a number of different areas across Scotland and found really good examples of practice that is working very well. We are saying, “Let us build on that and get the energy of those ways of working, which will involve the voluntary sector, professionals and other sectors.” That is definitely the way forward. If the committee would like to see that evidence, we are happy to provide it. I agree with you that it is not enough to say that we do not agree with something; we need to offer solutions as well.
I am sure that the committee would appreciate that information.
Like Theresa Fyffe, I do not think that the answer to this problem is to throw everything up in the air and rearrange all the structures. That would simply cause chaos and would not solve the problems. Never mind Australia—one need look only at England to see the problems that are caused by significant reorganisation.
As someone who, as a young regional organiser, was involved with the joint futures project in Perth and Kinross, I am struck by the impression that, many years on, we are still having the same circular debate on these issues. That is frustrating not only for our organisation but for the professionals on the ground who are delivering the service. Everyone accepts the principle that greater integration and closer working together are good things, but the models that have been proposed have been a bit top-down and handed down to people. Indeed, some of the CHP models are weak on transparency of decision making and, in particular, democratic accountability at local level, and we need to come to grips with those things if we are to challenge the current situation and bolt on the Christie commission’s recommendations. The big worry for people and communities on the ground is that these changes will be cash driven, not quality driven. If we are serious about preventative care, we need to focus on putting quality at the centre of the system, irrespective of the cost.
I have a supplementary to Bob Doris’s question. As spend to save has been on the agenda for more than four years now, I would like to know more about your close working with the Government.
As was highlighted in a previous evidence session, when you are faced with fiscal problems, you look first of all at your workforce and find out whether you can make any savings on your fixed costs. It is reasonable to point out that nurses seem to have come off the worst in this respect, but the history of nursing suggests that it has been ever thus. As I pointed out earlier, when the funding ended, the Macmillan nurses were whipped out, even though they were there to deliver. I should say, though, that some of those savings were planned in partnership with us.
That is a valid point. As my colleague pointed out, nursing numbers have been significantly reduced. It would be a mistake to gloss over the fact that 1,100 admin workers have been taken out of the service as well. They do a valuable job, quite often facilitating registered professionals to deliver the front-line service.
Given that the spend-to-save focus has been with us for a few years, what I am really asking is why spend to save had such a dramatic effect on nurse numbers. Most of the witnesses have been talking about efficiency savings or cuts. There are no explicit efficiency targets for next year. Will that help the workforce? Will it change the focus? Over the past 21 months, why has the spend-to-save focus led to a loss of 1,700 nurses as well as the admin staff? We are looking at that same focus for the next five years.
The reason is pretty simple. By and large, across the board, health boards have centralised services. As my colleague pointed out, with centralised services you take a number of beds out of the acute side, and the biggest group that is affected by that at the front line is nursing staff. Because of the way in which boards do their workforce planning, there is a direct correlation between the number of beds and the number of staff on a ward-by-ward basis.
I am reading from a briefing from the Parliament’s information centre.
The other panellists want to respond to the question, Mary.
There has not yet been an agreement on efficiency savings, actually. It is not clear that the figure will be 3 per cent—we expect something, but we have not heard yet. That takes me back to the point that workforce measures have become the best way in which to try to balance the books. As I said, that is understandable. It is where you start, and any organisation will do that. We have just been through the latest round of workforce planning. I believe that boards are working with a financial envelope, rather than on the basis of what services they need to provide. We have workforce plans with very little lift in the numbers of advanced nurse practitioners, who are essential to the delivery of the service. I could count on the fingers of one hand the number that one board thought it would need. That tells me that boards are thinking, “This is the money we’ve got, and this is what we do.”
Mr Woodrow, do you wish to comment?
I have nothing to say on the specific question about nurse numbers, but I echo Theresa Fyffe’s comments about what is happening to services. It is obvious that boards are planning their workforce on the basis of what they can afford. As we said in our written evidence, we need a country-wide discussion about what health services we can and cannot afford to provide. That discussion cannot exclude things such as reconfiguration of services, as many such discussions do at present.
There are 1,700 fewer nurses and 40 fewer doctors than there were 21 months ago. The changes seem to have fallen disproportionately on the nursing profession.
We have mentioned the effect on morale of making savings through wages and conditions, and we take the point on that. We heard in evidence last week that the level 4 information in the budget shows £24 million for merit awards. Can we have a debate about the future of the health service when people are having their pay frozen and we are openly discussing holding back increments, yet there is £24 million in the budget for merit awards?
I suppose that that is a question for me more than anybody else, as you would expect me to defend the pay of doctors, and consultants in particular. Distinction awards are a significant, although relatively small, part of the pay bill for consultancy. They have been part of the consultant remuneration package since 1948 and are an important part of rewarding doctors who do the most for the health service.
What about fairness and all being in it together? We need a debate about what is important in the health service and how we spend our money. Irrespective of the consultation, there is £24 million in the budget for merit awards when the lowest paid, who deliver the services, are expected to take a pay freeze. Is that justifiable?
I will follow up on some of the things that Mary Scanlon said. It is interesting that she provided numbers for staff changes and I provided percentages. It is interesting that Matt McLaughlin talked about the 4 per cent drop in administrative staff. I used to be a health librarian, so I would probably have fallen into that.
You are absolutely right. That is what I meant by balance. To be honest with you, nurses have had no problem accepting the evidence for change. Changes to the skill mix in nursing teams have already been happening for a number of years. Matt McLaughlin’s point was very well made: without administration staff behind them, registered nurses will end up doing things that are inappropriate and that they should not be doing.
There is no dispute within Unison nor among Unison members that preventative intervention is the way to go; the issue is how we get there. However, the reality is that irrespective of how much money is put into it today, the benefit of that model of provision will not necessarily flow tomorrow; its real impact has a longer tail. Therefore, we need to have a discussion about how we run things properly in parallel.
As I said earlier, we support the need to look at the configuration of health and social care services. Doctors very much want to be part of that discussion.
In some of the evidence last week, we heard the argument that we should just get on with it. It is strange to hear that we need to wait for all the evidence to assess any gain, yet we identify the loss quite quickly. We heard this morning that some intervention posts for young people in schools have been taken away. We know from evidence that more elderly people are taken into hospital over weekends because of the absence of a home help three times a day. We recognise such loss immediately, so why do people continually put forward the argument that we really have to wait years to see benefits from any initiatives? If you take away the Macmillan nurse, the loss is seen immediately.
It goes back to the fact that a number of years ago boards struggled with what they called creeping developments. Notably, one board ran itself into serious funding difficulties—in fact it was called to answer for what happened. It let things happen but could not manage the budget. Boards have gone back to being concerned about being clear about funding for their core services.
What you have said leads into my questions quite well. I will start by assuring Theresa Fyffe that my question on increments was intended simply to identify the fact that, even with a wage freeze, there will be incremental drift, which will probably be greater because fewer people are leaving post and fewer new people—who are cheaper—are coming in at the bottom.
On the first point, I agree that unexplained variation is an area that we should look at. Richard Simpson has highlighted prescribing, which I am aware that a number of boards are looking at with practices and the local medical committees that represent GPs locally. They are supportive of those initiatives. Such variation can often be explained by differences in practice populations but, where it cannot be explained, GPs are working locally with boards and are going along with that agenda.
I draw your attention to the work of the efficiency and productivity strategic oversight group. EPSOG was run as a committee, but it has now gone into the Government’s quality alliance board work stream, in which there is a clear move towards removing variations. It has been decided that the chief executives should now run that programme. The question will be whether they use it to demonstrate the changes in variation that they need to make. We keep a close eye on that, because the point is: if evidence has been found on a more efficient and productive way of doing things, why are we not following it through? We have not been doing so. The committee might want to pay attention to those attempts to make changes.
I would like to come back on that. I am glad that you have put on record the point that the main boards have considerable value, provided that they focus their work.
I agree entirely. That is what I meant. It is very easy to target individual posts when you are trying to make your saving. When savings are dropped down a very big system and you are told that you have to find your percentage of the overall figure, if your only saving can be in fixed costs, as in staffing, you go for your staffing. I have been pleased lately to hear senior people in some boards say, “We cannot do any more of that.” This is the first time that I have started to hear that being said. I was becoming increasingly concerned when we were not hearing it—Matt McLaughlin and I shared that point earlier on.
Theresa Fyffe’s description of the reality of the situation is dead on. Across the NHS in Scotland, people today are having to make cuts to balance their books. They do not necessarily have the opportunity to implement a proper spend-to-save agenda or make some of the other investment that they might want to make in preventative care; it is about balancing the books today.
If you are committed to changing the culture and bringing about early intervention, prevention and all of that, that should be at the heart of your decision-making process. The hard thing is that we have just heard in evidence that it is not. Decisions that have been made will prevent us from moving in that direction. We have heard some evidence about elderly care and the education, training and development of the care workforce—not only the professional workforce but, for example, training home helps to recognise dehydration, a urine infection or whatever it is that causes people to be taken into hospital, who sometimes, and at great expense, will never come back to their home. Such basic stuff must be done. If none of that education, training and development is being done and that budget has been sacrificed, how do we develop the workforce so that our approach is truly preventative?
That is a challenge. Matt McLaughlin is right that some boards are trying to turn that around.
With all due respect, they might be planning for more care workers or registered nurses. Are they not doing that either?
That is an interesting point. When a ward was closed and a team taken out, healthcare support workers, registered nurses and others were also taken out. The move to giving teams healthcare support workers and others was a good one, but we are still targeting a workforce figure because that is the only way the books can be balanced in the end.
I want to speak about a similar area. The problem for us all—in industry, government, health boards, councils and so on—is that when we have a fixed budget, we have to work within it. Perhaps the difference between a health board and, for example, my business, is that I can borrow so that I can achieve my priorities for the financial year. The Government and health boards do not have that ability to borrow. On top of that, we are facing a budget cut.
I think that everyone recognises that NHS inflation is rampant. It would be more helpful if we had a sense that the Scottish Government also understands that and factors it in when it is talking about settlements for boards.
I echo much of what Matt McLaughlin said. The prescribing budget is big and, as we have already suggested, work is on-going to control it. However, it is difficult to do so with all the new treatments that are coming online and being approved. I believe that in its evidence NHS Lothian drew particular attention to the consequences of new and particularly expensive drugs being approved. All that is outwith a board’s initial control, and the fact is that it will have to provide medication that advances in medicine have made expensive. As I have said, although everyone is aware of the issues and is convinced that the matter needs to be addressed, it will be incredibly difficult to do that.
If there are no answers to that and if the Government is already using all its resources—after all, we must remember that everyone else in the public sector is being squeezed significantly—I believe that the current spend-to-save approach will, in the medium to long term, be the salvation. When I said that there might not be enough funding, I was not blaming the Government, as it is constrained. From the evidence that we have taken so far, I feel that the only way that we can make long-term savings is to spend now to save for the future. Of course it is painful just now, but we have to find some way of making savings.
You are absolutely right. As colleagues have pointed out, social Scotland needs to have a debate about core NHS services. I am sure that people have already said as much in evidence—certainly, the chief executive of NHS Greater Glasgow and Clyde has been vocal about the impact of free prescriptions on his board. Although the measures are having a real impact, I believe that there are opportunities to grasp. The same health board put significant amounts of money into examining patient food production and has now invested significantly in a new cook-freeze system that serves all NHS Greater Glasgow and Clyde—and, one might argue, beyond. It took an up-front investment of millions of pounds but, in the long run, it has delivered long-term sustainable jobs for people, particularly in the Royal Alexandra and Inverclyde hospitals, and has led to local and affordable production of quality food.
Each of the witnesses has rightly highlighted not only the need to invest in preventative spending but the fact that the financial settlement has been tough and tight and that there is a fixed envelope of funding for health boards. If I understood her correctly, Theresa Fyffe said that what is considered to be preventative spending often sits outwith mainstream budgets and is therefore vulnerable in tight financial times. Can you shed more light on that issue?
When there is funding for a separate project, the leverage model that the CMO spelled out to the committee is a good one, particularly when the funding is given to people who are working in teams and actually delivering. It would be good if those who account for such funding could build it into the continuing budget, but because it is separate funding they do not do so. Instead, they keep the project separate and it is funded for a period of time.
Where is your thinking taking you on how we can reconfigure spending priorities?
I am always interested in how boundaries work. It might be cheaper for a patient to use a service in another area, but they have to stay within the boundary of their area, even though that might cost more, given that some of our areas are big. We need to think differently about where patients are and where they can travel to. We have done significant work on that already. I used to work in Tayside, and I remember when we decided that certain types of surgery would be provided in Angus and certain types in Perth. At the time, the public did not travel beyond Ninewells in Dundee, but they do now.
I address my questions to Mr Woodrow and Mr McLaughlin. To recap, how do we embed preventative spending and do you have any ideas on how we can reconfigure services more effectively?
To clarify an earlier point, I think that Jim Eadie suggested that we had engaged with the cabinet secretary on reconfiguration. I was actually talking specifically about how we can re-engineer the structures of health boards and CHPs to ensure that decisions are made by appropriate people, that they are not so manager led and that there is more clinical input.
If we want a faster transition to preventative spending, we need to work out how we can get an adequate funding formula for that, which allows us to run in parallel and deal with the training issues and development issues as well as taking the communities along with us as we go. We also need to have a clearer understanding of how we evaluate and determine the quality of interventions, and we need to come to an understanding of what an improvement is, why it is an improvement and why it needs to be mainstreamed.
Rhoda, as a substitute member, you have sat patiently while others have asked questions. Would you like to ask a question?
Yes. We are talking about changing the balance of care from care that is delivered in the hospital to care that is delivered in the community, and about preventative spend. We have also talked about the numbers of nurses that are leaving the service. It occurs to me that that could be because we are asking people to work in a different way. Given the age profile of some of the professions, being asked to work differently—for example, working in the community instead of in a hospital—might be challenging, and it might be that people would rather leave than change their way of working. What work has been done to equip the workforce—some of whom have huge amounts of experience—for a change in the way of working? Is that being carried out? If not, could the scenario that I have outlined be behind the figures that we are seeing?
There is no doubt that, among the older workforce, there has been a move towards taking opportunities for voluntary redundancy. I do not think that that is to do with an inability to move to the new model; I think that it is more to do with being tired and thinking that they do not want to deal with another change.
My question is in addition to Jim Eadie’s. Will each of you give an example of where you would invest additional money for preventative spend to save, and where you would take that money from? A ballpark figure might be £5 million to £10 million. We have heard plenty of reasons and the evidence has been interesting, but we have not got to the specifics. I hoped that Jim Eadie’s question would bring that out, but it did not.
You are being very helpful and I am sure that Jim Eadie appreciates your taking his question on. Whether the panel appreciates the question or not, I am sure that they will attempt to give us an answer.
To be honest, as a professional leader of a group of nurses, it would be very arrogant of me to think that I could make such a suggestion without a proper working model that suggests a change you could make at a local level, and that takes me back to what Martin Woodrow said. We need to be partners in that process and, as an organisation, we are happy to be partners in it. I have done such work in the past. We sat down and proposed a change and we worked with the public and everybody who was interested to come up with a plan. It would feel very wrong if I were to say what I think we should do, because that work has not been done. I am not saying that the boards have not tried to do it, but it has not been done with us in partnership. We would be prepared to be at that table, but we need to cover the local context and we need both public and patient engagement. That is the way forward. If we do that, we will come up with something that will definitely identify such specifics.
Like Theresa Fyffe, I find it very difficult to say what we would stop doing. The decision-making process needs to be a local one. We can talk about the preventative activity we would support at a national policy level to deal with alcohol, tobacco and obesity, but I cannot say that an individual health board should do this, that or the other and should take out money from something else. That is not a question that I am in a position to answer.
I would struggle to get it into a £5 million envelope. That is a difficult question to answer. Theresa is right: it would be terribly arrogant of us to sit here and say, “This is what you should do.”
I am hoping to get some perspective on some of the numbers that we have looked at today. Although there is £1.3 billion less in the Scottish budget from the UK Government this year—the previous UK Government took another £0.5 billion out of that budget—there is a 0.5 per cent real-terms increase in the NHS board funding allocation. I fully accept what Mr McLaughlin said about inflation in the health services. The stats show £800 million Barnett consequentials coming to health over the next three years.
We can certainly give you some examples. You are right about the figures, but that is why media coverage in England is the way it is. Are we heading in that direction? I have been around the health service all my career and I could not bear to be in a place with such figures. That is why they are where they are in England. Scotland has an opportunity to step back from going in that direction. When people see the figures they say, “England has that number, so why can’t you go to that number?” They do not make the corresponding link with quality, safety and public opinion of the service, which in some parts of England is at an all-time low.
That information would be helpful. Thank you.
Mr McLaughlin, are you going to disappoint Bob Doris?
As Theresa Fyffe said, we would be really concerned if we were to start following the English model of healthcare.
So would we.
Excellent. You asked for good examples. A lot of good work was done initially around crisis teams and drug and alcohol action teams in trying to deal with bed-blocking issues. To be fair, in the past 12 months some of that has foundered a wee bit. Audit Scotland recently produced a report that said that things had stalled. However, that is the kind of engagement from which the public, our members and the service all benefit. People quite like working in that kind of intensive area, where they can make a real difference to somebody’s life and where their intervention helps somebody come out of hospital, get back into their home and be properly supported in their home. That is the key balance. Those are the kinds of area where there is good practice.
That is helpful. Thank you.
There are no other questions, so it remains for me to thank you on behalf of the committee for your valuable time and interesting insights. I am sure that the evidence that you have provided will be useful in our budget scrutiny.
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