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Good morning and welcome to the first meeting of the Health and Community Care Committee after the recess. I hope that members had a refreshing recess; I will not call it a holiday, because I know that you have all been busy. We have flung ourselves to the four corners of Scotland to find out more about community care on the ground and we have more witnesses with us this morning to give evidence of how community care is working—or not—in Scotland.
I thank the committee for asking us to come along and give evidence today. Members have received our original submission and our "We Care" petition, which has more than 10,000 signatures. David Brownlee and I would like to say a few words about some of the current issues. David will talk briefly about the problems that relate to care provision and charging and I shall address my comments mainly to the Sutherland report. We are aware that we have only about five minutes to do that, so we shall stick to our time limit.
I am Age Concern Scotland's information officer and my remit is to advise people on income and social inclusion. I get a lot of inquiries from Age Concern members and other members of the public about problems that they encounter in community care provision.
Thank you. I hope that this meeting will be a good experience for you, David. I echo your comment: people do not come to us often with good experiences. One reason why we went out to speak to people was to get a balance between the good and the bad, rather than merely hearing anecdotally that the system is bad.
I would say that the problems do not affect only a few thousand individuals—they affect us all. We all hope to grow old, but we have no way of knowing what our care needs will be as we get older. Some of us will live healthily until we are very old and die in our sleep, while others will become frail and will need a lot of support for a number of years. The Sutherland report made the point well that, as a society, we are prepared to pool resources to pay for accident services, or pay for a health service and police on our streets. The principle of providing for those in our population who need that underpins the recommendations of the Royal Commission on Long Term Care.
I will pick up your point that implementing the Sutherland report in full would, at a stroke, lift anxiety from older people. There will be anxieties left. There will still be costs to be borne because people will still be assessed and they will still have to pay housing and living costs within residential care. Because of that, not all of the anxieties can be lifted at a stroke. However, what would the impact be if the recommendations of the Sutherland report were not implemented in Scotland?
If the recommendations are not implemented, the situation will continue in which older people—even those who have savings—are frightened to spend money because they think that they might have to pay for care later. The principle of contributing towards what the Sutherland report calls hotel costs—bed and board costs—is accepted by most people. Older people do not object to making a contribution to having their housework and shopping done. However, our research shows that people feel that the range of care that would be classified as personal care—help with eating, dressing and so on—is different.
If the current system continues, the boundaries of the laws will continue to be tested both by local authorities and by individual service users who feel that they have been caught out by the unfairness of the regulations. Cases are regularly subject to judicial review, such as Yule v South Lanarkshire Council and Robertson v Fife Council. In those cases and others, individuals look to the courts to provide fairness and give answers that people cannot get from local authorities. People feel that they have been badly let down by local authority policy and practice—that will continue and will lead to difficulties for many people.
Putting the issue of equity and fairness to one side—which you have dealt with well—what effect do you think that full implementation of Sutherland would have on the manner in which the system functions? Would it make for better delivery of services? If so, why?
It would, because the system would be easily understood. The principle of paying for hotel costs but not for personal care costs is understood by us, by most people to whom we have spoken and by the committee. That is seen widely as being a system that could be implemented and that would be easier to run after an implementation period.
I take it that you think that implementation would have an impact on the bureaucracy of the system.
It could.
In what way would the implementation of Sutherland alleviate the funding problems that are faced by local authorities?
There would have to be more money going into the local authorities to provide the care. We find the sums quite mysterious. We know that there has been a shift from older people spending fairly long periods in hospital towards them living at home. However, no parallel shift in resources has followed—there is a shortfall. There is already a mismatch. If a decision were taken to implement Sutherland—making personal care free—considerable work would need to be done to ensure that the money followed the people. One of the recommendations is that there should be better joint working—that is already under way and will make a big difference.
Would local authorities need more funding if personal care was to be free?
Yes, they would.
I want to move on to the section of your submission on the representation of consumers and national standards for care. How could the views of older people on the services support that they want to receive be heard more effectively?
There is a need to ensure that consumers' voices are heard at national and local levels. We are encouraged that the Scottish commission for the regulation of care will involve representatives of users and carers groups.
You said that you were pleased that users and carers were to be involved in the commission for the regulation of care, but your submission also says that you would like
No. That is a matter for investigation. Consider the model of the local health councils, which were set up to champion the interests of health service users. There is a need for an equivalent body to cover community care. The local health council model works well, and something equivalent would have a useful role to play in helping to ensure that community care services are up to scratch for the needs of the users.
But you would not want the commission for the regulation of care to undertake that role; you would prefer a separate body to be established.
The body would have to have the independence that the commission, by its nature, will not have. I mean no disrespect to the work that the commission may do, but it is a different beast.
May I ask a supplementary? You referred, rightly, to the need for more research overall, but has any research been done into the cost of means testing, which is an expensive business? Sometimes doctors and others are paid for their part in the process. Do you have any indicators of that cost, or would you like the matter to be explored so that we can get a balanced picture of the cost of means testing?
I am not aware of any research. Are you, David?
No.
You talked about a muddle, and we are gradually coming to the same conclusion. May I ask about the provision of information, advice and advocacy services, and barrier-free housing and transport, as part of a holistic approach? You mention such an approach in the conclusion of your submission. How do you feel about the progress that has been made towards an integrated policy response to the development of community care services in Scotland? Are we moving towards greater integration?
The short answer is yes. Initiatives are taking place in which the authorities are trying to get together to ensure that people who use the services do not have to chap on one door after another to get what they need. We are moving in the right direction. The political will exists to make things happen, and local authorities seem to want things to happen. It is only a matter of time before consumers feel real improvements.
I understand what you are saying. The learning disabilities review, which is an excellent document, goes a long way towards addressing that gap.
I do not have a case study.
We have seen better practice in Perth, which is probably one of the better known local authority areas. Efforts are being made there to join together the services of the local authority and the health service, to ensure that people need only one port of call to get services. We have also had good reports from Dundee, where individuals are receiving a good level of service and where accessing services is easy.
As far as I am aware, Perth is one of the few places in Scotland that has a service—set up by the citizens advice bureau—that has been set up specifically to address community care needs. I am not aware of other information providers at a national level in Scotland who have the level of expertise that is required to give full answers on community care issues.
Mary Scanlon mentioned seamless care. We know that that is the way forward, but it has in-built financial barriers at the moment. Should the resource transfer be put into a pooled budget, or should we stay as we are?
The pooling of budgets into a single community care budget is quite complex; there is clearly a point at which you have to say that community care begins and health care ends, and vice versa. Having one budget for community care would certainly make life easier but, as you said, there are real barriers to doing that. Budgets are held by different authorities. To have one budget for community care would require a tremendous amount of work to establish what the community care services are, and when the community care budget kicks in. We have all heard about the dreadful health bath or social bath nonsense. If we are to get away from that, we must consider having some kind of pooled budget, but at the moment we are not aware of that working successfully anywhere. A lot of work will need to be done.
Would you advocate going down that road?
It should be explored. However, we need to work in the context of the bodies that exist at the moment. A proposal of ours that we would like to be considered is to have an authority that would be responsible for delivering community care. It would straddle what currently comes under health and social work. Local authorities and the health services would have to work on the practicalities of that.
That leads me to my next question. In England, the national plan has introduced the opportunity to create new care trusts; such trusts represent a new level of primary care trust with a broader health and social care role. Should we follow that route in Scotland?
Again, we should certainly explore that option. There is a blurred line between health and social care—that is what we are talking about. The health service is clearly changing: there is more emphasis on people accessing health services more locally. If that is to happen, we imagine that it would make it much easier to set up a new trust such as that, which would probably take charge of public health as well as health and community care in its own area.
Has your organisation evaluated what has happened in England?
No, not yet. However, we work closely with our colleagues in Age Concern England, which is a separate organisation. It has more resources than we do to do research.
I have a brief supplementary question. I do not understand your position on this issue. You advocate a separate, independent body that pulls together the various strands of policy, and you are quite clear that the structure should be unified, but you seem to be much more reserved about saying that there should be a unified budget. What would be the point of having a separate structure that would pull it all together if we did not go down the same road for funding?
It is not reluctance to consider that as an option. We have to separate out the delivery of the service from the point of view of somebody who has needs that must be met—having a one-stop shop and putting in place the resources for that. It is about moving from the current position to where we feel that we want to be. At the moment, the structures are quite rigid and it is difficult to move towards having a single budget for community care.
Surely, as long as you get your definition right, you can say, "This will actually happen and will make a difference." Colleagues have found projects round the country where pooled budgets have been set up in miniature. People have said, "Right, we will pool this money; we will pool that money; we will bring in this member of staff; we will bring in that member of staff; we will make the managerial team knit together." Those people might hate each other for 18 months, but eventually they will provide a service. When you go in and talk to them, it is not impossible to tell who is the health professional and who is the social work professional, but they are much more of a team, providing the service that the users need. In essence, that is what we need to do first before taking that approach to a grander scale.
One of the frustrations that I experience comes from the fact that projects often fall between two posts—they are neither health board work nor social work—yet they are vital in keeping elderly people, who are at the margins and vulnerable, in the community. I am thinking about lunch clubs, transport and barrier-free housing. I wonder how we can provide seamless care and recognise, for example, that lunch clubs and satisfying the nutritional needs of the elderly are vital to keeping them in the community. At the moment, many projects throughout Scotland are not funded because they fall between health board funding and social work funding. How could such projects fit into the structure and funding regime that you are thinking about?
That is a tremendously important point. We have not yet touched on the role of the voluntary sector. What you describe is precisely the type of role that local age concern groups play.
Exactly. I have one such group in my constituency.
Preventive measures do not always mean someone getting a jag in their arm to stop them getting flu; we are talking about researching what enables people to live in the community without more intensive care being put in place. Funding for the voluntary sector's provision of such services has dwindled. Age Concern Cupar is being run by one woman and her sister, who provide a lunch club for 60 older people in the course of a week. They are working all the hours to make that happen. Their funding does not appear in the equation that is under discussion and you are right to hit on that as a problem.
The financial gap that the voluntary sector is filling is an important point for us to note.
You would find wide agreement that, without voluntary sector input, we would be pretty well sunk. We rely too heavily on that sector and perhaps exploit it too.
You are right that we do not need to wait for everything to happen from the top or for major policy changes. Progress depends on finding practical ways of making things happen. Giving people access to aids and adaptations and to equipment such as wheelchairs is a practical way of making progress. That does not cost anything and probably saves money. We would encourage people to do that.
I must wind up the discussion at that point. Thank you both for giving us your time this morning and for your written submission. Thank you also for submitting your petition; we decided to take it on board as part of our on-going inquiry rather than consider it separately. I hope you feel, having spoken to us today, that we recognise the fact that there are 10,000 signatures on the petition. We also recognise the great concern among Scotland's older population on the issues that are involved.
Meeting adjourned.
On resuming—
Our next witnesses are from Alzheimer Scotland—Action on Dementia. I think that Jim Jackson and Jan Killeen are well-kent faces to most of us.
That makes it sound like an exam question.
Do not say that—exams is a bad word here at the moment.
Thank you for the invitation to give oral evidence, in addition to our written submission, on behalf of the 61,000 people in Scotland with dementia, and their families and carers.
On page 2 of your submission, you say that you support free provision of personal care. What would be the impact if that recommendation were not implemented in Scotland? How would that affect your client group?
The first impact would be the continuing sense of unfairness and injustice. The care that people with dementia receive is the treatment. They need that care not just because they are growing old, but because they are ill—we are talking about a physical illness, with changes in the brain that affect behaviour.
The NHS plan for England will provide for nursing care to be administered free of charge. You are saying that it is difficult to define nursing care for people with Alzheimer's and that there is a personal care element resulting from the illness from which they suffer.
We could define personal care as nursing care—indeed, that is what I propose to do. People with dementia need rehabilitation, stimulation and support. They need help with feeding, dressing, washing and bathing, and they may need supervision if they are at risk when left alone. Some people with dementia wander. Recently I heard about an older person who always wanted to go upstairs to look after the bairns, even though the children had long since gone. Because they were a little shaky on their feet, they were at risk of falling down the stairs.
Kay Ullrich has a supplementary.
Basically, you have answered my question. If the Executive follows the English plans, what hope do you have that the needs of people with dementia will fall within the definition of nursing care?
We do not really know. We have tried to peruse some of the material that has been issued by the Department of Health; it appears that nursing care is defined either as something provided by a nurse or as something done under a nurse's supervision.
So it has been retained within the health service.
The problem is that the services to which I have referred do not need to be provided by a nurse or to be done under nursing supervision, although nurses may be involved. In many parts of Scotland, community psychiatric nurses do some of the tasks that I have listed. In "Alice's Adventures in Wonderland", the Queen of Hearts, I think, says something like, "I mean it exactly as I mean it to mean." If the Scottish Executive decides that nursing care for people with dementia should include the tasks that I have mentioned, we would see that as a positive step. There is a Scottish choice.
As I see it, the problem is not with the type of care that is being provided, but with the intensity of that care. A frail, elderly woman without dementia may require some supervision going up the stairs, but she will not be going up the stairs every 10 minutes because she does not have dementia that makes her think that the bairns are still upstairs. Someone with dementia will require a more intense form of care. This is about the boundary between what constitutes nursing care in cases of dementia and what constitutes nursing care in relation to physical problems.
That is part of the complexity of the problem.
Are you saying that the only way of dealing with it is to make all personal care free?
No, I am not saying that, although we would like that. I am saying that if we list the types of care that people with dementia require as a consequence of having an illness, and if those are included within the definition of nursing care, that would be a positive step from the point of view of people with dementia.
That is exactly my point. The types of care that you would list apply to others, but less intensely. We are back to the argument about boundaries. One of our major problems relates to what constitutes health service care. Clearly, that is defined as care that takes place in an establishment owned by the health service; it has nothing to do with the type of care. Equally intense care is provided in nursing homes—sometimes even in residential homes—for dementia patients, as it is in NHS care. Should we now consider this issue in some other way?
The royal commission recommended that all personal care for all client groups should be free after an assessment of need. Whatever definition is used, there will be boundaries, and under the royal commission's recommendations the boundaries were the assessed level of need for personal care. Although we all have a need for personal care, we would not necessarily have a need for such care to be provided because of frailty or dementia. I cannot give a definitive answer to your question, other than to say that, if intensity is the issue, it would have to be assessed and a tool would be needed to do that easily. Wherever we end up, there will always be boundary issues; we have had them in the past and will have them in the future. The crucial point about boundaries is that, ideally, they should be easily understood rather than judged on a particular case.
Your submission contains a comment that might be referred to quite a lot over the next month. You appear to say that the Scottish Executive should not "go it alone" over Sutherland and you refer to the
I thought that someone would ask that question. We gave our written evidence before the results of the public spending review were known. However, we now know that, over the next three years, there will be an increase of more than £3 billion in public expenditure through the Scottish block. Our arguments applied before that decision had been made. Although my arithmetic is probably a little shaky, if we take the figures included in the royal commission report and assume that roughly 10 per cent will cover the impact in Scotland, it seems fairly clear that, if the Scottish Executive had the will, it could fund the royal commission's recommendations from that extra funding without jeopardising other public services.
I want to move on to a more general question. Will you outline the major current barriers to the provision of effective support to individuals with dementia and their carers?
The first barrier is that there is still not a full understanding of the complexity of the needs of people with dementia from the point of diagnosis through to palliative care. Moreover, there is little understanding of the need for comprehensive services.
Before I ask you about carers, I have a quick question about your comment on the Scottish Executive going its own way. In your submission, you also say that responsibility for the shift in the way that services are paid for lies with the UK Government, not the Scottish Parliament. Perhaps you could say more about why you think that that is the case. Other submissions tend to take a different view. You mentioned that the money that will come on stream will never be used for that purpose. Presumably the responsibility for that lies with the Parliament and therefore the majority of the recommendations can be implemented.
Paying for long-term care is intimately linked to the social security budget, which is a UK budget. Some of the royal commission's recommendations and some of the Department of Health's responses relate to that funding process. If, ahead of the public spending review, the Scottish Executive were to come up with a solution funded entirely from the Scottish block, the fact that it would be spending more on one thing would mean that it must be spending less on something else. That is why we made that recommendation.
That ties into a whole different area.
The first thing that would benefit carers would be quicker access to appropriate services. At the moment, people often have to wait for an assessment and there are waiting lists for particular services. In some cases, there is an absence of services—advocacy, counselling, support and information may not be available in some parts of Scotland. Access to drug treatment is another example. Such treatment benefits people at the early to middle stages of the illness. If there is a six-month wait, it may be too late.
In response to a question from Malcolm Chisholm, you mentioned funding. You claim in your submission that resource transfer has not facilitated the commissioning of new community-based services for people with dementia. What is necessary for that to happen?
For resource transfer to be better, there must be better identification of the services that might be lost. In that regard, we made the point strongly about respite care. We are concerned that much of the respite care that is provided by the NHS does not have that label on it. It is provided in long-stay wards or other wards. When the ward or bed place closes, we may not know that the respite care has been lost.
Would it be beneficial if, rather than having each health board and each local authority arguing about what the level of resource transfer should be, we had a tool for measurement throughout Scotland and a national figure for every bed that is transferred?
That sounds a bit Stalinist to me.
I think that it might be needed, particularly in relation to Ayrshire and Arran Health Board.
I can see the attraction, but there is a disadvantage. When hospital wards are closed, the price that the land is sold for will be different in different parts of the country. Selling off the Edinburgh royal infirmary is different from selling off a facility in Ayrshire. The real amount that is transferred depends on local costs. The formula could perhaps be defined nationally, so that the transfer is appropriate.
Before Margaret Jamieson gets us all out in the field, I will ask Kay Ullrich to ask a question.
We were in Ayrshire on Monday. One of the problems that we encountered was that, although a hospital had closed in August, the area was still waiting for the resource transfer. That means that local authorities are having to pick up the cost without any idea of what money will follow the patients.
I agree with that. I was part of a delegation that said that to the Scottish Affairs Committee some years ago. I would add that the resource transfer should be timeous. It is hopeless after the event, as local authorities will be picking up the bill for people in nursing homes right away, not at some time in the future.
That has a knock-on effect on others who are on a waiting list for long-term care. We have evidence that a local authority is having to pick up the cost when it should have had the resource transfer money. The knock-on effect is obvious.
I am sympathetic to the idea of having a national sum, but certain practical objections would have to be worked around. Variation from a guideline figure might have to be justified. Evidence put to a number of committees over the years of the variation in the amounts transferred in relation to beds for particular people in particular client groups is not easily understandable from the outside.
For example, a person with a certain level of dementia will need the same care whether they are in Edinburgh or Ayrshire. The cost of land should not come into it.
We need to take into account the capital element of the costs of a service. I would like to talk to people who know more about the proportional breakdown. We know that the money should be transferred timeously and transparently. I support that.
I agree that transparency is the key. At the moment, we are punching in the dark.
There is a case for having national guidelines, perhaps with a percentage swing either way, according to regional differences, although not to the level that we have seen in the past.
I was struck by the point that you made about links throughout a patient's illness—probably the greatest link that any patient has throughout their life is their general practitioner. In your submission, you list some best practice examples, but only one of those involves a GP. Are local health care co-operatives making a significant impact in improving the co-ordination of service delivery?
The honest answer is that it is too early to say. However, the rather depressing answer is that I cannot give an example involving a GP other than the Midloch centre. The Midloch centre in Glasgow is an exciting project, not only because it has a specialist nurse, but because the doctors in the practice recognise the importance of monitoring the progress of the person with dementia and the need for close liaison with social work and other service-providing agencies, so that their patient is not only assessed, but gets services as and when they need them.
We keep talking about the NHS trusts and social work services. Do you think that GPs are being squeezed out of the equation? Why are GPs not at the heart of the service delivery?
That is probably because the guidelines for the new Alzheimer's drugs require such drugs to be prescribed by consultants because of the need for specialist diagnosis and follow-up. That means that the role of the GP is to pass patients on. However, consultants are now saying that GPs are making more referrals to the psychogeriatric service because that is the route to getting the drug treatments. Whether the GP service should be at the heart of the diagnostic service is an issue that could be fruitfully explored. The problem is that some forms of dementia are not at all straightforward and require the skills of a consultant. We must also ensure that we are not talking about people with illnesses that have symptoms that appear to be dementia but on closer examination are revealed to be something else.
The best practice examples in your submission are interesting and good, but they are somewhat piecemeal. Structure is one of the many obsessions of politicians; you may be aware that in England there is a plan for new care trusts—primary care trusts with a broad remit. Is that something that you would support and what would a national structure be like in your ideal world?
We would welcome a move towards a structure that brings together what we see as the separate social work responsibilities and health responsibilities. However, we would be cautious because such a structure would have to be genuinely multidisciplinary, involving the other professions, such as occupational therapy, dieticians and a range of disciplines.
Have you had any recent feedback on people's homes being sold to pay for care? That is particularly contentious in relation to people with dementia.
That is a long-standing concern, which is clear from evidence that we have taken from our members in the past five years, who feel that the whole system is unfair. The royal commission's proposal was to raise the thresholds, but people were still to be means-tested for their accommodation costs. As I understand the English proposal, there will be a modest return to the 1996 threshold levels, so I think that there will continue to be resentment.
You have spoken about resource transfer this morning. Is better resource transfer the way forward, or should budgets be fully pooled to fund new merged agencies, such as a new umbrella agency to integrate health and social work?
On the whole, we would favour the new agency approach, although we are a little cautious. I am on record as saying that we all want to avoid mass reorganisations of the health service and local government because they are very disruptive. On the other hand, if budgets are pooled, who will have authority to decide how they are used? There are difficult decisions, especially if one is dealing with a fixed amount of money. If one wants to develop something new, something else has to go. Pooling makes that task easier, and additional funding makes it even easier, but it is still a difficult task.
Therefore, you think that it is essential to have one new agency to co-ordinate and provide consistency of treatment.
I would not go quite so far as to say that it is absolutely essential. However, it appears that resource transfer has a whole set of historical problems, with which we are still living, despite the best efforts of the Scottish Office and now the Scottish Executive. Pooling budgets goes a long way. We are still waiting for a response from the Scottish Executive to confirm that pooling budgets is legal—that question was asked in an earlier consultation document. The logic is to create new agencies, but we need to do so on an evolutionary basis rather than taking a big-bang approach and putting all our eggs in one basket. That is the reason for an element of caution.
There are joint police boards, which pool things between different local authorities.
It may well be rational. It may be theoretically and logically consistent—indeed, it is—but the threshold of when to start charging people with dementia who are receiving long-term care in hospital for their accommodation costs is one that I leave to you as politicians to judge when to cross.
But you have argued today for equity, and you have argued consistently that there is no charging in the NHS—day care was the example that you gave—yet there will be charging in the day centre. If you are really arguing for equity, why do you not argue for equity for all citizens? Let us leave the sacred cow of the NHS alone for the moment. If you put all long-stay care under the new agency that you propose, it would become the new supported care agency, or whatever you wanted to call it. There could be a level charge for all care. I am not asking you to make the decision—politicians have to do so—but what argument would you put against that, apart from the shibboleth of the NHS not charging, which is to do with boundaries of care, which is exactly what you are arguing against?
I am starting from a position that my organisation has accepted in principle, which is that people should pay for their accommodation costs, and that that should be means-tested. To apply that process to what is currently the NHS component of long-term care is something on which we have not consulted our members. I will retreat to the position of saying that I would want to consult our members first. I understand the logic of what you are saying, but given the way in which people view their health service, I am concerned that they would find it difficult to accept.
It must be remembered that if people go into long-term care, they lose their pension.
The poorest people already pay for their NHS accommodation because they lose their benefits; it is only the better-off people who do not. I will not get into socialist principles, but there is a strong socialist argument.
Go on, Richard.
Go for it.
If we are to have a Scottish solution that is different, and if we are to fund that solution without seriously damaging other care, we must look at new equity. Organisations such as your own are hugely capable of consulting on the matter, and are changing attitudes.
We would be more than happy to consult our members on those issues. Our starting point in arguing against some of the charges is that if someone is fortunate enough to live without dementia or other health needs, inheritance tax will kick in at £234,000. If someone has to pay for their long-term care, at present, they start paying at £16,000. It is important to work towards incremental improvements, which might be moving in the direction that you suggest. It is better to make improvements that benefit people here and now, or as soon as possible, than to go back to basics and reopen all the theoretical possibilities. That is not to say that we will be able to stop others doing so.
I thank Jim Jackson and Jan Killeen for their contribution this morning, and for their written submission. I thank them for their time.
Meeting adjourned.
On resuming—
I call the meeting to order.
Good morning. I am Douglas Philips and I work with Argyll and Clyde Health Board. I am chair of the Scottish Health Boards Network on community care. I invite my colleagues to introduce themselves.
I am Lindsay Burley, the chief executive of Borders Health Board.
I am Moira Paton, head of community care with Highland Health Board.
I am Emelin Collier, community care development manager with Western Isles Health Board.
We welcome the opportunity to present evidence to the committee and hope that some of the information that we provide will be useful to you and stimulate debate this morning. At the outset, it might be worth making it clear that this is a view from Scottish health boards, as opposed to NHS trusts. We have submitted written evidence; we do not intend to go through all of that. However, perhaps you could bear with us while we touch on a few of what we see as the key issues.
Thank you. Margaret Jamieson will pick up some of those points immediately and we will move on from there.
I was interested in your comments on resource transfer. I think you said that it had served its purpose. I certainly do not share that view, given the difficulties that several health board areas in Scotland have experienced. We discussed issues related to resource transfer, such as what happens when a hospital closes, with the previous group of witnesses. One hospital in Ayrshire closed on 1 August, yet no agreement on resource transfer has been reached with the local authority and the health board. That difficulty has been there for a significant period. Why do you believe that resource transfer has served its purpose, when your colleagues in local government are saying that it has not, because they are still waiting for the money?
I will start to respond to that question; my colleague, Dr Lindsay Burley, might want to add something.
I support the statement that resource transfer has probably served its purpose because I believe that in some places it is used as a battleground between agencies. In no way are we suggesting that we can simply go back to a time when the health service saved money, did not declare it and expected other agencies to pick up the tab.
There are obviously different ways in which budgets can be pooled, and joint work can be undertaken. I acknowledge your point about joint training, which I presume you would start at the earliest point and would not just be on-the-job training. How do you go about pooling budgets effectively? Can they be pooled from two totally separate organisations, or do you need to create another umbrella organisation, to provide community care in the widest possible sense?
It depends partly on the scale. The example from my locality that I can think of was when we closed a ward, and were keen to pilot a joint commissioning pool. For the value of the money concerned—about £250,000—we have set up a joint pool under the same accounting arrangements as those which we used for the resource transfer mechanism so that the respective finance colleagues in the health boards, in the trust and in the local authority concerned, are happy that an open accounting process will operate. Given that the money is currently health money, we will probably retain it in the health systems and use health accounting mechanisms for it. All the calculations, including all the expenditure statements, will be transparent and open for all.
In going down such routes, or when using any other form of joint pooling that you are aware of in Scotland, have you come up against any legal problems?
To date, I have not come up against any legal problems, although my colleagues may wish to add to that.
I agree. The problems are sometimes cultural. The key point is about trust, transparency and openness and the quality of the joint working arrangement. If that is historically based on trust, the accounting arrangements are such that one agency is effectively acting as a banker for the others. I am not aware of any legal barriers.
What about confidentiality and data protection, for example? Do you have no problems there either?
In my experience, those are issues that are raised by professionals who do not want to share, rather than real issues.
So you do not believe that there is any reason why people cannot share information?
I do not believe so.
Margaret Jamieson explained that during our journeys around Scotland we discovered a health board in Ayrshire where a hospital closed on 1 August and that, to date, there has not been any resource transfer. That means the local authority has to pick up the cost but that it has not received the funding. It also means a serious knock-on effect on other people on the waiting list. Do you believe that there should be a method by which health boards can be held to account for that sort of foot dragging? It is not just a matter of expense for the local authority; it is a matter of expense for the people who are waiting for long-term care.
I would not like to comment on a particular case that I do not know about. It depends on the time frame. If it takes a few months for everything to be sorted out, it may not be a big issue; if it takes a long time, there is really no commitment to transferring resources—
The hospital in question has been due to shut for six years. It finally shut on 1 August.
Let us stick to the general point.
There are ways in which we are held to account: we are accountable through the Scottish Executive—previously the Scottish Office—and the management executive for what we do on behalf of health boards. I would have thought that there are already ways of holding health boards to account if resources that should have been transferred have not been transferred.
You propose that, when there is a closure, all resources should go into a common pool, but I invite you to look a step further. There are about 17,000 long-stay beds left. That number is declining—as your paper says—by about 7 per cent per annum. Why not transfer the whole of the long-stay provision into a joint board? The resource transfer issue would not then arise, as the joint board would decide on the most appropriate use of all its resources. The decision would not be cost driven or health service driven; it would be driven by the joint board with responsibility for supported care for the elderly.
That is a very attractive idea. The one reservation that I would have—I speak personally rather than as a representative of health boards—is that it should not mitigate against a continued move towards care outside institutions. However, I do not think that that is what you are suggesting.
No. Absolutely not. The establishment of a joint board would make that movement more rapid. In any cost drive, the care agency—the joint board—would want to use all its resources to the greatest effect and without any corporate health needs being considered, which would drive the situation towards domiciliary care.
It depends on the local circumstances. I prefaced my earlier comments by saying that any change depends on the scale of the joint pool. People can be encouraged incrementally to move along that path if the attitude and culture is right in a given locality, but it would be difficult to impose a specific solution on the whole country, as people may still not be ready in a given locality. However, local initiatives have succeeded in taking the agenda forward.
In paragraph 4.3, you suggest that
Things are at different stages in different parts of the country. Our network, with the Association of Directors of Social Work's standing committee on community care, organised the conference to which we refer in that paragraph, which was entitled "Beyond Joint Commissioning". We brought together a significant number of people—180 people attended, and perhaps many more wanted to attend—who are interested in joint commissioning. They wanted to know what joint commissioning is and what are the best examples of joint commissioning around the country.
It may not surprise you to know that we have received submissions and evidence from Age Concern and Alzheimer Scotland this morning. Both organisations put forward the idea of a new body to integrate the services. Is that what you are referring to when you say one partner, or are you considering one or other of the existing partners?
In part, we are seeing an evolution from where we are to where we might get to. We are watching very closely the Perth and Kinross project, and recognise much merit in all the work that is being undertaken there. The project works in those specific circumstances, although it may not be the solution for everybody everywhere else.
I support that. I can give members an example of the direction in which we are moving in the Highlands.
What are the key community care issues that require resolution?
That is a big question.
You have a maximum of five minutes.
You should consider my question in relation to more effective use of the community care pound.
My colleagues will want to add to my answer, but, off the top of my head, we want to be sure that assessment and care management arrangements are working well, that the services that are being delivered are based on the assessed needs of each individual and that local services are responsive and flexible. In resource terms, that means that local managers must have their own budgets and that they must be able to use those budgets flexibly, rather than be tied in to services. For example, home help services—good as they are—are appropriate for some people but inappropriate for others. It is therefore crucial that the use of resources locally should reflect people's needs in that locality.
I have a couple of comments.
I would reinforce those comments. We should bear in mind the fact that one size does not fit all. There is still a tendency to fit people into services rather than fitting services around people. Resolving some of the fundamental issues that my colleagues have talked about would help to address that problem.
We talked about resources being intensive in relation to public involvement. I suggest that commissioning planners should also be able to go out and talk to service providers about changing how they operate. Perhaps not enough is being done to free up funds and to allow people to be a bit more innovative in local areas.
I would like to ask a final question. We have talked a great deal about partnership and better working practices. In the Western Isles, the service is far better integrated than it is anywhere else. Do you feel that, with that integration, you have overcome many of the difficulties that are experienced elsewhere? Do you feel that the elderly benefit from the greater integration, openness, transparency and partnership working in the Western Isles?
In the Western Isles we have benefited from the fact that people have been stable in their jobs and have learned to work together. Culture is another very important issue. We have the same problems as our counterparts everywhere else in Scotland, in that we do not have enough resources to provide the elderly services people need in their localities. We have additional problems of geography. We have been able to make more rapid progress in dealing with other care groups, for whom there has been additional funding. That applies to mental health services and children's services, for example. At the moment, we have a joint working group of elected members and officers that is examining care of the elderly, as that requires additional resources. However, people work together very closely within the resources that they have.
Before I ask the question that I was intending to ask, I would like to follow up on what you have just said. You have talked about rooting community care in primary care. Do you think that we can do that and still achieve a holistic service for elderly people? At the moment I feel that in my area it is difficult to get the health board to take a wider view and to provide funding for services outwith primary care or health functions. I am thinking about things such as the nutritional needs of the elderly, breakfast clubs, lunch clubs and assistance with transport. Often, those tend to fall between two posts. I wonder whether rooting community care in primary care will overcome that difficulty and produce a holistic view of elderly services.
Maybe I am just an optimist in thinking that primary care can move in that direction. I also come from a part of Scotland where practices and communities tend to belong to one another. There is a great strength in that. The general practitioner is seen as a leader in communities. That is a responsibility and a privilege that we as health boards need to work with our colleagues in primary care to extend and enhance. Irene Oldfather was talking about community development activities. The health promotion department at Borders Health Board is located in the primary care trust and has achieved a good deal for older people as regards nutrition. It is not always easy for health promotion services and primary care providers—particularly GPs—to work well together. Part of health boards' job is to ensure that those relationships are enabled and not cut asunder.
I would not disagree with you about the commitment of general practice and primary health care. The difficulty is empowerment. The health centre is 100 per cent signed up to the project that I am thinking about, but nobody sees it as a health function, even though it is in the HIP, the TIP and so on. There is simply not enough money to fund projects of that sort. We need to examine how we can empower people on the ground, so that they can make such projects work. It is no good talking about it theoretically. We must devolve power and resources to that level.
That is what I am saying, too.
Irene, could you ask your other question?
No doubt the network has examined the NHS plan recommendations and the implementation of the Sutherland report in England. What are your views on the report and what would the network like to be done in Scotland?
As we said in our introductory remarks, we are keen to see fairness across the whole country, but we would be anxious about any client group being disadvantaged. We know that you have already heard from Alzheimer Scotland—Action on Dementia this morning and we have also heard that organisation's comments. We recognise that there is an issue about how much overall cake is available to be split up. If money is spent as the Sutherland committee proposes, it might have an adverse impact on health and social care, and we would not want that to happen either. In that sense, we want to have our cake and eat it.
On delayed discharge, you have been fairly critical of the degree of integration that has been achieved by the Scottish Executive in its recent allocation of additional resources, both to the NHS and to local authorities. Could you evaluate the impact and effectiveness of those additional sums on the whole area of delayed discharge?
The first thing to say is that delayed discharge is not new. For some of us, it has been around for three years or more. In various planning documents, we have proposals as to how we might tackle it depending on the availability of resources. Sometimes it depends on disinvesting in existing services, such as long-stay wards, and putting the money on the table to use in a better way. The impact of that will be to reduce the number of delayed discharges and to place people in more appropriate care.
Although the money is welcome, it is non-recurring and tends to be a piecemeal, quick fix solution, and you have already said that there is no quick fix solution. In allocating that money, the message seems to be, "Here's £100,000. Get 20 more folk moved." That is what has tended to happen across the country. Local authorities are telling the local papers, "Thanks for the money. We've moved 20 people and now we have only 90 on our waiting list."
The health funding is recurring money and the £10 million to local authorities is, as I understand it, non-recurring. As you suggest, the risk is that the money will be spent simply on buying more nursing home places, but that is not what we want to do when making plans with our local authority partners. That money can be useful in other ways, such as buying smart technology or other types of equipment to support people with dementia in their own homes. Non-recurring money is also welcome, but we would use it in different ways.
I was interested in what you said about the uneven provision of nursing home places. You called for a population needs assessment. How much does that happen already? I recently read a report on nursing home places in Edinburgh and Lothian that said that the projection is downwards, despite people saying that there is presently a shortage of nursing home places. That is an interesting conundrum. Do you think that a population needs assessment would help to deal with the problem of delayed discharges? What would happen to the number of nursing home beds if such an assessment were carried out, given that the number of elderly people is rising slightly? Do you think that we will need fewer nursing home places over the next 10 or 20 years?
There is scope to continue to reduce NHS long-stay care and nursing home places and to develop alternatives to support people in homely settings in their own communities. However, we must recognise that there are regional variations. In some places, such as the Western Isles Health Board area and parts of the Argyll and Clyde Health Board area, there are very few, if any, nursing home places. In some of those places, one might want to commission more nursing home places. We must consider each locality separately—it is horses for courses—to assess what those local communities need. In general, however, there is scope for fewer nursing home places in total.
There is an apparent paradox between the falling demand for nursing home places and the claim that we still need more of them. When health services are under a lot of pressure to make quick fixes to get people out of hospital, the easiest way of doing that is to move people to another place. If that is done without appropriate assessment and rehabilitation, people will be moved into an institutional setting when they could have been moved back to their own homes.
I must bring this part of the meeting to a close. Thank you all for taking the time to share your experiences and comments with us and for your written submission.
I agree that the questions are fine—but I would add a caveat. The paper says that the questions should be submitted and returned prior to the meeting. Can we ensure that they are returned at least three days in advance, so that we do not get them on the morning of the meeting?
Do members agree?
We must also consider the next set of witnesses. I am keen to get through all the witnesses and to get all the evidence together before the October recess. I will add one point about the list of possible witnesses. We have tried several times to get Perth and Kinross Council to come along. I would like to hear from that council because it is part of a national pilot scheme. If members agree, we could try to find a spot for that council—possibly on 18 September when we will be in Stirling.
Why are we going to Stirling?
I was not aware of that either.
It would be better to go to Perth.
The clerk has advised me that all committees are encouraged to have full committee meetings outside Edinburgh. A lot of other committees have already done so in the Parliament's first year.
Should not committee members make that decision?
Yes—the suggestion should have been brought to the committee and we should have made the decision. I had no idea about the meeting.
In Ayrshire, 18 September is a public holiday. I am a bit amazed, first, that we will have the meeting on a Monday and, secondly, that it is in Stirling.
There is a problem because that date is also a public holiday in Edinburgh. I have to put my hand on my heart and say that I cannot remember how the meeting was organised. It might have been something that I agreed to prior to the summer recess—I cannot honestly remember. It was so many weeks ago.
When the committee meets outside Edinburgh, it should be for a specific purpose. We have talked about the Perth and Kinross project; Ben Wallace has joined us, so we could ask him whether he was able to visit the project during the summer and whether there were any obstacles. It seems that a wall is being built and that the people in Perth and Kinross do not want to talk to the committee. We want a Scotland-wide view so that we can find out about good practice.
I have had the opposite response from Perth and Kinross. Richard Simpson, I think, heard the initial presentation. I have written to the council in Perth and Kinross—it has kept in contact and has offered on a number of occasions to come and visit the committee.
But you were to visit the council during the summer recess.
Yes, and I have been in contact with it as well.
Have you visited it?
We want to get the council to come to the committee, and I have an appointment with it later this month.
I would like to come back to the general principle that Kay Ullrich raised. We are being notified of meetings—not being consulted about them. Now we will have two meetings in one week. I am on two parliamentary committees and on the European Committee of the Regions—I need a wee bit of notice of such decisions.
As for having two meetings in one week, members were e-mailed about that and only one member has so far said that that is a problem. I am trying to pull together all the evidence that we still need to take in the short period before the recess so that the clerks can get to work on compiling the report. There is a lot to be gained by doing that. I do not want to begin again in October with unfinished business and more evidence to take. That is why we are having the Monday meeting. It fits into a wider picture. The Executive will comment on the spending review on 20 September and will respond to the Sutherland report shortly after that.
Were you told to go to Stirling?
As I say, I cannot remember.
Did they say, "You shall go to Stirling"?
The fact that committees should be moving out of the city has been discussed at the conveners liaison group.
Surely that should have been discussed in the committee—surely this committee has a say.
We are equal partners in this. We are saying that we do not think that going to Stirling is a good use of our time. The cost involved is unacceptable and Jennifer Smart should cancel the meeting because some of us will not be there.
The clerk has reminded me that information that this was going to happen was circulated to all members some time ago.
It is a fait accompli.
I am not aware that anyone, at the time the information was circulated, said that there was a problem.
We were not asked for our views. That is our point.
This has not come about because we said that we wanted especially to go to Stirling.
So we have to do what we are told.
This is part of a wider move to ensure that the committees of the Parliament work outwith Edinburgh.
Would not it be better if we were going for a meaningful reason? Why Stirling? Why not Auchtermuchty?
It is very much within the spirit of the Parliament—to which we are committed—that we perambulate round Scotland. We must take it or leave it. It would be good if the venue for the meeting could suit what the committee is working on at the moment. Had we imposed ourselves upon people in Perth and Kinross, we could have gone there.
Exactly.
However, the clerks must have a big problem arranging accommodation. I hope that we are not going to be in town halls and rather upmarket premises all the time. I suggest that we book some premises in major housing schemes.
What—like Easterhouse?
We are small in number and we could easily go to a local public hall.
Work has been done in the conveners liaison group on suitable venues in Scotland, taking on board the particular needs that committees have for the Official Report and other things. A small number of places were identified as being suitable and affordable. Some were in Glasgow, but other places that were considered were not suitable for committee needs. Another suitable place that was identified was Stirling. I do not have the papers with me, so I cannot tell members the other places that were considered.
I have three separate points. Let us not revisit the argument over whether the Parliament should travel: everyone agrees that it should. The issue is a specific meeting. We are tied to the meeting on 18 September, so let us simply accept that. However, we should put down a clear marker that, from now on, the committee members will decide where they are going, why they are going, and whom they will meet—the meeting will not simply be presented to us.
There are two or three ways in which we could proceed. It is a matter of who we ask and when we ask them. Originally, I had hoped to take care of the evidence-based part of the report prior to the October recess, as that seemed a natural break. However, when officials of the Executive come to speak to us on 18 September or—I spoke to officials about this matter yesterday—the Deputy Minister for Community Care comes to speak to us on 4 October, we will not be able to get the full story in either case because the Executive will not have made all of its announcements.
Precisely.
The committee must agree to delay its conclusion and continue to take evidence after the October recess. That is the choice that committee members have to make.
It would be wrong of us to do otherwise. I cannot imagine why the Scottish Executive is coming to the meeting on 18 September in Stirling, of all places. If the Scottish Executive is to attend our meetings, why not invite the Executive and the deputy minister when we have all the facts and have formed our thoughts cohesively, as a committee? Let us then put the matter to the Executive and get a resolution. If that means that we delay for a month what will already be a multi-month inquiry, so be it. I propose that formally.
It is a good ambition to take as much evidence as possible before October. I suggest that we do that, with the exception of inviting the deputy minister. We could ask him a lot of questions that do not concern the Sutherland report, because there are lots of other issues. If we are going to invite him to attend only once, we could do that on 4 October.
That is a good idea.
The committee agreed before the recess that we wanted to hold a meeting in private to consider the working procedures of the committee and to deal with some of the issues that have arisen today.
That has been suggested by the clerk, from whom I received an e-mail this week. Is not that meeting planned for 20 September? I agreed to that private meeting.
No. The meeting on 20 September is a private one in which we can begin to pull together what we have done during visits and so on.
Let us return to the issue of reaching a committee decision. Malcolm Chisholm's position is correct. We can try to take all the evidence by the October recess, but can we reach a decision to return to the civil servants and the deputy minister after that? Can we agree also not to write the report, or even get to the substantial point of the report, before that is done?
I am happy to accept Duncan Hamilton's suggestion. Irene Oldfather wanted to make a point, but her contribution then moved on to another issue.
So is it agreed to?
We should find as early a space as possible on an agenda to consider the workings of the committee.
Is the action that I suggested agreed?
I agree with what Duncan Hamilton proposes.
Can members bear with me for a minute? I am picking up on the point that Irene Oldfather made about the need to examine the workings of the committee and the way in which it has functioned. If members all agree, we will find a spot on the agenda to do that as soon as possible.
Yes.
That is one suggestion. Do we want to take that evidence in a formal session, at which representatives would come to speak to us?
Yes.
I heard some muttering from members around this table, suggesting that we should go and visit the council. I am just trying to clarify that.
Those are the three actions that we need to take in relation to that discussion.
No. We need to go back to the meeting on 18 September. I understand that the chamber desk will be closed on 18 September, which will cause inconvenience to Parliament staff who must travel to Stirling. It is also a public holiday in Ayrshire.
It is not a holiday in Baillieston.
We will have the meeting in Baillieston the following Monday, in that case. There must be a bit more understanding and co-operation. Members would like to be involved before decisions are made—
Every member of the committee was told that there was a possibility that the committee would be going to Stirling—nobody said that there would be a problem.
No. That was because we understood that the meeting would take place on a Wednesday. Nobody said that we could not meet on a Wednesday.
I understand that Parliament staff are not on a public holiday on that day, although that may be an issue for Executive staff. The chamber desk will be open. Most people are happy to move a parliamentary committee outside Edinburgh and that is what Parliament is trying to do.
We do not have a problem with that. Do not twist my words. We are objecting to a meeting on that Monday.
Committee members were given a date some months ago. I confess that, at that point, I did not know that it was a public holiday for certain people in Edinburgh and Ayrshire.
We have never discussed whether we are willing to meet on Mondays.
The conveners liaison group decided that committees that were meeting outwith Edinburgh had to do so on days on which committees did not usually meet in Edinburgh. That is because of resource considerations, such as official report staff and other staff. Several reports about the difficulties that that stipulation causes have been submitted to the CLG, which contains members of all parties. There are issues about the type of venues, the use of official report staff, staff time and so on. The question of what can be done outwith Edinburgh has been examined in detail. It seems that there is not the same option of meeting and using members of staff outwith the confines of the Parliament on Wednesdays as there is on days on which committees do not usually meet.
Was the Scottish Pensioners Forum asked whether it would prefer to give evidence in Stirling or Edinburgh? Are there cost implications for it in going to Stirling?
The Scottish Pensioners Forum has not confirmed its attendance yet. However, I understand that witnesses can claim expenses from Parliament.
If the forum has not confirmed and the Executive is not coming, why are we having the meeting?
Members have said that they do not want to hear from the Executive until after the October recess. If we decided to cancel the meeting on 18 September, we would have to find a space elsewhere for witnesses from the Scottish Pensioners Forum and Perth and Kinross Council. If members are happy to do that, I will discuss it with the deputy convener and the clerks.
Now we know that the Monday meeting is not essential because nobody is coming.
Two groups of witnesses are still meant to be coming. We have to find another slot for Perth and Kinross Council. The deputy convener, the clerks and I will find time to arrange that. That is agreed.
Have we agreed to bin the meeting on Monday 18 September?
Yes. I do not know whether that is the technical term, but we have agreed not to go ahead with the meeting on 18 September.
It must be an Army word.
It is.
While we are discussing logistics, I will add to the problems. The timing of the flu report—which I was asked to do some time ago—is important because we are about to enter the flu season and, although the report is mostly concerned with the long term, some aspects of the report are relevant to this winter. I have some amendments to make to the draft that the clerks have, but the report should be ready within the next week. Perhaps discussion of the report should be slotted into our agenda sooner rather than later, because its relevance will decline as the autumn progresses.
The other consequence of what we have just decided is that we will not hear from the minister on 4 October. If we cannot fit the flu report in before then, there will certainly be a slot for it on 4 October. Members should leave it with the clerks and me to work out the best way of organising our agenda—obviously, we have to talk to members about diaries and so on. We will try to ensure that we have covered the flu report before the recess.
Can we set aside a time for a private discussion on how the committee operates? We have asked for that about three times.
We will try to find times on our agenda before the October recess for everything that we have discussed under this item.
Would you clarify the situation regarding the meetings on Monday 18 September and Wednesday 20 September? Are we back in limbo?
The meeting on 18 September will not go ahead.
Can we vote on that?
We have a consensus.
Have we?
If we do not have a consensus, I am happy to hold a vote.
There is no business to be done, so we would be going to Stirling only for the shopping.
I propose that the meeting scheduled for 18 September be cancelled.
I will oppose that.
What is the proposed business for 18 September?
As matters stand, we would hear from the Scottish Pensioners Forum. It would also be an opportunity for us to speak to Perth and Kinross Council.
As the forum has not confirmed whether it will attend, we could hear evidence from it on 20 September.
We could. I move, which is supported by the majority of members—
An engagement has been made and people have been troubled in some way.
Please speak through the chair. Dorothy-Grace, do you wish to lodge an amendment to my motion?
Yes. Although there should, perhaps, be a better system in future, we should stick with the meeting on 18 September.
Are we all agreed?
No.
There will be a division.
For
The result of the division is: For 1, Against 8, Abstentions 1.
Amendment disagreed to.
The question is, that the meeting scheduled for 18 September be cancelled. Are we agreed?
No.
There will be a division.
For
The result of the division is: For 8, Against 1, Abstentions 1.
Motion agreed to.
The meeting on 20 September was mentioned. Part of that meeting is to allow us to pull together the work that we have done during the summer. That is a substantial piece of work, which I do not want to be compromised on an agenda on which we overrun on other issues. I want members to have a chance to report back.
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