We move to item 2 on the agenda. I welcome the witnesses to the Health Committee. Our first witnesses are Christine Lenihan, who is the chairman of the Scottish NHS Confederation, and Hilary Robertson, who is the director of the confederation. We also have Alexis Jay, who is the director of social work services and housing with West Dunbartonshire Council, and Councillor Kingsley Thomas from the City of Edinburgh Council, both of whom are representing the Convention of Scottish Local Authorities.
The proposals will be helpful in bringing together primary and secondary care. The joining together—or the removal of the separation between—acute and primary care trusts and the creation of operating divisions, which will be part and parcel of the new unified boards, should allow much greater consistency and better joint working between those two sectors than is the case under the trusts.
Do you have reservations or issues to raise or do you think that the new system will run smoothly?
We support the principle of the unified boards.
We also support the principle. I am not sure whether I need to declare an interest as a member of a health board and, I presume, as a member of one of the forthcoming unified boards.
Thank you both for your written submissions. I noted that you said that although the bill is about partnership, councils are not referred to in the bill. Do you accept, though, that the minister would have difficulty making legislation for local authorities in a health bill? It would be difficult in terms of statute.
That is the big issue when we seek to put in place any structures where services cross the divide between the local and the central. We are clear about our democratic responsibilities to our local areas and constituents, and about our responsibilities to deliver council services. Although there may be issues to do with the high-level wording of the bill, the partnership nature of the health agenda needs to be reflected more. Health improvement is no longer just a matter for the health service, because it relies heavily on local authorities too.
Our preference is not to specify partners, because the danger is that if local authorities or other partners are specified, that might neglect or exclude other potential partners by implication. We would like the bill to be as all-encompassing as possible, so that health boards can work with as many partners as possible, without it being prescribed that they should only be local authorities.
Might the relationships be dealt with in regulations?
Councils see themselves as the key partners in health and social care. Many other partners and stakeholders will be involved in the delivery of services, but councils are the purchasers and deliverers of social care services, so if there is to be a partnership involving social care, we see ourselves as central to it.
The minister is looking for more flexibility and joint working, which is along the lines of Hilary Robertson's evidence. Does COSLA envisage local authorities operating outwith their own boundaries, in partnership with other local authorities—given the flexible model that the health service wants to employ—and managed clinical networks operating outwith normal health board areas? Does COSLA have any difficulties with that?
Certainly not. There is a role for local elected members in having more influence over how traditional health services are delivered. With the joint future work in Edinburgh and Lothian, we are discussing members' involvement in community health partnerships and social care partnerships, so that they can bring a local democratic element to the services. It is about extending the boundaries on both sides to co-ordinate the services and reflect local communities' needs.
Is that not dealt with by the virtually automatic appointment of councillors to health boards at the moment? Do you want that to continue?
That is an element, but it is only the top-level element. For the whole agenda to work, we need to have structures in place at local neighbourhood level, at the level of the LHCCs or the community health partnerships. In Lothian we have eight areas, with one health board giving the strategic overview, but there still needs to be democratic input to the local structures that we are looking to put in place.
So far, we have seen interesting developments in managed clinical networks. The focus has mainly been on chronic disease management, but there is a lot of scope for councils to work flexibly and perhaps even take the lead in managed care and clinical networks—rather than managed clinical networks—on, for example, services for adults with learning disabilities and services for older people. Managed clinical networks have been health focused so far, but the concept is attractive, and we are interested in considering how it might work across boundaries.
You have already mentioned community health partnerships, and I want to talk a wee bit more about them. COSLA submitted a fairly lengthy response to the consultation on community health partnerships. At the moment, as we all know, the details are sketchy and we are trying to elicit some of the concerns that people have. I note that one of your concerns is how the joint planning for the financing of community health partnerships would work across two ministerial portfolios. What is the thinking behind that concern?
We provided evidence to the Finance Committee on that, and our concern was that financing the community health partnerships cannot be cost neutral if it is done properly, because we need to invest in front-line staff so that they understand such new concepts and can take them forward. We know that fact from the joint future agenda, on which much has been achieved, but only because we invested time and resources in training staff and introducing them to new ideas.
How do you envisage joint working taking place? There are concerns on both sides. In the health service, there are concerns about being subsumed in the community planning process, in which, although the health service has been a partner, it has not had as big a part to play as is envisaged under community health partnerships. You said that you considered local authorities to be key stakeholders in community health partnerships, but our health professionals would argue that they are also key stakeholders. Will you clarify how you envisage that partnership evolving?
We certainly do not think of community health partnerships as one organisation taking over the other's responsibilities—whether that is the health service taking over the local authority's responsibilities or vice versa. The key word is partnership, and the responsibilities that local authorities now have for developing community planning is an aspect of the community health partnerships. I can talk with two hats on—a health board hat and a local authority one—and can say from my experience that it is a question not of one organisation taking over the other, but of ensuring that they are equal partners in the important work.
The Scottish NHS Confederation's view of community health partnerships—on which we have been working with our members to try to elicit a bit more detail about how they would work, what they would look like and what they would do—is that they are about more than community and social care or primary and community care: they should also include secondary care. From the health point of view, it is important that the partnerships aid joint working and the integration of secondary and primary care.
Should anything on community health partnerships be added to the bill? Also, COSLA's submission talks about guidance being
We are concerned about the draft guidance that the Scottish Executive issued on community health partnerships. It was put out for consultation and I believe that there was a vast number of responses. We did not feel that the draft guidance was specific enough about the Executive's vision and what its intention was for community health partnerships. There was concern that there was potential overlap with the joint future agenda that was not clarified by the guidance. We hope that the final guidance will fuse together the different strands that are currently running in parallel.
I understand that the final guidance is coming out early next year. Is that correct?
Perhaps. I am afraid that I would not know.
I am being advised about that.
I will make a point about public partnership forums, which will be part of community health partnerships. We envisage there being two distinct elements to the system. The public partnership forums will be about the continuing involvement of patients and the public, whereas community planning is more about consultation. We see those as two slightly different elements of the system.
I do not think that you commented on whether anything about community health partnerships should be added to the face of the bill. We are talking about guidance and regulations, but should the matter be included in the primary legislation?
I am not sure exactly what you mean when you use the term "the face of the bill".
I mean in the primary legislation.
As I see it, the community health partnership—and beyond that the community health and social care partnership—is the one key vehicle for ensuring that all the principles that everybody signed up to in respect of the joint future agenda can be delivered at all the various levels within the health sector and local authorities. If adding a clear reference to that in the primary legislation would give a high-level commitment to that work, it would be useful.
The Scottish NHS Confederation's submission accepts that the minister should be able to intervene where serious failures occur, but calls for more clarity on what intervention will mean. Should the definition of intervention and the circumstances in which the powers of intervention would be used be included in the bill or in regulations?
It would be helpful to say in the bill what intervention means and, if possible, what the circumstances are in which it would occur. It is difficult to know from the provisions in the bill how such intervention might work—some clarity about that would be helpful.
Scottish NHS Confederation members understand that, rightly, responsibility lies with health boards. There should be strong local management, particularly through the performance assessment framework, which is the accountability mechanism, and the powers of intervention should be a last resort. At the same time, there needs to be a link to the indicators on the performance assessment framework to determine when use of the powers of intervention might be required in a supportive way rather than as a last resort.
Would regulations remove the flexibility for there to be ministerial intervention in a variety of circumstances?
No, not necessarily. However, it is important to retain flexibility where the responsibility and accountability is located, which is in the local health system and through the very comprehensive assessment framework that is in place. The detail that our members might like to see is about what circumstances might trigger an intervention, who might trigger the intervention and where responsibility for the costs of the intervention might lie.
So regulations would suffice.
We are not of that view. Our members are of the view that the definition of the powers of intervention should be enshrined in the bill.
Do you not think that enshrining a statement of when and how powers of intervention are to be used in the bill would be very prescriptive and would lead to a lack of flexibility? If the detail in the bill is too prescriptive, the primary legislation might have to be changed in the future to allow intervention in circumstances that none of us can imagine now. We can consult on regulations and change them much more easily than we can change primary legislation—that can be a reason for including a matter in primary legislation, but in this case it might be better to retain some flexibility to deal with situations that might arise in the future.
We concede that point, but it is important that there should be clear understanding of what is meant by intervention. That will depend on the wording in the bill; it would be helpful if there were a clearer definition of intervention in the bill, although perhaps the detail about how such intervention would be triggered and who would intervene should be in the regulations.
That could be done without listing the circumstances.
I think that the witnesses from the Scottish NHS Confederation are making the point that if accountability is the factor that is behind this section of the bill, it must be defined. I presume that if such a definition were to be included in the bill, you would also welcome a provision to allow a health board to call on the minister to intervene at an early stage, rather than wait until the end of another accountancy period—if there was a problem with financial flow, for example. Is that the kind of flexibility—on the back of a definition—that you would like there to be?
We agree that it is important that boards should be able to ask for support; that should be clearly recognised.
In the first session of Parliament, the Scottish NHS Confederation gave evidence to the Audit Committee, of which I was a member. It was clear that the confederation was looking to future legislation to tidy up the two-way process around difficulties that arise in the health service. I think that your main point today is that you would like accountability—and how people would step into that accountability process—to be defined in the bill.
Yes, that is right. We do not take issue with the fact that there is already a comprehensive accountability framework in place and we agree that ministers should have powers of intervention. However, there needs to be clarity about the triggers for and timing of intervention and about whether intervention—albeit a last resort—would be a late last resort. There should always be flexibility to allow those who are accountable for local delivery to be responsible for that, but at the same time, our members would like to explore the possibility of there being a series of triggers for intervention and much clearer understanding about when and why powers of intervention would be used. Invariably, the use of those powers would have to be linked to the information that is in the performance assessment framework.
Perhaps it would be appropriate for the confederation to send the committee a short document that explains exactly what clarification is required.
We would be happy to do that.
That would be helpful.
I would like to pursue the point, because I am now a little more confused than I was. We are talking about the requirement for flexibility, but surely to put triggers in the bill would have the opposite effect. Section 4 amends the National Health Service (Scotland) Act 1978 to include a new section 78A, on powers of intervention in case of service failure. The new section 78A(1)(b) states that the powers apply where
I think that we are talking about regulations rather than about the bill.
Our plea for clarity is simply around what intervention means. Having read through the bill, we do not think that it is entirely clear what intervention would consist of. It might be helpful to define it, to say that intervention would happen in certain circumstances and to say what those circumstances are. We have already accepted the point that was made earlier, that it would be more appropriate to do that in regulations than in the bill.
It seems to me that the ministers' powers in the bill are clear and specific. Proposed new section 78A(2) states:
We are not disagreeing with the flexibility that the ministers will have. We are saying simply that, from the boards' perspective, it would be helpful to understand better what the intervention might consist of. The bill mentions the ministers' power where they consider intervention necessary or likely to be necessary. It would be helpful to the boards, who would be the recipients of that intervention, if there was more clarity about what it would actually involve.
A preference was stated in the written evidence from the Scottish NHS Confederation that intervention should be defined in the bill. That is not what you are saying now. You are saying that, on consideration, it should probably be done through regulations.
Our written submission states that we would like a definition of intervention to be included either in the bill or in the regulations.
Your submission says that intervention should be defined
Yes. We accept the point.
On a point of information, it would be useful for the clerks to provide a note; these are amendments to existing statute, and it would be interesting to see where they slot into the National Health Service (Scotland) Act 1978, because that act might contain things that expand on the issue. The bill is not a stand-alone bill and should not be considered in a vacuum, so I ask the clerks to make that information available.
I will move on to the issue of health councils. I do not think that either organisation referred specifically to health councils, although you referred to public involvement. Will the national health council that is proposed by the Executive be more or less independent than the current local health councils?
The confederation supports a strong and effective independent voice for patients. It might not be appropriate for us to comment, as NHS boards are the organisations against which complaints would be made. NHS Quality Improvement Scotland has shown its capacity for independence in principle, but patient representation will be demonstrated as the process evolves. We strongly support the principle that an independent organisation should represent patients' voices effectively.
Do local health councils provide an effective patient voice?
I am sure that individual boards would be better able to answer for their areas, but local health councils seem to perform a useful and valued function. Our concern is about patients' and the public's perceptions of the new arrangements. As professionals, we and our members have confidence that the new arrangements will provide the required degree of independence, but the public and patients might not have the same perception. We would like that to be kept under review.
It is a bit unclear who will provide hands-on assistance locally. Local advisory councils are proposed, but there is talk about commissioning services to provide the advice and practical hands-on assistance that patients and the public receive at the moment. Do you have a view on whether that will work, and from whom services should be commissioned?
No.
That is fair enough. You do not have to have a view.
I am not sure whether I can answer the question directly, but I can offer the information that is emerging that many of our members are, with the philosophy of consultation, exploring new ways to engage and communicate with the public—whether or not they are patients—as individuals rather than on a representative or group basis, as has often happened in the past. The NHS has a tremendous commitment to such engagement. The philosophy behind representing patients' views through Quality Improvement Scotland or any other mechanism is the same; everyone is committed to finding ways to involve patients and members of the public as individuals in current and future care.
Does COSLA have a view on health councils and the changes?
Since October 2001, local authorities and health boards have had closer working arrangements. Health boards are benefiting from local authorities' experience of tried and tested methods of consulting service users and carers in social work, and from the various consultative structures that we have long had for developing measures such as community care plans and children's services plans. That expertise is being used in planning health service matters and consulting patients on them.
Obviously, we all welcome the duty to involve the public's being placed on health boards, but how do we avoid that effort's becoming tokenistic? There is huge public cynicism, and for good reason: some consultation has been very poor. What needs to be done to make the duty to involve the public mean something? How do we convince the public that the involvement is genuine and not merely a nice idea?
There are quite a number of examples around Scotland of NHS boards' finding new ways of involving people—ways that go well beyond what would be considered to be traditional consultation exercises—boards are learning from experience. In a number of parts of the country, before they actually need them, people are being asked how they would like services to be configured or provided. While they are well—that is, before they become patients—people are being asked what they want from the health service, how the service might be provided, and what would be particularly important to them. That is a relatively new approach. Examples from around the country are being shared, but it is fair to say that there is a lot of learning to be done about how to involve members of the public meaningfully, rather than tokenistically.
A view is emerging from our members that traditional consultation, which is necessarily issue-specific, may not be the only way forward. Hilary Robertson describes a continuous, meaningful and thoughtful engagement with individual members of the public; that is how members of the public will have a much more fruitful and effective influence on health boards' plans.
We need more effective consultation mechanisms, but we also need more effective feedback mechanisms. From their constituency case work, committee members will know the highly personal issues that can be raised in consultations. Quite often we cannot do everything; we cannot shape our services exactly as every individual would want us to. However, we need to be better at going back to people to explain why we have made certain decisions. We may need a better balance between trying to shape services to meet local community needs and trying to make services as universal as possible.
There is a view that NHS QIS looks at the delivery of patient care from a technical perspective. The health councils have said that they do not wish to be part of another organisation; they wish to stand alone as a new national body in a national framework. Do the health councils have a point when they say that they consider scrutiny differently from NHS QIS? The approach of NHS QIS is very technical and has the patients' perspective. Is that approach reasonable? I put that question to COSLA first and then to the Scottish NHS Confederation.
I am not sure that we are entirely qualified to answer that question from the patients' perspective. However, we would certainly promote such an approach and hope that councils would take it with their own services. What the consumer, customer or client—whatever you want to call them—thinks of the service is entirely valid and should form part of any process for developing services. We must hear that voice.
I pointed out earlier that NHS QIS has already demonstrated its ability to be independent in setting standards—we might be able to link such an approach to the establishment of standards for quality in patient care. Indeed, those standards are rapidly being established. The confederation sees no reason why, in that respect, the independence of patient representation could not be replicated along the same lines, although perhaps not using exactly the same mechanism.
In other words, you would not object if the proposed new health council operated outwith NHS QIS.
Our membership has no issue with Quality Improvement Scotland's early demonstration of its capacity to be independent. Of course, we did not refer to that in our brief written submission because the Scottish NHS Confederation represents the bodies against which complaints would be made. As a result, we did not feel that it was appropriate to elaborate on that matter.
Do you agree that, quite apart from the substantive question whether there would be a conflict of interest in that respect, there might be the perception of such a conflict?
Possibly.
I want you to confirm your views on the importance of contact within all the services as well as the importance of an independent voice outwith them. It would be good if everyone who worked in the system had the time to feed back problems that were highlighted by any one person and to marry that information with what might be happening outwith the system in the local health council. After all, I get the impression that an awful lot of patients have to contact outside bodies because they have problems with feeding into a system that should exist—indeed, does exist—in the best services. I am beginning to think that when a patient complains to a nurse or doctor, the nurse or doctor is too busy to feed it up into the system. As I said, perhaps many problems could be defused if people within our services had more time to listen to and act on them. Do you feel that your systems are robust enough to comply with that?
If I have understood your question correctly, I think that the situation that you described should be covered by the health boards' complaints procedures, which have been consulted on recently. Of course people want sufficient time to listen to patients' views; I have no doubt that staff within all our member organisations strive to do so. I expect that, where a problem has been identified and a complaint has been made, the complaints procedure that has been reviewed recently would kick in.
I would have thought that, in a good organisation, very few general complaints would require to be dealt with under the full complaints procedure. However, improving the situation within the system would probably even be of help to the independent voice outwith it. We should be listening to people and correcting things as we go along. I find that, whatever the system, people feel that they are not listened to, especially when they are in hospital or are dealing with a particular department. The problem should be sorted out there and then, before it becomes a complaint.
That comment brings us back to the continuing involvement of the public and patients in the system. I am sure that everyone would agree that, however well we listen to people, our ability to listen could always be improved.
The problem is that we very much need support from outwith the system because such support is currently lacking within organisations. Perhaps you do not agree with that.
The principle of emphasising public and patient involvement as a continuing process rather than as a response to particular decision-making processes is part of that. As Hilary Robertson said, the complaints procedures, which have recently been reviewed and which operate in all NHS boards, are another part. Underlying Dr Turner's question is a question about the point of the commitment to listen to individuals. NHS bodies are committed to doing that and Hilary Robertson mentioned some existing examples, such as NHS Shetland 100.
Rather than list good examples of public involvement now, perhaps you would write to the committee on that issue. It would be useful for the committee to have those examples in written form.
We would be pleased to do that.
The Scottish NHS Confederation welcomes the inclusion of formal duties on NHS boards to involve and consult the public on the development of services and to engage with patients. Who would not welcome that? We may be sent a list of good examples, but all too often, we read about poor examples. I accept that public involvement goes across the board and does not focus only on clinical or maternity services reviews. You mentioned additional finances. For the fun of it, will you say whether we get good value for the money that we spend on consultation? I will not go through all my experience—
You are on a springboard.
Consultation gives communities the expectation that they will be part of the planning process and not simply part of the education process. Reams of guidance have been brought forth, which is bureaucratic and time consuming. As it turns out, the process is confrontational and accusations have been made that it is less than honest, which leaves everybody cynical about it. Of course consultation is a good idea and we are all for it, but—until now—it has not helped the service to move and change. Instead, the process has made politicians and communities try to prevent changes. God forbid that politicians should influence the health service, which needs to change, renew itself and move on.
I am listening for a question. That may have been cathartic for you, but it was a speech.
There were a lot of questions in it.
I will pick one of them to answer. The confederation does not underestimate the challenge of finding new, different and more meaningful ways in which to involve people. Part of the context in which we live is that people expect to be involved and informed. That does not mean that consultation should be only on change. Change is inevitable, not only in the delivery of health services and health care, but in the way in which we live. The challenge is to ensure that we communicate thoughtfully, realistically and meaningfully with the people who are involved in the process.
You said that you are moving away from consultation on specific issues. We will return to that point.
The guidelines require us to consult on time scales in a specific way that can draw the process out for four or five years. Is that right? Do we need to look at that and shorten those time scales? Are we moving things forward or holding them back?
Do the COSLA witnesses want to come in on that point? I am getting answers from the committee members, but they can speak for themselves.
Health boards need to engage in general continuing consultation, and I genuinely believe that that has greatly improved in recent years with local authority members being on health boards. One of the reasons why that worked was that councillors, rather than senior officers, were put on the health boards. Not only did they knock heads together, but they brought to the boards the skill that politicians have for getting out and speaking to people about things. In general, health boards are benefiting from the experience of local authority members, which aids the process. However, if what is in question is a set of proposals to open a facility, or even to close a facility—
We are all aware of which one.
Exactly. I am not aware of the full details, but I would be concerned if we were to get too tied down in the bureaucracy of how we consult. If that could extend the process to four or five years, I would be extremely concerned.
I would like to move on, as I am conscious of the time.
How do you feel that the new duty on health boards to promote health improvement complements local authorities' duty to promote well-being? Does it complement it effectively?
The short answer is that the health boards' new duty complements the local authorities' duty very well. If you look at the range of activities that councils are engaged in and their contribution to health improvement over the years, environmental issues have been significant, as have leisure, sports, healthy eating, education and schools initiatives. We have a huge range of networks and are therefore extremely well placed to pursue health improvement. That is the position that we are in at the moment, as the situation has developed a bit more. We would certainly welcome strengthening of councils' role in health improvement. We might be concerned about how that is to be funded and developed, but we believe that we have a significant role to play in that area, not just in conventional social care services but in the wider remit of councils across a wide range of functions.
My question was really about whether you feel that there is any conflict between what the councils are doing and the authority that the bill gives to health boards.
That will depend on what the guidance eventually says about the role of councils. It appears to be absolutely appropriate that health improvement is located within community health partnerships. Of course, it will depend on how the structural arrangements work out, but I am confident that we could find ways through that. I know that health improvement staff across the board have some concerns. For example, one or two have said that they might not particularly like being managed by GPs and would prefer a wider scope in which to operate themselves. That is the kind of detail that needs to be worked out, but the development of health improvement through the proposals in the bill and its location in CHPs absolutely complements the relationship with councils. I am sure that we could work closely and co-operatively in ensuring that that is carried through.
The Scottish NHS Confederation also sees the two duties as being complementary. It is clearly not just for the health service to try to improve health; it is important that the functions of other bodies are also taken into account and that the health improvement focus straddles all the appropriate departments, functions and bodies.
I would like to broaden the scope of the question to include money, which is the root of all evil, as we know. You have both made pretty strong remarks about the lack of money for consultation, but what about money for health promotion itself? Do you feel that there is enough clarity in the bill about funding and mixed funding? For example, there might be funding from the education department in a council to promote life-improvement education, while the health board might already have allocated money to that, although it might not be listed under the same budget heading.
Quite honestly, I do not know the direct answer to that question. We hear about the negative examples, but we have lots of good examples of aligned budgets. Many partnerships work closely and have aligned budgets. My council has funded health promotion activities in partnership with two health boards with which we have boundaries. Lots of good things are going on, and organisations are working together, but health promotion and health improvement are not well funded on the ground. We tend to scratch around a bit, looking for funding to back up new initiatives and for areas that we wish to promote. However, I could not be specific about how that should be presented in the bill.
Would you like to write to us with COSLA's view?
Yes.
I have one small point. There is plenty of scope for joint working. Perhaps it would be helpful to apply the joint future model to health improvement. We note that the bill places a duty on health boards to promote health improvement, which includes giving them powers to provide financial assistance to any person. We interpret that to mean any body or organisation. That will encourage joint working between the health service and other partners, such as local authorities and any other relevant partner. We support that. More money is always welcome, of course.
Your understanding is, however, that such measures will come out of current funding.
Yes.
We are talking about reprioritisation.
Yes.
Are you appealing for more money?
No. We are simply recognising—
We have the evidence, convener. She said, "No."
In summary, the financial memorandum states that
If we are talking about the summary, we know that some of the structural changes—which is where we started our discussion—are not incurring the costs that might have been thought necessary before they were started. There are examples of single systems that are very advanced in their planning, which have management structures in place, and which are actually releasing efficiency savings that are being deployed within various health systems for other priorities. It is too early to say what will be required in terms of CHPs, but it seems unlikely that in the early days of their development there will be no need for resources from elsewhere in the system. However, on an on-going basis, that has yet to be determined.
I am trying to work out whether that was a yes or a no.
It is work in progress. Our evidence is that single-system working is releasing funds back into the system to be spent on other priorities. That is as much as the Scottish NHS Confederation can say at this stage.
I recall evidence from last week that conflicts with that, which was that savings of £19 million would be made at some point following restructuring, but the money just disappeared and was never accounted for. I will have to look back at last week's Official Report to see what it was. Does COSLA feel the same? Financial memoranda are important in all bills.
We have already given evidence to the Finance Committee on that point. We have been clear that it is difficult for us to see how the measures can be cost neutral. The changes that we are seeking to engage and involve local communities, patients and service users will add to the cost, but it will be money well spent.
That concludes our questions. Thank you all very much. If, on reflection, you feel that we have missed something, we would be content for you to write to the committee.
When the unified board was set up in October 2001, the chief executive and I had a long discussion about where the major challenges for Dumfries and Galloway would be, not in the next week or month, but 10 or 15 years ahead. We quickly identified for the board that the big challenge would be the demographic change in the population of Dumfries and Galloway: a 26 per cent increase in over-65s, a 26 per cent decrease in those aged 19 and below and an 11 per cent decrease in the working-age population. We realised at that stage that the status quo—a health board and two trusts—was not an option and that we needed to think radically about how we would start to modernise services in Dumfries and Galloway if we were to cope with the challenges of the next 10 to 15 years. That was the basis of the decision, to which we came quickly, to have an integrated health care system in Dumfries and Galloway that would result in the dissolution of the two trusts.
That is a practical example.
After the discussion that the chairman and I had, we had a process of engagement and consultation. It took 14 months from our taking the initial idea to the NHS board and the minister giving us approval to explore different models to put in place a completely integrated structure.
Coterminosity seems to be the key, as does getting rid of duplication. Integration could work in rural areas. It works in the Borders, probably for the same reasons as it works in Dumfries and Galloway. There are problems if people do not know one another. If the system is rolled out throughout Scotland, will it work in urban areas in the way in which you have described? There will be different local authorities involved in such areas and professionals will not know one another in the same way as they tend to in rural areas.
That might be possible but it will take greater effort. That said, it took an enormous amount of work for us to achieve what we did. It did not just happen; we had to drive very hard to achieve our ends. There is no doubt in my mind that the bringing together of primary and secondary services and, particularly, of clinicians who work in the primary and secondary sectors, is vital to the achievement of better care pathways.
The people part must be important. The personnel who know and work with one another have to be prepared to buy into that. That is why I am interested in what you said about urban areas.
I want to follow up what Malcolm Wright said because it is an important issue for the committee. We seem to have a problem knowing whether money will be saved if bodies are amalgamated into one board or authority. You said that savings were definitely made, but can you quantify those financial savings? Would we be able to make some judgment about whether money would be released by the process?
We have made local and recurring savings in excess of £500,000. However, I make it clear that that was not the reason for going down the road of integration and that those savings might not be directly comparable with savings that could be made in other NHS boards around the country.
The Executive says that substantial savings could be found by integrating, and that the savings could be channelled into the statutory requirement to engage with patients. From your experience, do you believe that such an approach could be replicated throughout Scotland? The Executive is saying one thing but some of our witnesses, such as those from COSLA, are saying that patient engagement will cost a lot more money and will not be cost neutral. That is the committee's dilemma.
My personal view is that public engagement is resource intensive if it is done well. Public engagement does not necessarily mean spending more money, but it involves staff time. I will give a brief example of a project that we have developed in Dumfries and Galloway around older people's services in Mid and Upper Nithsdale. We and the local authority jointly agreed a model of care for older people in the region. It was signed off at a full joint meeting of the NHS board and the council.
Before we move on to questions from other members, would the witnesses from Ayrshire and Arran NHS Board like to comment? Please feel free to do so, even though my question was directed to the witnesses from Dumfries and Galloway.
We have benefited from being a near neighbour of Dumfries and Galloway and we have been involved with the progress that has been made there. In Ayrshire and Arran, we welcome the move to single-system working, which we see as a natural progression from the unified system that we have now. It is a major step from integration to a single system, and one of our concerns is to ensure that our single system is based clearly on a model involving devolved decision making and control of resources. There is a concern that we might return to the old central command-and-control model that applied to single-system health boards in the past. We must be alert to that danger, and I hope that the bill, the regulations or the policy memorandum will reinforce that expectation of devolution, not centralisation.
With the change to divisions as opposed to trusts, you have lost out on non-executive input at that level. Has that been a major loss? You now have a much smaller amount of non-executive input to discussion at the divisional level, albeit that you have strategic input at board level. How are you compensating for that, or is it not a loss for you?
In Dumfries and Galloway, we do not envisage a division. We have a truly unified system, and the minister gave us permission to increase the number of non-executives from four to six, plus me. We think that we have sufficient non-executive input and involvement in the board. Also, the board is larger because we have a local authority member, a staff-side member and a clinical member on the board. The board is therefore much more inclusive than it was when it was a health board. Our non-executive involvement is sufficient to carry out the strategic thinking and, indeed, the governance duties that non-executives have to undertake.
There was certainly an important input on the governance side in the larger health boards, which had large machinery. Have you managed to change the model sufficiently to compensate for that, and to mix strategic staff and management?
We have done so in Dumfries and Galloway, but I would not say that the model could be followed in larger areas, where there would have to be divisions. Our model is particular to Dumfries and Galloway, and I would not necessarily advocate its use elsewhere.
We welcome the increase in non-executive input to the board, but we do not see that as a loss to the divisions. The board has wide discretion about its committees and how they are formed. Although it is required at the moment to have the management teams as a nucleus, it has considerable flexibility to add non-executive members to those teams, and we certainly intend to do that. We do not envisage that denuding the operational level of non-executives.
Do you base your thinking on a geographic model of representation at non-executive level, or is it based simply on skills?
It is based on skills.
I was interested in the comment that primary and secondary care people talk more to one another, as that is essential if the system is to become more efficient. It might be too soon to find out whether patient waiting times have been reduced or whether patients are more satisfied in the long run, but have you noticed whether patients are treated better in the unified system and go through it more quickly? I imagine that that might well be the case.
I will give an outline answer and ask the chief executive to be more specific.
One of the advantages has been the development of integrated strategies across primary and secondary care. I mentioned the groups for mental health, learning disabilities and cancer—the improvements on those issues are not directly down to integration, but they are all part of the process. We have Scotland's first managed clinical network for coronary heart disease, which is a good example. Patient representatives, who are supported by the local Hale and Hearty Club of patients with experience of using coronary heart disease services, sit round a table with primary care and secondary care clinicians. The network involves good dialogue on matters such as pre-hospital thrombolysis, door-to-needle times in the hospital and resuscitation issues such as resuscitation training in the hospital. I am not saying that we have gained huge improvements yet, but plans are in place that will allow us to make major advances in the future.
Kate Maclean has a question.
I want to return—
Sorry, Wai-yin Hatton wants to speak. I have done it again—just because I used to be a Gallovidian, that does not mean that I am biased.
I want to offer two pieces of evidence from Ayrshire and Arran. Although we have not yet gone down the route of formal integration, through the change in culture by which GPs and consultants work more closely we have reduced significantly the dreaded plastic surgery waiting list. The GP who is the chair of the area clinical forum spent a week reviewing the list, as a result of which some patients were rightly re-directed and treated more immediately.
I have a couple of questions that go back to previous answers. Malcolm Wright said that an ancillary effect of restructuring was a £500,000 saving. The figure does not really mean anything on its own; what percentage of your budget does it represent? Will there be recurring savings of £500,000 year on year? Where is the money going? Is it committed to your health authority area and has it gone into improving services?
It is £500,000 out of a total turnover of more than £170 million, plus the capital allocation to the board. The figure is significant but not massive. On 1 April, when we signed off our health and community care plan, we were able to put £1 million of investment into new clinical services. We were very proud to be able to do so. We were able to increase nursing staffing levels in Dumfries and Galloway royal infirmary, and to invest in a consulting gastroenterologist and in our infection control capacity. A list of things was on the stocks and prioritised and we were able to use some of our development money plus some of our savings.
We will come on to that topic shortly.
Yes, but when we invest resources in future, community health partnerships will be up on the list.
You said that you had coterminous boundaries with your local authority. Does that make things easier than they are, for example, in my health authority area of Tayside, which has three main local authorities and a significant involvement with another two? Is such a set-up much more complicated?
Having coterminous boundaries makes things hugely more straightforward. We are not talking just about health and the local authority; the police force and Scottish Enterprise Dumfries and Galloway also share the same coterminous boundary. We are able to design community planning on that basis—and not only at regional level. While we were going through our restructuring process, the local authority was going through a parallel restructuring process. We have tried to design our local health care co-operatives along the lines of the local community planning boundaries. We have local council ward boundaries that are coterminous with local health care co-operative boundaries. That may be the way forward for CHPs. We have a lot of coterminosity right the way through, which makes it much easier to plan for the future.
So, taking evidence from you is probably giving us the best-case scenario.
I would say so.
The best-practice group report has acknowledged that the development of local health care co-operatives has been patchy across Scotland. Community health partnerships are expected to evolve from the LHCCs. Will practice improve substantially by giving CHPs a statutory basis? Much of the detail of how they work will be subject to guidance.
Let us start with Ayrshire and Arran for a change. You go for it—Dumfries and Galloway is always pushy.
But we are always very interested to hear what is going on in Dumfries and Galloway.
I concur with George Irving. In Dumfries and Galloway, we were a bit concerned that minimum population figures were initially assigned to community health partnerships. We have four LHCCs, and as our population is 150,000, those LHCCs are small. However, as my chief executive said, those LHCCs' boundaries are coterminous with the boundaries of the local authority area committees.
You all support the statutory basis for moving forward. That is fine.
I call Janis Hughes—I am sorry; I have not taken a response from Ayrshire and Arran NHS Board again.
I will respond to Mrs Eadie's point about the statutory basis. We have concerns about the proposal to make CHPs sub-committees of NHS boards and our major reservation is about locking CHPs firmly into the committee structures of NHS boards. We expect CHPs to have a wider role than that. We consider the CHP to be the vehicle for the joint future agenda and a local vehicle for community planning. CHPs have huge potential and need statutory underpinning, but they should not be too locked into the health system.
That concerns the equality issue and the importance of involving the community in planning, which relates to earlier discussion.
I am loth to call Janis Hughes in case I cut short some witnesses again. I am becoming paranoid about that.
My question is about Ayrshire and Arran NHS Board's submission, which says:
We support fully the devolution agenda, which can be readily achieved through good delegation schemes, so that people who are on the front line know exactly the parameters and who has authority without having to keep returning to the health board.
What steps could be taken to address the concerns that you have raised?
Even though we have not yet come together as one legal body, we have been working together in that direction. All the decisions about changes and redeployment are taken jointly through a corporate team, which consists of chief executives and directors from the board and the two trusts. For the past year, we have been examining and assessing situations and problems together, to ensure that we consider all the different aspects before we come to a decision. That way, no one party or locality can take a decision in isolation, without taking account of the potential impact on other key colleagues.
A further point is that, from next Wednesday, we will start operating as a shadow board for the new single system, while the current board works itself out of existence. The shadow board is now empowered to set up the new system—that is virtually what it is there for. Between now and next April, such issues will be on the agenda. We are fortunate that, this week, we received ministerial approval for the non-executive appointments. We can kick off fully as a shadow board next Wednesday. That will be important for us.
You think that that kind of proactive working will lead to a situation in which fragmentation will not occur.
We are very committed to devolution and to equality throughout the area, but we do not want devolution to lead to dissolution and fragmentation. We want to ensure that there is a strategic centre for a highly devolved operational system.
Does Dumfries and Galloway NHS Board wish to comment?
No.
I overlooked a question. I meant to ask whether anything more on community health partnerships should be added to the bill.
We are reluctant to propose changes on community health partnerships because that might remove flexibility. The policy memorandum and subsequent regulations are much more important than what is included in the bill.
I have a brief follow-up to Helen Eadie's question. In my health board area, there are three local authorities—which, coincidentally, is the same situation as in Ayrshire and Arran—and there are three different joint future documents. It is not just the different geography that accounts for the fact that the documents are not identical. I want to tease that out. I understand why both boards seem to be keen on working closely with local government. Does Ayrshire and Arran NHS Board see a need for agreement on a single document throughout the three local authority areas or are you happy to have different documents?
There is certainly a wide variation in needs and equalities—or inequalities—in the Ayrshire authorities. We think that local authorities should reserve their right to have community plans for their areas. As a board, we contribute to those plans. We do not send teams of people to the relevant meetings; a small number of the board's senior officers take a common view from the board, which they input into the community health plans. Our three local authority members sit on the health board when such matters are being discussed. We are quite comfortable with the variations in the community plans for our community.
I have a question for both boards. You have heard us talking about the proposed new national Scottish health council. Will you give us your views on that? Do you feel that it will be more independent than the local health councils are and do you have any concerns about the loss of local representation? Do you think that the new local advisory committees and the new consultation duties will make up for what you have now?
I will start to answer that. The proposed new system will offer a number of advantages, particularly in relation to consistency and scrutiny of public involvement processes within NHS boards. In our area, we have positive experience of working with our local health council—it has a continuing involvement with us in the management and development of strategy and it works with us to design how we go about public consultation.
I will provide a point of clarification. I agree with our chief executive that we have a good, strong local health council in Dumfries and Galloway; it is a useful sounding board and is able to question the decisions that we take. However, it is not entirely independent because Dumfries and Galloway NHS Board pays the chief executive's salary and the board's chief executive line manages the local health council's chief executive. The local health council does not have total independence. Under the new arrangements, it might be even more independent than it is now.
Point taken.
Ayrshire and Arran NHS Board has a slightly different view. Even though we have a very good working relationship with our current local health council—the chair of the health council sits as an adviser at the board table—we feel that the health councils should be much more independent. If they are not, their actions may be compromised even though they are doing the right thing.
I ask the representatives of both health boards what your public think of the local health councils and the changes that will take place. Will they understand the differences that the changes to the system will make?
To be honest, I do not believe that they will understand the differences. In some cases there is confusion in the public mind between the health council and the health board. I do not believe that the public would have strong views one way or the other.
It depends on the profile of the health council locally. We have been fortunate that, due to circumstances, the health council has recently been involved in, for example, a major transport survey. The health council was involved in that survey independently of the board and it fed into the board. The health council has taken a lead in recent consultations on specific issues; that has elevated its profile and increased public interest in it.
Both health boards have said that the public may not notice a difference between the existing and proposed arrangements, but members of the public will notice a difference if they go along to get help with the complaints procedure or want to make a complaint. Currently, the local health council can walk the ward unannounced, but in the new set-up that will not be allowed, as the new Scottish health council will not have that advocacy role. It is explicitly stated that all that it will have is the role of monitoring the public involvement duty that the health board will have. Who will undertake the local health councils' current tasks, such as face-to-face contact with the patient who is guided through the system when they want to make a complaint?
I did not read the policy memorandum as making as clear a statement as that.
The Minister for Health and Community Care's view seems to be very much that the new Scottish health council will not have an advocacy role. Advocacy services will have to be commissioned at local level. That is my understanding of what has been proposed and is probably what is causing so much concern. For me, that very clear advocacy role will be lost. Although we are all in favour of making public involvement a duty, such an approach is not exclusive of the role that is played by local health councils. As it stands, the proposal does not follow the advocacy route. Instead, it seeks to ensure that public involvement will be monitored and, presumably, that advocacy services will be provided in some way, although not directly by local health councils. Are you concerned about that?
Yes.
If the proposal goes ahead, are there any obvious organisations in your area that would provide the advocacy service that is currently provided by the local health council or are you concerned that there are no such organisations?
Although there are specific advocacy groups, needs groups and patient groups, there is no general service as such. I would be concerned if the local health councils lost that role completely. That said, my reading of the proposal was slightly different. I thought that flexibility would still be available if the health councils chose to avail themselves of it. I would expect that if they are to link with local organisations, monitor their performance and advise them accordingly, they would raise such issues—or arrange for them to be raised—with the health service.
So you want the replacement local advisory councils to have the direct advocacy role that local health councils currently have. Indeed, you would be concerned if they did not have such a role.
That is right.
I am also concerned about where the proposal might lead. Our experience locally shows that the council and the NHS jointly commission advocacy services, which means that a single advocacy service plays into both the local authority and the health service. At the moment, that service happens to be provided by the local health council as a sort of arm's-length organisation. I am concerned about where that will go in future and about whether those functions will be carried out by the local grouping or some other body.
As it stands at the moment, it appears that no significant additional resources will be allocated in this respect other than what can be freed up through the reorganisation of services. Will public involvement cost money and, if so, where will the money come from?
We will not necessarily have to shell out a lot of money to meet public involvement obligations. However, it will be costly in the sense that it will take NHS personnel-time to consult adequately and properly. As my chief executive Malcolm Wright has indicated, we have just found that to be the case. However, I see it as part and parcel of something that we will have to do in Dumfries and Galloway if we are going to modernise services. We have to dedicate the management resources that are required to consult meaningfully with communities where it is important to modernise services. That said, I do not want to put a figure on the percentage of our spend that will specifically be allocated to public consultation and involvement.
Our campaigns cost additional staff time because we have to hire public places that are accessible and organise campaign material and leaflet drops to every household. However, one recent example highlighted the fact that, although such an approach resulted in additional costs, the proposal was enhanced before the health board considered it. The weighting of the criteria was changed in our appraisal exercise and public engagement led to two further options' being offered. I hope that in such circumstances the public will understand the reasons why a preferred option is ultimately chosen because of the information that they receive and because they know that we genuinely take their views on board.
As far as cost is concerned, there is also a duty on us rigorously to review how we currently undertake public consultation and how focused that consultation is. There are different forms of consultation; explanations in some cases and engagements or full consultations in others.
I think that we would all concur with that.
I highlight two other matters. First, although the health service is changing, there are still training costs for educating staff about involving the public in the design and running of services.
NHS boards will have a duty to promote health improvement. Will that be beneficial and, if so, in what way?
We very much welcome the increased emphasis on and clarity about health improvement. At the end of the day, I am a patient as well as a member of the health authority.
We also strongly support the inclusion in the bill of the duty to promote health improvement and the alignment with local authorities to consider money that is provided by the Scottish Executive. For example, the better neighbourhood services funding that the Scottish Executive provided to Dumfries and Galloway Council was discussed with community planning partners and then used to put in place a range of new facilities, such as youth clinics and youth services, which we used directly to focus on, for example, teenage pregnancy rates in the region.
Presumably, if the promotion of health improvement becomes a statutory duty, health boards will be entitled to more funding when they negotiate with the Executive.
We get the money from the Executive anyway—
That is not on the record; you will have to say something more—
More optimistic.
It reinforces our local work if money is put into such initiatives.
I was being helpful. I will move on.
My question is directed at Ayrshire and Arran NHS Board. In your written submission you referred to an omission from the bill, in that staff governance was not included. How would you like staff governance to be represented in the bill? Would you like the Executive to produce an amendment to ensure that health boards have a system in place to monitor and improve the governance of NHS staff?
Something was put out for consultation, which we were pleased to see. In addition to setting up governance committees within each NHS board, staff governance needs to be elevated to the same level as clinical governance, because our biggest investment and asset is our staff. If we do not properly look after their health, well-being and conditions—and I do not mean pay conditions—potentially we will have a depleted group of staff to tackle the winter pressures. They might end up being patients themselves because of stress. If we are to compete with other industries so that good staff remain within the public sector, we need to give them genuine evidence of commitment, as well as evidence that we value them. That is why we feel strongly that the staff governance component needs to feature more prominently and explicitly in the bill, so that all bodies are required to deliver on that.
I would be interested in any other comments.
I support that.
Thank you for your evidence. That concludes this evidence session. I will suspend for a few minutes. People have been peeling off, which is a warning to me. You are welcome to have a coffee. The same goes for the Unison representatives, who are about to give evidence and who have sat here patiently.
Meeting suspended.
On resuming—
I welcome the very patient Unison representatives, who are, they tell me, in need of the health service because they are both suffering from the cold; I am glad that they are both sitting some distance away from me. Jim Devine is the Scottish organiser for health, and Danny Crawford is the chief officer of Greater Glasgow Health Council; both are from Unison. I know that they listened to the earlier evidence, which is helpful.
Your written evidence welcomes the abolition of trusts, but you make a number of points regarding community health partnerships, about which, as you will have heard from previous evidence, we are asking a lot of questions. As you know, following consultation much of the detail will be set out in regulations. Is there anything on community health partnerships that you would like to see in the bill, rather than in guidance?
I will make a wider point. I was a member of the Bates committee that examined human resources and the joint future agenda, and I had genuine concerns. We have heard a lot about coterminosity. If we started with a blank sheet of paper, we would be talking about coterminous local authorities and health care bodies. Single-status agreements are coming to local authorities and agenda for change is coming to the health service.
That is an important point, which you made strongly in your consultation submission. You say that you would like guidance. In your written submission, you mention local standards of treatment, access and referral, which you say could lead to a postcode lottery. Could that issue be dealt with in guidance, or would you prefer it to be included in the bill?
This afternoon's debate has been partly about involving patients and staff. That could include having a Scottish strategy to examine what we are trying to do and the difficulties that we face; it should also include minimum standards. I am not convinced that we should have the current targets, because they give the health service a terrible kicking, which has a demoralising effect on staff. We can talk about national minimum standards, and targets that are agreed locally with community involvement. It is not about saying that if Danny Crawford is in Glasgow and I am in Edinburgh, he will get a better service. There is a need for a minimum level of service. That is part of the earlier debate that you had about involvement.
Does Danny Crawford wish to add to that?
No.
On the front page of your submission, you comment that you seek
One of the problems that trusts created was that they had the right to determine local pay bargaining, the consequence of which is that we have staff working alongside one another on different terms and conditions. The differences are often minor, but they exist. For example, if you were on a trust contract, your annual leave entitlement would be less than mine would be if I had worked for the past 20 years in the national health service.
It would be helpful if Unison could draw up a note to clarify its reference to that act.
It would be. I was not aware of what happens when staff move about.
There have been problems with staff moving to the care commission from local authorities and health boards and having different conditions and pay—that has caused some bad feeling. Do you want the bill to be delayed until the situation can be clarified and something can be firmed up on common conditions? From a previous life, I remember harmonisation, which came before single status, which the employer and employee sides have failed to implement. Single status has been around and agreed for years, and I do not think that we have reached the stage at which it will finally be implemented. If we had to delay the bill—which, in other aspects, would be an improvement—we would probably have to delay it for a long time to get agreement on conditions.
Unison would not want the bill to be delayed, because it sends out a lot of positive messages. When I worked in the Scottish health service, staff were employed by the Scottish health service. I hope that we go back to that system, because that would send out a powerful message.
I appreciate that you support a Scotland-wide human resources strategy for terms and conditions, but how relaxed are you about having different terms and conditions north and south of the border?
The union supports national pay bargaining and, to be frank, we would be daft to throw that system away. We have recruitment and retention problems in Scotland, but there are greater problems elsewhere. For example, the vacancy level for nurses in Scotland is about 1.8 per cent, whereas London hospitals have a vacancy level of 30 to 35 per cent. That situation allows us to tap into the benefits of national bargaining. However, the other side is that we should have the right to tweak the machine in Scotland, which we have done. For example, through the low-pay deal, ancillary staff members now earn £5.35 an hour; that rate is not great, but it is different from the rate south of the border of £4.62 an hour. If you were to say that I want to have my cake and eat it, you would be quite right.
I want to pursue the issue because it is of interest to me. In your job as a negotiator you want to get the best terms for your members, but if the Scottish Executive could give enhanced terms and conditions to your members in Scotland, would it be a difficulty that those conditions would not apply south of the border?
No. We have already negotiated different conditions. That has caused me personal difficulties with my national officers, but it is not a difficulty for our members. If the Health Committee wants to give us a 10 per cent pay increase, we will happily accept that.
Now I know why you are a negotiator.
My question is a little less exciting, but it is about a major issue. Unison's evidence states:
Yes. The important role of local authorities in promoting health improvement, which was mentioned in earlier evidence, must be considered. There have been great initiatives, such as the free entry into swimming baths in Glasgow. Health care must be considered in its broadest sense. When I worked in primary care psychiatry, I saw no one who had already been seen by a psychiatrist, but I was involved in taking people off medication. We held surgeries in a local leisure centre, which made people feel comfortable about access to the service. A few weeks ago, Greater Glasgow NHS Board had nurses in bookies' shops. Such initiatives are to be welcomed because we must get the message out.
Do hospitals make money from those vending machines?
I suspect that they do.
That is why hospitals have them.
That is a simple point, but the problem is that a shop outside the hospital could sell the same items in abundance. Do you agree that although such initiatives can be debated and considered, they are complementary to overall health provision and would not necessarily reduce demand for health services or the need to provide acute services?
I know where Duncan McNeil is trying to take me. It is interesting to read reports about the situation in Finland 15 years ago, when it had a greater problem with coronary heart disease in particular, and the situation there now. A community-based Government-driven campaign has been undertaken in Finland on healthy living, healthy lifestyles and healthy eating, and now it is being said that the demand on acute services is less. It would be wrong to pretend that implementing the strategy now would produce gains within five years. Healthy living will affect the next generation.
Jim Devine will be aware that such campaigns started in Finland not to improve health, but to address famine and hunger, and they have been undertaken for some time.
I am conscious of the time, and the piper playing outside the building is annoying me enormously. As a Scot nat, I should not say that, but he is. We will move on.
Earlier, we discussed public involvement. Your submission says that Unison
Convener, may I hand over to my colleague? We are a double act today.
Certainly—just leap in. I do not think that your man needs to be told that.
The short answer is yes. Unison has concerns about that matter. Unison welcomes the establishment of a Scottish health council and welcomes patient focus and public involvement in the NHS, but it feels that the changes that will be introduced with the Scottish health council mean that the body should be independent.
Shona Robison said that local health councils provide the complaints route into the health service. Will you comment on that?
Unison has concerns about that issue. We understand that the proposal is that the Scottish health council's local offices would not provide the support that local health councils have provided to individuals who want assistance to make complaints through the complaints procedure or who want to know their rights.
There is a duty to involve the public and it has been said that that will not involve significant additional resources. Will public involvement be improved in health service planning?
It would be wrong to say that consulting will not cost. One practical example of that was the introduction of the patients charter. Any member of staff who works in an accident and emergency department will tell you that everybody who walks in the door knows all about their rights as a patient. We are not against the charter. However, when it was launched, there were videos, television adverts and letters, and people were told, on their appointment cards, about their rights as patients. It would be wrong to pretend that all that had no cost. If we want to communicate, to involve people and to make a mark, that will cost money.
Consultation will have an associated cost. That said, Unison's position is that the NHS should be open, transparent and accountable. Making NHS boards the primary body responsible for public involvement is logical and appropriate. It will be the NHS boards that are hauled before this committee or the Public Petitions Committee to justify how they went about a consultation exercise.
I asked the witnesses from Ayrshire and Arran NHS Board about improving the governance of NHS employees. Should the Executive introduce amendments to the bill to place a duty on health boards to ensure that they have systems in place for monitoring and improving the governance of NHS employees?
I totally agree with the comments that those witnesses made. In the Scottish health service, we have a unique form of industrial relations. We work in partnership, and we sit down with management, to get away from the confrontation that went on for many years. We work on the practicalities of the development of services and the provision of care. The most valuable resource in the provision of care is the staff. They want to feel part of the team and to feel valued. As the witnesses from Ayrshire and Arran said, if you are to have clinical governance—if the chief executive was making an assessment—staff governance should be there as well. That has been pushed by all the trade unions and professional bodies in Scotland.
I want to pursue the issue of the governance of NHS employees. What are Unison's views on access to continuing professional development?
We are very supportive of that, but it comes with a price. Over the past 15 years, the work load for health service workers has more than doubled, because of an increase in the throughput of patients. The difficulties that we all have are in getting people off wards and departments so that they can have a clear career structure. The new pay mechanism, agenda for change, makes development and the knowledge and skills framework a crucial part of people's grading. Increasingly, people will want training and development and a clear strategy for that will be needed.
Do you agree that if staff have a higher skill base they will be able to take on more care, as well as more technical care?
We are very supportive of the developing role of nurses and other staff. Tragically, my mum died during the summer, so I spent time in a hospital ward for about six weeks. Increasingly, all grades and disciplines of staff are taking on developing roles, compared with those that they had when I worked in the NHS. Nursing assistants take blood, while senior staff nurses run wards and departments. In Glasgow, there is talk of some nursing staff performing minor operations. We are supportive of such initiatives, but people must be given the necessary training. Members will not be surprised to hear a trade union official say that not only do people need to be given training, but they need to be paid the going rate.
That will add to the difficulties that you have with the financial memorandum.
I have a practical suggestion for the committee. Whenever the Scottish Executive makes an announcement on health, it should put a price tag on that. There are serious difficulties with morale, especially among senior managers, who on a daily basis confront members of the public who point out that, according to Gordon Brown and Jack McConnell, record amounts of money are being spent on health. If a manager cannot deliver the service when that is being said, who is lying? Is it the manager or, dare I say it, is it you, the politicians? Whenever an announcement is made, the Executive should indicate clearly the cost of the service.
I agree.
As part of the package, should there be direct elections to NHS boards, on the basis that those would provide democratic accountability and transparency?
That is an interesting question and I am not trying to duck it. Until six months ago, I would have said that there should not be direct elections to boards.
You cannot now say no—in your submission you say that you are for direct elections.
I know. I have attended the past three meetings of Greater Glasgow NHS Board, at which the closure of Yorkhill hospital was discussed. It is very interesting that the elected councillors were the people who were most nervous about making a hard decision. There may be a lesson there.
I do not know what the lesson is, but you have hedged your bets cleverly. That concludes this evidence-taking session.
I do not want to prolong the discussion, but I would like to make a point about the statutory rights and responsibilities that currently lie with local health councils. My understanding of the position is the same as Shona Robison's. The changes that will take place will mean that those rights and responsibilities will no longer lie with anyone. That is a very important point. The rights include the right to visit facilities and the right to get information from and make comment to NHS boards. Health councils also represent people. People representing patients' interests and the public interest attend and have speaking rights at meetings of NHS boards. Hopefully, those rights will not be lost when the changes take place. We do not want the baby to be thrown out with the bath water. There ought to be change, but certain good aspects of the current system should be retained.
If you have any other thoughts about issues that we have not asked about, please write to let us know after the meeting.
Meeting closed at 16:35.
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