“Health and social care integration”
We move to agenda item 3, which is evidence on the AGS report entitled “Health and social care integration”. I welcome again the Auditor General, Caroline Gardner, and I also welcome from Audit Scotland Claire Sweeney, assistant director; Rebecca Smallwood, performance auditor; and Gordon Neill, portfolio manager. I understand that the Auditor General would like to make a brief opening statement.
As you know, the Public Bodies (Joint Working) (Scotland) Act 2014 sets out a framework for NHS boards and councils to integrate some of their health and social care services. This is an ambitious programme of reform that will in time affect most people who use health and social care services. The act creates 31 new partnerships, known as integration authorities, across Scotland—one for each council area and a joint authority between Clackmannanshire Council and Stirling Council.
Those integration authorities must have delegated responsibility for budgets and services by April this year. The report that I bring to the committee today looks at progress that has been made in advance of the deadline. It is the first in a planned series of three reports, and it also relates to my annual overview reports on the NHS and my forthcoming report on changing models of health and social care.
The scale of the reform that the 2014 act brings in is significant and covers services with budgets of more than £8 billion a year that affect the lives of people across Scotland every day. We found widespread support for the principles of integration from those who are involved in implementing the changes. All 31 integration authorities are expected to be operational by the deadline of 1 April 2016.
Despite the progress, some significant risks need to be addressed if integration is to change fundamentally how health and social care services are delivered. We found evidence that integration authorities might not be in a position to make a major impact in 2016-17. In particular, difficulties in agreeing budgets and uncertainty over longer-term funding mean that comprehensive strategic plans are not yet in place.
The report highlights other important issues. For example, the complexity of governance arrangements means that it will be hard for staff and people who use services to be clear about who is responsible for care. Workforce issues are also significant. There is a risk of inheriting a workforce that has been organised in response to budget pressures, as opposed to strategic needs. There are also risks around the different terms and conditions for NHS and council staff, and problems with recruiting and retaining general practitioners.
We make a number of recommendations in the report, which are intended to address the risks that we have highlighted in order to develop integration before the 1 April deadline. For example, we recommend that integration authorities should be clear about how governance arrangements will work in practice, particularly when disagreements arise. That would include clear statements on the roles and responsibilities of the integration authority and its individual members, the council and the NHS board, and it would ensure that members of integration authorities received training to prepare them for their roles. That would help to minimise the risks of confusing lines of accountability and potential conflicts of interest, as well as making clear who is ultimately responsible for the care that is provided.
As always, convener, my colleagues and I will do our best to answer the committee’s questions.
We will go straight to Richard Simpson.
This is a useful first report. Mary Scanlon and I have been around long enough to have experienced the joint futures programme in 2001, which failed, in effect.
I am particularly interested in the budget side of health and social care integration. If that goes wrong, there will be major problems. I hear anecdotally that the joint boards are likely to start with the possibility of absolutely huge deficits if they are to carry out their functions. Of course, the budgets have to be approved by the Government through the Cabinet Secretary for Health, Wellbeing and Sport. As I understand it, they will have to be approved by April.
Are you satisfied with the progress that is being made in approving the budgets? We really will not get far without them. Are those budgets likely to be for beyond 2016-17? Your report on the health service criticised the failure to have long-term planning instead of year-to-year planning. However, with the integration joint boards, we are going into a new set-up that does not have a plan even for a year.
We highlight in the report—for exactly the reasons that you highlight—the importance of getting in place not only next year’s budget but the strategic financial plan for the longer term, although that is one of the things that are not yet in place, as you said. We know that health boards and council social care services are under significant financial pressures. That is because of the pressures on the finances for public services more generally and because of the demographic pressures that they face, which will make the situation more challenging. That is one of the reasons why having the budgets in place and having governance arrangements that will be clear about how the budgets are used is key—they are the two key things that we highlight in the report.
I ask Claire Sweeney to talk you through what we know about the progress that is being made and to indicate our sense of optimism, or otherwise, about the chance of having things in place by April in the way that you described.
We recognise in the report that it has been challenging for partnerships to get this far. As the member will know, the report is the first of three reports that we plan to produce on integration, so we are looking at the very early stages of partnerships getting arrangements in place before they begin the work.
What we have seen is that the schemes were signed off and approved by ministers in line with the expected timescales. The intention is that all budgets will be in place by 1 April. We understand and highlight in the report that there are risks and challenges in that. We observed a number of difficulties in negotiating relationships between partners in various places across the country. However, we think that the budgets are likely to be in place on time. That is not to downplay the difficulties in the on-going discussions about, for example, what parts of the acute budgets for hospitals will be included in the new arrangements. It is clear that substantially difficult conversations are taking place to enable the partnerships to be in place by 1 April and get on with the job.
In 2008-09, the integrated resource framework system was beginning to be set out. I understand that it has a new name but, in effect, that should have been providing background information in the lead-up to integration. We are now seven years on from that, so I am disappointed that you say in paragraph 90 of the report that the
“data-sharing agreements are not yet in place.”
That surprises me because, by now, the integrated resource framework should have been providing such information in considerable detail. I know that there were initially difficulties at a local level, but the system should have been evolving. Has the Government not adequately resourced that? What has been the failure by the Government to provide that anticipatory information?
We have been tracking the developments of the integrated resource framework for a number of years. We identified in this report and previous reports that such information is central to making a success of the changes. We have observed over the years that that has moved from the developmental approach that was tested in various areas to a much more systematic approach now, in which the information is collected centrally and is reported to all partnerships. For example, a more recent big development has been that the Government has supplied information to partnerships about people who use NHS and social care services heavily.
We have had really helpful conversations with various partnerships throughout Scotland, and particularly in Tayside, that are using detailed information that is based on centrally held data. That process brings together health and social care information to give a much more rounded understanding of what the challenges are and to get beyond some of the high-level national statistics so that people can think about what the situation means for individuals who live on a particular street or people who need to access health and social care services regularly.
We are seeing a move forward and support to partnerships so that they have the information that they need. However, you are right that significant areas of development still need to be addressed quickly if partnerships are to make the difference that the vision of integration intends.
Are you satisfied that the Government, through ISD Scotland, is providing the information to an adequate level to allow the outcomes stuff to which you referred to be looked at appropriately?
Partnerships have better information now than they had before in order to make such decisions locally. The Auditor General referred to a report that we are working on about models of health and social care. That report will get under the skin of national data sets and produce examples of local partnership working where partnerships have brought data together locally, overcome the challenges that we mention in this report and started to focus on exactly where the pressure points are across the health and social care systems. That has developed over time. It is big and challenging, but the information is of a quality that it was not before.
Another aspect is the national care standards. Unless people know what standards they are applying, the whole thing becomes rather irrelevant. Those care standards have not been modified since 2002. In 2012, the Health and Sport Committee called on the Government to produce new care standards but, as far as I know—you might know differently—we still do not have them.
Here we are, going into the most significant reform in the health service and social care services since 1948, and we do not have national care standards against which to set that reform. Maybe that is a policy issue, which you cannot comment on. However, it seems to me that, without the data from the integrated resource framework—or whatever it is now called—and without the national care standards, the new organisations will be fighting an uphill battle to get in place the governance arrangements that they need.
We refer to the national care standards in paragraph 92 of the report, and a consultation is under way about the overarching principles that should apply to the new standards. The Government’s plan is that the standards will be in place some time during 2017. Work is under way, but you are right—refreshed standards are not yet available to replace the original national care standards from 2002.
How will the successor committees to this committee and the Health and Sport Committee hold the IAs to account against a set of standards that will be 15 years out of date?
That question is better directed to the Government than to us.
The report highlights the fact that there are significant challenges in what is a major and ambitious project. Paragraph 35, on page 19, comments on the guidance provided by the Government. Three Ayrshire integration joint boards have gone ahead in advance of that guidance. What are the implications of that?
I will ask Claire Sweeney to take you through the implications in more detail. The point that we are making is that some guidance was provided later than was ideal for partnerships to be able to use it. I ask Claire to pick up what that meant for the partnerships that went ahead before the guidance was available.
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The development of the reforms to date has been characterised by a great deal of consultation and engagement with the partners that are involved. We have been reporting over the past few years on similar issues, so in a sense a lot of that is not new. Partnerships have already been working towards some of the core standards on keeping people safer in their own homes that have now been set nationally, so they are familiar with much of the reporting, as that was already in place.
One of the challenges of the guidance coming later is that partnerships started without guidance in place. The consultation is on-going, and I understand that partnerships will continue to discuss performance reporting. That has been helpful, but it means that some partnerships published some of their information a bit earlier, so there is a risk that it will not fall in line with the guidance.
The overall ambition is common across all partnerships. They understand that the core aims of the reforms are about keeping people safer at home and involve a general shift away from unplanned emergency admissions to better care in the community, with all that that entails for GP and community services. There is an understanding of the general approach that everybody is aiming to take, but there is a risk in that the guidance came later for some partnerships than would have been ideal.
You just said that there seems to be a common understanding of the approach. Paragraph 42 states:
“The scope of the services being integrated varies widely across Scotland.”
Why is that?
The reforms were designed to allow for local flexibility to address local issues, so we would expect to see quite a lot of variation in the measures that are being used at a detailed level and the services that are being integrated. For example, if an area had a problem with drug and alcohol services, one might expect to see much more discussion there of that issue and a much greater focus from the resource—the money, the staff and the initiatives to improve performance in drug and alcohol services—than in an area in which the issue was less of a priority.
That is fine and correct, but we recognise in the report that there are inherent challenges in that approach. Focusing on outcomes at a very local level, which drives the entire system, is fine, but there is a challenge in tying that up with what we know nationally about what works well, how we share good practice and the general oversight of how the system is performing across health and social care services. There are challenges in that for the partnerships and the Government to work through.
Although you expect to see those variations locally, paragraph 42 states that there is
“a risk of fragmented services in some areas.”
That is a wee bit different from simply having local variations.
That is right. We highlight in the report the risk that reform will focus on services that are included in integration and that there will be a separation or a different direction of travel for services that fall outwith the integrated partnership arrangements. We have highlighted the importance of establishing a clear sense of good care and clinical governance; ensuring that there is clarity about who is responsible for delivering which services; and—crucially—making sure that people in the local areas understand what reform entails and the way in which their services will change and improve and that their voices are heard as much as the voices of the professions that play a key role are.
I understand that there has to be local variation because there are different priorities in different areas. However, many of the core elements of reform should be common. How will we measure the success of the new bodies if there are no common indicators?
There will be core indicators, in the sense that a series of national measures and targets will still exist, although they will shift and change over time. There will be nine national outcome measures, as we detail in our report, which are key to looking across the entire system at the impact that the reforms and changes are having. Those are the twin tracks that will give a national picture of how the reforms are having an effect locally.
I have a supplementary to Richard Simpson’s point. Paragraph 73 says that only six of the 31 authorities had agreed budgets by October. Given that we are now into January, what progress has been made on that figure?
Things have improved and there are on-going discussions. I cannot give you the exact number that have budgets in place. We looked at progress up to October last year and we will keep in touch as things develop. The issue involves the local financial audit work as much as the national value-for-money work. We want to keep a close eye on it.
I just wondered whether you had an updated figure.
I remember sitting on the Health and Community Care Committee with Richard Simpson when we dealt with what became the Community Care and Health (Scotland) Act 2002, which introduced the policy of free personal care for the elderly. At that time, we had thousands of bed blockers because of delayed discharge. The NHS could not get them out because it had to wait until councils had money at the end of the financial year.
I remember that every ounce of evidence that we had said that there should be a single budget. The committee did not recommend who should hold that budget, but a single budget was agreed on. We moved on to pooled budgets and aligned budgets. On pages 30 and 31, you talk about set-aside budgets and different planning cycles.
You talk about 31 out of 32 authorities, and the 32nd one involves Highland. Highland Council and NHS Highland use the lead authority model. I appreciate that the Scottish Government has not recommended one particular model, but I have quite a lot of experience with the lead authority model and, if someone comes to me and says, “My mum’s in Raigmore hospital,” for example, I know exactly who to go to, and there is no passing the buck or passing the budget.
Should we be a bit more robust? In 2001, we asked the NHS and councils to work together. Fifteen years later, because of their unwillingness to work together, the Scottish Government has had to introduce legislation—which I support—to get people to talk to each other.
We find that it is difficult to agree budgets. Is the NHS still hiding behind patient confidentiality to avoid sharing information, which is a point that Richard Simpson raised? Is legislation enough to deliver integrated authorities? The report shows that bodies cannot agree. Should we go a step further and say that the Highland model should be followed, so that we have one budget, one set of responsibilities and one accountable officer, instead of people sitting around a table and not coming to an agreement? The Highland model has been in place for a while and I think that it is good.
I recognise the frustration about the slow progress that is being made in this difficult area—there is no doubt that it is difficult. In exhibit 2 on page 11, we give a brief history of the integration of the services in Scotland. It shows a long list of initiatives leading up to the 2014 act.
It is important to say that some things are different now. For the first time, there is a statutory requirement to have shared budgets and shared resources. In the past, that was only encouraged. There is a requirement to focus on the outcome measures rather than on activity and the sorts of things that might have been focused on before. Importantly, for the first time, the people who use the services will be required to be involved in designing their own care. Those are all new things that came with the legislation.
Having said that, on your question whether legislation is enough to make the system work in practice, I think that legislation is never enough. It can provide a useful underpinning, but it requires people to be willing to work together and to have some give and take for a genuine commitment to shared planning for the benefit of the people who use the services—in time, that will be all of us.
We cannot answer the question whether everyone should use the Highland model. The legislation clearly provides for two different models. It is interesting that everywhere except Highland is going for the integration joint board approach rather than the lead agency approach. We will continue to watch with interest how all this plays out in practice.
In my introduction, I said that this report is the first in a series of three reports that we hope to produce as the legislation is fully implemented. I hope that, as that work progresses, we will be able to answer exactly that question about which model is better and which of the 31 integration joint boards are having the most impact on changing things for people.
I come to my final question. The NHS budget has been largely protected—although we know that there have been efficiency savings and so on—in comparison with the huge challenges for local authorities that we read about day by day and the savings that they have to make. Given that there is perhaps not quite so much pressure on the NHS as there is on councils, is that leading to difficulties in agreeing budgets?
There is another point that I will throw in. Back in 1999-2000, we were always told that there were cultural differences between the NHS and social work, for example. We were told that they did not really understand each other and that they spoke different languages and used different jargon. Is that still an obstacle to making the process work? Could you address those two points?
I will ask Gordon Neill to comment on both points. I will kick off by saying that one of the risks that we highlight is the risk that not only are councils and health boards trying to do this at a time of tight finances and rising pressures but—exactly as you say—because of the additional pressure on councils, they have understandably responded by reducing staff numbers and outsourcing large numbers of care staff.
That raises a risk that, instead of being designed around how best to deliver joined-up services, the staff set-up that the new integration authorities inherit is designed around how people have been managing against the background of the pressures that they have been facing over a period. That will be a challenge for the authorities. There are also, as we know, a range of different terms and conditions for staff, which can make the process trickier.
Gordon, would you like to add something about the cultural and staffing differences that you have seen?
Yes. Mary Scanlon is right to suggest that the NHS has had relatively protected status—that has been a policy decision for a number of years. Social work has had to compete against other council services, so among the people who are involved in integration authorities there is certainly at least a perception that the NHS side of the authorities will have more protected status.
There is a concern—again, this is a perception and we will have to see how things pan out in the future—that social work staff might be more at risk. If the shape of the workforce has to change in future years, there is a perception that it will be easier to downsize the social work side than the NHS side.
We can already see cultural differences. There are the obvious ones. There is the politics—local authorities are very political animals. They are also very local—the clue is in the name—so they have a different perspective. There are also more subtleties in that local authorities are more used to outsourcing and using the private sector, so about a quarter of care staff come from the private sector, whereas that is not the case in the NHS. Such cultural differences will have a profound impact.
On that point, you mention the voluntary sector quite a bit in the report as well as the private sector. Is there potentially a risk to that outsourcing of care to voluntary sector organisations such as Crossroads and others, which have provided excellent care over many decades? Is there a risk to that, given that the NHS is perhaps not as accustomed to outsourcing work, now that the budgets will sit with the NHS as well?
There is a risk of that. We have had a fair bit of contact with the voluntary sector as we have been doing this work. It is still relatively early days, but some of the voluntary sector people we spoke with did not feel that they were being engaged enough in the strategic planning at locality level. It is certainly their perception that there is a risk of their being excluded, and that it is seen as an NHS and local government agenda.
As regards GPs and GP recruitment, in paragraphs 86 and 87 you specifically mention concerns about workforce planning in the context of the delivery of integrated care, given the shortage of GPs. Just how significant is that problem? How much of a danger is it?
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We know that GPs are central to getting health and social care well integrated and ensuring that people are kept safe and healthy in their own homes. They are key to avoiding unnecessary admissions and ensuring that people who are vulnerable in various ways get the care that they need at home and that it responds to their changing needs, and they are also key to getting people safely discharged if they need to go into hospital.
We have reported elsewhere—particularly in my annual overview report on the health service—on the pressures on the GP workforce. It is a significant enough issue that we are planning some more work specifically on the workforce in the health service, and GPs will be a key part of that. I am not sure that there is much more that we can do to quantify that just now, but we identify it as a risk for exactly those reasons.
I am sure that that is fair.
You say at the end of paragraph 87 that
“it will be many years before these measures will have a significant impact”,
the measures being the Government’s interventions to try to tackle the GP recruitment shortage. This thing is meant to be up and running, but it seems that there is a fundamental issue between the availability of full-time, permanent GP staff not just in my part of the world but right across the country and the practical implementation of the policy. That sounds to me like quite a big problem.
It would be a challenge whether the policy was in place or not. We know that GP recruitment and retention is a problem for a range of reasons, and it is not one for which there is a quick fix.
So you are flagging up a really significant issue.
Absolutely.
Okay. Many thanks.
In paragraphs 26 and 27, you highlight the scrutiny element of the integration joint boards. When I was on the Local Government and Regeneration Committee, we discussed benchmarking, and I know that Audit Scotland has produced reports on that. Will local government activities in the IJBs be covered under the benchmarking tool that is in operation?
I suspect that they will not be a major part of the benchmarking operation other than in general terms through things such as corporate support services. The benchmarking project is now owned by local government and it has made big strides because of that. The primary means of benchmarking the IJB policy is the nine outcomes and the supporting performance indicators that we outline in the report. They are much more focused on the quality of care that people receive, their experience and the experience of staff who are involved in the services. The benchmarking project may be able to make a contribution, but I think that it will be at the margins.
That is helpful. Thank you.
I want to pick up on the same issue that I mentioned under the previous agenda item. Are you confident about the asset registers and that the substantial capital assets are going to be properly assessed, valued and managed? I am conscious that local authorities and the health service are trying to fill some of their financial gaps by selling some of their land and assets.
We know through the annual audit process that the asset registers of the 32 councils and the 14 territorial health boards are fit for purpose, with the very occasional exception. There is a question about how far those assets will be transferred into the integration authorities. They may well continue to be held by the health boards and councils, and a question then arises about who is accountable for the decision making around them and whether there may be conflicts of interest for members of the authorities.
Claire, do you want to say any more about that?
We say strongly in the report that clear systems need to be in place and that it is important to be explicit about who is responsible for what. As we were looking at the reforms at an early stage, we were able to make recommendations about some of the risks that we saw coming through. When the partnerships go live and the financial audits start, we will be able to see how they are operating in practice, but we do not have that level of detail yet. In the report, we stress the need to have clear systems from the outset, and we will continue to look at the matter as the partnership arrangements develop.
Thank you. I think that we will come back to that in a moment.
Another subject that is dear to this committee is IT systems. I presume that, if there are 31 integration joint boards, there will potentially be 31 IT systems that are separately procured and maintained and that will not talk to one another. Am I being too cynical? Is there any prospect that they will be integrated?
I think that you are absolutely right to flag the concern. Our expectation is that, to start with, the authorities will continue to use the systems that are in place within the councils and the health boards for managing care services and health services. If, over time, integration happens, there will certainly be a real push to have much more integrated and fit-for-purpose information systems that move on from what is there at present. I think that it is too early for us to see that being a priority for any of the integration authorities that we have looked at, but it is very much on our risk register as something that we want to keep abreast of.
That means that there is a real risk that, because there are fewer health boards than there are local authorities, a health board will find that it is trying to interrogate two, three or possibly even four local authority systems, all of which are different.
In a sense, they are already doing that, albeit not directly. A member of staff in the Royal infirmary of Edinburgh who is trying to arrange the discharge of an older patient with complex care needs will have to work with information and staff from at least four different councils before they start looking further afield. In some ways, I think that bringing that issue to the fore through the integration authorities could be a positive, but it also brings the risk—which you highlight—of attention being diverted into managing the challenges of an IT system rather than managing the care of the people involved.
That leads me back to the issue of who is responsible for what and how we can see the process going. Under the previous item on our agenda, we talked about the Scottish Police Authority and Police Scotland. They are separate because the chief constable has to have operational independence. We understand that, but we also recognise that it has caused problems in recent years.
Surely we can see coming the same kind of problem—this is not meant to be a comment on any individual person—when people who head the health service are trying to work with people who head the local authorities. I am not talking about anything that is not entirely obvious.
I recognise that you cannot answer this at policy level, but from what you are seeing, do we have good models of how that might work? Do we have good examples of how people can divide up responsibilities and still come to good decisions, or are you seeing the same thing that I am seeing, which is that the vast majority of cases are prospectively a problem simply because people have split responsibilities?
In the report, we have tried to highlight exactly that risk. I understand entirely the policy rationale for saying that the answer is not wholesale reorganisation and that we will work with what we have—14 health boards and 32 councils—and put integration authorities in place to bring services together around the key groups of people who are affected.
As I say in the report, that decision brings with it complex governance arrangements and a risk of unclear responsibilities and accountabilities and of conflicts of interest. That is why we are recommending that those things are pinned down at this stage, before people take on their operational responsibilities in three months’ time.
As you say, in the case of policing in Scotland, we have seen the impact that such arrangements can have. We are talking about another group of very significant public services that spend lots of money and affect people’s lives. I am keen for those arrangements to be clarified now, to avoid the risk of those effects happening as the reforms roll out.
Therefore, should I expect you to do something to audit those arrangements before we get too far down the road?
Again, this report is the first in a series of three planned reports that will enable us to stay close to what is happening in practice.
When will the next report come out?
We will do stage 2 once the arrangements have been in operation for a full year. We have a further piece of work scheduled for later to look in the longer term at what impact the reforms have had. That is our plan as far as the national performance audit work is concerned.
Of course, local audit work will be done routinely throughout the process, which will look at the parent bodies as much as the new arrangements, once they are established. We will also have on-going discussions with all the parties that are involved as the reforms start to take effect.
As the Auditor General has said, we are clear that there is a big risk, so we want to stay very close to it.
As Mary Scanlon said, we have been looking at such partnership arrangements for a number of years, going way back. I remember the social inclusion partnerships that existed when I was a councillor in the late 1990s, which involved local health boards forming partnerships with the local authorities. Even then tensions existed because there were, in effect, two budgets—the health budget and the local authority budget. Those tensions continue. Indeed, I cannot see any evidence that progress has been made in that regard, because while everyone may present a picture of partnership, in practice there are significant tensions. That has been a significant challenge in different authorities.
This is not a policy question, but if we had one budget and, for example, local authorities were responsible for healthcare as was the case in the distant past, would that make it easier to audit things and to ensure that the work was progressed, because we would not have two budgets for which both authorities were responsible?
As Mrs Scanlon highlighted in her question, one option under the legislation is to have a lead agency model. In Highland, the council is responsible for all children’s services and the health board is responsible for services for older people. Only Highland has chosen to go down that route. Why that is the case is an interesting question. The other 31 integration authorities will have to have a single budget for money and resources such as staff and so on. That is a new development; it has never previously been a statutory requirement in the long history of initiatives and approaches to try to get integration. That may make a difference.
As you said, there are challenges and tensions. We have tried to highlight the risks that we think need to be managed before 1 April and we will, as Claire Sweeney said, continue over the next 12 months to look at what happens. However, I cannot give you a definitive answer about what we will see in that work.
We talk about the public having confidence and there being transparency in the arrangements. I would defy any member of the public to interrogate the information and say, “Yeah, I really understand what’s going on in the local health partnerships.” Even for those who are well informed, it is extremely challenging to be completely aware of what is in place locally. Most members of the public want to know how to access local services, but even that is a challenge because of the complex arrangements that have been put in place for various reasons. Does that not also present a challenge in auditing how effective the organisations are being?
It is complex. If the policy works well, people will know how to access the services that they need. At the end of the day, it should not matter to them who is responsible for providing the services if they are available readily at the time that they need them and are of the right quality. That is what matters to most of us. The challenge will relate to what will happen if the policy does not work well and, particularly, to establishing who is formally responsible for the quality of care, as well as for the money that is spent. That comes back to our recommendations about clarifying the situation before 1 April, so that everyone who relies on the services gets what they need.
You have said that GPs are fundamental to the reform. They were very disengaged from the community health partnerships. Have those all been abandoned to be replaced by the integration joint boards or the integration authorities?
I think that they were disbanded under the legislation.
Has that happened?
Yes.
What about the staff? Do we know whether they were made redundant? There are obviously costs involved in the reforms.
Yes. This is not a reform programme that has led to the redundancy of the staff involved. Those staff tend to be people who continue to deliver services and, as far as the management of their responsibilities is concerned, some of them will move into the integration authorities. We will be picking up that issue in the next phase of this work.
I thank the Auditor General for her briefing.
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