Finance Committee

Meeting date: Wednesday, March 13, 2013

Official Report 687KB pdf

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Demographic Change and Ageing Population Inquiry

Item 4 is to take evidence from the Convention of Scottish Local Authorities on the committee’s report “Demographic change and an ageing population”, which was published on 11 February.

I welcome to the meeting Councillor Kevin Keenan, Councillor Peter Johnston, Ron Culley and Andy Witty. I would like the witnesses to make an opening statement.

Thank you very much, convener. It falls to me to make an opening statement.

COSLA is delighted to provide oral evidence. We certainly support the committee’s agenda and recognise that the impact of demographic change is of the first order. If it was second to anything—in a marginal way—that would be to tackling health inequalities.

Thank you for introducing our spokesmen. I am the health and care spokesperson for COSLA.

I am the capacity and resources spokesperson for COSLA.

I am chief officer, health and social care, at COSLA.

I am the policy manager in the finance team at COSLA.

Local government has long known about the challenge relating to demographic change. Since 2010, we have undertaken modelling work to look at the future funding gap between the services that we will need to provide and the available funding. That revealed that the gap will rise to almost £3 billion by 2016-17 across all council services. We believe that the greatest impacts are likely to be felt in social care, housing and welfare.

Our ageing population and the consequential increase in demand form only the headline. By dint of the change, a smaller working-age population will have to bear the costs of supporting a larger non-working-age population. We believe that we will also have a more atomised community, with more single households, and more people potentially moving away from the towns, villages and communities that they grew up in. In turn, that could have a wider impact—for example, in producing a deficit in the number of unpaid carers, in family support for people in their own new homes and in mounting greater pressure on formal state provision.

Local government is undertaking a range of actions to try to close the gap, which include redesigning services, modernising working practices, driving through efficiencies and engaging in sensibly planned shared services when they are appropriate. Preventative spending is clearly one example of that. COSLA’s view is that preventative spending approaches must be the focus for future financial planning. Change funds are a start, but we accept that the evidence of the shift towards prevention is inconclusive so far. We have witnessed significant levels of innovation in delivering new upstream interventions, but we have yet to fully capture their efficacy or lever out the resources downstream.

COSLA is therefore asking questions that are similar to those that are raised in paragraphs 60 and 61 of the committee’s second report in 2013. Whether the emphasis on the shift towards a preventative spending approach will result in sufficient savings in the short to medium term to address any future gap remains to be fully examined.

Our key message is that, even with the actions that local government and our partners have taken, it is highly unlikely that the funding gap will be entirely closed and, what is more, it could well remain substantial. A second key message is that we cannot separate out our efforts to support early intervention from the broader public spending constraints and increasing levels of demand. Unfortunately, upstream interventions tend to be most squeezed under conditions of financial constraint, but that could militate against our efforts to address what some have termed failure demand. Therefore, COSLA is aware of the risk that shorter-term issues could become a distraction due to, for example, a focus on the short term to deal with the current financial challenges and other agendas such as welfare reform.

Colleagues, those were our opening remarks. We are happy to take questions and we look forward to engaging with you.

Thank you very much, Peter. When we put questions, they will not necessarily be specifically to you, so your colleagues should also feel free to answer. I will start with a few openers and then allow colleagues around the table to come in as they wish.

COSLA has provided us with two submissions, which are quite similar. In the document entitled “Written submission by COSLA in advance of giving oral evidence to the Committee”—I mention that so that people know which one I am quoting from—paragraph 7 refers to an issue that you touched on in your opening statement. It states:

“COSLA is calling for a fundamental discussion about how the funding gap can be addressed.”

How should that discussion be structured, given the resource constraints? How do we take on and address that gap, given the economic situation that we are in?

Wow—that is a huge question. Ron Culley will have a first stab at that.

Yes, that is a huge question and there are several parts to our answer to it.

For a number of years, COSLA has asked for some reflection on the overall financial arrangements that support local government and our local partners. That has ranged from our contribution to the Beveridge report, which was published a few years ago, to our contribution to the Christie commission report and our more recent discussions with the Government.

The discussion should probably explore two fundamental issues, of which the first is the policy framework that we have in Scotland. For example, if we want to focus in the future on preventative spend while recognising the current circumstances of living in a highly constrained public spending environment, there is a question about priorities. With the Government and others, we want to open up the question of the priority that we attach to different policy agendas. That is one area in which we would like to take the conversation forward.

The other area, which is tied more specifically to health and social care issues, is about how we structure the funding of care and support. As the committee will be aware, the UK Government recently commissioned Andrew Dilnot to examine that issue at UK level. The UK Government has not faithfully pursued his recommendations, but his report is nonetheless an attempt to grapple with the big structural issues that we face about how people finance care into their old age.

Much of the media commentary on Dilnot focused on his ideas about individuals trying to protect their assets when they need to draw on formal support from the state in their older years, but a big component of the Dilnot argument that was missing in the media’s analysis is the desire to allow people to plan for their older age by making decisions as younger adults so that, when they come to need support in the future, they have in effect insured themselves against that risk.

Dilnot makes the point that we try to make such insurance decisions in every other area of our lives, whether as a motorist or a householder, but we do not insure ourselves in relation to such support. One argument is that we should not need to do so because the state, through the formal taxation system, should be there to provide support. However, Dilnot recognised that the consequences of demographic change mean that it is difficult to envisage the state supporting all people at all times during the later years of their lives.

We need to give some thought to such issues in Scotland. Our policy framework is at odds with the Dilnot work in some respects. For a start, we have free personal care, so we would need to think about how the discussion would play out. We do not have the answers on how to structure the funding of care and support, but that needs to be thought about.

Do any colleagues have additional comments?

I think that we would all like to add to that.

The point is that we should never bury our heads in the sand; we know what we are moving towards. COSLA and its partner agencies are working to reduce the number of individuals going into hospital, perhaps by putting in the early interventions that make a difference. The pot of money that is going into that at the moment possibly is not enough. However, demographics suggest that another sweeping of people will come in to fill the gap that we clear.

The total direction is unclear; all of us in government need a joined-up discussion about how we best move forward to make a difference. In the committee, and when we meet the finance minister, we discuss the pressures across the whole local government sector. We have seen severe pressure on budgets this year. We need to best use resources to make a difference to people’s lives.

There are a number of high-level aspects. The approach is about partnership working with the organisations that local government works with and delivers through—an example comes from shared services. We need to look at the best way to deliver the capacity in the community. We are talking about looking at our role and our responsibility with the community—the Christie report talked about doing things not to communities but with them. We need to develop that aspect of the discussion.

Another high-level element is taking demand out of the system for whatever aspect is being dealt with. There will be different ways of taking that forward, which will depend on the area of local government work. Having local solutions that deal with an area’s needs will be important, and that requires local government to interact at the local level and understand its communities.

I will add to that from my perspective as the health and care spokesman. In my introductory remarks I touched on preventative spending. If we are really going to shift the balance of care, it is implicit that there will have to be a resource shift. We would want to engage in that. I am sure that you are aware that, in the past decade, spending on acute health services has virtually doubled, yet we would view that as meeting failure demand.

When I addressed the COSLA conference last weekend I talked about an ancient Chinese lesson. It was believed in ancient China that a doctor’s job was to keep people healthy; if a patient became ill, the doctor’s pay was stopped. I should clarify that I am not advocating that we stop paying doctors when patients become ill. However, the lesson is that it is important to invest in keeping people healthy. We need to discuss how we can shift into preventative spending the resource that we currently deploy in looking after failure demand. That is the key part of the discussions that we need to have.

I will let other members explore that aspect; I am sure that they will do so.

Something that came out of the committee’s report was the need to pool resources between, for example, health services and local government to get the optimum outcomes. The example from Highland, which is doing that in a lot of areas, has been mentioned to us on a number of occasions. How does COSLA feel about more sharing of budgets to secure better outcomes?

11:30

COSLA certainly does not oppose the sharing of budgets between partners, and of course the model of local community planning partnerships is the best way forward if we are to integrate services and make a difference. There are many different good models in the country, and there is a monitoring group in COSLA to ascertain how well they perform.

There is a clear commitment to pooling resources, because we realise that the pot of money is continuing to diminish and that the best approach is to work together and make a difference.

We have had and continue to have positive engagement with your Government colleagues, convener, on the integration of adult health and social care bill, which will shortly come before the Parliament.

You mentioned the Highland model. There are other models, such as the West Lothian model, with which I am familiar, given my role in West Lothian Council. The West Lothian model is likely to be the second option that will be available to local authorities under the forthcoming legislation. Currently we have aligned budgets; following legislation, we will look to move to integrated budgets.

I regard health and care integration as a massive opportunity to tackle health and care inequalities and to operate more efficiently and effectively. For example, in West Lothian an integrated council and health management structure can save the council alone £300,000 annually.

More than that, integration offers an opportunity to build on building bricks that COSLA will advocate in the ministerial task force on health inequalities. We are saying that we must develop a toolkit, and we need an evidence base. We should start with a community health profile, which should deliver the evidence base, and then move to a commissioning model that is driven by the health and care partnership, with councils and health colleagues working in partnership to deliver the services that will meet the needs that the community health profile identifies. That is a massive opportunity to deliver preventative spending, tackle health inequalities and achieve our long-held ambition of getting more from less.

We have government at different levels—local government, with 32 local authorities, the Scottish Government and the UK Government—and we have different political parties, all of which have different views. There will be differences of opinion in some areas, of course, but in specific core areas is there potential for a consensus approach, whereby all political parties in local authorities and the Scottish Government take a joint approach?

That is the purpose of the umbrella group that is COSLA. COSLA reaches consensus on the policy that must be rolled out across the 32 local authorities. There is a commitment to delivering the best across Scotland, whatever the council area, and policies are developed in the manner that you described. I am convinced that we have in place a mechanism to deliver the best.

I hope that that answers your question. Our organisation is about reaching the kind of consensus that you are talking about, and everyone is committed to making a difference to the people in their area. I think that everyone who gets involved in politics is interested in making a difference.

Sure, but best practice does not seem to be shared across areas as much as it could be. For example, we heard in evidence that the City of Edinburgh Council has a 10-year plan to consider how demographic change and so on will impact on its budgets, whereas other local authorities are looking at only three years. Given the major challenge that we face in relation to demographics, is there further room not just for COSLA to have an agreed position but for a solid commitment from member organisations on specific areas?

COSLA would certainly look at best practice across every local authority. There is a drive towards that. We are starting to look at key performance indicators to see how authorities are doing against each other. When it comes to planning and budgets, we look a lot deeper than the three years that we put on paper. It is important to have that level of discussion.

As to whether the best thing is to put a plan for the next 10 years down on paper, most people are comfortable with housing perhaps having a five-year budget programme and with local government sticking a bit more closely to the spending review period, which is around the three-year mark, given the unknowns of the spending review. However, if there were benefits to having a longer projection, I am sure that officers and councillors would be well pleased to have that.

I will pick up a couple of those themes. As part of our duties, if we know of good practice—the convener cited the example of the City of Edinburgh Council—we will make sure that that is shared with our members, either through a political route or through our professional associations. We take that role seriously.

A question was asked about the extent to which we can reach consensus. That will be a crucial question over the next few years, particularly as some of the issues that we will have to deal with are potentially divisive. Given that democratic politics is by its nature competitive, and people will therefore try to secure competitive advantage in that arena, there will be challenges to reaching consensus.

One of the big themes that we need to grapple with is the idea of disinvesting in the acute sector so that we can redeploy resources more effectively upstream. There is probably a policy consensus on that just now, but we fear that that consensus might break down when we have to decide to take beds out of hospitals and to say that we will no longer provide a service in a locality. That is where the tension comes in. Consensus is hugely important; the more we can consolidate that over the next few years, the easier it will be to make those very difficult decisions.

The final paragraph of your submission states:

“A preventative approach to long term housing supply may be set back as a consequence of competing social policies at the UK level. It is COSLA’s view that effective action to address longer term demographic challenges to housing supply requires not just adequate resources but consistent policies at all levels of government.”

Are you talking about consistent policies at all levels of government over a long period? Will you be a bit more specific about the kind of consistency and policy that you are talking about for housing supply?

Unfortunately, our housing spokesperson could not be with us today. Housing is not our particular expertise. We would be happy to get back to you with a detailed response. I am also happy for any of my colleagues to answer.

A more general observation can be drawn from that. We want to work in a policy context that prioritises early intervention, prevention and shifting resources upstream. In that context, there is an element of longer-term planning.

The challenge of course is that public authorities—by which I do not mean just councils—are inevitably pulled back to dealing with the demands of service provision in an everyday context, which can militate against the idea of supporting early intervention and prevention. Some of the statutory duties that councils and national health service boards have require a certain type of behaviour, which can be at odds with the idea of using money flexibly to invest in the longer term. I do not think that there is an easy answer to that, other than to say that we need to strike a balance and to innovate.

In the past few years, we have identified things such as the change fund as a mechanism to do that. The committee will be aware that that work is on-going and is not yet concluded, and it has not conclusively shown the success of the venture. A balance will be important. We need to ensure that short-term pressures do not prevent more strategic long-term thinking.

I have one more question before I open out the questions to colleagues. Paragraph 18 of your written submission states:

“Spending figures from the Scottish Government, projected to 2030, show the funding required for residential and home care for adults is set to increase at around three times the rate anticipated for NHS services.”

Is that a plea for a rebalancing of some of the Scottish Government’s financial allocations to local government relative to the NHS, or will the issue be covered by integrating budgets?

From our perspective, it should be covered through the health and care integration agenda and the way in which the budgets are allocated. However, there are significant challenges for us. The figures speak for themselves. It costs £300 to £400 a week to support someone living independently in their home, compared with about £4,500 a week for an acute bed in a hospital or about £500 to £600 in the current care home sector. People want to be supported in their homes. We believe that people can live independently and well in their homes and that that is where they want to be.

COSLA believes that, as yet, we do not have the best possible working relationship with the care home sector. For example, at present, we simply procure care—we simply buy places through the national care home contract—and we do not have the ability to shape the market. One of our key objectives is to move to community health and care partnerships having the ability to commission and shape care.

For example, if we are to reduce unplanned front-door admissions to the acute sector, there is an opportunity to do that locally by people going to a step-up facility rather than immediately from their home into an accident and emergency department. Likewise, if we are to meet the targets on delayed discharges, which present opportunities to release considerable resources, a different kind of commissioning in the care home sector would allow step-down facilities to be made available. Some such facilities already exist throughout the country. That is best practice, but it is not rolled out across all council areas. Through health and care integration, the opportunities to use budgets more effectively are there to grasp. We are looking forward to taking those opportunities.

In Councillor Johnston’s opening remarks, he referred a number of times to the welfare reform agenda. As colleagues are aware, Michael McMahon and I have an interest in that through our membership of the Parliament’s Welfare Reform Committee. Paragraph 10 of your written submission refers to

“financial pressures ... arising from welfare reform, which in turn will contribute to future pressure as a result of demographic change and an ageing population.”

You continue:

“Welfare reform is likely to be another driver towards an older but poorer population with increasing needs on services.”

Will you say a little more about that and what the specific impacts of welfare reform will be on local government?

Every time that somebody comes to talk to us about welfare reform and gives us a bit more evidence or advice, we end up thinking, “That’s another disaster we’re walking into.” Some of the pressures that might arise for councils will be on social care. The amount of money that is available through discretionary grants, whether for housing or the social fund, is exhaustible. The funds are not never ending. We are starting to consider food banks and the like and how councils can support people. We have taken on more advice staff to try to help people to attract benefits if they are still entitled to them, to ensure that no one misses out.

Welfare reform makes a difference in housing. When someone gets universal benefit, will they pay their rent? That is a concern for social landlords as well as council landlords. Many aspects of welfare reform will make life difficult for individuals and they will look to local government to pick up the slack and provide support. That throws budgets in every direction.

11:45

You mentioned the social fund. Of course, we are getting the welfare fund, which has been put in place by agreement between COSLA and the Scottish Government.

I think that I am right in saying that figures were presented to the Welfare Reform Committee that suggest that, in the past five years—I cannot remember the figure, but I think that that was it—the amount that has been granted to the welfare fund has not been reached in the fund that it seeks to replace. However, you express concerns that the fund is not inexhaustible. Is your concern that the other changes that are made will increase demand on such funds?

I think that they will increase demand among people looking towards such funds for assistance.

The pressures of the bedroom tax will be felt in housing. When we consider what housing need is or what it is likely to be, perhaps we will have to grapple with building three and four-bedroom houses, which are in demand, and still having a need for single-bedroom houses as we move forward. There are so many aspects that will make a difference.

There is a raft of areas to do with welfare reform that cause concerns for local government, such as the impact that the move to universal credit and direct payments might have on people’s paying of rent and council tax. Some small pilots down in England have already reported a reduction in rent payment once direct payments have been established. More pilots will happen before it is fully implemented, but that is an area of particular concern.

A parallel issue is that water payments seem to be getting preferential protection. The water direct scheme establishes a means not only to deal with debt but to prevent the most vulnerable people falling into debt on their water payments. However, that same approach has not been extended to council rents and council tax, so it seems that water is being prioritised over other bills. It would be good to consider a more universal system and approach.

Another issue is the stopping of the council tax benefit and the reduction in moneys that come from London—the £40 million gap that was identified. Local government and the Scottish Government worked together and came to a one-year deal to prevent that from having an impact on the most vulnerable people, but it is only a one-year deal and we need to see what sort of solution we come up with for the longer term. Those discussions are still happening.

There are a number of particular pressures with welfare reform.

My frustration is the lack of joined-up thinking. We are all committed to, and working towards, tackling health inequalities and implementing preventative spending but welfare reform is actively trying to dismantle what we seek to do.

For example, someone who is bringing up a family and who has a 25 per cent reduction in their housing benefit will have to choose between eating, heating their homes, feeding their children, buying family essentials and finding the extra money to pay their rent. That is an example of what we said about the focus being shifted from what we look to do—long-term investment in tackling health inequalities, preventative spend and early intervention—and the sudden need to firefight. It is such a pity that the agenda was not joined up, with welfare reform helping us to achieve the targets that we all seek to work towards.

You are not the first to point out that the welfare reform agenda cuts across a range of measures.

Councillor Keenan mentioned the possibility of having to consider the types of housing stock that will need to be provided in light of the bedroom tax—

This session is not really about the bedroom tax; it is about demography and the ageing population. Try to keep your question on the theme.

I am trying to. Clearly, the issue of welfare reform has been raised. I recall that we have previously talked about how welfare reform will impact on the types of houses that will have to be built. That is what I was going to deal with, if that is okay.

Stay focused.

I will.

Previously, it was suggested that registered social landlords are reluctant to build more one-bedroom properties. However, we have also been told that, as a result of demographic change—I am staying focused, convener—there will be more single-person households. That might lead people to conclude that we need more single-bedroom properties. Is local government likely to build more single-bedroom properties, or do you think that those properties do not offer enough flexibility?

The debate needs to happen at some stage. Given that 3,300 people who rent a house from Dundee City Council will be affected by the bedroom tax, we will have to consider the housing investment that we make in the future and we might have to change the direction that we are travelling in. Registered social landlords are reluctant to invest at the moment because they are under cost pressures, which will increase if people receive universal benefit but do not pay their rent. A lot of things need to unfold in relation to welfare reform, and they will have an impact. People will present themselves to social work and advice services for benefits advice. Such things cause cost pressures in local government.

There is an air of doom and gloom about a lot of this debate. Does COSLA have any feeling that the fact that people are living longer is good news? For example, people can work longer—I think you have made the point that people do not have to retire at 60 or 65 or whatever. Are there any other positives?

People are living longer, but the key thing is to ensure that they live longer with good health. The agenda of supporting people to live independently and well in their own homes is positive, because that is where people want to be. Positive things are happening, but we need to tackle the glaring health inequalities that exist within the cohort of people who are living longer. A child born in the Ladywell area of Livingston—which I have represented since 1985—can expect to live 11 years less than a child who is born on the same day just 10 miles up the road in the leafy suburbs of Murieston. That is not acceptable. We have to accept that we have to tackle that agenda. It is not that there is an air of doom and gloom; it is that we are being realistic and focusing our attention on the problems that we need to solve.

In the short to medium term, is there any scope for reducing the inequalities, or do we have to accept that we are involved in an extremely long-term project in terms of the big gaps in the life expectancies in different areas and in terms of the fact that, for example, for men in my area, unhealthy life expectancy is a lot shorter than actual life expectancy?

It is a bit of both. There are opportunities to make significant changes in the quality of people’s lives through early intervention, and some measures are under way. For example, there is a project in Armadale that is being run through the West Lothian community health and care partnership that aims to tackle obesity in young children. That will hopefully have an immediate early impact.

We must recognise that tackling health inequalities requires a consistency of approach and a consensus that will take us through—we should avoid being distracted and changing course. It will take time to get the benefits, but we think that the prize is worth working towards.

The doom and gloom point is important. There would be concern if public authorities were articulating a dispiriting view of the world, but that is not what we are trying to do. We have a very positive message regarding the policy agenda that we are pursuing, particularly on the way in which people can live into their old age in a healthier way.

The other element is our vision of communities, which is that of a more vibrant, better-connected community infrastructure, with greater capacity for people to be sustained with the help of friends and neighbours and so on. All of that is hugely positive. The challenging aspect is that of public finances and how to support that infrastructure. That is where things are more doom and gloom, frankly. The aim is to balance all those things.

Earlier in the meeting, John Swinney gave an answer on people in employment and the realisation that things fell to pieces a bit in 2008. The game changer for us now is welfare reform. In Dundee, for example, it looks as though the amount of money that will be coming out of local communities will be anything from £14 million to £28 million—that will affect families big style. It will make a difference to the quality of food that people can buy, and to their ability to make choices about whether to put the heating on, feed the kids or feed a drug habit, if that is how bad things are. That game changer leads us towards a bit of doom and gloom.

However, a lot of positive work is going on in local government to make a difference and make changes.

You and others have mentioned a shift of resources to early years, upstream or whatever we want to call it. Welfare reform, which you have just mentioned, probably makes that more difficult. Does the shift have to be linked to health services, social care and other local authority services? Is it possible to shift resources within local authority services from the more acute services for elderly people to those for younger people?

There are two elements to that. Resources can be shifted laterally within a defined population group. For instance, within local authority provision for care and support for older people, we would like a greater proportion of our finance to be spent on supporting people at home as opposed to in care homes. That lateral shift can happen within a defined population group.

There is then an intergenerational question, ultimately, about our relative priorities expressed in terms of early years versus older people. Inevitably, it is a question of balance and the extent to which we can channel investment upstream into early years while being faithful to the agenda that we want to pursue for other parts of the population. It cannot be all or nothing.

Considering the extremes within Dundee’s budget, we have 600 or 700 looked-after children and an ageing population, so we need to put money into the social work budget to cope with that. A lot of the work that is going on in local government aims to make a difference to the educational outcomes of looked-after children and to deliver them into employability at a later stage. There is a big focus on that, but a real cost pressure. A lot of great work is going on, but more people might present themselves.

You make the point about having people at home rather than in care homes. The question was posed earlier: can local authorities shape care homes? I think that Glasgow City Council is in the process of building five large care homes, presumably so that it can shape what happens. Is that common throughout Scotland, or is it unusual?

12:00

It is still relatively unusual. Local authorities are increasingly going the other way and divesting themselves of responsibility for direct provision within care homes. We have only about 15 per cent of the total market now. That is why the relationship with the private sector is hugely important.

We want to progress an agenda that envisages an arrangement whereby the commissioning agendas of health and social care partnerships become the bedrock of how we shape the local care home market. It is difficult to do that just now. Care home providers often build speculatively, without necessarily having had discussions with local authorities beforehand.

We have not been able to innovate as much as we have in other sectors with respect to care homes, so they still provide a very traditional service. We want to change that in the future. There is a change agenda, but we have not gripped it strongly enough yet.

Are local authorities not involved because they do not have the resources or because they choose not to be involved in that area?

It is a mixed picture across Scotland. It is certainly true that providing in-house care is more expensive than procuring care from the private or voluntary sector. The national care home contract rates are less than the rates that local authorities would have for in-house provision, so there is an economic advantage, from a council’s perspective, to outsourcing that care. However, there is a wider question about the priorities of individual councils in that respect, and that is why there is a mix.

You mentioned Glasgow. Other authorities have completely divested themselves of care homes—Dumfries and Galloway, for example, has none. It is a mixed picture across Scotland, but in general terms it is a very small proportion of the overall market.

There is a variety of housing as well—the committee has had quite a lot of evidence on that topic. Do we just need more mainstream housing or do we need more very sheltered housing and, if so, how do we deliver that? Is there a COSLA view on that or should we accept that we need a bit of everything?

I realise that your housing spokesperson is not here.

Thank you for making that caveat for us.

We were keen to ensure that the housing strategy for older people, which you may have seen, was closely aligned to the work on reshaping care for older people, because people need a continuum of care and support that runs from acute hospital provision right through to their housing requirements as they enter older age.

We thought that it was important that local authorities and partners were fully equipped to plan effectively through housing needs assessments and to align those planning mechanisms to the commissioning agendas of health and social care partnerships. In other words, we need to ensure that there is a strong fit between the housing sector and the health and social care agenda in the future. We will have to work continually on that.

Inevitably, some of this comes down to how people choose to live their lives. Do we anticipate, for example, that as people enter older age, they will want to downsize—choose different types of housing? That is perhaps true for some, but ultimately we need to give thought to the importance of individual choice within that arrangement and to factor that into the housing needs assessment process.

It is difficult to answer the question in the abstract. It has to be grounded in a local needs assessment, which most partnerships will undertake.

Is there a good relationship with the third sector, including housing associations? We have been given the impression that the relationship is perhaps a wee bit patchy across the country.

In general, we have an improving relationship. It has not always been as strong as it could have been, but certainly in the past few years there has been an increasing policy focus on bringing the housing agenda closer to the health and care agenda. That has only improved the dialogue between the third sector and the statutory sector.

You mentioned universal benefits in your comments. Does COSLA have a view on universal benefits and where we should be going with regard to them?

We have made the case to ministers that, if someone was in difficulty, we would like the rent to be paid directly to the local authority or the registered social landlord, as we feel that the potential exists for—

By “universal benefits”, I meant services that are not charged for as opposed to services that are charged for. Did you think that I was referring to universal credit?

Yes—sorry.

We would argue that there must be a balance between universal benefits and more targeted initiatives. For example, the preventative and early intervention agendas would best be used in a targeted and focused way, but we accept that universal benefits have advantages. We are arguing that we would like a discussion to be held about how to strike the best balance.

There has been quite a lot of debate in Parliament and, I guess, among local authorities on the issue. You would not go as far as to suggest that we should charge people for being in hospital or anything like that.

Absolutely not.

We need to look at the debate in light of the fact that local authorities face a 3 per cent cut in their budgets, so the challenges will become much more difficult as we move forward. We will need to have a debate on the issue at some point.

It is not the case that we have not thought about the issue, but we have focused our work on it on process rather than substance. In other words, we have not looked at a suite of universal benefits and said, “That one’s good but that one can go.” We have said that we need to think about a process that local authorities and their partners can go through and which we can pursue with the Scottish Government in respect of the correct balance to strike between universal and targeted benefits in more straitened economic times. We want to have that conversation and we have pressed to have it; it is just that we have not got to the position of identifying the relative value of different universal benefits.

But you will do that at some stage. At that point, might you put into the public domain which universal benefits you think are good and which ones you think are bad?

We will take forward our discussions with the Government on that.

Our discussions with the Government are about how best we focus and target our efforts. We also discuss the cost pressures that local government is under. We do that fairly regularly, in the hope that our case does not fall on stony ground and that John Swinney manages to come up with a pocket of money for us at some point. However, we realise that we must keep identifying where we see the cost pressures being in local government and putting that case to ministers so that we can make a difference.

The whole issue of universal benefits, along with all the other cost pressures and funding aspects for local government, will be a topic of debate when the next spending review discussions start.

I suppose that we have to be realistic. We would always like things to get better, but we realise that we are going through difficult times and that difficult choices need to made.

That was really interesting.

Like the convener, I am working from COSLA’s second submission, which, as Ron Culley did in his opening remarks, raised the issue of the Dilnot review in England. That is interesting because, if something like the Dilnot solution were imposed on top of free personal care, we would end up with a lot more public expenditure, whereas the tenor of your argument is that we have too many cost pressures already. I am curious about why you threw Dilnot into the pot, unless you have a hidden agenda of getting rid of free personal care.

Is that a leading question? [Laughter.]

I mentioned Dilnot because, regardless of whether you agree with his conclusions—incidentally, I did not purport to endorse the recommendations that he put to the UK Government—he has established a review of demographic change and the future funding requirements of social care, which we definitely need to pursue.

We do not necessarily have a view on what the conclusion of that process should be, but we have a view on the need to discuss how we pay for care in our older years. The danger is that we think of demographic change as tomorrow’s problem. As the committee will know from the evidence that it has taken, we have dealt with the issue over the past decade. However, although we now have 50,000 more older people in Scotland than we had 10 years ago, there has not been a concomitant increase in resources to deal with that.

One implication of that has been that our demand management has had to be much firmer. Over the past decade, the number of people in care homes and receiving care at home has decreased in absolute terms against the rising population. We are concerned that, unless we address the perceived funding gap, demand management will have to become much stricter and more robust—indeed, more aggressive at times—to ensure that at the end of the day the books balance. That is not a vision that we want to pursue; we want to be able to support the entire population of local communities in living rich and fulfilling lives, but our worry is that, unless we address the longer-term funding question, it will become increasingly difficult to realise that aim.

In paragraph 21 of your second submission, you say:

“COSLA is currently working with the Scottish Government and other partners to refine our understanding of the size of the funding gap for health and social care services into the future.”

What does that work consist of? How far can you refine that understanding? After all, much will depend on the models of care that you can establish.

Absolutely. A lot of that will be based on assumptions for profiling demand into the future. The group that is mentioned in that part of our submission, which has met a couple of times and comprises a range of individuals including health economists, will allow us to gauge from projections that are based not just crudely on the change to the population’s age structure but on changes to healthy life expectancy and so on the gains that we might see from integrating health and social care.

That is an important piece of work, but no one thinks that, in itself, it will make the funding gap disappear; the gap will still be there and will still need to be addressed. The longer it remains unaddressed, the more difficult it will be to fund the types of early intervention and prevention that we want to support.

That is interesting. When the cabinet secretary gave evidence to the committee, he concentrated on integration, which will obviously deliver benefits.

In your submission, you say:

“emergency admissions”—

which were the other big issue that we explored—

“and delayed discharges are not the only, or even the most important, problem which integration needs to address.”

I suppose therefore that the third element that you are flagging up in your submission and in your last comment is improving healthy life expectancy. You might have seen the table in our report that suggests that, even if every extra year of life was healthy, there would still be significant increases in cost. No matter how much we manage to do things differently and ensure that more people get, say, continuous care in the community at home and more years of healthy life expectancy, will there inevitably be large cost increases?

Yes—and if you canvassed opinion from local government and the NHS, you would get the same answer from both. They would both say, “We will work awfully hard to make all these interventions and deliver a new integrated model of care but, ultimately, a public finance question needs to be addressed.” That will not be terribly easy for local government or the NHS to do; after all, it falls more within your territory than ours.

That comes back to Councillor Johnston’s point about keeping people healthy, and I suppose that we do not know the extent to which we can succeed in that.

Another related question that some have raised is how much money an ideal model of care—I know that West Lothian has certainly been a pioneer of integration in housing and other areas—will save. There seems to have been consensus for the past decade on what we would like to achieve for continuous care in the community. However, I think that the Royal College of Nursing said that that would not save as much money as we think. How much money could it save?

12:15

We do not have sufficient evidence to answer that question. Clearly, the difficulty will be that many of the resources that would be freed up would have to transfer from the acute sector. We still have some way to go towards securing the shift in the balance of care from the acute sector to the community.

As I said, it is difficult to answer your question at present, but there is consensus that preventative spending and early interventions are the way to go. The quantum that they release will be determined by how successful our health and care partnerships are. We are not giving the message that sorting out delayed discharges or reducing unplanned admissions to A and E departments is not important, because that is important and will release resources. However, until we get engaged in that and begin to deliver the release of the resources, it is not easy for us to put a figure on that.

I will not ask about housing, because your housing representative is not here. I suppose that the only general question about housing that would apply to the health and social care people is about the extent to which housing is built into the current integration agenda. A criticism of the initial consultation paper was that housing was not sufficiently covered and involved. Has that been rectified since then or is there still an issue about whether housing is sufficiently built into the integration agenda, which will obviously be important for us over the next few months?

We have probably reached the right decision on the formal integration of health and social care, which speaks to NHS services and councils’ adult social work services. However, housing is obviously very important. We probably envisage that issue being advanced in the context of joint strategic commissioning processes. We need to ensure that linkages are made between our assessment of need in a local population, the types of health and care services that we want to support in that context and the types of housing provision that will support that agenda. In truth, we are making some progress in bringing the housing community into that discussion.

I do not think that the housing issue has been formally adopted into health and social care partnerships. There are some funding issues regarding why the housing budget cannot be formally pooled with the health and social care budget. However, I agree that the commissioning agenda must ensure that there is an integrated approach that goes beyond just health and social care.

In Dundee, a great deal of joined-up working happens between social work and housing. Because there are many people in social housing with social work needs, there has to be that level of joined-up working. I am sure that, in that work, thinking is going on about outcomes and future need.

A number of questions that I had have been answered. Councillor Johnston referred in his opening statement to examples of innovation in preventative spending. How do we change the culture in the country from one that fears getting old to one that regards it as a positive experience? Most of us are looking forward to it, because we have to. [Laughter.]

There are examples across the country of really good practice, in which different local authorities address different problems in different ways. How do we share that best practice? The good practice in some parts of Scotland is unknown to other parts of the country. We could definitely benefit from asking how we can create a positive culture about people growing older.

Another issue that I want to ask about is academic research, which I am always pounding on about. A number of universities have research students looking at demographics, but our academic institutions seem quite far removed from COSLA and sometimes from local authorities. There are examples of really interesting work being done. Sometimes we can keep older people out of hospital through different activities. Loneliness makes people ill—common sense tells us that, too.

How much of our preventative spend are we proactive about putting into the poorest areas, where it is often needed most? Do we positively discriminate? The report talks about Scotland being the worst country in western Europe when it comes to longevity and the health of our older population.

You covered a range of topics there.

It would be easier if you asked your questions one at a time, Jean.

I will try to answer them and, if I cannot, Ron Culley might be able to fill in the gaps.

On innovation, you are absolutely right that there is lots of good practice across local authorities, such as reablement schemes, where social care staff are actively involved in helping people to live healthily and well in their own homes after they have come out of hospital having had a fall or whatever. Those schemes do what it says on the tin: they allow people to gain confidence and get back to living independently and well.

With advances in technology, there is now the opportunity to use technology to help support people in their own homes. There are lots of innovations in that regard. Telecare systems across Scotland are fairly well known, but there is also the opportunity to create virtual wards, where people are cared for at home and have their vital signs monitored through technology, rather than being taken into hospital. As you would expect, COSLA looks to share that best practice to make our fellow councillors aware of it and to roll it out.

I turn to Jean Urquhart’s 13 other questions. Do you want to help me think, Ron?

It is not just COSLA that works with our member councils. We have a fairly well developed improvement infrastructure through the Improvement Service and the joint improvement team. Both those organisations could offer excellent examples of practice that is shared across the local government and health community so that we can begin to learn from each other. You are absolutely right to say that that should continue to be a priority.

Another element of Jean Urquhart’s questions was the academic interface. The improvement community—probably more than COSLA, in truth—would engage with the academic community to take the learning in institutions into a practice-based environment. Some institutions straddle academia and practice. The Institute for Research and Innovation in Social Services is a practice-based academic body that looks to filter such information through to local partnerships, so there is quite a well-developed structure. You are right that COSLA probably does not interface as much as we might with the academic community, but that is because we know that others are doing so and because that is not necessarily our role.

Jean Urquhart asked whether we prioritise areas of deprivation. Across local authorities, work will be taking place to do exactly that. You will have heard me say that it is fundamental for the emerging health and social care partnerships to have a community health profile that is evidence based, which will be used to commission and deliver services to meet the needs identified by such a profile. That would go a long way to helping us tackle much more effectively the health inequalities that exist.

Before we came to the meeting, Peter Johnston told me about the breakfast clubs in his area. Free breakfast clubs have been targeted at schools in areas of multiple deprivation and, obviously, people are looking at how that makes a difference to the children in those areas. I know from having previously been an education convener and having gone around that teachers have said, “I would pay for the breakfast myself, because at least the child will learn if they are not hungry.” If a child needs something to eat but has to wait until lunch time, that will be too late and a shift will be missed at school instead of the learning process going on.

There is a lot of good work. Local government is looking at how positive discrimination can make a difference to health and inequalities.

Finally, do you think that we are really increasing that work? That people in poor areas die younger is not new, and we are seeing no shift in that. Councillor Johnston mentioned two areas of Livingston as examples, but we all have such examples.

We are arguing that, in times of plenty when resources grew substantially, such as the previous decade, we did not make the inroads that we potentially could have made, so things will be more challenging when resources are declining. By doing things differently and recognising that prevention and early intervention are the way ahead—I am sorry to repeat that—we can begin to tackle health inequalities more effectively.

We have not discussed in detail the reform of the community planning infrastructure. That will be important in allowing us to take that agenda forward. In the past, our statutory organisations and others came to the community planning table essentially with preset agendas, and there would be a bit of chat around the table about working together in partnership.

We envisage that, in the future, the community planning partners will come to the table with their resources and ask how, in response to the local population’s needs, they can spend those resources more effectively to target the issues that have been raised relating to deprivation and so on. That was a key feature of the Audit Scotland report on health inequalities. The reform of community planning to create stronger and more robust community planning partnerships will empower them to work with communities to deliver the improvements that we seek.

I thank colleagues very much for their questions and thank all our witnesses for answering our questions.

On 6 March, the committee agreed to take the next agenda item in private, so I now close the public part of the meeting.

12:28 Meeting continued in private until 12:52.