The second item on our agenda is evidence from the joint improvement team on the reshaping care for older people change fund. I warmly welcome to the meeting Dr Margaret Whoriskey, Dr Anne Hendry, Mr Pete Knight and Mr Gerry Power. Dr Whoriskey will begin with a short opening statement.
Good morning. On behalf of the joint improvement team, I thank the committee for inviting us here today to discuss the reshaping care for older people change fund.
The joint improvement team is a strategic improvement partnership between the Scottish Government, NHS Scotland, the Convention of Scottish Local Authorities and the third, independent and housing sectors. We are governed by a joint improvement partnership board that represents those sectors. We work with health, social care and housing partnerships to help create the conditions for implementing national strategies and to deliver and sustain improved outcomes for people.
The document “Reshaping Care for Older People: A Programme for Change 2011-2021”, which was launched in 2012, sets out a 10-year whole-system transformation programme that seeks not only to shift the location of care from institution to community, but to transform the culture and philosophy of care from reactive services that are provided to people to preventative, anticipatory and co-ordinated care and support at home that are delivered with people.
The £230 million invested so far through the change fund has provided partnerships with additional resources and capacity to progress with policy goals and outcomes to enable older people to remain as independent as possible and live in their own homes or in local community settings for as long as possible and as long as they wish to. The change fund is a catalyst to enable partnerships to accelerate local progress and develop plans to drive sustainable improvements through greater collaboration and integrated working within and across sectors. Sustainable change requires the longer-term transformation and integrated working that are being enabled by joint strategic commissioning and the integration of health and social care.
The joint improvement team, on behalf of our national partners, invited all partnerships to submit a summary of local progress by the end of September 2013—that followed similar processes that were undertaken in 2011 and 2012. Therefore, we have had a series of progress reports since the inception of the change fund for older people. The main purpose of the reports is to share examples of how local partnerships have developed their change fund to make a difference to the lives of older people and their carers across Scotland.
Many of the examples that have been submitted by partnerships are initiatives that have been tested and found to provide benefits, and they are now being embedded in practice. There is evidence of some spread of particular initiatives that have been found to be of benefit. There are other examples of recent initiatives that are yet to be fully evaluated but which are already showing some early benefits, and they provide valuable insight into how local partnerships have deployed their change fund.
It has become clear that, first of all, preventative approaches are reflected across many pillars of the reshaping care for older people pathway and are not confined to the preventative and anticipatory care pillar alone. Secondly, we are seeing evidence that partnerships are beginning to join up interventions within a locality to amplify their impact. Thirdly, examples that describe benefits for carers were evident across all pillars of the pathway and more generally are seen as enablers of the reshaping care for older people programme. Fourthly, partnerships are developing different models of care as alternatives to admission to hospitals and care homes. In many cases, those models utilise the assets of all partners in providing an integrated response.
However, there are still some challenges in evidencing attribution from preventative supports and services. Partnerships also seek greater engagement and involvement of secondary care and acute services, and there is a real recognition of the imperative to build on work that is already under way and to develop robust joint commissioning plans to address issues of investment and disinvestment.
We are encouraged by the shift in partnership behaviours and evidence from local and national outcomes and indicators of a difference in the delivery of health and care across Scotland. With the focus now on strategic commissioning for older people’s services and integration of all adult services, the change fund has acted as an important first step in changing our view of the design of services and how we collaborate across sectors and boundaries. We believe that it has acted as a catalyst for bringing all relevant players to the table and, crucially, has led to co-production with individuals and their carers increasingly becoming the norm rather than merely something that is nice to do.
Thank you for the opportunity to make an opening statement, convener. I welcome the committee’s questions.
Thank you, Dr Whoriskey. As this is your first time before the committee, I should explain what will happen now. I will ask a few questions, which you or one or more of your colleagues can answer, after which I will open out the session to colleagues around the table.
Given our wee chat before the session began, you will know that the committee is concerned about performance over the past five years in relation to the national indicator of reducing emergency admissions to hospital. The appendix to your excellent submission shows that although the figure for the average daily beds used for emergency admissions of people over 65 has reduced significantly, there has been a general rise in the number of admissions of patients over 75. As you know, that is using up 5 per cent of the entire Scottish Government budget. Why has there not been the reduction in the number of admissions of those patients that we hoped to see?
I invite my colleague Pete Knight to give you an initial response with regard to the data and my colleague Anne Hendry to elaborate on the service aspects.
Good morning.
Just to get behind the issues a little bit, I should explain that when the reshaping care for older people programme began a few years ago, one major concern—which, in fact, remains a concern—was that many older people were in hospital for very long periods of time. Evidence showed that that was not a very good situation to be in and that the longer the older person remained in hospital, the harder it was to get them out and, particularly, to get them back home again.
As a result, the programme initially focused a lot on that issue, and that approach was matched with the health improvement, efficiency and governance, access and treatment, or HEAT, target of reducing the rate of emergency admission bed days, the focus of which was on getting people out of hospital once they had been admitted. Of course, it was accepted that many people have to be admitted to hospital. This was not about putting the barriers up on the doors but about ensuring that once a person had been admitted there was a good flow back out again and that the person could leave—and, one would hope, go back to their own home—as quickly and as safely as possible.
More recently, however, we have become aware that, as a result of a number of factors that have not been fully identified, admissions of older people coming through the door have continued to rise, despite the marked change in the bed days situation, which is shown in one of the charts on page 21.
Our improvement work has focused on the issue of emergency admissions, which is now very much part of our interest. We have data that might begin to explain why there has been a continuing rise in emergency admissions. For example, we now know that a disproportionate number of those extra admissions are for relatively short stays. I have not shown the data in the sample in our submission, but we have gone below the surface to begin to understand what the issues are. We are then able to begin to consider what actions will be necessary in order to deal with that particular unfavourable trend.
As you can see, I have presented the emergency admissions chart in our submission on a rolling annual basis. Without putting my neck on the block and saying that we are perhaps reaching a plateau, I would say that we have certainly reached a more encouraging position in terms of trends than was the case six months or a year ago.
I will happily hand over to Anne Hendry to follow up on some of the detail.
I will rewind to October 2008, when there was quite a large consensus conference event with health and social care partners throughout Scotland. One challenge that we faced was that an ambition to reduce emergency admissions for older people that was not matched by a HEAT target to reduce emergency admissions for all ages was perceived by practitioners—and, arguably, by the public—as intrinsically ageist. What we really wanted to do was reduce inappropriate emergency admissions to hospital, but that is very difficult to measure as a national target.
We emerged from that consensus conversation with the service with the idea that we wanted to focus more sharply on the rate of emergency bed days that were spent in hospital as a consequence of an emergency admission, which essentially compounded that admission with an inappropriately long length of stay. When we did that, it changed the climate in the service. People bought into that ambition, and my clinical community now believes in and gets behind the over-75 emergency bed days target.
As you can see from the graph on page 21, which shows the difference in the emergency bed day rate, a 10 per cent reduction has been achieved in three years. When I talk about that throughout the UK and in Europe, people are staggered. We need to take care to focus on the right measure, and we must remember—as Pete Knight said—that some of the increase in the zero to one-day length of stay, which has undoubtedly gone up, involves inappropriate or avoidable admissions of people who could, if the right care and support had been rapidly available when the GP made the phone call, have been kept at home.
Equally, a significant proportion includes those people with chest pain or an acute exacerbation of respiratory disease who need access to rapid diagnostics, which they cannot get at home. With a preventative ethos, it is far better to have one or two zero or one-day emergency admissions for someone who has had a minor stroke or a mini stroke than one six-week life-changing admission as the result of a major stroke.
We have to be quite nuanced in the way in which we look at that particular target. During the past nine months, I have been very encouraged to see that we are now beginning to grow the menu of alternatives to emergency admission—through, for example, what we describe as intermediate care services. Across Scotland, most localities are starting to enhance the menu of hospital-at-home alternatives to emergency admission.
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As I pointed out, however, the national indicator talks about reducing emergency admissions to hospital, not just the number of bed days.
The global national indicator in the performance framework looks at all-age emergency admissions. Sitting below that is the HEAT target for over-75 bed days. The other relevant HEAT target relates to delayed discharge.
Thank you. We will move on to something slightly different.
In evidence to the Health and Sport Committee, the Coalition of Care and Support Providers in Scotland expressed concern that
“some of the change fund has been used to fund short-term preventative interventions, so once the change fund stops, so will they. The change fund was supposed to be a kind of lever to shift the bulk of spending that was behind it; it has, in fact, been used in creative ways, but almost as an isolated project fund.”—[Official Report, Health and Sport Committee, 8 October 2013; c 4447.]
We have talked about progress on, for example, the number of daily beds. No doubt, progress has been made elsewhere that we will talk about later. What concerns do you have about that good work lasting beyond the change funds?
I will start with that and Gerry Power and other colleagues might want to add to what I say.
It is a good question and observation. As I described at the beginning of my evidence, the change fund was not set up in isolation as an end in itself. In the very first set of change fund guidance, one of the objectives was about partnerships developing robust, long-term joint strategic commissioning plans. We have worked with all sectors and local partnerships to build some of the capacity and capability to do that. As was pointed out during the discussion on the early years, something like 1 to 2 per cent of the total spend on older people is represented by the change fund. The key is how we use the change fund to access and redesign that wider resource.
From day 1, the change fund was set in the context of partnerships being supported to work on the bigger strategic planning, and that is progressing relatively well across Scotland. We recognised that there was quite a lot of work and development to do, so we invested Scottish Government funding in a programme of developing and training partnerships to support that.
The work that we have supported through our improvement network is also trying to ensure that we are capturing early information and examples of improvement to share. Although everything cannot transfer exactly from one locality to another, we need to pull out the learning and challenges around what is and is not working well to inform the rest of Scotland. That is a big focus.
The opportunity for partnerships to develop the bigger picture will, in part, address some of the concerns raised by the Coalition of Care and Support Providers in Scotland, but we recognise that it is also important to continue to focus on the funding, where it is going and its sustainability. The committee will have noticed that, in our current review of the change plans, for the first time we asked for evidence of the spread and how initiatives are being mainstreamed. It is very important to keep those things at the forefront.
I ask Gerry Power to come in with any additional points.
Those concerns are not a surprise to me. Traditionally, the third sector has been funded on the basis of short-term grants, and there is a legacy of concern about that continuing. However, I came into the JIT right at the start of the process and my experience has been that influence and confidence have built up around local partnerships, particularly in the third sector, being full partners in determining how services should be developed in the future. They have gone from a standing start, finding it difficult to influence the process, to being seen by all partners as central to decision making on how services go forward.
The bigger picture of how the third sector is able to influence the continuation of service models has changed significantly, and that will continue regardless of whether the change fund comes or goes and of how funding takes place. As Margaret Whoriskey said, the idea is not about the £300 million change fund, which was a catalyst to influence the £4.5 billion of health and social care services. In many ways, the greatest achievement that I have seen is the influence that the third sector has on the greater picture, and I do not think that that will stop simply because the change fund comes to an end. I think that that influence will continue and grow stronger.
On Monday, I was at a meeting between the Edinburgh and Glasgow partnerships. It was a shared learning event, and one of the things that came out from both partnerships, which started from different points before working together, was how influential the whole change fund process had been in bringing those partners together to influence matters. Going forward, I have confidence that the third sector will be able to continue to influence the bigger picture. We need to see the process from that perspective.
Thank you. Your report states:
“Partnerships provided 234 examples that offer valuable insight into how the Change Fund has been used to make a difference to the lives of older people and their carers across Scotland”.
Could you touch on a couple of those for us?
It is a challenge to extract lots of examples, but we are working on developing a number of shorter publications to support the overview progress report, which will allow thematic areas to be drawn down. I ask Anne Hendry to provide a few specific examples.
We invited partnerships to describe up to five examples of practice with at least one of them from each of the pillars of the pathway, which is a tool to get them to focus not just on one part of the life stage or the setting of care. The examples that they described are around anticipatory care planning. It is not just community nursing teams and social work practitioners who are making those thinking-ahead plans to help people to plan for what they might want to do or to be done with them at the point of a crisis; we are also now working with primary care GPs as part of the quality and outcomes framework.
Anticipatory care planning is now being rolled out across Scotland, and examples of that are evident. We have a little publication and a DVD—which I am happy to leave with you—which show the impact on people and their families of those anticipatory care planning conversations. In the past 12 months, another 40,000 people will have had the opportunity to have those anticipatory care plans, and the information contained in the plans is automatically shared electronically with emergency services so that the right things happen if people have to use emergency services such as NHS 24 or the ambulance in the middle of the night, when their usual care manager is not available.
Examples also included intermediate care, such as the introduction and roll-out of a reablement approach to care and support at home. There are partnerships such as the one in South Lanarkshire, where reablement is now being embedded in the way that care and support at home teams do their business.
Linked to that is the introduction of more integrated care and support services at home, such as the integrated community support team in South Lanarkshire and Dumfries and Galloway’s integrated hub. The community ward teams in North, South and East Ayrshire are now providing integrated health and social care support that is specific to the locality, which is making a difference in supporting people to remain at home.
Other examples that I could point to include the work that is being done on telehealth care. We are moving from a pilot that provides such care to 20 people with chronic obstructive pulmonary disease to working with a collection of seven partnerships across the Ayrshires, the Lanarkshires, East Renfrewshire and Renfrewshire to help them to scale up that provision and take it to an ambitious level of 10,000 users by 2015.
That is a selection of examples of practice that has been shared and which involves people working together across the country. It is very similar to what the chief medical officer described as the collaborative model, but we tend to have a series of almost mini-collaboratives that work together on specific topics.
Thank you very much.
I have one more question before I open the session to colleagues. Many other committees feed into our draft budget scrutiny. The Local Government and Regeneration Committee has said:
“we remain to be convinced the delivery of the preventative spending agenda is keeping pace with the ever-growing demographic pressure local authorities are facing.”
What is your view on that?
The opportunities and challenges that our demography presents are well known. We must look at the fact that the focus on what is, increasingly, an ageing population provides assets as well as a requirement for services.
Pete Knight referred to information that projected forward. When we started the reshaping care engagement exercise with leaders across Scotland, a projection was made that looked at where we were likely to be in three or four years’ time if we continued to do what we were doing. At that point, we projected that, among other things, we would require a new district general hospital to be built every three years and a new care home to be built every two weeks.
Over the piece, we have been able to evidence—as part of the work that was done in advance of reshaping care through the long-term conditions collaborative and shifting the balance of care—a redirection of people’s activity, which has meant that, for some, the locus of support has shifted. In addition, we have seen a levelling off in the number of people who enter a care home on a long-term basis. If the level had kept pace with demographic change, there would have had to be significant growth in care home capacity but, in fact, the number of residents is slightly smaller than it was a number of years ago. Therefore, there is some evidence of those shifts.
One of the challenges that we need to address is the shift in the workforce. It is possible to shift the location of care and support, but the big opportunity is how we shift the workforce. Again, I think that we can learn from some of the work that we did a number of years ago on mental health and learning disability, which saw a significant redesign and a move away from institutional care to a much more upstream approach that involved providing services that are supportive of people’s lives and how they want to live.
Pete Knight might want to say something about the demographic challenge and the shift to prevention.
We acknowledge the fact that the demographic shifts are quite strong. The first chart in the annex to our submission reminds us that Scotland’s changing profile is constantly in the background. However, as Margaret Whoriskey mentioned, the second chart—which is on care homes—illustrates the fact that change has been under way for some time, particularly in local authorities. Whether we can answer directly the question that you have asked is a moot point, but we can see a number of distinct trends beginning to emerge.
Another trend is the adoption of reablement in local authorities, whether the intention is prevention or trying to avoid people becoming dependent on services in advance of their genuinely needing them. Local authorities are addressing some of those issues in that way. I have not put any evidence about home care in that particular example, but we are beginning to see a reduction in the home care that is being delivered.
11:30
There are a lot of examples and there is quite a lot of energy around the health and wellbeing and social inclusion, connectedness and physical activity areas, as well.
I listened to the CMO referring to physical activity and diet. Many partnerships are quite active in supporting physical activity. For example, Aberdeen ran its golden games last year. Other partnerships are looking in particular at promoting physical activity in sheltered housing and care home settings, and we have been working quite closely with NHS Health Scotland on how we can provide support and guidance for partnerships that want to do such activities. We have also been working on that with the older people’s assembly and a number of older people advocacy groups. The partnership with seniors together in South Lanarkshire is quite a good example of a partnership that we have had.
It is probably over a year ago now, although it may be even longer than that, since two of your colleagues—Stewart Maxwell and Richard Simpson—hosted in Parliament a celebration of active ageing in the path to active ageing conference. The Musical Minds dementia choir performed at that. We are keen to keep a focus on that aspect of prevention, obviously in partnership with our colleagues in public health and sport, and not to lose the chance of the Commonwealth games legacy being relevant to that age group.
Okay. Thank you very much.
I will now open out the session. Malcolm Chisholm will be the first member to ask questions.
What you said about emergency admissions was really interesting. In a way, they have become the indicator of whether there has been progress on this agenda. The agenda has been around for a long time. People have talked about words that you have used, such as “continuous”, “integrated” and “anticipatory” care in the community, for a long time. For example, such care was the central recommendation in the Kerr report 10 years ago.
There is a lot of good work going on, but it is almost being discounted because everyone is focusing on the emergency admissions indicator. Could other indicators be used, or does the Government need to sort out that indicator? There seems to be a contradiction between what it says in Scotland performs and what it says in the health department. Dr Hendry said that there are inappropriate admissions. Is it possible to quantify the inappropriate admissions and accept that the other admissions will not reduce, not least because of demography?
It is certainly possible to get to that kind of detail at a local level, and partnerships are taking that deeper dive. Their local improvement measures and metrics will involve that level of scrutiny and challenge around their admissions. For example, a partnership with which I worked looked in great detail at every emergency admission of someone over the age of 65 across all its hospitals for a week, and it could say robustly which were avoidable and which were not.
We will never be able to get that level of reliable judgment at a national level, even with some of the measures that are used internationally, such as ambulatory care-sensitive conditions, which members may have heard of. It is very difficult on a case-by-case basis to say that everyone who has asthma or COPD has an ambulatory care-sensitive condition and that their episode was avoidable.
It is great to have the ambition to reduce emergency admissions, but I would argue that it should apply to emergency admissions across all ages, not just to admissions of older people. Also, the target that sits below that could be much more focused on reducing both the admissions and the bed days that are a consequence of those admissions. That is where we have the traction.
The next level of ambition is to see whether we can grow hospital-at-home alternatives where consultant geriatricians, nurse practitioners and allied health professionals are not in the hospital; instead, they are in the community, responding within hours to a crisis and providing the treatments that people would get in hospital in people’s own homes.
Can we grow those alternatives at scale across Scotland? They are alive and flourishing in Lanarkshire, in Fife and in some parts of Lothian. I am working with another couple of boards that are at the point of trying to commission such alternatives. However, as Margaret Whoriskey said earlier, we need to learn not only from what worked well in mental health moving to the community but from what did not work well or has caused some difficulties. For example, it is now easier for a GP to get hold of a psychiatrist than it is for a consultant in a hospital because consultants do not have a physical footprint in the community. We need to ensure that specialists for older people have a footprint both in the community and in hospital.
The process is obviously related to the question of disinvestment. There has been a lot of discussion on that in relation to the Public Bodies (Joint Working) (Scotland) Bill because a lot of people, particularly perhaps from local authorities, are envisaging a massive transfer of resources from the acute sector to the community as a result of that bill.
We need extra resources to develop the services in the community that you describe but, given what you have said about people’s unrealistic expectations about emergency admissions, how realistic is it to expect that acute service budgets can be significantly reduced in order to pay for those services?
I am optimistic. Not all beds that are operationally managed and within an acute hospital’s budget are delivering acute care and interventions. Some acute hospitals or acute divisions are also supporting off-site facilities that are in a local community and do not have on-site medical staff or on-site diagnostics. Such community-based facilities are ripe for a redesign and for a considered decision—through joint commissioning—about the benefits of a facility and whether there are opportunities to reinvest the resources and the workforce that are wrapped around the beds in the facility into support for people to remain at home.
Such decisions are happening gradually across Scotland. As Margaret Whoriskey described earlier, the challenge is to take that to the next level through joint commissioning and to make some quite hard local decisions. Currently in Scotland, something of the order of 300 people have been delayed in hospital over two weeks. The vast majority of those individuals are not sitting in an acute district general hospital; they are in a hospital bed that does not have on-site doctors or those sorts of facilities. That is a good place to start. The target around reducing delays over two weeks by 2015 is a good place to focus our partnerships with regard to disinvestment and reinvestment.
Obviously, delayed discharge is a good example but there are other ways in which we could influence the hospital spend. Is disinvestment possible given the demography? Will the gains that we might make in reprovisioning in the community always be countered by the demography that faces us in the next few years? Is there any realistic prospect of reducing acute budgets in the next decade?
One reason that the 2020 vision and the route map to it have a priority around multiple morbidity—multiple chronic illnesses—is our recognition that we are making some progress and gaining some traction on the reshaping care for older people ambition. You heard earlier about the work on early years, but there is a large cohort of adults under 65—working age—with multiple physical and mental health conditions: think about the alcohol misuse, obesity and mental illness that are causing the trend of the drive in emergency admissions at all ages.
We recognise that we have to do this piece of work in tandem with some quite significant changes in the way that we address adults with multiple conditions, particularly in areas of deprivation, where people experience multiple physical and mental health conditions about 10 years earlier than they do in the more affluent parts of Scotland. It is a challenge given the consequences of demography—of not just older people—and the healthy life expectancy that we have. If we are playing a long game, we have to go much further upstream and ask what we need to do differently with our population in their 40s and 50s to start to get a grip on the problem.
What is going to drive the changes? The question is related to the extent to which there is variation at the moment. You do not need to name areas of Scotland, but there must be great variation and some areas must be doing a lot better than others. Taking account of that, can you say what will drive progress across Scotland? Will it be the Public Bodies (Joint Working) (Scotland) Bill? Presumably that will help. Will it be you? What will drive the changes and how do we get rid of the variations, so that everybody will at least be making good progress—although some will be outstanding—whatever situation we have?
The bill will enable. For many years, we have had the opportunity to develop more integrated ways of working, and the opportunity has been taken forward in a more significant way in one or two areas. The bill will provide for a mandatory legislative requirement on integration.
A number of things will drive the changes. We talked in the early years about leadership and the importance of clarity on the direction of travel and ensuring that there is high-level leadership and engagement, as well as building capacity throughout the organisations and across sectors. Our view is that the change fund and the reshaping care programme are providing a very good foundation for the work on health and social care integration, because they have been shadowing integration and the way that partnerships have been working.
The point about variability is important. Through the support of the community care benchmarking network and other things, we have encouraged partnerships to use information and data to help the conversations around the table and set the improvement targets for the partnership. We have seen more evidence of the incorporation of data and its analysis into the way that people make decisions on their change plans.
We have variability. There is a balance between variability that is expected because of slight differences between populations and contexts, and unexplained variability—for example, if you are 10 times more likely to be admitted to a hospital if you live in one locality with one GP practice than you are if you live a few miles down the road. That is a challenge, and the integrated resource framework has helped by gathering relevant financial information.
I ask Pete Knight to come in, particularly on benchmarking.
The charts that we have in our submission are Scotland-wide. Malcolm Chisholm identified the central measure of emergency bed days, which we tend to focus on. Lots of things wrap around that, such as the fact that it is the largest spend and the question of what happens next after a person has been admitted—where do they go?
11:45In conferences, for example, we have issued to partnerships across Scotland similar trend data for each of the partnerships. When people noticed that information on the table in front of them, you could see that they immediately wanted to know where they were in relation to their peer areas. Part of what we are doing is trying to build an awareness across the country of the kind of natural benchmarking that goes on and ensure that the awareness is there at various levels within organisations.
My other comment will partly answer Malcolm Chisholm’s previous question. The challenge ahead is a little unknown; we really do not know how people are going to be in the future. The future is always uncertain. Harry Burns mentioned the issue of obesity, and the gains in healthcare might be lost in the future if it is not resolved.
We are trying to get improvements in the information that we have. I think that the work that the Information Services Division is doing, particularly in relation to the integrated resource framework and the linkage of health and social work data, will allow us to develop new ways of examining the information and helping partnerships to identify the issues that they can make improvements on.
We will be able to see that variation on benchmarking. It will be much more possible than it is using the relatively crude measures that we use at the moment, such as the number of emergency bed days and the level of care home admission. The information will be nuanced. There will be an ability to do an analysis of what is behind the figures in local areas. I am optimistic that we will have more tools available to us over the next two or three years.
On the issue of what is making a difference, Gerry Power alluded to the need to build capacity for co-production in designing and delivering services. Although it has not always been without its challenges in some areas, the genuine engagement of third sector colleagues and independent care sector colleagues in the discussions on the redesign and what will take us forward in terms of vision and the outcomes for people has brought some of cultural shift that is referred to in your report.
The issue is not just about the money or the way in which we structure things; there is quite a significant cultural aspect. I do not think that we should underestimate that. We must ensure that we keep our focus on supporting that.
I want to pick up on some of the things that have been mentioned, particularly the area of partnership. When many of us think about partnership, we primarily think about the NHS and councils, but other bodies have been mentioned—Dr Whoriskey mentioned the housing sector in her opening remarks. However, housing witnesses from the public, private and third sectors have told us that they feel left out, although they believe that the house that someone lives in is a big factor in a lot of the things that we are talking about. How do you see housing fitting into all of this?
From its inception in 2004-05, the joint improvement team has had housing as part of its focus. We recognise, however, that as the work has evolved with health and social care partnerships, housing has not been at the table in the way that it should be. We have actively been working with our housing colleagues to try to build some of that capacity.
I will give you a concrete example. With regard to the work that partnerships were tasked with in developing their first joint commissioning plan for older people in March and April last year, we worked with housing colleagues—policy colleagues in Government and housing stakeholders—to develop what was referred to as a housing contribution statement, in an effort to ensure that the chief housing officer was engaged in the signing off of the joint commissioning plan.
In a sense that was symbolic, but, over the past few years and particularly in recent months, practical work has been under way to get the housing sector engaged nationally as well as locally. I mentioned that the joint improvement partnership board has a housing representative on it. That is hugely beneficial not only to how we address housing at a strategic level, but to how we support housing at the local partnership level. It is work in progress, but the housing lobby has been particularly constructive in its engagement on health and social care integration. We have seen some progress on the work to reshape care and the change fund, but I know that there is an aspiration for housing to be more ably reflected in legislation, regulations and guidance.
I echo the concerns that have been brought to your attention. However, I offer the assurance that we have clocked those concerns and are working actively and constructively with our housing colleagues to ensure that they are at the table and contributing in a very real way to the work of local partnerships.
Is that work easier at a national level, where you may have only one representative covering, say, housing associations? At a more local level in areas such as Glasgow, private house builders, a big housing association in the form of Glasgow Housing Association and loads of small associations are involved. Does that make the work more difficult in practice?
It is difficult in practice. In fact, in recent months, we facilitated with the housing sector the setting up of the housing co-ordinating group so that we could have all the national partners around the table and try to get some coherence in the housing sector’s voice.
A couple of areas have been trying to mirror that by engaging with a range of housing providers and stakeholders. That is a challenge but, as I say, we have seen one or two areas take it up and look at how to get a representative housing voice while recognising that there are a number of stakeholders.
What about the third sector? The committee has heard about a bit of variation—Malcolm Chisholm touched on that. One area told us that the third sector was at the table and that everyone was discussing all the issues together, but another said, “Well, the third sector can bid for a contract,” which struck me as a slightly different approach.
I ask Gerry Power to comment on that.
If I understand the question correctly, the issue is the relationship between the third sector and partnerships. I have heard that some partnerships expect the third sector to bid for a contract, but that happens in only a very small number of isolated cases. In my experience, the vast majority of partnerships see the third sector as a full partner in planning, designing and delivering services, and the issue is who is best to deliver those services.
As I have said, I have seen partnerships go from an approach that is suspicious of the third sector—with 20 people from health and 20 people from the council sitting around the table with one part-time individual from the third sector who has not been given the papers in time and does not speak the language—to one in which there is much better engagement. Let me give an example. The JIT and the Government’s third sector unit saw the need to support third sector interfaces to better engage in partnerships. Therefore, along with the Health and Social Care Alliance in Glasgow, we invested in developing and enhancing the role of the third sector team—that does not trip off the tongue very well—dedicated to supporting third sector interfaces to better engage with partnerships. I have seen how that relationship has developed. As I have said, in only a small number of isolated cases has that relationship remained difficult and not become one of integrated working.
Do you play any role in trying to roll out best practice to the few remaining difficult cases?
That is absolutely one of our roles. As I have said, we have, if you like, put our money where our mouth is by investing in and developing assistive practices and a team that will support the third sector in that work. We sit on the steering group for that team along with the third sector unit and any difficulties that emerge come to that table through either the Health and Social Care Alliance or a number of representative third sector groups, particularly the one that represents the third sector interface.
We have an opportunity in that the JIT has a lead for each of Scotland’s 32 partnerships. Obviously they will not be there all the time but they will sit around the partnership table, providing a conduit for national policy and expectations to local partnerships and drawing out some of the issues and challenges. That said, it is not that everything is cosy all the time. As the relationship develops, we can also bring a constructive challenge element to the partnership as well as supporting it on its improvement journey.
As Gerry Power has pointed out, there are some quite useful examples that highlight the significant development of third sector engagement over a relatively short period of time. When the change fund came along coming up for three years ago now, people had to develop the partnership way of working early on. However, a few years down the road, things have matured.
We still need a bit of grit in the oyster. It is useful for those involved in a partnership to have respect for one another and the confidence to work together, but they should also be able to challenge one another to ensure that the partnership does not become overly complacent.
The third area with regard to partnerships is family, which I think Dr Hendry mentioned with regard to anticipatory care plans. Where are we in that respect? Indeed, is that not an even more difficult issue? There probably cannot be one representative for all the families in Scotland. Has the situation been changing over time? I recently dealt with a case of two sisters with busy high-powered careers whose father was in a residential home—or, I think, sheltered housing—and who had quite high expectations with regard to the public sector’s input. Families have traditionally taken a big responsibility for their elderly relatives; indeed, Asian communities in society are often exemplary in the amount of care that they put into families. Is the situation changing or expected to change?
I am sorry, but I cannot remember which member of the committee—it might have been Mr Chisholm—asked about the key drivers in taking that forward. A key challenge that the JIT and Government, and public sector organisations beyond it, need to address—and, indeed, one of the key issues for driving change—is public expectations. Speaking from 30 years’ experience as a clinician and general manager in the health service, I can say that we were trained with the best possible intentions to deliver a service for people and to people. However, there have been changes in society and things that might have been done within families are not done that way any more.
We therefore need to strike a balance between what public services should be doing to enable people to facilitate their health and wellbeing and understanding what the public’s expectations are, and a conversation or a debate—indeed, a change—needs to take place to ensure that we get that balance right. Speaking personally from my 30 years in the health service, I think that we might have gone the other way. We have probably trained our workforce to deliver services to and for people and created expectations in the public about what the workforce does, but as far as prevention is concerned we probably now need to focus on how our workforce enables, facilitates and supports individuals, families and so on in addressing their own needs. Perhaps the expectations of what the public sector will do need to be debated and changed a bit.
12:00
There are some practical examples of work that we are taking forward around that in the living it up programme, which is sometimes described as the DALLAS—delivering assisted living lifestyles at scale—programme. In the programme, the emphasis is on supporting people to use day-to-day technology, social media and digital television to get more information and advice, and empowering them to take more control so that they can manage their life and conditions and get more connected and involved. There is also the work that Gerry Power and colleagues are leading around co-production and working with partnerships and some local authorities in which the ethos is implemented local authority-wide.
So not just the individuals but the wider family group are involved.
Yes. Another example is the use of family group conferencing for people affected by dementia. Some of our improvement work around the theme of dementia is very much grounded within the wider family network.
Thank you.
One thing that I found interesting when listening to the earlier evidence from the minister and others about the early years programme, and which I think everybody in the committee noted, was the description of the meeting with 700 or 800 people in a room getting really excited about how they could influence and improve some of their work practices. Do you do that?
I mentioned that we have established an improvement network. That was initially for the reshaping care for older people programme, but it now extends to support health and social care integration. It is a network of all partnerships across Scotland and key stakeholders to facilitate cross-sector collaborative learning. We do a range of activities, but to date we have not done the big 800-person collaborative-type sessions. However, we will have a range of national events and regional events, and we are increasingly trying to engage people through our WebEx sessions. That provides the opportunity to engage people while they sit in their own offices and for them to get involved through developing practice guidelines and case studies.
We focus on trying to share learning and improvement through links with national work and through regional and local networking. Anne Hendry might want to comment, because she has been involved in a number of the collaboratives.
In 2008, I led work on the long-term conditions collaborative, for which we used a model that was similar to the one that Sir Harry Burns described. However, we learned early on that, for complex and whole-system change in the community, the model that employs a breakthrough collaborative series in which 700 or 800 people meet in a room two or three times a year is not necessarily best for partnerships that are engaged in other types of collaboratives and learning events. The feedback from partnerships during the process was that they wanted more themed learning events involving perhaps 100 or 200 people; events that were much more interactive and perhaps more local; and some virtual learning events for the island boards, which do not want to have to fly people down to go to the SECC.
So we have the same approach, but we have modified it over the years because of feedback from partnerships. For every learning and improvement event that we do, we get feedback from partnerships about what worked and did not work, and what they want to see the next time. We build our programme of learning events on that feedback, and all the events are done in partnership with other improvement organisations, so it is not just the work of the joint improvement team. We have a collaboration between various improvement organisations, including the Improvement Service, Healthcare Improvement Scotland, NHS Education and the Care Inspectorate. All our collaborative learning events are therefore truly collaborative products.
Building on what Anne Hendry said about collaborating with other areas, I think that the person-centred health collaborative that is being taken forward by the quality unit has a distinctive people-powered health and wellbeing element, which focuses on co-production. That is being led by the alliance. We are very much involved in developing that with the alliance. That is one of those big breakthrough 700-person events.
It is important to say that JIT has run two national conferences on co-production, which have been attended or linked in to by more than 400 people, and we will have another one in April. Along with the Scottish Community Development Centre, we have established the Scottish co-production network, which has 400 members who share information and so on, and we have distributed more than 6,000 copies of the book “Co-Production of Health and Wellbeing in Scotland”. There are a number of ways in which we link people together, including setting out good practice on our website. We also link in to other aspects of the Scottish Government’s work to ensure that it ties in with relevant parts of that agenda.
On the issues of intermediate care, the alternatives to hospital admission, supported discharge and anticipatory care planning work, since October, I have been in a room with about 600 people from throughout Scotland, although not at the same time. Between October and December, we had events in Dundee, Kilmarnock, Edinburgh and Fife. We are keeping the energy going, but not always on the basis of a meeting three or four times a year.
My reasons for raising the issue were twofold. I represent the most rural part of Scotland, from Shetland to the Mull of Kintyre, and I have met a number of organisations, particularly in the third sector, some of which are doing extraordinary and innovative work. However, I have met frustration among those organisations that they are not part of the main stream or able to influence things. That was my reason for asking, so thank you for those answers. Another issue that has come up is that of a change in how those organisations might be funded or in their relationship with other agencies. Will you comment on that?
Do you mean third sector organisations?
Yes. Will you also comment on access to the change fund and any review of the work that those organisations are doing?
The joint strategic commissioning work that organisations are engaged in is very much based on partnership. It is not just the statutory sectors sitting in a room, deciding how they will plan and use the resource. Building on the experience of the change fund, the third sector and the independent care sector, which provide a huge amount of care and support throughout Scotland, are engaged in those discussions and in decisions about the funding.
In relation to the change fund, we have moved from a point at the beginning, when people were looking at how they would work together and what the relative voting powers, if you like, of the different sectors would be, to a building of trust and recognition of what the sectors and parties bring to the table and a more shared understanding. There are a number of examples of a collective approach being taken to decisions on funding. The third sector voice should be as strong at that table as that of the statutory sector. We are working hard with our third sector and independent sector colleagues to ensure that that capacity and capability is developed and further supported as we go into the more significant decisions on the wider resource and the joint commissioning plans.
We should always bear that point in mind and we should not be complacent about it. There might be some areas in Scotland where people in the third sector who are doing excellent work are harder to reach. However, the issue is how we ensure that the partnership is reaching out and engaging with stakeholders. We can provide support for that, as well as constructive challenge where that is required.
I do not have the figures with me, but are you aware of any increase in emergency admissions—particularly in overnight and zero-day stays, as you put it—following the introduction of NHS 24?
In rural areas, the process was very different. Doctors were sometimes flown in from Holland, France or somewhere else, so there were language and geography difficulties. If a doctor did not know someone’s family history, for example, it was, in case of doubt, better to send them to hospital in an ambulance. That approach was becoming common currency, and people were aware of it. Did that have any effect on the unusual increase in overnight-stay admissions?
Yes. Pete Knight can comment specifically on the data, and on any aspects of the service side.
The furthest that I can go is to say that that is a possible explanation. There has been an increase in the past five years in the number of people attending accident and emergency departments, and there will be a spin-off from that in admissions to hospital. However, people might well suggest other reasons, which makes it difficult to say yes or no with regard to attributing an increase to that particular reason, other than noting that it is a possible issue.
You made it clear that you looked at only one area—Aberdeen or somewhere—and analysed those figures, so I just wondered whether there was any evidence.
The whole of Scotland is covered. It is clear that the number of emergency admissions in the past five years has risen pretty well in proportion to the ageing of the population. That could be coincidence, or it could be a factor. However, the proportion of those who are admitted for very short stays—a zero length of stay; they are admitted and discharged on the same day or admitted for one night only—has risen much faster than the general figure, but it is proportionally a smaller group of people.
Anne Hendry mentioned that the partnership looked in detail at everybody over 65 who was admitted over a week. Have you anything to add on that, Anne?
The increase in emergency admissions is not just a Scottish phenomenon, but a globally recognised issue, certainly in developed countries. There is no obvious single cause-and-effect relationship; greater minds than ours have been put to that question.
Some changes in system access are probably contributing, as are, undoubtedly, some changes in clinician behaviours, as well as a significant change in public expectations and behaviours, and attitudes to managing risk. All those factors are contributing, which is, in a sense, why we have an unscheduled care action plan, and why all boards and partnerships are progressing a set of actions—which are not just about older people—across the system.
I have a couple of specific questions on the change fund. First, am I right in thinking that, although the work will continue, the change fund itself ends in the financial year 2015-16? Secondly, when it ends, will it taper downwards or is there in effect a cliff edge at which it goes to zero or close to zero? Thirdly, if it is the latter, are there any risks attached to that, or will the fund—in your view—have served its purpose by that point?
12:15
The change fund is a four-year fund, which went from £70 million in year 1 to £80 million in years 2 and 3 and will go back to £70 million in April this year, for the fourth year. The new integrated care fund was announced as part of the spending review and work is under way to develop the guidance and principles for how that will work. It is important that that is not seen as year 5 of the change fund. It will build on the change fund but will be more widely applicable.
That has been signposted to partnerships from the beginning. If you remember, in the first year we had only a year and until the spending review there was a bit of nervousness around investing in any developments that might have recurring costs for the following year. We saw a delay in implementation between when money hit partnerships and when services and initiatives started. My sense is that we are running about six months behind the allocation of the finances.
The work on joint strategic commissioning, to which we have made several references, is key. From day 1, the change fund guidance heralded the importance of partnerships thinking in the long term about sustainability and embedding initiatives that work.
Some of our third sector colleagues have expressed anxieties about work that they are involved in with the partnership and how that will be sustained. However, a focus on the evolution to joint strategic commissioning and the opportunities around the new integrated care fund, which, as I said, will have a wider reach—particularly in taking account of adults with multiple morbidity, as well as older people—will be important.
That concludes questions from committee members. I have one final question: how could the delivery of the change fund be improved?
That is always a good question. We have probably underestimated the start-up time for engaging partnerships in dialogue and conversation. You can look transactionally at a change plan, ticking boxes and developing initiatives, but collectively we underestimated the time that would be required to develop the culture and ways of working. There were unrealistic expectations in year 1 that caused pressure on partnerships.
The evolution from a one-year fund to a longer-term fund was important. If you have only a year’s fund, it encourages short-termism and projectitis. I ask my colleagues if they have any thoughts, because they have probably all reflected on that question.
Can you clarify the question, convener? I am not sure whether you mean delivery of the change fund nationally or its implementation at local level.
How can it be implemented at local level to ensure the changes in culture and the construction and delivery of services that we want to see?
Okay. I will go back to the joint commissioning issue as well. I am seeing a step change in people. At the beginning, in 2011-12, people saw it as a change fund and took a fairly narrow view. Now, the conversations that I am involved in around partnership tables are about seeing the bigger picture. I would focus my energy on helping partnerships to manage that shift in ambition and scale from the 1.5 per cent to the totality of the budget.
For me, the answer is about partnerships focusing on the wider picture and the ultimate goal of what can be achieved. The change fund was only for four years, but the reshaping care for older people strategy will last for 10 years; it will not end after year 4.
Allied to that is the Public Bodies (Joint Working) (Scotland) Bill. The policy memorandum in particular is quite clear about the Government’s vision for the future of services in Scotland. If I was to advise any partnership on how it should see the change fund, I would say that it should see it in that wider context and continue to focus, as we have all said, on not just the £300 million, but the £4.5 billion. That is the great aim.
We have to continue to focus on that and we have to remind partnerships that that is what we are trying to achieve; that will not last for just four years.
Do the witnesses wish to make any further points before we wind up the session?
Not really. That was useful and your range of questions will help us to reflect on our role in and contribution to this work. Thank you very much.
Thank you, Dr Whoriskey, and your colleagues. It has been very illuminating.
Meeting closed at 12:20.Previous
Early Years Change Fund