Finance Committee

Meeting date: Tuesday, October 26, 2010

Official Report 553KB pdf

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Preventative Spending Inquiry

Good afternoon and welcome to the Finance Committee’s 22nd meeting in 2010, in the Scottish Parliament’s third session. I ask everyone to switch off mobile phones and pagers, which interfere with the broadcasting system.

Agenda item 1 is evidence for our inquiry into preventative spending. The theme that our first panel of witnesses will address is violence and offending. I welcome to the meeting Detective Chief Superintendent John Carnochan, who is head of the Scottish violence reduction unit; Karyn McCluskey, who is his deputy; Laurie Matthew, who is co-ordinator of Eighteen and Under; Jenny Kemp, who is a prevention network officer from Zero Tolerance Charitable Trust; and Angela Morgan, who is Includem’s chief executive.

I will start by asking a general question. What are the best proven means of preventing crime from occurring?

I am happy to start. If we speak only about crime, we miss a big lump of violence. Women will be victims of domestic abuse 34 times before they find the courage to report it—it is classified as a crime only then. When we speak about violence, we mean bullying through to suicide and everything in between. Scotland has 800 suicides for every 100 homicides.

What will make a difference is certainly not what we have been doing. We need to think about providing young adults in particular with the life skills that allow them to make good decisions about themselves, about alcohol, about drugs and about violence—good decisions that help them to negotiate life. That is about the early years, non-cognitive skills and the first three years of life.

We need a good and effective criminal justice system that will stabilise the patient, but the cure must happen far earlier than our involvement does.

You can see that such activity works.

Absolutely.

At Zero Tolerance, our main concern is with the roots of violence. The best proven means of tackling violence is by tackling its root causes. That means promoting awareness of gender inequality and promoting understanding of the patterns of systemic violence by men against women through education and publicity campaigns. We promote young people’s understanding of how their gender role might have an impact on their experience of violence in later life. That is crucial.

It is important not to focus on just one strand of violence—we must consider all violence. I agree that it is important to tackle the roots of violence, but if we go down just one route, such as tackling violence against women, we will exclude all the other forms of violence and we will therefore never reach the root causes.

I agree with John Carnochan about the early years. The earlier we can implement prevention strategies, the better. We must work with toddlers—very young children—and parents to give them alternatives and show them different ways.

I will reinforce what other speakers have said. We must recognise needs and deeds. That is the fundamental Kilbrandon principle. In identifying vulnerable families, we must focus on welfare-based interventions rather than justice-focused interventions. The value of prevention must be promoted at all stages. Includem focuses on young people who are already caught up in the children’s hearings system or in the justice system through youth justice.

There is still proven value in working with young people from a welfare-based perspective. That is supported by research such as has been carried out by Lesley McAra and Susan McVie in Edinburgh, as well as that of Fergus McNeill. There is also evidence about the vulnerability of young people who are excluded from school, so it is important to provide interventions to address that.

Lastly, there is a great deal of evidence about the various types of effective intervention for the most chaotic and vulnerable young people. Research has been done by McNeill, McAra and McVie on relationship-based and persistent interventions. Those are not quick one-offs, and they are intended for young people who might have many years of abuse and deprivation behind them. Such interventions can be effective if they are sustained and if they cross over the black holes of the children’s and adult justice systems.

I invite questions from members.

I thank everyone for their written evidence. I pay tribute to the people whom I have come across over the years for their effectiveness. Zero Tolerance goes back a long way, and I acknowledge the more recent work of Detective Chief Superintendent Carnochan.

I was hoping that the different approaches that have been taken would now be complementary. In that context, I must mention that I was very astonished by the attack that Laurie Matthew made in her written evidence on the violence against women work that has been undertaken, which I think has been an important part of the work of the Parliament. Detective Chief Superintendent Carnochan has referred to that in relation to the prevalence of domestic abuse. Rather than challenge Laurie Matthew on that directly, I ask Jenny Kemp about the evidence base for the kind of work that Zero Tolerance has been doing over the years.

We tried to make that clear in our written submission. Violence against women is still at epidemic levels in Scotland. We define that more broadly than just being domestic abuse, about which John Carnochan has spoken. As far as rape and sexual violence are concerned, the attrition rate is still very alarming: the conviction rate for rape in Scotland is at an all-time low of about 4 per cent. A whole lot of factors contribute to that. We are also increasingly concerned by the sexualisation of children—girls in particular. There is a huge evidence base of statistics.

Some people say that the fact that domestic abuse and the reporting of incidents are on the rise suggests that none of the work that has been done has been effective. We would question that: we would say that that is evidence of people’s increased confidence in the authorities and their knowing that their report will be treated seriously as a reported crime, and not just as a domestic incident. That is actually evidence of success. Domestic violence is not a “growth industry” in Scotland, as it was defined in one of the submissions. It is still an epidemic problem, but confidence is increasing and there is an evidence base to show that.

I would like to come back on those points later, but I will leave it at that for now.

If you wish to carry on—

No, it is okay.

I wish to ask about some of the evidence in our papers for today. It shows that

“just 50 of 1,222 council wards”

provide

“a quarter of prisoners in Scotland’s jails”.

I will ask Mr Carnochan about this to begin with. Does your unit target those wards as a starting point, because they are where most known criminals will come from? How do you see that working?

We try to be effective where we can be effective, and that is in the busiest areas. We set up a gang intervention programme in the east end of Glasgow, for example. There were some votes for one in Bearsden, but that was not a particularly popular idea.

We have gangs there, too.

Absolutely. However, there are more victims of violence in the areas of deprivation—which are where most of the violence occurs, and that is where most of the violent people are. I am sure that you also hear evidence about health outcomes from people who are better informed about it than I am, but the situation is exactly the same in that regard.

Our point was that nobody who requires our assistance needs to hide from us. In my view, the problems have not been due to a lack of resource over the years. The inequality still exists and the disadvantage in some communities remains the same. It is time that we decided to do something a little bit different—something that might result in a change.

You talk about doing

“something a little bit different”.

In a policing context, what would that mean in the sort of council wards that we have mentioned?

The gang initiative that we use is CIRV—the community initiative to reduce violence—which has reduced violence among the group of 400 young men who have engaged with us by 46 per cent over two years. The initiative is about services, enforcement and the moral voice of the community. Includem has a big role in that and we work on all aspects of the issue. The young men we deal with who are in gangs right now will become fathers. Some of the young men who are in Polmont young offenders institution are already fathers. There is an opportunity. It reaches everywhere.

Domestic abuse, or violence in the home against women, is the nexus that should bring everything together. It should be the one issue on which we can apply easy consensus among agencies to do something, because we have a victim, an offender and, often, onlookers. It is contained, pernicious and chronic and it is in almost every street in Scotland. That is where we can start to make a difference. However, that should not be done to the detriment of our tackling other forms of violence, because we have invested a lot in our work with the gangs. It is important that we try to do as much as we can.

We have received evidence on early intervention—an issue to which you have alluded. In particular, we have heard about reaching vulnerable two-year-olds. We even had evidence that we should spend more money on nursery education than we spend on tertiary education in universities. You mentioned young men in Polmont who are already fathers. They have partners and children back in the vulnerable areas that we are talking about. I ask all the witnesses what kind of preventative measures you would like that would link up those two, while we are dealing with the person who is in prison for whatever reason and who has left a family behind.

We try to apply a public health model with primary, secondary and tertiary approaches. The primary, or prevention, part is that when young women have the first test that shows that they are pregnant, we immediately make an assessment there and then of their vulnerability. We support that work. There is one nurse-family partnership in Scotland, based on the David Olds approach—it is in Edinburgh—but there are 50 in England. The secondary part involves thinking about young men in school, because education is key. The tertiary part involves the young men who are already in Polmont and who need parenting skills and some understanding of what parenting is.

Do they get those skills while they are in Polmont?

Along with Mr McGill, who was the governor at the time, we introduced courses on parenting skills for young men in Polmont. The challenge is that that is not high on the agenda. Drugs and alcohol are high on the agenda, but the difficulty is that all those issues are important. The notion is that we need to do everything now. It is for people who are far smarter than I am to prioritise those things. We are just here to make suggestions.

The education part for young people at school is important, because we can start to change things there. We need to have all the measures in place, because they are all effective. However, the most important four years of a child’s life are those up to age three. There is already a range of interventions that we know work; for example, David Olds’s approach works. The case for early years intervention on life skills is made and done—we are at the “So what?” stage. When we think about education, I would prefer that we thought about education from year 1 to tertiary education. We need to consider what Scotland wants from education as a whole, not what it wants from tertiary or primary education.

James Heckman, who gave the Allander lectures in 2004, said that for every pound that we spend on early intervention, we save £7, yet nursery school teachers are the lowest paid and least valued. The highest incomes are in tertiary education. Universities are opening and nursery schools are closing. To me, that just seems wrong. I am not saying that we should close universities or that we do not need tertiary education, but we need to consider education in the round. If we think only about university education, we will get the answer back that we need more universities and more money for them; if we consider education from end to end, we might get more informed and helpful outcomes.

We have to capitalise at the teachable moment in any offender’s life. That might be when they are arrested, when they are assaulted or when they are in prison. The one thing that is sure is that they are able to procreate and will have children. We have spoken to many young offenders and we know that they are motivated not to pass on their lifestyle to their kids. They want a different lifestyle for their kids. Providing them with parenting skills is important. Many young adults—women and men—will never have been parented themselves, so we need to teach them those skills.

14:15

We have a different set-up in Scotland now, and the nuclear family is not the norm. Single parents are often the norm, and it is estimated that 60 per cent of households in Glasgow will be single occupancy or contain single-parent families by 2014. That is the new reality, and we need to teach parenting and good life skills so that young children grow up in a different Scotland and are not affected by violence.

That brings me to my next question. How easy is it to identify at an early age those who might be likely to fall into the path of getting on the wrong side of the law? I am not sure whether it is obvious, but I would welcome your views.

It is not, but there is a perfect storm. To be clear, we are not suggesting for a minute that there will be negative outcomes for everyone who fulfils the categories and ticks all the boxes. However, work by David Farrington, who is a psychologist at the University of Cambridge, lists factors such as parenting, lack of positive role models, lack of educational attainment and outcome, lack of family structure and whether there is already criminality in the family.

In terms of science, we know about the damage that drugs do to pregnant ladies and to the unborn baby, and about the damage that can be done by domestic abuse, which we know tends to start and increase during pregnancy. Stress hormones such as cortisol will burn the baby’s brain; if you bring a child up in a war zone, you create a warrior.

There are loads of things around. Michael Marmot’s recent United Kingdom-wide report, “Social Determinants of Health”, is about the same stuff. Whether a young man lives in Manchester, London, Glasgow, Edinburgh or Aberdeen, the same social determinants apply.

When we run the very early years abuse prevention programmes in schools at nursery level, we can spot behaviours in very young children—I am talking about ages three, four and five—that could possibly lead to bullying behaviour and to the child being a perpetrator, and we can also spot children who are already “victims”. Because we can identify some of the tendencies in children at that age, there is more opportunity to do focused work with them.

Perhaps I could give one answer to both questions. To look at the issue from the other end, if you examine the profile of prisoners in the prison system and the characteristics that many of them share, you can see the effects of the deprivation that John Carnochan and Karyn McCluskey have described in relation to educational experience and achievements, such as problems with literacy and lack of parenting. That is the characteristic profile. I agree with Karyn that there is an opportunity at the point when people who have been caught up in offending become parents. They do not want their children to follow the same path as them, so it is an opportunity that really should be grasped.

We are currently running a very small project at Polmont, for young men who are being released on home detention curfew. Instead of those men being sent out with only the tag and no support, which results in frequent breach raids, we are providing support.

As a by-product—an unintended consequence—we have become involved in situations in which the men have gone back to their partners who have very young children or babies. We have identified child protection concerns, and through that we have managed to work effectively. We have alerted the appropriate authorities, but because we have built a relationship with the young man and his family, we have been able to support the situation and, we believe, prevent a continuation of the cycle, which would otherwise result in another child being taken into care and possibly growing up to become a prisoner. There are real opportunities there.

A lot of good work is being done in prison, but the key is to ensure that the practical support that is required on the outside continues when a young person leaves prison. That is where the reinforcement is needed.

I do not disagree with anything that has been said so far, but I will sound a wee note of caution about targeting. We would always argue that violence against women is such a widespread problem—we are not talking about a minority concern; somewhere between one in two and one in 10 women will experience some form of gendered violence in their lifetime—that a whole-population approach must be taken.

Targeted interventions are important, and there are a lot of effective ones in Scotland. In our sector, I particularly commend the CEDAR—children experiencing domestic abuse recovery—project, which takes a group-work approach with mothers and children together to build the family bond after domestic abuse. That is a wonderful, fantastic, cost-effective and well-evaluated project, and it works.

On the other hand, the original Zero Tolerance campaigns and a lot of the work that we have done over the 15 or so years in which we have been on the go have targeted the whole population. We have said that no one is immune and that everyone is responsible for recognising, challenging, speaking out against and educating on violence against women. A whole-population approach definitely still has merit.

Eighteen and Under and Includem have said that children and young people do not trust statutory agencies. Will you amplify your thoughts on why that is the case? If it is the case, will we have to scrap the statutory agencies that we have to deal with such problems and invent new ones or come up with a different approach?

Our experience is with young people who are required to work with us. They come to us on statutory orders. They do not choose to work with us: they come to us through either the panel system or the courts. Therefore, it could be argued that we have exactly the same problems as social workers, although we are not called social workers.

Many young people with whom we work come from families that have passed on attitudes that they hold about statutory bodies because of their involvement with the police or the authorities. Their children may have been taken into care and they may have a general problem with trust. By the time young people come to us—some of them call us “the last-chance saloon”; we are recognised as being that—they have long experience of working with agencies into whose services they do not fit. Ultimately, services give up on them and walk away or the young person acts in breach of the services and something worse happens to them. Their general experience is that adults in their family or authorities have let them down. We expect that, so the starting point of our approach and our way of developing relationships is the expectation that they will be incredibly unco-operative and difficult to work with. We expect that they will never turn up to appointments on time and that we will have to demonstrate to them that we will not give up. That is how we pursue matters. We use those relationships to begin to challenge their attitudes.

I find reassuring something that our outcome research consistently shows, as I often need to counter the view that our system is some sort of buddying-up system. It is not. We develop trusting relationships with young people and use those relationships to challenge attitudes and help them to develop a different sense of themselves and the world around them. It is a matter of highlighting to them the consequences of not changing their view of the world, themselves and the attitudes that they have displayed towards authority. The process is complex. As I have said, the problem is partly their own experience, partly what they have inherited, and partly their having no decent adult role models around them. John Carnochan referred to that.

There are two strands to why I said what I said. If we look at the current statistics for serious abuse, we will find, for example, that about one in 10 males and one in four females have been sexually abused by the age of 18. Those are worldwide statistics. The figures for children growing up with domestic violence are also huge. However, those kids are not coming to the attention of the authorities. They did not do so 10 or 20 years ago and they are not doing so now. Kids wait until they are adults and then use adult services. We must consider why that is the case and why they do not go to child services.

ChildLine and Eighteen and Under, for example, offer confidential services to children and young people, and they are heavily used. We get the kids who want nothing to do with statutory agencies and who fear many things, including being taken into care. Of course, many of those fears might be unrealistic, but they still have them. As a result, they want other agencies that they can go to. We also get the throwaway kids, whose parents have no interest in them. Although they have not come to the authorities’ attention, they still need somewhere to go instead of the street.

The issue is the sheer number of kids who come to us, and they find their way to us via our message boards, the e-mail on our website, texts, the phone and just dropping in. They can do that because the facility exists, and we then try to hook those kids up to statutory agencies wherever we can. However, given that our centre is the only one of its kind in Scotland, you have to wonder where the kids who do not live in Dundee are going.

As I say, there are two strands that we need to consider. You have only to look at the statistics to realise that children are not using child protection services. It would be great if they were all going to the police and saying, “This is what’s happening to me,” but they are not.

The conversation has moved on a wee bit from when I first wanted to come in. The experience of all MSPs and those on the panel suggests that, for a long time, we have simply been managing the problem rather than treating the root cause and finding the best way forward. We know what the problems are, what we want to achieve and what we aspire to, but the bit that is missing is how we get there.

There is a distrust of statutory agencies among people of all ages and in all walks of life, but do you think that individuals and communities in general as well as the defined voluntary sector are engaging sufficiently in—to use the buzzwords—partnership working and co-operation to ensure that we truly address these problems? How do we get to a point at which we look at the preventative measures that are required based on the person whom we want to prevent from having the kind of issues that, for all sorts of reasons, they end up having? Given that the person-centred, family-centred and community-centred work that must be carried out will never be successful unless individuals, families, groups and communities want it to work, they must have some say in the systems that are set up to allow that to happen. How far away from that goal are we and how do we start working towards it?

I hesitate to plunge in with an attempt to answer that question, but I suppose that I would simply reiterate some of the points that I made in my written submission about the drivers in the system. At the moment, individuals, families and communities have limited impact on systems that have been set up, which are driven not necessarily by any evidence of effective practice that quite a lot of people might recognise but—quite understandably—by the governance arrangements that different organisations and systems have put in place to manage the resources that they spend. In my submission, I tried to lay out what I saw as a particular disincentive in the hearings and justice systems, but I have another example that illustrates the problem of continually trying to address a problem at its end point rather than at its starting point.

In my submission, I refer to an intensive support and monitoring service model that was developed and used very successfully in Glasgow and which resulted in a dramatic decrease in the use of secure care places. With the cost of an ISMS intervention estimated at £1,000 a week and the cost of a secure care place estimated at £5,000 a week, that meant huge savings for Glasgow and freed up spaces in secure care. However, sheriffs in the adult system who were dealing with 16 and 17-year-olds realised that those spaces were available and felt, for very good reasons, that it would be much better to send young people on remand to secure care rather than to Polmont. That has left the council with a £2 million bill over which it has had no control and it is now working with us to try to beat the problem. We are supporting the council by providing sheriffs with an alternative to remand to ensure that they do not have to send young people into the secure system, which costs a fortune. Moreover, more than half of those young people are not ultimately sentenced to custody.

That is good problem solving and we are happy to be involved, but it would be better not to have to solve the problem in the first place. I return to the difficulty of the overlap in the system for those aged 16 or 17, whereby young people can end up in the adult justice system, which everybody knows is the worst possible place for them to be, as it results in increased reoffending and return to prison and generally affects their life chances. This is the end point of the drivers. I guess that it is where the power lies and why there is continued debate on how to reduce the size of the prison population, because you have to pull all the threads at one time. I know that that does not answer the question, but I am hesitant to put responsibility in a place where power does not lie. That is my main point.

14:30

The question was how far away we are from that goal. In some places, we can just give a little push and it will happen—some amazing people are doing some amazing things. We need to bear in mind that strategy, policy and standard operating procedures are dead easy—we could write those right now—but the challenge is people and attitudes. It is very difficult. There is still a deal of territorialism between agencies, including the voluntary agencies, that is more corrosive and pernicious than that between the gangs in the east end of Glasgow, Bearsden or wherever. It is very difficult to get through that.

Over the years, in always looking towards a statutory resolution, we have ended up deskilling lots of communities by applying that far too soon. Also, we seem always to value innovation above effectiveness. Fabulous little bits of work are going on all over the place from the Jeely Piece Club to the PALS—parents altogether lending support—programme in Dundee. There is a whole range of things that we just need to throw a few hundred quid at for them to work a treat. We do not need to worry about scaling up those projects and spending £10 million on them. If something is working or someone is doing a great job, let us not say, “There’s a great bit of voluntary work. Let’s professionalise it.” If we do that, two years later, the wee voluntary group that was working in a community has become an agency that employs five members of staff and needs a million quid before it can wash its face.

We need to change how we do things. If we are talking about really listening to communities and supporting them, we need to be a bit more relaxed about how we do things. If a voluntary group that is doing a little bit of work in an area is given £1,000, we get back £10,000-worth of work. With all due respect to voluntary agencies, if £1,000 is given to a big agency, we get £250-worth of work back—the rest goes on rates, computers and employees. We need to be careful about how we do things. We are in difficult times. If we are going to be brave, this is the time to start to be brave and to think about things in the longer term.

You asked a very complicated question—

I got mixed up myself.

What you are getting from the evidence is that violence is a wicked problem that is complex and complicated. At times, we can make some of the solutions very complicated. Harry Burns, who will give evidence later to the committee, is much more erudite and knowledgeable than I am—

Oh, I doubt it.

He will talk about primary prevention. We need to understand that primary prevention has many outcomes that relate not only to violence but to health. We need to support parents—we absolutely do. It is integral to tackling violence, but it is the right thing to do for a range of other reasons, too. We need to be brave enough to understand that we might not see the results immediately—it is not like tackling crime; we cannot measure it from year to year. However, I know that if we intervene early, by the age of three, when children turn up at nursery school, they will be ready to learn and will have the skills to talk to each other and negotiate their way round arguments and so on. There is a load of good things that that will teach them.

Secondary prevention targets those at risk. All of us do that in one way or another. This is where it becomes very territorial. John Carnochan alluded to the fact that lots of good people do lots of different things. That is no bad thing. There is then the tertiary end, where we target those who cause harm to our communities. They need the jail—lots of them do—but that is very expensive. It costs £49,000 per year to keep a prisoner in jail, which I am not sure is a great use of money. I would rather use the money earlier, as that would prevent people from becoming victims in the first place. I am sure that John Muir would rather that his son Damian had never been stabbed. There are loads of mothers in Glasgow and around Scotland who would rather that their children had never been victims of crime.

I think that we have to be brave, and politicians have a huge role in that. We should look at the evidence—there is loads of it. We do not need any more evidence; we need to take the step and do something slightly different.

I will add a point about national indicators. One of the barriers to progress is that, although there are myriad strategies, policies and so on, what the Government currently measures does not relate to what we are talking about today. I was looking at the indicators on children. The only specific indicator is on child dental health in primary 1, and there is no general indicator about child health, wellbeing or parenting—any of the things that we have talked about today. If we want to push those things, we have to look at the indicators, because they push community planning partnerships in their decision making. We notice that fact in gender, too: some good analysis of single outcome agreements has shown that, unless violence against women is spoken about as a national priority, it does not translate into local planning.

In their submissions, the people on our second panel talk about the big picture. They tend to talk about it in terms of education, justice or violence reduction but, as we know, the bigger picture is how the individual issue affects all the other things that form the society in which we live. For example, if we reduce violence by all the different measures that we have talked about, that has a knock-on effect for the health service and every element of our society. Considering the structures and institutions that we have—how they are set up and funded and the self-interest that so many have, which has been referred to—do you think that it will be possible, perhaps in the medium rather than long term but probably not in the short term, to make a real difference in how all the different organisations work together and see the bigger picture rather than their own narrow box?

The short answer is yes. Some good things are happening around the place, such as the public protection arrangements through the MARACs—the multi-agency risk assessment conferences. There are also some good examples in the getting it right for every child pathfinder areas.

What we need to bear in mind—particularly Scottish politicians, who have an economy of scale and a notion to aspire—is that we should no longer just chip away at the top of the iceberg. Let us think about violence as an iceberg: if we keep chipping away at the top, we are not making a blind bit of difference to the size of the iceberg—it just bobs up a bit. The thing that will change the size of the iceberg is raising the temperature of the water. That involves big things, including gender equality and work with young people. Why do we not have an ambition to make Scotland a great place to bring up kids? I am not sure that we like kids in Scotland. I think that we tolerate them rather than like them. That is the truth of the matter. We use with impunity against young people language that we would get the jail for if we used it against other groups. We also need to think about alcohol and how we view it. Those are some of the big issues.

Enough is going on in little bits and pieces, but a big lead needs to be taken. We are speaking from a violence perspective, so we tend to think that, if we help parents, it will be 13 or 15 years before we see a difference. The truth is that, as Karyn McCluskey said, we will see differences very quickly—in nursery school and as we go along. As criminal justice practitioners, our job is to keep a lid on violence. The job of Includem is to look after the young men who present a risk to themselves and others. Our job is to keep a lid on violence but, while we are doing that, we should not be wasting the great effect that we are having. The detection rate for murders in Strathclyde is 98 per cent. We travel round the world and tell people that and that we still police by consent, and they do not believe us. However, that work is the last resort—that is not the problem fixed. We need to be doing other stuff.

In Scotland, we have the opportunity with partnership and co-production. Partnership and consensus at a national political level would make a big difference to what we are talking about. We stopped the cigarette stuff because there was a ready consensus and because everybody understood that it is not about who is important but about what is important. Early years also falls into that category. We need a consensus in Scotland that says, “We’re going to do this in Scotland for the next 15 years. We are committed to looking at this and supporting the work.” That is what we need to do.

I totally agree with John Carnochan’s comments, particularly his emphasis on targeted intervention in the first three years—or, as I think he said, the first four years up to the age of three, which is a more interesting way of putting it. People on the next panel will make the same point, but in a different way.

I was also struck by Jenny Kemp’s comment on the need for population-level action. I am coming to the preliminary conclusion that we need a combination of those two approaches, and I am particularly interested in hearing what people think about the second. I suppose that John Carnochan touched on the issue in his previous answer, but what kind of population-level action is needed to complement targeted early years action, as consensus appears to be growing that that is fundamental in dealing both with this problem and with other problems that we will discuss later?

Karyn McCluskey referred to the teachable moment. This might sound like I am stating the bleeding obvious, but schools are a venue for education and we should not be getting tripped up around the idea of what the curriculum is and what we should be doing. The curriculum aspires to be a curriculum for excellence and an opportunity to provide young people with the necessary skills to ensure that when they leave school they can negotiate life, not bump into it. The kind of population-level action that you refer to is needed right across the board from the day children walk into nursery until the day they decide to go to university, if that is where they want to go.

In that respect, the language that we use and the example and standards that we set are important. Again, that is a matter for politicians. Of course, we can all address the same issue within our own responsibilities, but small things such as our language and the example that we set make all the difference. Two or three weeks ago, I was speaking at the national community safety strategic group conference, which was all about challenging young people and alcohol—as if alcohol were just an issue for young people. That is the classic position; I suggest, with all due respect, that it is an issue for all of us. I told the delegates, “What you can do is stop holding conferences in hotels and having dinners at night with free wine at the table. That would be a good start.” [Laughter.] I got the same response at the conference. The suggestion did not go down too well.

The truth of the matter is that that is what we need to do. We need to demonstrate that we are setting that kind of example. For example, chances are that the Scottish guy in a television drama will be a violent, drunk wife-beater. Are we happy with that reputation? It is simply absurd. People on the radio laugh about how drunk they were the night before. Not only do we let these things happen and think that they are okay, we celebrate them. We need to challenge such attitudes, which means challenging at every point not only the language that we use but all these other issues that we have mentioned.

Finally, men need to get involved in tackling violence against women. Why is the issue the responsibility of the Scottish Government’s equalities unit? Do we really think that it is just an equalities issue? I can tell you that it is far more than that. By leaving the issue where it is, you are simply saying that it is not a problem for men. However, 99 point something per cent of rapists are men. This is a man issue and until men—including the men in this room—start challenging other men on how they speak about gender issues or talk about other men’s daughters, wives or mothers, we will not change the temperature of the water or get the required population shift.

Does anyone else wish to comment on population-level action?

I want to speak in support of the Equality and Human Rights Commission’s report, which sets out the very interesting case that many of the tools to carry out good preventative work already exist—we just need to use them. For example, we could carry out proper equality impact assessments with regard to existing duties on gender, race and so on. Indeed, the current spending review is an excellent example of the complete failure of that process. There was no proper equality impact assessment of the budget—certainly no gender impact assessment was carried out—and, lo and behold, it is going to hit women heavily. Women will account for more than two thirds of the job losses in the public sector and, given that benefits are a fifth of women’s income and only a tenth of men’s, they will also be hit harder by the measures in that respect. If, when the budget had been drawn up, someone had thought to carry out a proper equality impact assessment, it would have had a less detrimental impact on gender equality when translated into policies and services. At the moment, however, we are concerned that it is a hammer blow for gender equality.

If the Scottish Parliament is serious about this agenda, it must carry out proper impact assessments on everything that it does, think about these issues and challenge dominant norms. John Carnochan has made a good case in that respect. In many communities and places in Scotland, sexist, racist and derogatory language is still acceptable. We need to tackle that culture and, as I say, the tools to do that already exist.

14:45

I agree with what has been said already. If we put in the early years work as John Carnochan suggests, we will have within our schools and nurseries a population to whom we could teach violence-prevention strategies and with whom we could tackle all the different equality issues using evidence-based programmes as part of the curriculum. That would begin to challenge and change attitudes in very young children, particularly if it were part of the curriculum year on year and not just at secondary school. It should start early and go all the way through, and it should be consistent and tackle all the different messages.

The context in which we are conducting this inquiry is one of squeezed resources; as John Carnochan said, these are difficult times. It is therefore important for us as politicians and our colleagues in local government to make sure that we target resources so that they achieve the desired outcomes. There was talk earlier about making sure that we have indicators that match that. There is a consensus that early intervention is the most important thing that we can do, so how can we make sure that what we spend now will have the expected outcomes in the future? How can we be certain that we are spending the money in the correct places?

You will need to have some bravery. It will be difficult for politicians to say, “We are going to spend our money on children, but you will not see the outcomes next year.” I mentioned that earlier. We could come up with lots of qualitative and quantitative indicators that will show you that what you are doing is working, but it needs to be done in the long term. You cannot just say what the spend is going to be for the next four years; you will have to commit to the long term. There is a huge amount of evidence and the Scottish Government has a lot of skill. I am sure that Dr Harry Burns is a leading light on this.

It is the right thing to do. We have looked at the research into violence and we have espoused an approach for the past five or six years. It would be interesting for Scotland to take the leap when we are facing the budget cuts. We are facing a perfect storm in which there will not be so much employment. These are challenging times for crime, disorder and a range of other things. We need to support parents and children more so that they will come through to the other side relatively unscathed and perhaps ready to do the wealth creation stuff later on.

You mentioned indicators. Could you give us a list of those in writing to show us exactly what you have in mind?

Yes. It would be helpful to see a broad-brush indication of what you are thinking.

The World Health Organization published a report last year that was produced by Mark Bellis, who is a professor of public health at Liverpool John Moores University, and Karen Hughes. The report describes the big seven, which are evidence-based policies from around the world that will reduce violence, whether it be in Somalia or Shettleston. Those policies are enriched early years and adolescent life skills—if we do more of the former, we will have to do less of the latter as time goes on; gender equality; victim support; reducing access to lethal means; reducing access to alcohol; and tolerance in community norms. If we work on those, we will make a difference. There is evidence for that from around the world from middle, high and low-income countries. If we concentrate on those policies, we will reduce violence.

However, the key point is that there needs to be a commitment to the policies that goes beyond three years or five years. This is a 10-year commitment. There is a real opportunity here. We gave the world the enlightenment, when we thought our way through our problems, and now we are trying to do what is right. It is not about who is right but about what is right. If we concentrate on that, we will stand the test of time and leave a legacy of which we can all be proud.

We are well reminded.

We are obviously looking for long-term outcomes and things that will happen over five, 10, 15 or 20 years. However, all the programmes that we have been involved with, and doubtless many others, also have short-term outcomes. We developed an education resource that is used in 21 local authorities in Scotland, and we evaluate that resource after every implementation. We find that behaviours start to change very quickly. During the pilot evaluation, we found that 78 per cent of primary school children said that their behaviour had changed as a result of going through our intervention. So yes, the long-term savings to health, justice, welfare and so on will be reaped years down the line, but we will see changes in behaviour within weeks, and that will have a positive impact.

I am a bit confused by what Karyn McCluskey said about waiting for wealth creation later on. There is a broad correlation between the postcode areas to which David Whitton referred and particular outcomes in relation to health—our next panel will deal with that—violence and so on. There are postcode areas in Tweeddale in my constituency with family incomes that are lower than those in other postcode areas. The big difference is in employability and economic activity, not Government spend per person in postcode areas or necessarily in some other outcomes. Why on earth should we leave wealth creation until later on, given the key element of economic activity and employment?

I am sorry; that is my mistake. I meant that we should support children so that they will be ready for the labour market later on. Many young people with whom we deal do not have the skills to go into the labour market. They cannot communicate, work in teams or negotiate—they would be no good in a call centre, for example. The point that I was trying to make about preventative spending and early years support was about equipping people with skills so that they will be able to go into the labour market later on, as opposed to the work that we are doing now on trying to address some of their gaps. That is very expensive to do. My apologies.

That is fine.

I have a question for Jenny Kemp. I understood the argument about the gender impact and am interested in our not starting from zero. Councils have already set budgets, and we have had 10 budgets since devolution. In the past, the committee has looked at how the Government makes its spending choices and whether they are linked with Government policy outcomes. I am not saying that you have no reason not to be highly critical of the budget or of the spending review that has just passed, but how is that different from the ones that councils or the Scottish Executive have done or what the Scottish Government is doing now?

Good research evidence will be published shortly. The Equality and Human Rights Commission commissioned the report entitled “Counting the Cost”, which considers how local government uses impact assessment tools, specifically relating to equality, in financial decisions. That report identifies some fairly poor practice. Obviously, gender is our main interest.

It is not a case of one piece of work being out of kilter because everything else has been done so brilliantly.

No. Absolutely. That is a particularly striking example because there has been such a huge cut compared with what we have been used to in times of relative wealth. There is quite a lot of evidence that local authorities are not using the tools that they could use and that detrimental decisions have been made.

So what is the way forward? A spending choice could be made and the spending could be allowed to drive outcomes, or a policy outcome could be set and the budget could be shaped around that. Ultimately, there are two big choices relating to how we form budgets, and things do not tally at the moment.

Malcolm Chisholm criticised a point that Laurie Matthew made, but I think that it was a good point. There can be a high-profile political agenda with resources behind it that is pushed by ministers, politicians, local councils or voluntary sector lobby groups, but that will not necessarily be the right thing to do, although it is done at the moment. Other groups have told us about initiative-itis. That seems to be happening. Is the single outcome agreement process working? Is it allowing budgets to be shaped on the outcomes that we are seeing? That is what we have at the moment. Unless we change it, that will be the mechanism for shaping the community planning partnerships over the next few years. We can do all the blue-sky thinking we like, but there is a process under way now for next year’s budget and the budget for the year after that. Is the single outcome agreement process working to ensure that money is going towards achieving the outcomes that we want to achieve?

As far as violence against women is concerned, there is a mismatch between strategising at national level and what happens on the ground. Single outcome agreements do not reflect the priority that has been given politically to tackling violence against women over the past 10 years. Services have been cut and withdrawn. As soon as ring-fenced funding for tackling violence against women is removed, it is one of the easiest things to go. Abused women and children are not going to march in the streets and protest over the withdrawal of those services. They are a very easy group to hit. The same probably goes for some of the other groups who are represented here today—it would be very easy to take money and services from them. There has not been a translation from national strategising to local community planning. The single outcome agreements do not reflect how important we think violence against women is.

I would echo that rather dispiriting experience. We work in an area of high risk, and we have 10 years of evidence-based research. We have proved that the model that has been developed will save money. Given the change in funding arrangements between central and local government, councils that, through their own evaluation units, had demonstrated big savings in young people being sent to secure care—which I think was for political reasons, although we were never aware of the drivers behind it—have made immediate cuts, and we have seen the consequences.

It is difficult to know how to intervene in that cycle of decision making, which, as Karyn McCluskey said, would require bravery. The easy thing is to send young people to prison and pay the price for that later. The more difficult thing is to stand firm and acknowledge that that is not effective. A welfare-based response will ultimately protect the community and will be more financially beneficial. However, that takes guts.

I said earlier that we need to do things differently, because what we have been doing until now does not work—and I include everything in that. We need to think about what we want to do. There is only one public purse. It is not a health purse, an education purse and a criminal justice purse—it is the public purse, and there is only one. Where do we decide how we divvy it up if not in Parliament, through the democratic process? When the decisions filter their way down, they do not match up, and they do not hit the pavement.

When I started in this work, I had only 32 years’ service, and I was incredibly naive. I thought that people would do the right thing because it was the right thing to do. Unfortunately, they do not. I include everybody in that—we do not do it, but it is time that we did. It is time that we started doing the things that are right.

As for what we have done until now, the areas that are the most deprived have been that way for 30 years. What have we been doing up until now by way of wealth creation? It is not working.

We built the Fort in the east end of Glasgow to give young men jobs, but young men would not walk through the gang territories that they had been fighting in since they were 10 or 11 to go for the jobs there, and that is a fundamental problem.

We all need to start thinking in a new way. It is not about initiative, or about innovation over effectiveness. It needs to be about doing the right thing, and that needs to involve everybody.

I agree with a great deal, if not all, of what has been said so far today. Previous evidence also makes the case with regard to early intervention—that is a given; there is no question about it. I hear what you are saying about being brave. However, being brave would require a degree of political consensus here that is absent, frankly, and there are no signs that it is going to appear any time soon. There might be idealistic notions, but this Parliament and other Parliaments quickly become tribal and territorial on such matters, which is very difficult to break down.

You must know that we live in a society that has a very high degree of professional demarcation. I worked in industry, and I learned pretty early that the people with the fancy dresses and the good shirts and ties were much better at that compared with the people who worked in engineering plants. They are really good at it in Scotland—there is a huge collection of vested interests. It is easy to agree with everything that you have been saying and to say that we need to be brave, but the task is huge.

Putting aside the politics for a moment, how can we break down the professional demarcation that would undoubtedly be encountered? Are you talking about a significant realignment of existing resources, or a realignment of existing resources plus additional resources, which would be difficult to find, given the times that we find ourselves in?

15:00

We need to start off not by thinking about the resources that we have and matching them up to what is there, including the professions, but by thinking about the challenges that we face and whether we have the resources to deal with them. Rather than chapping on people’s doors and offering them services that they might not want, we need to ask what the challenge is and either deliver the service that is required, if it exists, or invent it, if it does not exist.

I wish I knew how to do away with professional territorialism, which is corrosive. I will continue to challenge it wherever I go. I have a 50-minute input on territorialism and professions—it used to be a 15-minute one—and I know that the issue is very difficult to deal with. At its heart, however, is the struggle for funding, in which one profession is played off against the others. We have a negative, deficit-based approach to things, which means that it does not pay for voluntary groups to say that they are improving a situation. Instead, it pays for them to say that things are getting worse, because that way they will get more money. Of course, evaluation is built into that process, but it still does not pay for people to say, “Hey, we’re making a difference here—things are getting better.”

Resources are important. I know that it is difficult to deliver three-year fixed funding, but we need a consensus around that, and I am not going to stop asking for it. That is the holy grail, and we need to go for it. There is a time to lead and a time to follow. If we always followed, we would still be hanging people, no one would be wearing seat belts and I would be having a fag while I was speaking to the committee. We need to lead. That is my plea to politicians of every hue. We must use violence as an issue around which we can get a consensus on funding. Are we serious about having a safer Scotland? We were given a national responsibility by the previous Labour Administration, which was supported by the current Administration, as part of a recognition of the consensus view that the matter is important.

If we chapped on the door—to use your phrase—of every social work department in Scotland and asked whether they thought that they were managing the problem or were making inroads into eradicating it, most of them would say, “Aye, we’re making some progress—maybe not as much as we’d like, but some.” They would effectively try to defend the status quo rather than tell us what we could do a lot better. If you spoke to them in the right context, I believe that they would open up, but the discussion would change the minute that they started to think, “Actually, this is going to mean big changes for me. Am I less secure than I was?”

Let us take the example of the early years. It would be fabulous if we could say that we were going to focus on nothing other than early years and that we were going to shift all the spend down there for the next 15 years and let extra police on the streets deal with all the other stuff. The premise in that situation would be that we would need fewer and fewer resources to deal with all the other stuff as time went on. If that premise has any validity, what we are saying is that we should start to demonstrate what needs to be done in the early years and reskill people so that that work can be done. It is not about sacking people; it is about getting people to do the right things. A lot of things that are happening out there are nonsense, and we have to challenge that. This is the time to do it, when money is tight. We have spent the past few years getting ourselves into a position in which, as you said, the need for early intervention is a given. I am at the “So what?” stage in that regard. So, it is a given—so what? What does that mean for Scotland? If it is a given, let us do something about it. If we do not, we might end up looking back and thinking that we missed an opportunity.

We are politicians who work at a strategic level in Parliament, but we certainly see the problems in our constituency. People come through our doors with those problems every week. In my constituency, I see an increasing number of people who are effectively becoming an underclass, to use a bad phrase: they are outside society and are experiencing the problems that you mentioned earlier. However, how do we get people to fess up to the fact that much of what we are doing is not contributing to solving the problem? In my experience, it is difficult to get people to say, “You’re right—the £3 million that we spent on that project last year was £3 million down the drain.” How can we break into that and properly identify what we need to stop and what we need to start?

I nearly used the phrase “big government”, but that would be wholly inappropriate. However, if the national Government thinks that far more should be done about early years, there might come a time when it needs to decide that X amount of expenditure must be ring fenced and that, instead of leaving it to 32 autonomous local authorities—as we did with the sure start money—it will have intrusive supervision of how that money is delivered. Sure start was a fabulous idea that received £65 million, but where is it now? Until the situation changes, the Government should take control of how it will be changed, which will mean asking difficult questions and, as I say, having intrusive supervision of how the money is spent in certain areas over the next few years.

Of course, some great work is going on and some local authorities, such as South Lanarkshire Council and West Lothian Council, are doing effective things and facing up to those challenges. However, we probably need leadership from the centre, with the Government saying, “We’re going to control this money and spend it where it should be spent.”

I agree with that. I believe in benign dictatorships, but I do not think that my colleagues agree with me.

The fact is that the political rhetoric in this Parliament is heading in the opposite direction. Now we cannot tell local authorities the time of day, and everything has to be done at their hand. After all, they know best, and we simply hand over the money and hope that we get an outcome. I agree with what you are saying—I think that most people would—but I am sad to say that, if you examine the political rhetoric, you will find that it is going one way and you are going the other.

You still need the Government to change that rhetoric.

David Whitton has a specific question.

I want to ask Laurie Matthew about the violence is preventable project, which, according to her submission, has won keen praise around the world. However, it has not been expanded across Scotland. Can you give us a quick résumé of what it is, how good it is and why you think it has not been expanded?

About 12 years ago, after a great deal of research, the VIP project was developed in Scotland to look at all inequalities and all the roots of violence. Various programmes were developed and evaluated at different stages in what became quite a comprehensive series aimed at parents and children, the very early years, primary and secondary kids and vulnerable adults. It has been very thoroughly evaluated and researched; indeed, the latest piece of research, which was carried out by the University of Dundee and published this year, deemed it to be one of the best programmes worldwide with proven outcomes not just at primary level, with children retaining the information, but at secondary level, with children taking action to prevent anything further from happening. I believe that, during that particular research, about 33 per cent of the children in the programme made disclosures ranging from sexual abuse to bullying and domestic violence. That was all verified by the University of Dundee.

As a result of that robust research, which has now been published in international child abuse reviews, there has been increasing worldwide interest in the programme; indeed, we have secured funding to take it out of the country. I must point out, though, that there has been some progress in Scotland and that we ourselves have raised money to push the programme out across the country. It is up to individual schools whether they want to take advantage of it—and many schools that have heard about the programme have done so. As a very small organisation, we are obviously limited in what we can do.

So this is one of these good ideas from a small organisation that, despite having been tested worldwide, peer reviewed and all the rest of it, does not appear to be getting the required assistance.

Ten years ago, when the programme was in its infancy, it received quite a lot of really bad press. The media made up things; I recall, for example, the Daily Record headline, “Sex lessons for toddlers”. That is not what the programme is about but, as a result of that press, we were asked along to what at the time was the Scottish Office to demonstrate parts of it. We did so; however, when we asked whether the programme could simply be put into every school in Scotland, we were told—I do not know why—that that could not happen. At the end of the day, we are not looking for Government funding, because that money comes with strings and we would have to go in a certain direction.

We are saying not that the Government should not be doing work on violence against women but that it should be doing other work as well, because all violence is interlinked. The evidence from independent research is that the programme works at different levels by tackling the root causes of violence, challenging the perpetrator, giving information to the bystander and helping the victim.

I have been with Zero Tolerance for only three years, so I do not know the history of all this. However, I imagine that at the time the Scottish Office or Scottish Government did not want to support the VIP programme because of its support for our educational materials and our respect education programme, which seeks to build in children a foundation for developing healthy relationships by focusing on their communication skills and allowing them to come to an understanding of respect, power, violence and so on.

In the early years of the decade—although not in recent years—the Government gave us good support and funding to print those materials and roll out the programme, which, at the moment, is used by 21 local authorities. I acknowledge that all this looks a bit like the territorialism that we have been discussing, with different organisations having different resources that they think are the answer. There are probably more discussions to be had on this issue. After all, there is a plethora of different resources on violence; indeed, there are probably too many.

Whatever gets done or gets used should be thoroughly and independently evaluated to a very high standard. I do not feel that we are in competition with any other programme in Scotland, because we are not—and do not particularly want to be—funded by the Government or local authorities. All we are saying is, “We are giving you a gift. Would you like to share or use it?” Some schools in Scotland are embracing and using the programme, but there is no reason why they should not be able to use different resources or programmes. The point is that people must use what works and, indeed, what they like to use. We should all be working together on this.

I must draw this evidence session to a close. Do our witnesses have any final comments?

I want to finish with a plea. It might be partly to do with semantics—and I stress that I fully support everything that has been said about early intervention—but I really feel that a distinction must be drawn with regard to prevention at all stages. I am concerned that an implicit assumption might be made that although early intervention might work for many there will always be some that it will not work for. With regard to the underclass to which Mr McCabe referred, I do not think that Scottish society should accept that there is a group of people whom we cannot do anything with and who should therefore be written off—and particularly not when they are in their teens.

We have had a good session and I thank our witnesses for their attendance and their evidence on the work that is being done in our communities. It has given us much food for thought.

We will have a short suspension to allow a changeover of witnesses.

15:14 Meeting suspended.

15:18 On resuming—

The theme of our evidence taking from our second panel of witnesses is health and social care. I welcome to committee Mike Brown, who is the convener of the Association of Directors of Social Work resources committee; Nigel Henderson, who is the convener of Community Care Providers Scotland; Dr Harry Burns, who is the Scottish Government’s chief medical officer for Scotland; Rachel Cackett, who is a policy adviser for the Royal College of Nursing Scotland; and Dr Philip Wilson, who is a senior lecturer in infant mental health at the University of Glasgow.

The committee has been given examples of where spending public money on one area, for example caring for people in their homes, can reduce the amount of public money that is spent in other areas, such as hospitals. To what extent do different public sector bodies pool their individual budgets to prevent negative social outcomes arising and to ensure that future demand for more expensive remedial public services is minimised?

I am sure that the committee is aware of the integrated resource framework initiative that the Government is running in a number of pilot sites across Scotland, the aim of which is the greater integration of resource planning between the national health service, councils and the voluntary sector in terms of their social care provision. I have to say that progress is somewhat slow.

There have been a lot of such initiatives, and if they had been in place and achieved five years ago we would be in a much better place to deal with the financial challenge that faces us, which is one of growing demand for health and social care services—from the ageing population, from increasing numbers of disabled people in the population and from the consequences of rising addiction levels—at the same time as there is less money to find solutions to the problems. The great challenge to be faced in integrating resources is how to free the money that is locked up in acute care and hospital provision, which is a bit higher in Scotland than in England, so that it can be put into preventative services at a time when there will not be enough funds to continue with the current service model aims to meet the needs of people with high-level needs. That is the big problem that faces us.

If progress is slow, how can you speed it up? Can you give us some examples of what is not being done or what is slowing the idea and actuality of co-operation?

It is difficult to free up the money that is locked up in existing models of care without having the alternatives running alongside that demonstrate that if we spent money differently—on community rehabilitation rather than on rehabilitation in in-patient wards, for example—we would produce better outcomes at a lower cost. Some of the double-running costs are hard to fund. Although there is some central Government investment for innovation, there is arguably not enough.

Part of the problem is vested interests, which was mentioned with the previous panel. For example, consultants are interested in their in-patient beds. There is a lot of territorialism in the public sector, and we need to find ways of breaking through it. Part of the issue is leadership: there needs to be much clearer leadership and an expectation on health board executives, as well as local authority chief executives, that resources need to be brought together to get better value from the public pound.

In the late 1980s and early 1990s, when we saw the large-scale reprovisioning or closure of long-stay hospital beds, particularly for people with learning disabilities and mental health problems, there was some incentive in the process, such as bridging finance to meet some of the double-running costs. We also saw health boards transferring some of the savings from the closure of those beds to local authorities to continue with the community services. Those mechanisms still exist, and the money is still transferred, but we are not seeing any more money being transferred for similar initiatives.

Mike Brown is right about some of the issues in how things are joined together. I can give an example of an area where health and social work created a joint team. They both had computers, but the computer systems were different, and only health people could work the health computers and only social work people could work the social work computers. There were therefore double-running costs. The health computers had access to the internet, but the social work computers did not. It was a bizarre situation, and the team was not fully integrated.

Another barrier to integration is the lack of trust between different departments and authorities—and, if anything, we are beginning to go backwards. I have a recent example from my own work. We were commissioned jointly by health and social work to provide a service. Our understanding was that we would get a single contract, jointly commissioned, but in fact we are getting two separate contracts so that each body can protect its half of the funding. We are seeing people protecting their own funding and not transferring it to another body, so that they have control of their funding if they have to make savings.

We seem to be hearing about organisational barriers to progress.

I will pick up on a couple of points that have been made so far. To return to the convener’s initial question, the fact that the Government has been investing in the integrated resource framework shows that there is and has been a gap in how well budgets have been pooled. I agree with Mike Brown that the IRF is progressing slowly. It is often difficult to find out information about what is happening, yet the IRF seems to be put forward on occasions as the answer, before the evaluation has come out. To pick up on what witnesses on the previous panel said, there is a risk of running with initiatives before we have tested and evaluated them. I want to sound that note of caution.

Another point that has been made is about disinvestment. If we want to invest more money in new initiatives or new areas or in increasing our preventative spend, given that, in the current climate, we will not be double funding, almost certainly we will have to take money away from somewhere else. We need a much better national process for making the major decisions about disinvestment, which could involve some of our major acute areas of spending. To return again to the previous panellists, there are societal and political interests in how that is or is not taken forward and where the leadership comes from. Without an agreed national process and coherence in how we do it, we will not be able to free up resources to deal with some of the issues that the committee has been talking about and which have been put in the submissions.

I know that Dr Wilson and Dr Burns, and possibly the other witnesses, are interested in the early years. Some of you will have heard the strong view from the previous panel that intervention in the first three years of life is critical in relation to many policy areas. From the evidence that we have heard, it seems that there is a wider consensus on that and that more people are talking about the issue. I will speak personally, because I cannot speak for the world. I have come to the view that that is fundamental and should possibly be the number 1 priority for preventative work and for protecting public expenditure.

If you accept that assumption—and some of you do—the point arises that, although we have identified the early years as important, we cannot spend in a scattergun way across those early years of life. A key question for me is, what are the most effective interventions that can be taken in the early years of life to have the biggest benefit in the long run? That is the benefit that people talk about, but I hope that such interventions would provide benefits in the short run, too.

The problem that we have in looking at what works and does not work is that, as the House of Commons Health Committee concluded last year in its report “Health Inequalities”, we have spent hundreds of millions of pounds on trying to reduce health inequalities and we have learned nothing. There is a pervasive problem of failure to collect robust outcome measures for any of the interventions. So the first thing that I would like to say is that we need outcome measures by which we can judge progress.

I want to focus on language development in children. In my submission, I mention that, in our pilot work in Glasgow, we found that about 10 per cent of two-and-a-half-year-old children had what most speech and language therapists would consider to be substantial language delay, which is more than twice the rate of language delay that has been found in studies in Sweden, for example. We know that children with language delay have a 70 per cent chance at age seven of having a psychiatric diagnosis such as attention deficit disorder, autism spectrum conditions or conduct disorder. We know that children with language delay will have problems when they get to school. They will not be able to understand what the teacher says and it is likely that they will not be able to sit down to pay attention to what is going on in class. Children with language delay are by and large destined to have problems in their lives. I cannot say what the specificity of the test is, but it is certainly a sensitive test for vulnerability in children.

There are several possible explanations for language delay. I believe that the reason why our rates of language delay are so poor compared with those in Sweden are that parents do not talk to their children enough. There might be other explanations, but that is probably a key one. Language impoverishment is a key issue.

15:30

We have dismantled, with the best of intentions, a universal service for identifying language delay. In my submission, I explained in some detail the policy changes that have led to the loss of a universal health visiting service. In my view, the first thing that we need to do is find children with language delay. We must reinstate a system so that we can identify those vulnerable children and offer interventions. We must be systematic and screen 100 per cent of children some time in the third year of life to identify those with language delay. We then need to think about language enrichment interventions and, in some cases, carry out more detailed assessments of the causes of the language delay. There are lots of candidate interventions. We could go on to talk about some of the interventions that might be relevant.

In many cases, the language delay will be associated with major conduct and behaviour problems in the children. We know that children with major conduct problems in the third year of life will have conduct problems later on. Many of those children are the children whom John Carnochan spoke about so eloquently, who will run into trouble later. Well-proven interventions, such as the incredible years programme and the triple P parenting programme, are known to reduce conduct problems in the third year of life. There are a lot of interventions and we must put in place a system to identify vulnerable children.

There is no single answer. The reason why we have been so unsuccessful over the past 20 or 30 years in the United Kingdom in narrowing health inequalities is that the problem is very complex. If there was one thing that we could do to fix it, we would have found it and done it. There is a complex set of issues, and our response should involve a lot of what you have already heard about this afternoon.

I was recently invited to a Nordic Council conference. I was the only person at the conference who was not from a Nordic country and I was there to talk about Scotland’s approach to health inequalities. My opposite number in Iceland put up a slide of infant mortality rates in the Nordic countries plus Scotland. Although Scotland has the lowest infant mortality of any of the UK countries, at 4.2 deaths per 1,000 live births, Iceland’s infant mortality is 1.9 deaths per 1,000 live births, which is the lowest in the world, and the other Nordic countries are all slightly above that figure. They achieved that through a step change in how they looked after children in the early part of the 20th century. Their infant mortality figures used to be much higher than in the rest of Europe, and now they are much lower.

As John Carnochan said, we need to adopt a combined approach to change attitudes to children within society. I have heard him say that many times, and he is right. It is sad that as a civilised country we are having to talk about how we nurture our children and to think about ways of doing that, but we have to change our attitudes to the way in which children are nurtured and we have to support parents in doing that through a number of organisational interventions.

The organisational interventions that we should start off with are all things that we know work. We should get young women into maternity clinics early on in their pregnancy and we should get them to stop smoking. Undoubtedly, somewhere we have a target for maternal smoking rates that is not zero, yet we know that if women smoke during pregnancy, their baby will have a low birth weight, and that low birth weight is the biggest single cause of death during the first year of life. It is ludicrous if we have a target for smoking in pregnancy of 20 per cent. How many dead babies is that? We must set the target at zero and set the target for alcohol consumption at zero, because we know that alcohol also harms babies.

We should teach parenting during pregnancy and support both parents in dealing with the baby during its first year of life. We should then move into the educational interventions that Philip Wilson talked about. We should encourage mothers to read to their babies, we should get the children into school early and we should measure at age 5 their readiness to learn when they hit school, which involves both their social and intellectual skills.

East Lothian Council will shortly implement an educational development questionnaire. If, as a system, we did consistently and at all times for every parent and each baby all the things that we know work, we would make a huge difference to the capacity of our kids to behave appropriately. We could do that within five years. Once children reach school, we can move them into nurture groups, which take place in a special area of the school. A number of local authorities are using such programmes for children who are poorly socialised—I am thinking in particular of Glasgow City Council. Those children do not know how to use a knife and fork—they eat with their hands—and hit people instead of talking to them because that is what they have experienced pre-school. At the end of the process—typically, it takes two terms—the children are significantly better; their readiness to learn is improved. I am saying not that one intervention is better than another, but that we should do consistently throughout the early years, school and into the workplace that which we know works. There are a whole load of things that we can do; we need to stitch them all together.

Fundamental to all of that is consistency of parenting. Mr Chisholm has seen me take a journey on this. Over many years, I have tried to link adult ill health to the various biochemical changes that are associated with socioeconomic status. I first noticed the link when I was a consultant at Glasgow royal infirmary. It is now utterly accepted in the scientific literature that those biochemical changes have their origin even before birth. Babies in utero whose mothers experience domestic violence develop certain changes to the genes that control the stress response; they become unable to modify their stress response in later life. Not only that, they pass on the abnormal genes to their own children. Domestic violence is incredibly toxic to unborn children. There is now a whole range of evidence on that in the literature. We did not discover it; Canadian scientists showed us the evidence.

The literature shows that exposure to hazardous, difficult and inconsistent circumstances pre-birth and in the early years of life leads to changes that increase the risk of heart disease, cancer, diabetes and so on in later life. We absolutely need a consistent approach to parenting. We need to teach young mothers who have not learned how to empathise and attach to their babies to do that. This work is critical. At the same time, the system needs to put in place a consistent set of support interventions throughout the process. We are not talking about just one thing.

That is all very helpful, but should the range of measures that Dr Burns and Dr Wilson have discussed be targeted or universal? For example, do we need a certain level of universal provision to pick up on the language issue that Dr Wilson highlighted?

In part, the reason for our failure has been that we have tried to target and identify individuals. We have said, “They need this, but they don’t.” If the service is available to everyone, folk who genuinely do not need it will not access it. The system should be set up so that the default position is that every baby and every mother is supported; in that way, no one will fall through the cracks. When we spoke to East Lothian Council about how to start measuring child development, we talked about starting about age three when children go to kindergarten. The problem is that the children with problems do not go to pre-school and so miss out. The one place that we get all of them is at age five when they go to primary school.

Some of the stuff about territoriality and failure to address problems comes down to the fact that we have carved up the landscape in ways that make it too easy for organisations and institutions to ignore certain parts of the population. I note the experience of my colleagues in Scandinavia, where everybody has access to the same service. It is not expensive: it is not as if we are building heart transplant units all over the place.

There is a quality improvement programme in the health service, and it is proving to be extraordinarily successful in changing a number of adverse events in hospitals. The key point is to do the right thing with the right people all the time. If we had that mindset in our public services, it would not take long to make a difference.

Could you follow up on that? On what timescale did Iceland and the Scandinavian countries work to achieve clear long-term results? What resource levels were used? Could Scotland do it?

I have no doubt that we could do it. During the 1960s and 1970s, Iceland had a higher infant mortality rate than the other Scandinavian countries. Progressively, Iceland caught up and overtook the other Scandinavian countries, over about 10 or 20 years.

Reference was made earlier to the indicators—the things that we should be measuring in relation to child health and so on. There is one important indicator: healthy life expectancy. That is the summation of all the other influences, from early years through working lives into old age—it all comes together to tell us where we are at. Scotland’s healthy life expectancy has been going up progressively year on year, although other western European countries have been outstripping us.

Socially and economically deprived areas have the slowest gains in healthy life expectancy. Take areas of eastern Europe that experienced the same kind of industrial collapse that west central Scotland experienced. From 1989 onwards, the countries in that area have increased healthy life expectancy at a stratospheric rate. When the iron curtain came down, residents of those countries developed a greater sense of control over their own lives, and they showed a degree of resilience that has been returned through a step change in healthy life expectancy gains.

Take, for example, Katowice in Poland—there is also an area of the Czech Republic, although its name escapes me at the moment. In the Czech example, healthy life expectancy was three or four years lower than the level in Scotland in 1990. Czech women have already overtaken our women in healthy life expectancy, and the men are about to do so, too. It is possible, if we change the way in which we work in our society, to produce great step changes in health.

I will add something about universal services as opposed to targeted services, and the tension and difficulties around that. If there is not a universal approach to identifying children with language delay, and instead a formulaic approach is taken to predict what might cause language delay, half of all the children affected will be missed. That is what we found in our study in the west of Glasgow: 50 per cent of the children with substantial language delay had not been classified as vulnerable up to that point. Unless we ask all parents what their children’s language is like, we will not pick up half of the cases. We need some kind of universal case-finding service, if it is not possible to construct a standard of education such that everybody knows what to expect with their child’s language. So far, we seem to be a long way from that. We need a universal case-finding system that actively looks for problems in children, so that people can be offered appropriate services at an appropriate level.

There is a further issue concerning universal access to services. We know about this from countless pieces of work on health inequalities, and I mentioned Julian Tudor Hart’s phrase “the inverse care law” in my submission. In other words, the likelihood of getting care is inversely proportional to people’s need for it. We all know that it is pushy, middle-class parents who are most likely to access services, because they know how to get them.

In my view, we need a mechanism for ensuring equity of provision of services so that the people who need the services are most likely to get them. That involves some systematic way of assessing the severity of people’s problems so that they can be helped to find the right service. If we do not have a mechanism for evaluating the level of somebody’s problems, unfortunately the people who are most able to negotiate the system will get the services while others will not. There is a need for a universal service, for case finding and for some systematic assessment of the level of need, at which point people could be directed to services.

15:45

Does that exist anywhere?

In virtually every other country in Europe. I had some visitors from Seville last week, and they were horrified that we have abandoned universal child health surveillance in Scotland. Colleagues from Scandinavia are absolutely horrified that we have dismantled universal contacts with children in our health service. In Denmark, you will expect, as a right, a dozen contacts with a nurse before your child goes to school—everybody gets that. In most areas of Scotland, once your child reaches four months of age, if you do not have any identified problems, you will have no contact with the health visitor.

I will come in on that point. Harry Burns has talked about the increase in understanding of what may not have worked over the past 15 to 30 years. I have a real sense that our understanding of how we need to respond as a profession has also changed as we better understand some of the causes of the long-term effects that we see.

There is a real opportunity for us. Nursing is by no means the only profession that is involved in how the issues are addressed, but from looking at things such as the equally well strategy and from listening to what Phil Wilson has said, we know that health services—and nursing in particular—have traditionally had that on-going universal contact with children and parents at a very early age. I want to flag up to the committee that the Government is looking at the future structure of community nursing. We have a modernising community nursing board, the timing of which is such that, with the evidence that Harry Burns and others are producing and with our improved understanding—which is still not complete—of what might be causing the issues and how we might best respond to them, we have the opportunity to look at how our community nursing teams can respond in future to deliver the best outcomes. The timing is fortuitous.

Since we started the inquiry into preventative spending, most of the witnesses we have questioned have spoken about the spending side and how we should be spending more money on various things. I guess that, with the cuts coming from Westminster, we would have hoped to hear more about the actions that we can take to prevent us from having to spend.

There cannot be many magic bullets, but in the previous session of Parliament one was found in action on smoking. We are now seeing the benefits of that relatively inexpensive action, which is saving money on a daily basis. Dr Burns spoke about the other possible magic bullet that could save us money for a relatively small investment—dealing with our alcohol problem. In his submission, he talked about saving £83 million over 10 years. Will the witnesses tell us how important tackling Scotland’s alcohol problem is to their area?

On many of the major causes of death, Scotland is doing rather well: we are getting closer to the European average for lung cancer, heart disease and so on. There has been a 50 per cent reduction in heart disease mortality in the past 10 years, a lot of which is due to the impact of the smoking ban—there is no question about that.

Our position in relation to alcohol is appalling. As other European countries see falling alcohol mortality rates, the UK as a whole and Scotland in particular are seeing significant increases in deaths associated with alcohol. That is not just because of liver disease. People do not appreciate that alcohol is a significant contributor to breast cancer mortality, for example. In my written submission, I list a range of conditions in which alcohol has been incriminated, which include mouth cancer.

The return from any action to control alcohol consumption would come fairly quickly. Within the first year or two of taking action to limit the availability of alcohol, which is the quickest way to control the issue, we would have significant reductions in deaths, particularly from directly alcohol-related causes and social causes such as drunk driving and violence. It is for Parliament to determine the approach, but there is no question in my mind but that raising price and reducing availability through controlling licensing must be the way to do it at the start.

When I first took on my job, I fervently believed that a cultural change had to happen. That might still come, but the reality is different. When I was at the Glasgow royal infirmary, when I told patients to stop smoking, the reply that I got on umpteen occasions was, “If smoking was really that bad for you, the Government would do something about it.” The Government has to send a signal and take a stand on alcohol. We can then get on with changing the average Scot’s relationship with alcohol. However, limiting availability in one way or another will produce rapid benefit.

The RCN was a strong supporter of many of the measures that were originally proposed in the Alcohol etc (Scotland) Bill. There is a need for Government to take a stand, as Dr Burns said, and measures on seat belts and smoking have been mentioned. Some of the research that went into the equally well programme considered the importance of such national initiatives in changing behaviour. They are important, but there are other interventions that, if well invested in, work. Brief interventions by doctors or nurses have been shown to have a major impact on alcohol use. In our written submission, we told the committee about a project in Belfast involving alcohol liaison nurses and the savings in terms of bed days that a particular hospital made. There are initiatives out there that we can invest in to save money over the longer term.

Community Care Providers Scotland members’ experience of alcohol is that it probably affects all our services in different ways. Whether we are working with young people, some of whom might be binge drinking, parents, whose children might be affected by their drinking, people with mental health problems or people with offending backgrounds, alcohol gets in the way of much of our work and often inhibits the progress that we can make. If people are not prepared to address their problem drinking, that is a problem not just for them, but for those of us who are trying to provide services for them. I cannot give you figures on the impact, but I know that problem drinking is one of the single biggest reasons why people are asked to move on from services or why services are refused to people. Drug taking is also an issue in some cases. Problem drinking is a significant issue.

I want to mention the impact of alcohol on early child development. If a mother consumes alcohol through pregnancy in substantial amounts, there is a risk of direct damage to the child’s brain. I do not need to dwell on that, but it is an issue. Whether tiny amounts of alcohol can cause damage is up for debate, but that is not a debate for now.

Alcohol is also a tremendous problem in relationships between parents and children. It is a common factor in intrafamilial violence and harsh parenting. Perhaps more subtly, it is a common factor in child neglect. We have paid insufficient attention to the effects of neglect on children. The headlines are all about child abuse, but in the vast majority of cases, the key factor in neglect is the failure of a parent and child to attune with each other because the parent’s mind is on something else. The mother’s mind can be taken off the child because she is concerned that she will be the victim of violence or she is dependent on drugs or alcohol.

A real difficulty that we have with children’s services, social work services and health services is that we have failed to be systematic in assessing the effects of alcohol or drug use on children. We need to find a way of paying attention to the child’s state of mind when we are assessing whether they will be safe to remain with a family in which there is problem drug or alcohol use. Pilot work is beginning in Glasgow on the New Orleans model of child protection, in which the attachment relationships with parents of children who come into the care system and are suspected of having been abused or neglected are carefully assessed. We need to pay attention to the way in which the child presents so that we can make decisions about the level of help that the family needs. The effects can be quite subtle. For example, a child can be overfriendly with strangers because their parents do not pay any attention to them. We need to focus on the child in assessing the severity of the impact of alcohol and drug use.

I have two questions, the first of which is about alcohol and health. We got a fair steer, certainly from one member of the previous panel, that we have to think big and take radical action, and I think that there is unanimity on this panel that our alcohol record is appalling. I think that the chief medical officer said that.

There is an interesting table in Scottish Government officials’ evidence to the committee. If I understand it rightly, it says that the cumulative spend on the NHS in Scotland over the next 10 years will be just short of £100 billion and that a minimum alcohol unit price of 45p would mean a cumulative saving of £83 million for the NHS. An £83 million saving on a budget of nearly £100 billion is not big. The submission states:

“The aim is to shift priorities and resources from damage limitation to prevention and early intervention.”

That is the thrust of the report. How much have you seen of resources that have been shifted in your respective areas? Is a process under way to shift resources?

In terms of alcohol or in general?

I am using alcohol as an example. I have not detected a big shift.

I have done something on that. I was going to send the committee a copy of a paper, but it is in a book that is now out of print. If I find the book, I will send the committee a copy of the paper.

When I was director of public health in Glasgow, around 15 or 16 years ago, we did quite successful work in gynaecology services. We undertook a programme budgeting with marginal analysis process. Basically, we sat down and counted everything that we spent on gynaecology services in the city, from cervical screening in primary care all the way through to palliative and terminal care for gynaecological malignancies. Off the top of my head, I think that the programme budget 15 years ago was around £18 million.

We asked the nursing and medical clinicians and allied health professionals what they could do differently that might free up resources. At the time, the technology for a range of in-patient procedures was changing. The nursing and medical clinicians and allied health professionals said, “If you buy us that equipment and give us appropriate space, we will do the things that we are doing for in-patients on a day-case basis out in the clinics,” so we did that and saved something like 60,000 bed days a year, which is equivalent to about 20 beds in gynaecology in the city.

We then shut those beds and told the clinicians that, as part of the deal, they could spend half the money that the savings freed up. The changes in the configuration of Glasgow’s gynaecology beds saved the health board about £1,500,000. The clinicians asked for an enhanced oncology service for gynaecological malignancy, so they got extra staff to run that, and the city also got five or six new physiotherapy posts to develop an incontinence service for women in the city.

That is a demonstration of how PBMA frees up money.

16:00

I do not want to interrupt, but it occurs to me that, even though the health budget is four times what it was 15 years ago, we are still asking about the same health outcomes as we were then.

The reason is that finance directors do not like programme budgets because they are ring fenced, which limits their capacity to make trade-offs across the whole of the system. Not using programme budgets limits your capacity to decide in a vertical sense where the trade-offs will be. With a programme budget, you can work out how much you can spend to prevent ill health, when the benefits will come through and what the impact will be on fixed assets such as property, which allows you to see exactly where you are. However, finance directors do not like it. I have lost track of the number of times that I have said, “Why don’t we try programme budgeting?” Finance directors feel that it makes it harder for them to deal with the very difficult financial problems that they face.

You mentioned the savings in relation to alcohol and so on, but I am not sure whether that counted the savings that might be made across the wider public purse. I think that those savings were for the health budget alone, but there would be knock-on savings to be found in housing, social work, education and so on.

At the moment, the savings that are to be made do not necessarily benefit the people who make them. For instance, if social work were to invest in an early intervention programme, the savings might accrue to the health service, but that money would not be released from the health service to cover the cost of the investment that social work made. That is a big problem. Investment by the social work department might save money in the housing budget, but that saving is not transferred to social work.

I do not know whether those budgets are programme budgets, but they are budgets that people hang on to, which causes a problem. We talk about outcomes, and the Scottish Government sets out the outcomes that it wants to achieve, but the money is sliced into departments and institutions and is somehow supposed to come together again at the front line to achieve the outcomes. We need to stop budgeting for departments and start budgeting for outcomes. We need to ask what the outcome is that we want to achieve and what the total budget is that we can put towards that, regardless of whether it involves housing, health, social work or education.

That is absolutely right, but we also need to consider the issue of time. Although investing in preventative spend might well result in some fairly quick outcomes, we are being asked to save money not only between budgets but over time. After all, the NHS finance directors that we have been talking about are under immense pressure to make their 2 per cent cash-releasing in-year efficiency savings. There is no easy way of banking efficiencies over time within departments, never mind across departments, and real tensions could arise between Government policy or political will that seeks to move towards dealing with health or social care outcomes over time and a budgetary process that makes it very difficult for finance directors and senior clinicians to make such decisions.

Perhaps I can give an example. At 2002 prices, prevention of conduct disorder, which tackles extreme antisocial behaviour in children, costs by age 28 about £100,000 in extra services. A large part of that £100,000 falls on education, to meet the extra costs of additional educational support, and some of it falls on social work and criminal justice but, by age 28, relatively little falls on the health service. There are excess costs to do with overdoses and problems related to substance use but, as I say, most of the cost falls on non-health services.

However, at the moment, most agencies see early identification and prevention of conduct disorder as a health service responsibility. Health visitors identify such cases and until very recently interventions were largely delivered by health psychologists and health visitors. The pay-off for the health service does not occur until well over 20 years in, whereas the pay-off for education services probably happens about seven or eight years in. However, all those things are well beyond a Parliament’s lifetime.

Is there any answer to that problem?

I see no other answer than to make specific, targeted investment now in early years services, simply because I believe that that will save a substantial amount of money later, possibly beyond the tenure of many parliamentarians.

So the solution itself brings its own problems.

As has been rightly pointed out, the central problem for the Parliament and the Scottish Government is that, although certain very important initiatives, such as those on smoking and alcohol, can make inroads and will make a difference, the percentage that each of them saves to the public purse is not massive compared with the spend. They will improve our healthy life expectancy and reduce our mortality rates, but a lot of evidence suggests that there will still be massive health inequalities in our society linked to a lack of equality in the distribution of wealth, status and power.

What can be done? Well, with regard to the examples that have been highlighted, some appropriate leadership is required. One of the reasons why health boards and councils do not carry out better financial planning is that they receive their yearly allocations at different times in the financial year. Unlike councils, the NHS often does not know its final budget until after the start of the financial year. One would have thought that it would be easy for the Scottish Government to resolve that situation. As for Harry Burns’s advocacy of programme budgets with marginal analysis, that has been a central Government initiative in England and Scotland. However, if it is felt that such an approach will deliver the solution, why has there not been more leadership from the centre in that regard?

Ultimately, the only way in which we can turn around the huge amount of money that is locked up in things such as prison that do not work or in acute in-patient facilities, when in fact the money would be better spent on lower-cost community health and social care measures, is to begin to think about top slicing allocations to those things to ensure that we save more money to fund prevention measures. Otherwise, I cannot see how we will realise that approach.

We started off this evidence session with Nigel Henderson’s anecdote—or should I say true statement—about the inability of two different parts of the public service to get their act together to meet the task in hand, and we have now returned to a discussion on programme budgets and so on. Is it the case that if people at all levels of bureaucracy and society who make their living from the public purse recognised that fact and worked for the public good, a lot of preventative spending would already be going on?

I feel very strongly about this. Over the past year or two, since a number of us who have been carrying out research internationally in this area pretty much agreed the fundamental psychosocial drivers of health inequalities, I have been looking quite closely at the kinds of interventions that seem to correct some of that imbalance. At this point, I should say in response to Mike Brown’s point that this is all down to inequality in society, that that is not the case. That fallacy comes from an epidemiologically very flawed book called “The Spirit Level”, but that is another point.

I note Mr Brown’s dissent.

I did not say that it is “all down to inequality”, but a lot of evidence—some of which is in “The Spirit Level”, some of which is in Michael Marmot’s inequalities work and a lot of which comes from cohort studies of civil servants—shows that income, status and power have health effects and quite a lot of biological work has also been carried out on the various causal mechanisms. Unlike Harry Burns, I am not a doctor and obviously we do not want to spend the committee’s time discussing the issue, but my point is that it is not quite as done a deal as Dr Burns is suggesting.

I think that you have made your point.

As it happens, I have done a lot of that biological work, but let us not get into that.

Please do not.

All I will say is that Richard Wilkinson has significantly oversimplified the problem, which is often the case in this matter.

The interventions that are most effective in changing individuals’ health behaviour are those that—for want of a better word—activate them. The public sector—by which I mean the public sector in the UK, not just in Scotland—tends to do things to people, but the successful programmes, projects and organisations do things with people by, for example, finding their internal assets. John Carnochan is a case in point. He works with gang members and develops things to a point at which those people suddenly wake up and say, “Hey, it doesn’t have to be like this. I can make choices in my life that do not involve having a fight every Friday and Saturday night.” The activation of a sense of control in individuals is a key element in all of this.

Instead of working to the paradigm of meeting deficits in individuals’ lives and telling them that, as they are deprived, we will do certain things to them to deal with those deficits, we need to find what people are capable of doing and, through engagement, to activate those assets. Too often people report how in their meetings with public servants they are simply talked at and told what to do. In the really successful interventions there has been genuine engagement and at the end of the process people feel that they have had a share in finding a solution.

The best example of this is a programme in the Beacon and Old Hill area of Falmouth in Devon. Although in the 1980s there was full employment in the area, the naval dockyard closed down and, by the early 1990s, Falmouth was known locally as Beirut.

Two health visitors changed that place. They wanted to recruit local people to participate in the process, so they wrote down the names of 20 people whom they thought would help, and 15 turned them down. So two health visitors and five local people turned the whole place around through engagement with individuals, building social networks and activating skills that were dormant in the community. Five or six years later, the statistics on issues such as teenage pregnancy, criminality and post-natal depression have all turned round.

Linda Fabiani is right that the attitude and the way in which the public sector engages with individuals needs a lot of careful thought. I would put in a lot of effort on culture change.

16:15

Although Community Care Providers Scotland is not in the public sector, we provide public services, many of which take exactly the approach that Harry Burns has outlined, in that they are person centred and consider people’s assets. That is not always easy, because we are not always in a funding environment that encourages us to do some of those things. We hear a lot from local authorities about their duty of care to people. Unfortunately, that often means that we take people into the system, wrap them up and hold on to them and make them dependent. I would far rather that, instead of a duty of care, the mindset was about a duty to promote independent living. That gets us thinking differently—rather than doing things to or for people, we are doing things with people and constantly checking to consider whether we can let go and back off a bit. There is a tendency to make people more dependent on services than they need to be.

I could not agree with that more. One initiative that my council, the City of Edinburgh Council, has been doing in the past couple of years is called home care reablement. That is particularly for people who come out of hospital and who need to have their abilities reinstated. They are given practical assistance and are encouraged to do things for themselves. That change in philosophy has had a huge impact on our service and is being developed across Scotland. We learned from work in England. There are significant savings in doing that. They will not be enough to offset the likely expenditure reductions, but they will make a contribution.

The change in mindset and the overall care philosophy that Nigel Henderson has just outlined, and which Harry Burns mentioned in speaking about community development ideas and working with communities to develop resources in the community, are a really important part of prevention and making better use of the public pound.

I agree with much of what Mike Brown said. Most people who work in the public sector, whether in direct taxpayer-funded services or indirectly through the voluntary sector, do so because they have a genuine desire to make a good difference. It is worth remembering that those employees, whomever they are employed by, are part of wider society and bring in the culture that we as a society run with. What is being described is a fairly major cultural shift generally. Our staff are part of that culture, too. I absolutely agree that if we are looking to take an enablement approach and to build on the assets of the public and voluntary sectors and the communities with which we work, we need to nurture our staff to allow them to make that shift, as much as everybody else who is having to make it.

As well as being an academic, I am a general practitioner, which is another perspective. As a GP, a third of my salary depends on my performance. That GPs are being encouraged to improve performance is part of the reason why the number of cardiovascular deaths has dropped dramatically in the past few years. GPs are paid to take a systematic approach to identifying people who are at risk of cardiovascular disease and then to screen them, get their blood pressure under control, monitor their cholesterol levels, give them aspirin and so on. If we do not do that properly, we do not get paid that bit of our salary.

I think that a strong case can be made for more public sector workers to be paid for their performance in improving outcomes that are relevant to preventative care.

The other problem that we have on incentives is that there are often disincentives for people to get better. People worry about the fact that we have highly linear systems—it is a bit like playing snakes and ladders, I suppose. Once someone gets hooked into the system, they will get additional benefits and they might get support or whatever. The worry is that if they start to show progress, they will lose that support and go back to the beginning again. In that way, we create dependency.

How do we incentivise people and make them want to change their lives? How do we help them to move forward? There has been quite an interesting development in mental health over the past few years. We used to run a lot of sheltered employment projects, which would involve people doing work in an extremely sheltered environment or being trained to do work but not necessarily going on to get a real job doing that work. Many services have moved to the individual placement scheme, which involves supporting people first to get a job and then to keep it. The training comes later. There is no point in training people for jobs that they will not get. Once people have a job, they will have a social role, a value and an economic ability that will start to change their lives. It is about adopting a different way of thinking. Instead of offering people a nice wee job on the side filling envelopes or whatever, we need to ask what assets and skills a person has and how we can place them in a job and support them to keep it.

I can offer an anecdote that supports that. There is a hotel chain that operates in the UK that has a specific policy of employing young people from deprived areas. The lady who runs the programme once told me that if she took on a girl from a deprived part of Glasgow and gave her a job as a chambermaid, she would work for the company for six months very satisfactorily and then she would leave and the company would never see her again. If she put that girl behind the front desk, gave her a uniform and taught her how to work the computers, how to deal with difficult customers and so on, she would work for the company for two years and then she would leave to go to college. I am talking about the business of activation. If we give people responsibility and opportunity and support them as they learn to cope with that, we do not know where they will end up—they will surprise us.

However, the point at which we activate people is often the time when we withdraw support. We say, “Oh, you’re managing fine. You’ve got a job, so we’ll take all the support away.” We need to think about how we can follow that support through and continue it.

I think that I will have to draw the session to a—

No, I am not finished yet, thank you.

That is all very well but, with respect, the panel seems to have answered the question that I put to the first panel. What I want to know is whether preventative spending would already be going on were it not for the bureaucratic barriers that exist across organisations, for all the reasons that we have heard about. Is the level of self-interest among bodies that use public service funding, whether charities, local authorities, health boards or umbrella organisations, preventing the cross-organisational working that would allow the public interest to be properly served? If that is the case, do we need to sort that out before we can be serious about spending that is truly preventative?

Who wants to comment on bureaucratic barriers and self-interest?

A huge amount of NHS money goes into preventative spending, specifically around health care interventions such as screening and immunisation. Programmes such as the keep well programme are directed at identifying and managing people with risk factors. As Philip Wilson says, his job is to manage the folk whom those programmes identify. There are large amounts of preventative spending—

That is within a single organisation. If we go back to Nigel Henderson’s anecdote, it illustrated the thinking that stops sensible initiatives going ahead. Everyone thinks, “Oh, no. That’s my budget and I won’t get recognition for that.”

Within community planning partnerships and so on, there is evidence of interventions developing across agencies—local authorities, the health service and the third sector—very effectively. It is happening at different rates in different areas. In part, that is dependent on the complexity of the relationships in those areas, but it is happening. My point is that it needs to happen faster and needs to be built very firmly into the public sector ethos.

A colleague from Canada has examined school readiness and has produced some marvellous maps, initially in Vancouver and British Columbia and then further afield, of school readiness: which children were and were not ready and what particular issues were stopping children being ready for school. When he showed the maps to politicians and policy makers, the response was, “Why is my area worse than his or her area? What are you going to do about it?” That was a stimulus for service improvement, because it became competitive. Because people were identifying their area as having a particular problem, policy makers who were responsible for that area and politicians who were responsible for that area, or were answerable to the people of that area, were moved to knock heads together to make services work properly. Although a spirit of collaboration is essential, a little element of competition can also be useful.

I do not think that I will comment on self-interest and other things, but the notion that we could do things differently arises partly because people are sometimes inhibited by the risk-averse culture that they work in. We have overbureaucratised a lot of things and we are sometimes reluctant to give people responsibility. In a couple of the examples that Harry Burns gave, including the one of the two community nurses down south, it sounded to me like they were people who are prepared to step out of the mould and maybe break the rules or stretch them a wee bit. Why do people have to break the rules to make a difference?

If I go back 20 years—more than that, in fact—to when I started in the voluntary sector, we were often characterised as the people who were doing things that were a wee bit difficult. We were often looked down on. We were not seen as equal partners and we were often seen as being fairly well-meaning do-gooders, but it is interesting to note that the models that we created at that time are now the mainstream models. Supported living, supported accommodation, getting people into real jobs and so on came from the voluntary sector and from the creativity and flexibility that exists in the voluntary sector because we are often not as hidebound by bureaucracy—although I have to say that that has increased over the years and we are now quite heavily regulated, which means that we have to fit into certain strands.

I do not think that people set out to be self-interested, but the processes start to militate towards people being worried about someone pulling them up for not doing things right as opposed to for not doing the right thing, to paraphrase one of the previous panellists.

In the recent English work on health inequalities and the social determination of health—part of which is captured by what Harry Burns says and part of which, I believe, is not—the figure that is given for preventative spend in the NHS in England is 8 per cent. I do not know what the figure is in Scotland, but I would be surprised if it is much different. That is not a high proportion of spend. Why is that the case? It is wrong to think that bureaucrats are somehow stopping preventative expenditure and are not being innovative and so on. Bureaucrats are delivering services according to the current statutory frameworks and sets of guidance that are laid down by Government in legislation and so on. They are not, by and large, sitting as a vested interest and stymieing innovation, although at the boundaries there are problems, some of which I have mentioned.

16:30

We come back to the problem that the majority of public expenditure in health and social care and in criminal justice is locked up in meeting acute high-level needs in expensive ways. In my area, roughly half the budgets of social work in local authorities is spent on accommodation, despite the fact that we have policies on caring for people in their own homes. Even though we are implementing those policies with enthusiasm and vigour, half of our spend is still caught up in accommodation. We are accommodating people who would have been in long-stay NHS beds 20 years ago because we are doing work that the NHS used to do.

The question is how, in a period of radical expenditure reduction, we can move expenditure away from meeting the needs that have to be met. Acute high-level needs are not going to go away if we decide to stop spending money on them and instead to put it into prevention. That is the real difficulty through which we have to find our way. I have suggested that we look at some kind of innovation funding or preventative funding, but top-slicing makes the task difficult. We have to raise efficiency targets in the NHS, for example, to release money. We need to put the accelerator on to achieve more with the integrated resource framework work. However, there is no easy solution. If I thought that it was just a matter of knocking a few bureaucrats’ heads together with my own, I would recommend that.

Convener, there is some defensiveness going on, so I will clarify that I am not talking about individuals’ salaries and jobs; I am talking about the culture of some institutions in our society. It becomes an all-pervading culture that affects everyone. I just clarify that I am not really after your head, Mike.

I have to draw this to a close. We are looking for practical well-thought-out schemes for innovation and changing the way of doing things for greater effect and impact on those who receive the services and are part of the community.

We have had a detailed and good session today, for which I thank all our witnesses. I will now allow a short suspension to let our witnesses leave.

16:32 Meeting suspended.

16:33 On resuming—