Budget 2012-13 (Preventative Spending)
Item 2 is a round-table discussion on the Scottish Government’s response to the committee’s report on the 2012-13 budget, specifically in relation to preventative spending.
I welcome to our discussion John Downie from the Scottish Council for Voluntary Organisations; Dr Laurence Gruer from NHS Health Scotland; David Dorward from the Society of Local Authority Chief Executives and Senior Managers in Scotland; Ron Culley from the Convention of Scottish Local Authorities; Angela Cullen from Audit Scotland; and Mark McAteer from the Improvement Service.
As we are taking evidence in a round-table format there will be no opening statements and we will proceed straight to questions. Anyone who wishes to ask a question or make a contribution or statement should feel free to do so.
To give you a wee bit of background, the committee is keen to focus on how preventative spend is becoming embedded across public service delivery; whether budgets will be better pooled; and how good examples of preventative spend will be identified and assessed and then shared and rolled out when appropriate.
John Downie will start us off by talking about the importance of community-based interventions.
John Downie (Scottish Council for Voluntary Organisations)
Thank you, convener. We submitted a briefing note to the committee on preventative spending. People are talking about building community capacity, and in our analysis the change fund plans that were submitted last week show that the third sector is in some senses pigeonholed and restricted in that regard. We need to define what we mean by community capacity. Is it the capacity of small local organisations to deliver public services? Is it about helping the most vulnerable in society? There are a wide range of possible definitions.
For us, it is about focusing on what those plans will mean, and what prevention actually means. There has been a great deal of rebadging of existing programmes as prevention so that they sit within certain budgets and with the prevailing flavour. Overall, there is a greater emphasis on prevention, which is to be welcomed. I will talk later—perhaps in response to members’ questions—about our initial response to the change funds.
I will give a practical example of community capacity. I am chair of a social enterprise, Impact Arts, that is based in the east end of Glasgow. We are launching a report this morning with the Minister for Public Health on the work that we have done in conjunction with Cassiltoun Housing Association and Elderpark Housing Association on how the social return on investment model helps older people with regard to social isolation.
Helping older people to re-engage with society is a prime example of community capacity. The benefits for them are improved wellbeing and better health, and I will happily submit the report as evidence. We broke down the benefits into those that applied to older people themselves and—most important—those that applied to the national health service in terms of reduced visits to general practitioners and less requirement for treatment. The scheme was a small pilot, and we will continue it. It shows the benefit of community capacity in an arts organisation that is working with older people and in some cases with young people.
We need to look at what we mean by community capacity and examine where prevention exists. Not all third sector organisations deliver public services, but they can build capacity.
Another example is community jobs Scotland, which the Government continues to fund and which gives young people support and real jobs, mostly in community organisations. Its work is building not only the capacity of those organisations to do more for people but young people’s skills, experience and knowledge and giving them an opportunity for the future.
I think that John Downie heard our previous evidence session, so I hope that I am not catching him on the hop. Towards the end of the session, the director of the IFS suggested that, as the longer-term demographic challenges that the country faces put more and more pressure on health, pensions and so on, further cuts in public spending will be necessary. As the convener has indicated and as Mr Downie will be aware, we have been doing a lot of work on preventative spending, which we did not actually discuss with the IFS, and one response to the projected increase in public spending on acute services is to invest in prevention to reduce demand and offset a potential rise in costs.
I know that the SCVO is worried about the impact on the voluntary sector and the fact that those services seem to be the first that local government and other partners are cutting, but do you have any views on using social finance to offset that potential cut, make the necessary investment in preventative spending and deal with the longer-term problem of the projected growth in costs that the IFS highlighted?
Where do I start? In the long term, as we move into the preventative spending agenda, we will be looking to intervene before needs or problems arise. At the moment, we seem to be talking about preventing problems from becoming crises. Social finance has a place, but although the evidence from the small number of pilots shows some good indications, no one has yet taken it up in the belief that it will really work. Having looked at how we might use social finance effectively in the reshaping care for older people agenda, we think that it can work, but we would need to be very clear about the outcomes and savings we would want to achieve. There is probably only a small number of very achievable outcomes and, to really try out and test such an approach, we need investment from the Scottish Government, the Big Lottery Fund and other funders. Obviously there are various key areas to target such as the reshaping care for older people agenda that I mentioned and areas of justice such as offending and reoffending rates.
Social finance seems to have gone off the radar over the past year. It is still around, but those who are assessing the pilots and what has happened so far are asking how it will work on a practical level. That is, indeed, the issue for us. We think that it has potential and the SCVO has even said that it is happy to invest in it with others in the third sector to find out whether it actually works, but as yet no good proposals have cohered around it. The question is difficult to answer at the moment.
I raised it merely as a proposal that might stave off some of the potential cuts in the important work that your members carry out locally and to find some means of bringing in additional money to prevent those cuts from happening.
I think that, with the move to the preventative agenda, attitudes are changing. There is more of a recognition that we are all in this together and more opportunities are emerging in the third sector. As far as the change fund is concerned, the third sector is restricted in some ways; nevertheless, we are making in-roads.
Of course, the situation is different in different areas. Many local authorities are investing in their third sector, others less so. We have always said that the third sector needs to step up; prove its case about the impact that it has on, and the difference that it is making in, people’s lives; and set out the facts and figures that demonstrate that difference and the savings that it can make. It is easy for us to criticise local authorities and public sector agencies, but the onus is on us as well.
In the previous evidence session, someone referred to tipping points. The third sector has the opportunity to do much more in, for example, the integration of health and social care, but it will mean a change in attitudes and culture. I am not saying that we have gone far down that road, but we have certainly started the process of change.
Many third sector organisations that are funded mainly by local authorities will be finding out how much they will get over the period and what authorities will want them to do. One of the big changes that needs to be made relates to the procurement process, which I am sure the committee has discussed; at the moment, the process is great for buying tables, chairs and pens, but does not really work when it comes to buying services for real people. The personalisation agenda will also change the approach of the third sector and public sector agencies. However, this is a time of positive opportunity if we can grab it.
You said that you have met with resistance from some in the public services who are not convinced about the preventative approach, and in your submission you make it clear that
“evaluation is the most important missing ingredient. Without quality evaluation it is difficult to share information about what works, and why it works.”
As we keep saying to our sector and indeed everyone else, we need to be able to measure these things. I have already mentioned the social return on investment report by Impact Arts; I am sure that many MSPs were at the launch of the report by Edinburgh Cyrenians on its partnership working with the City of Edinburgh Council and its interventions to prevent people from becoming homeless, all of which saved the council money in rent arrears and so on. We need more such evidence and that will require the third sector and the public sector to work together.
Aside from that, we need culture change. We need people to be saying, “We know in our gut that this is the right way to go.” We will not have every piece of empirical evidence that we need, but we know that this is the right direction and that we need to invest. Of course, that will require people to have some trust in change.
Returning to your quotation from our submission, convener, I think from our initial analysis of the new change fund plans—which we have submitted to the Scottish Government and which I am happy to submit to the committee in evidence; we did not do so because the plans have not yet been published—10 partnerships are allocating more than 30 per cent of funding to preventative spending. The average is about 22 per cent—some are allocating less than that—but that shows a big change from what happened last year. Obviously, we need to dig deeper and find out whether they are really spending the money on the preventative spend agenda. However, although we might have some concerns in that respect, we simply need greater third sector involvement. We do not want NHS boards thinking that the change fund money belongs only to them.
In short, we are seeing signs of change in relationships and approach in the third sector and the public sector, and I hope that it is generally positive.
Angela Cullen (Audit Scotland)
I agree that, in the shift to preventative spending, a huge cultural and behavioural change needs to be made, but such changes are never easy. Indeed, we know that from trying to do the same in our organisation. A lot of it will be about prioritising things and spending money differently, and it might also involve stopping certain services or delivering them very differently. As I have said, there will have to be a lot of changes to culture and behaviour.
I also agree that the evaluation of the success of prevention across the country is mixed. Evaluation is key to identifying what might work and what does not work, but obviously it is hard to carry out because one needs to take a longer-term as well as a short-term perspective. Changing outcomes is a long-term issue, so the question is when the evaluation should be done and what measures need to be in place to ensure that it happens.
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We have identified some examples that we think have contributed towards prevention. In a telehealth report last year we identified that more investment in telehealth could keep people out of hospital and that there was even scope to reduce the number of GP visits. The use of statins in the health service to prevent heart disease is also having an impact.
Work that we did on drugs and alcohol a few years ago identified that, although there was some evaluation of interventions, there was not so much evaluation of what made for good prevention. Work definitely has to be done on that. We have indicated that we will follow up our work in that area. Prevention is one issue that we will look at.
In a criminal justice overview last year, we identified that around 10 per cent of the total spend on criminal justice was directly on prevention. That was a rough estimate based on the information that was available, but it was the best estimate that we could make at the time. We are now doing a detailed performance audit on reducing reoffending. We are looking at prevention as part of that work and we hope to identify some examples of good practice that could be rolled out across the country.
We have identified a couple of examples of good practice, but they have not been rolled out. They have not necessarily been evaluated, or a longer period is required for the evaluation to bed in. When they have been evaluated, the experience has not necessarily been shared or rolled out across the country.
Ron Culley (Convention of Scottish Local Authorities)
I echo a lot of those sentiments. There is a need to better understand the evidence about what works with regard to preventative spend. I sense that there is a developing evidence base. For example, reablement work with older people has proved to be successful. More and more local partnerships are picking that up and running with it.
As Angela Cullen said, the other part of the preventative agenda—in addition to understanding what works in prevention—is having a rational assessment of what not to do. That is just as difficult, for different reasons. It raises questions about where, as a nation and in localities, we should be disinvesting. That is a difficult issue both politically and operationally. It is important that we put that message across, given the broader context of the public finances. We have heard about the impact that demographic change will have on the overall demand for services such as health and social care.
The disinvestment part is crucial. If we do not get that right, the preventative agenda will founder. Difficult decisions will require to be made. For example, figures that I got recently from the joint improvement team indicate that, over the next three years, there will need to be a 12 per cent improvement in emergency admissions to hospital in order just to stand still. In other words, demographic change will happen at such a rate that we will need to achieve a 12 per cent improvement to stand still. That means that if we do not do better than 12 per cent, disinvesting to reinvest becomes awfully difficult.
Huge benefits could accrue from getting this right, but tremendous challenges lie in our being able to disinvest appropriately at the right time in the right places.
Emergency call-outs have been highlighted a number of times, particularly given their huge cost.
I put on record my interest as a member of Aberdeen City Council.
My question is for local government colleagues, although Audit Scotland might also have a view. When I have tried to get people to do things differently at the city council, I have all too often come up against the cultural problem of how to get people to shift their focus from doing things the way that they have always been done to doing something a bit more radical and different. It is not always the practitioners or the people at the front line who are the problem; indeed, some of the very best ideas for doing things differently come from the people at the coal-face who deliver the services. There seems to be a blockage between the strategic direction and the front line that prevents some of those innovative approaches from being taken. I wonder whether our colleagues around the table have come across that mentality and those difficulties and how they think the issue might be addressed.
In my view, the biggest difficulty with the move to preventative spend is getting people on board with the mindset. As I have said in the chamber, I think that it is as much about the mindset as it is about the money, and the key is having the will to deliver services in a different way.
David Dorward (Society of Local Authority Chief Executives and Senior Managers)
I do not know where to start, or whether answering that question would be the right thing to do.
On John Downie’s question about cuts, I cannot answer for all 32 councils, but I firmly believe that councils see the third sector as a full partner in the delivery of services. To me, that is a very important change. It will, of course, depend on which community planning partnership you look at, but I know that in Dundee the sector is a full and active partner; it was a partner in the change fund applications and it will be a partner in their delivery. There is no question about that. In fact, it would be absolutely wrong to do otherwise. In certain situations, we will transfer services from, if you like, the public sector to the third sector because we think that it is the most appropriate place for their delivery.
As for culture change, there is no question but that the culture in local authorities has changed. In Dundee, it changed because of adversity, child protection issues and so on. We need to change from the situation in which the local authority, the health board, a group of voluntary sector organisations and the police work individually, because, if we do not, we will never address prevention and intervention. Now we are all working as a partnership.
The budget issue should be secondary. Instead, we should concentrate on getting the services on the ground working as one, because that is what the communities want. The budgets will follow. As an accountant, I find it very difficult to say, “Let the funding come later”, but if we start arguing about who is putting what into which pooled budget we will lose sight of the vital issue: service delivery on the ground. We have given the voluntary sector a three-year funding commitment because we know that the sector will find it difficult to employ people if it does not have surety of funding. That is a very important issue.
Although I think that the culture change happened first, the change funds give us a real opportunity to go out and take a bit of a risk. Mark McDonald is right to suggest that there has been an aversion to change and that people have simply wanted to stay with services that have or have not worked. However, a serious culture change is happening with regard to considering innovative ways to provide services.
The point about front-line services is very important; indeed, it was those very services that drove us to the changes that we made in our response to child protection. Those people know the day-to-day things about what is required, when it is required and what level it should be provided at. The other important partner in that regard is the community and we are running a pathfinder in Dundee to allow the community to tell us what it believes is required with regard to early intervention and prevention.
We are using Dundee’s two universities to help us with gathering evidence. However, it is still quite early in the process. When I surveyed local authorities on what they would put forward as evidence of change with regard to early intervention and prevention, I was quite surprised by the broad spectrum of responses. However, the point is that I did not know any of that information, and it demonstrated the importance of sharing practice. Good examples exist, but people in the sector are not very good at sharing them with one another. I cannot put my finger on why that should be, because, after all, one would have thought that to be the best thing to do. We are certainly not precious about that anymore; indeed, we will go abroad to examine models to find the best way of dealing with an issue.
That is where I think we are at the moment, but I stress that there is certainly no resistance from local authorities to early intervention and change.
It is interesting to look at the various practical examples of approaches that, as Mark McDonald mentioned, have come from the front line. For example, I was speaking to people from a big housing association and a hospital about a number of older people who were, in effect, subject to delayed discharge at £3,000 per month when they could have been in the housing association at £1,000 or whatever the cost was. The reality is that the people at the front line were not able to transfer those older people into that housing association and save the £2,000 because the decision was made by someone at a much higher level, who was no doubt sitting there, thinking, “This delayed discharge is costing us a fortune. How can we save that money?” We need a culture change in decision making about budgets and implementing prevention, and perhaps the front-line staff who know more about those needs should be more empowered at various levels.
Prevention also comes down to the political will of cabinet secretaries and ministers. If a health board chief executive wants to shut a local hospital in order to move resources to prevention, he or she will no doubt get a phone call from a minister, saying, “We don’t think you should be doing that—and particularly not when local government elections are going on.” However, if ministers are buying into this approach and telling health boards to move resources to prevention, they need to have the political will to back up the boards in making those decisions. I understand the issues here, but we cannot simply be thinking about short-term political gain.
We need to make prevention work on a range of levels. The drivers for it are strong, but ministers need to realise that hospitals and prisons will have to shut if the approach is to work.
My comments follow on quite nicely from what John Downie has just said. They are in some ways related to Mark McDonald’s points but are less about those who deliver the services than about those who receive them and their families.
The fact is that people are often resistant to change. That came to mind when I was listening to John Downie’s comments about personalisation, which is often perceived by the families of recipients of such care as a cut in services and the closure of facilities. Indeed, instead of being seen as offering a service that was tailored to people’s requirements, the term “personalisation” became something of a dirty word in Dumfries and Galloway and was associated with plans to close adult resource centres and so on.
As a result, politicians, councillors and others can get heavily lobbied by their constituents and become drawn into campaigns to resist change. Does anyone have any experience of overcoming resistance to a change that people perceive as a loss—not a gain—in services and of presenting the case for a change in a way that the public, not just professionals, can understand?
Mark McAteer (Improvement Service)
If one of the themes of the discussion is the challenge of the change, I have to say that, if we characterise that only as a need for cultural and behavioural change, we will misdiagnose the problem. The vast majority of the people with whom I have worked at the middle level that we have discussed make decisions on the circumstances that present themselves and, by and large, will try to do the right thing.
To take Ron Culley’s example of emergency admissions, any doctor or clinician who is confronted with a frail, vulnerable older person in the middle of the night will admit them to hospital, because it is the safe thing to do. For us, that is a reactive response, not a preventative response—that would be to ask how we stop that older person getting in there—but it is the right thing to do in that circumstance.
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The problem that we have across a range of public services is that they were designed not with prevention in mind but for other purposes. It is therefore the system failures that build up across public services that leave a doctor in the position of having to admit an older person to hospital at 2 o’clock in the morning. The fundamental issue that cuts across everything and which is also important in driving behavioural change is that we must design public services to do different things. That is a hugely difficult task but, as John Downie said, it must be a massive political priority for all of us.
Allied to that issue is that of the duties that we place on public authorities. It was in the Christie commission report and has been picked up in some of the committee’s written evidence that we do not have a common duty for outcomes across public services. If we look across the range of duties that apply to public services, by and large they refer to making arrangements for the provision of services but do not say anything about outcomes for people or customers. That is another fundamental issue that we must pick up.
If we keep characterising the situation as being only about the people in the middle making decisions, allocating resources, aligning or pooling budgets and so forth, we are misdiagnosing it. The fundamental issue is that we need to design public services in a particular way. Again, that includes how we interact and work with the voluntary and third sectors. That is another fundamental issue that we should explore and think about as we go forward.
I will pick up on some earlier points. I agree with what David Dorward said about the system of partnership working, which is fundamental to the preventative approach. Organisations cannot continue to work in silos. There needs to be a preventative view across the whole system, and organisations must work together on joint planning, particularly if they intend to share or move resources at a later date.
I agree that the decisions on the approach need to come first. I am also an accountant, and it pains me to say that the decisions need to come first and the money will follow—apologies to other accountants sitting round the table. It is absolutely key that the decisions come first because the decisions that individual bodies or individual people within bodies make could have positive or negative consequences for others. Changes or decisions in an individual organisation could affect others in the organisation or affect other organisations in the system, be it in a region such as Tayside or elsewhere. There is real collaboration and whole-system work to be done.
An organisation that changes its services to do things differently for a preventative approach might not see the benefits of that; other organisations in the system might reap the benefits. I echo the view that the users of the services are paramount in that regard.
As for resistance to change, strong leadership is the key to winning the hearts and minds of staff, stakeholders and users. I appreciate the comment that Elaine Murray made about personalisation and how difficult it can be to change the approach, but we can prove that the preventative approach works and can make a difference, although not necessarily in one particular area. However, we should be able to call on experiences from across the country. As David Dorward said, we are not necessarily good at sharing such experiences. However, proving that the approach works can make a huge difference.
I am pretty sure that the SCVO welcomed in its budget submission the Government’s commitment to preventative spend and its provision of £500 million for that. However, I think that the SCVO also pointed out that a pretty low percentage of money in the existing change fund was genuinely going to preventative spend.
Yes.
I think that it was about 20 per cent.
I am interested in anyone’s responses to my questions, but particularly those from the SCVO. What oversight is required to ensure that the amount of money for preventative spend is not so low next year and for the following two years from the three change funds that are, or are about to be, in place? What level of stakeholder engagement has there been so far to ensure that the percentages become significantly higher?
I might return to some of the points that Ms Cullen made, but I was struck by a point in the SCVO’s briefing note to the committee on prevention. Under the heading “Making good practice more widely available”, it states:
“There are some tensions around doing what has already been proved to work versus innovative new projects. Sometimes ... pilots are given priority over tried and tested models but ignoring new models removes the opportunity to improve best practice.”
In round-table sessions, a couple of examples of pilots were mentioned, one of which is certainly relevant to the south of Scotland as it is from East Ayrshire Council, and I took it up with the council when it was at a committee meeting. The council has a successful MEND—mind, exercise, nutrition, do it!—programme to deal with childhood obesity, which has had a high impact. I subsequently visited the council, and people there said that they were nervous about the possibility that a top-down programme would be imposed to replace what they feel is a successful programme at a local level.
On the other hand, we have initiatives such as family-nurse partnerships, which seem to be very successful. There is good evidence that they will deliver great benefits for parents of young children. Perhaps that initiative needs to be rolled out nationally to ensure that the impact is felt nationally.
The data on delayed discharge that was released yesterday showed that, although there is an overall downward trend, there is huge variation among local authorities and health boards. My area, the Borders, shows a two-thirds reduction in the number of delayed discharges and the elimination of delays of more than six weeks.
There is clearly much variation across the country. A number of people around the table might want to comment on the balance that we need to strike in allowing innovation to continue and in taking risks in coming up with new programmes—not punishing people for taking a gamble, if you like—while rolling out good practice.
This is probably going to be more of an observation than a question, but folk can feel free to comment on it. John Downie highlighted an important issue when he spoke about the problem of short-termism versus long-termism. It has long been a bugbear for me that all too often in politics we focus on the short-term gain rather than the long-term gain. If we are told that there are two choices before us and that if we take one we will see a marginal benefit within a four-year window, while with the other one we will see a much greater benefit within a 10 to 15-year window, most politicians will take the four-year window, because they are likely to face the electorate again at the end of that time.
Those choices do not always have to be in conflict. Too often, we assume that people are looking for the short-term benefit when, in fact, the wider public out there are more subtle than that; they recognise that, when we take tough decisions, that is a demonstration of leadership. If we can show them that the tough decision will lead to a tangible, long-term benefit, most people out there are nuanced enough to see that it is the correct decision to take.
Too often, as Elaine Murray highlighted, we get a bit worried about constituents or pressure groups who are obviously emotionally attached to a particular way of things being done—for example, perhaps that might be about a particular school or local facility. If we can take them on a journey and show them where the long-term benefit lies, they will come on board. That will not be the case for everybody, because there will always be people who will not be happy. However, the majority of people will eventually come round.
I speak from the experience of having inherited the administration of a local council that was in a very bad way. As I am sure Angela Cullen will agree, the way in which budget setting is now done in Aberdeen is being held up as a model for other local authorities in terms of priority-based spend and other areas.
Sometimes, taking tough decisions with a view to long-term benefits is not always incompatible with the sort of short-term view that John Downie spoke about.
Dr Gruer, I note that you point out in your submission that other than
“measures to reduce tobacco and alcohol consumption ... there are few other options for additional investment in health and social care services that we can be confident would prevent future ill-health or social problems in a cost-effective way.”
However, in that context, Mark McAteer referred to call-outs for elderly people, which Ron Culley also touched on, and Angela Cullen talked about statins. The field of preventative action that you describe seems somewhat narrow. Given that the approach has a budget of more than £10 billion a year in Scotland, surely there must be other areas in which preventive spending can impact in a positive way.
Dr Laurence Gruer (NHS Health Scotland)
The issue arose when we started to focus on the particular interventions and the costs. NHS Health Scotland has recently begun a programme of work to examine cost effectiveness and has been struck by how little evidence is available on it.
In my written submission, I referred to the Australian study “Assessing Cost-effectiveness in Prevention”, which is a tremendous piece of work because, for the first time, it uses the same basis to assess a range of interventions. It asks what the evidence is that they actually work, for whom they work and how much it costs to get outcomes that can be measured consistently—that is, how many quality years or disability-adjusted years we get in return.
It is shocking to see how many interventions we take for granted. When we examine the inputs and outputs, we cannot determine whether the interventions work or we find that the cost effectiveness is low and we are reduced to a much smaller number of interventions that work than we would want. Many of those tend to be at the higher level, such as tackling smoking or alcohol, or to be more politically sensitive interventions, such as the taxation of food.
We would all like to be certain that community-led interventions produce good results but, four or five years ago, NHS Health Scotland did a review of all the evidence that it could find on such interventions for the community-led task force and could not come up with any evidence that showed that they would definitely lead to improvements.
When I worked in Glasgow, we were involved with the starting well intervention for young, vulnerable kids in deprived areas. In many ways, it looked like a good intervention but, despite input that was probably more than we could afford to roll out across Scotland, the team found it difficult to identify the families who were most in need at an early stage and, when the whole programme was assessed and the outcomes evaluated, very little impact was found.
The results were similar when we evaluated the have a heart Paisley programme, which aimed to reduce cardiovascular disease. It, too, was an attractive programme with a lot of community input, but we were not able to show that it definitely led to a reduction in heart disease and fewer heart attacks in the area, which is what we were looking for.
On the other hand, when we evaluated the smoking ban, we were amazed to see what a large impact it had throughout the country over a short time on admissions for heart attacks, which reduced. The reduction in childhood admissions for asthma was probably even more surprising. They reduced probably not only because the ban reduced the exposure of kids to smoke in public places—we do not really see too many kids in pubs—but because it modified the behaviour of parents, who suddenly realised that breathing smoke on other people was bad for those people and changed their behaviour at home and also, potentially, in their cars.
That was a dramatic indication that interventions on smoking still have a massive potential for preventing ill health across the whole population. Smoking is the biggest driver of health inequalities in deprived communities in Scotland, because they have much higher rates of it.
The big issue is how we go about persuading and helping people to stop smoking. In deprived areas and disadvantaged circumstances, it is quite difficult for those who are addicted to cigarettes to come off them, because there are so many other things to deal with. However, over the past 50 years, the smoking rates among men in the most deprived areas in Scotland have halved. That is much less than in the more affluent areas but, nevertheless, many men in Scotland have stopped smoking, which is narrowing the difference in life expectancy between men and women in Scotland over the years.
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We need to focus smoking-cessation services on deprived areas, doing all that we can to encourage people to stop smoking. There will be benefits in healthcare outcomes, but there will also be quick benefits for individuals and their families. If someone spends more than £2,500 a year on fags, and we can encourage them to stop smoking, that money will be released and could, we hope, be spent on much less unhealthy things for them and their families.
The evidence strongly supports a range of measures to tackle alcohol misuse, which has such a big effect on our most deprived communities. Having taken account of the evidence, NHS Health Scotland has strongly supported minimum pricing. On one level, the policy could be regarded as regressive, because it could make alcohol more expensive for people who have little money. However, if the policy can encourage people not to spend more on alcohol—or to spend the same amount but to drink less—it could have a major effect in our more deprived areas.
Despite the desire to make preventive community interventions, it is difficult to obtain evidence on the effectiveness of such interventions. When reading the committee’s papers, I was struck by the absence of detail on what preventive spend really means. What exactly are we going to do? The answer to that question makes all the difference. The Australian study shows that, although a range of measures can be taken to improve mental health, some are pretty cost effective but others are a waste of money.
We have to be careful about the idea that preventive spend is always a good thing, and we have to be specific and focus on what we want to do—asking who is going to do it, for what and when. If we do otherwise, we might dilute all our efforts and lose our opportunity. If, in order to spend on preventive measures, we stop taking some other measures that are fairly effective, we might end up with poor results, if the preventive-spend choices are not particularly effective.
As has been mentioned in the committee’s papers, NHS Health Scotland is keen to build up support in local areas and to offer guidance on the best areas in which to develop preventive spend. To pick up on what John Downie said, we must find ways of evaluating measures, so that we can be clear that what we are doing is worth the money. If we do not do that, we will not be in a position to make good decisions. We have to know whether what we are doing is worth it or whether we should stop doing it and start doing something else. We need information based on good evaluation.
Members of the committee might well know the keep well programme. Across the country, it is one of the flagship programmes for reducing cardiovascular disease in deprived areas. Unfortunately, although the programme has been running for four years, we do not have evidence to allow us to say whether it is reducing cardiovascular disease. We are therefore introducing a new set of studies that we hope will take us down that road. A problem has been that different areas are interpreting the keep well idea in different ways. Sometimes, we do not know whether the essential ingredient, as it were, of the intervention is still there; some areas will still have it, but others will have lost it. We can end up not knowing whether all our inputs to a programme such as keep well are giving us the results that we are all looking for.
Having proposed the bill on the smoking ban originally, and having chaired the cross-party group in the Scottish Parliament on tobacco control for eight years, I find much of what you say to be music to my ears.
However, I have a number of concerns—particularly over what seems to be the narrow focus of your paper. There is screening for breast cancer, and people are encouraged to go for bowel cancer screening and prostate screening. Such measures must have had a preventive impact, I would have thought, and that impact must have been assessed.
The committee has also heard a lot of evidence on the effectiveness of family-nurse partnerships, and I understand that they are being rolled out. Your paper says that
“diet and exercise programmes for overweight people in primary care would contribute little additional health gain.”
Even if such programmes do not make people live that much longer, their quality of life would surely be better if their morbidity was reduced. Surely that is self-evident.
That might be the case, and I am very much in favour of measures to help people to lose weight. We tend to find, however, that community interventions result in very small amounts of weight loss in only a small proportion of people. Typically, once the intervention stops—they tend to have a limited life—people’s weight goes back up again, so they are left hovering at the same level as they were at before, despite the fact that a lot of people have gone into the programme and tried very hard.
Many people understandably hold up their hands in horror at much more radical measures, such as gastric banding, which is a really big deal. However, the facts are now emerging that it is far more effective and results in something like a 20 to 25 per cent weight loss in most people, whereas the primary care interventions give only something like 2 per cent weight loss, a lot of which is short-lived. The big problem with gastric banding is that it is very expensive because a big infrastructure has to be set up with surgeons, nurses, operating theatres and so on, but it looks as if it is far more likely to be cost effective in the long term because those who go through gastric banding are much less likely to get diabetes or heart disease and are more likely to maintain lower weight once they have their gastric band. It looks as if there is a big payback in the long term from gastric banding, whereas—unfortunately, and much as I would like to say otherwise—the community-based interventions do not give that payback.
I have had very little time to produce my submission, so it is limited in many respects. There is no doubt that a range of screening interventions are worth doing. Cervical screening and breast screening are definitely effective, although there is still controversy around at what ages and how often it should be done, because those factors make a big difference to the outcomes.
Which other issues did you mention?
I also mentioned prostate screening and family-nurse partnerships.
Prostate screening is highly controversial at the moment; there is no evidence that it is worth doing. The screening often gives false positives, so the doctor tells a guy that his level is raised and he should have a check up, which could end up in an operation, but the person would not have developed cancer at all. The Australian studies on cost effectiveness came out firmly against that way of doing things.
Family-nurse partnerships have been shown to be cost effective in the United States, which is one of the reasons why we are taking them on here. However, we have to recognise that levels of community support in areas of the United States where the partnerships were introduced might not have been as good as what we have in Scotland; we already have health visitors and a lot of other social support. Although family-nurse partnerships are a runner as a worthwhile intervention, it is too early for us to know whether introducing them in Scotland would be cost effective, and whether we could afford to roll them out across the whole country, which would mean employing a host of new staff who might have to be taken away from other work.
I am hopeful that family-nurse partnerships and other initiatives such as the positive parenting programme will make a difference, but we are still at an early stage. Health Scotland is in the process of reviewing those different types of early intervention to see which might be the best to recommend.
The committee should also remember that it is not just about whether an intervention works well in theory or whether it has worked well in a research situation, but about whether it will still work as well when it is handed over to an average, ordinary primary care or other service. The quality of a service tends to diminish when it is rolled out, because not everyone has the same commitment to it. Therefore, the cost effectiveness of a service that has been rolled out is often less than was demonstrated in the research situation.
We have heard evidence from a number of organisations from other parts of the UK, including Birmingham City Council, that family-nurse partnerships are by far their most effective intervention, full stop.
I must let other members in.
Dr Gruer’s comments are interesting. Obviously, there seems to be a clear benefit from all the anti-smoking measures, although I think that Dr Gruer expressed concern—which I share—about how we put the approach into practice.
Yes.
I have questions about that. The Government response, in discussing the definition of preventative spending, states:
“Accordingly, boundaries should not be drawn too tightly around what constitutes preventative spending or a preventative approach, and our working definition is broad”.
I throw that out for discussion. I understand where the Government is coming from and agree that we do not want to be too prescriptive. On the other hand, if virtually everything is preventative spending, I wonder where that takes us in practice—which is maybe the point that Dr Gruer is making. With gastric banding, my gut feeling is that it is not preventative spending but totally reactive spending, although I acknowledge that it has an impact on prevention later on.
Mr Dorward, I think, made the point that services need to be joined up. He said that we should consider what services we need and then the money will tag along later. As an accountant—I am the third person to admit to that today—I have slight reservations about that, because all individuals and organisations live within budget constraints. Even if services are joined up, there will still be constraints and we will have to consider what we can do in the situation, not what we would like to do.
My final point to throw in relates to the question of respect for the third sector. I am delighted that the relationship is working well in Dundee, but in my constituency there are two citizens advice bureaux that could be closed a month from today, although I would have thought that spending on those is good preventative spending and a good way of helping people before they hit problems. Something is not working somewhere. I feel that we have a long way to go, in practice.
I will begin by picking up on Gavin Brown’s point about the change fund and then I will perhaps mention John Mason’s final point.
Our analysis of the change fund plans is cursory because, as I said, the plans came in only last Friday. There was a small but significant increase in the allocation for preventive spend, from 19 to 22 per cent. That is the average, although one local authority has increased its allocation from 31 to 40 per cent, whereas another that had 37 per cent last year has reduced its allocation to 13 per cent. Overall, 10 of the change plans that we looked at involve spending more than 30 per cent on prevention, while the others involve less than the 22 per cent average. However, within that, one local authority that spent only 3 per cent last year is spending 13 per cent this year. There are changes and, obviously, the devil is in the detail. When we have gone into more detail on the councils’ spending, I will be happy to submit our findings to the committee.
There is an issue about what preventive spending is in reality, and how we define it. Many workstreams need more interrogation by us, COSLA and others so that we understand, and can say definitively, whether they are about prevention and measures that will help prevention.
I would have thought that, in this day and age, evaluation would be built in to any investment, whether it is by the Scottish Government, a local authority, a third sector organisation or an NHS board. It should be built in from the start, because we need evidence to make good decisions. We can find such evidence from the third sector. The report that I mentioned on the Impact Arts craft cafe programme showed that the independently estimated return on investment is £8 per £1. The programme has tackled many harmful behaviours among older people who were suffering social isolation—it has reduced their smoking and drinking and has improved their diet. That means less cost to the NHS and the local GP. That is a small pilot programme, which we hope to roll out in other areas. A lot of things are working; we need to build on them, which requires the sharing of good practice and working with others.
We have been talking to a number of agencies and organisations in the sector, not about a new body, but about a third sector improvement service. Mark McAteer and his colleague Colin Mair have offered all the Improvement Service’s tools to third sector organisations. There is a lot of good practice out there on how to help organisations to improve their evaluation and their local impact, but it is not being shared; we are not building on and learning lessons from what works. I include regulators as well as third sector organisations.
John Mason made a clear point: the Scottish Government’s definition of preventative spend is far too broad and it needs to be clearer about what it means. That will help agencies and organisations to be clear about what they can spend and what that spending is about. The definition needs to be tightened up.
12:45
I would like to pick up on a couple of the points that Laurence Gruer and John Downie made about the sharing of good practice on evaluation and so forth. Sometimes we look for simple answers to highly complex questions. The idea is that there must be good practice out there and that all we have to do is go and find it and implement it in our organisations—in other words, it is a case of discovering the magic bullet.
In looking around the globe for best practice, we typically find that projects report successful evaluations in this way: “We set out to do X, we did X and people liked X, therefore that is good practice, which should be picked up and implemented in all our organisations.” The trouble is that, when we do want to find out whether the project had a sustainable impact and whether, over the longer term, it genuinely delivered the results and outcomes that we were hoping for, we often do not find such a trend impact analysis, so it becomes highly questionable whether it was a good, cost-effective intervention in terms of outcome. That is why Laurence Gruer is absolutely right to suggest caution; we should be cautious about what initially appears to be good practice. We have to go beneath the surface to see whether an intervention has had a genuine impact.
It is often difficult to replicate results. It is not just a case of what worked; the question that we have to ask is why it worked and—this is fundamental—whether the circumstances can be replicated across different projects in other contexts. Last year, we worked on a project on outcome budgeting. We worked with two community planning partnerships in Fife and Aberdeen to look at how they work collectively with their budgets against their outcomes. We found that people did not understand what their outcomes meant to them in practice. They were good and bold aspirational statements, but people were not sure what they meant in day-to-day terms and, as a result, were not sure what they should do.
We also discovered that there was no common performance framework across the partner bodies so, even if progress was being made against the outcomes, no one could be sure that it was being made, because there was no common understanding of how to measure or of what was being measured. We also had problems with system incompatibilities. The finance systems in some of the partner bodies simply did not talk to one another, so even when people wanted to share resources, it was difficult. On top of that, there is the issue of how to do joint planning on resources, which Angela Cullen mentioned.
We can take the learning from that project and work with another 30 partnerships across Scotland, but we will not be able to replicate the results, because although every partnership will have common problems and, therefore, potentially common solutions, each partnership will have particular problems. When it comes to best practice, it is not simply a case of passporting something from one area to another; it is about having people who can go in and support, challenge and facilitate, and who can help organisations to use that best practice in a way that works for them and, more important, in a way that works for the communities and the service users with whom they are trying to work.
There is another aspect that we have not spoken about enough on preventative spending and early intervention. Where is the customer in all this? I have yet to hear a discussion about what the customers want and—if we are talking about outcomes—how we can intervene to support them in ways that will make their lives better. Very often, we still talk about doing things to people, as opposed to doing things with people, with communities and with families. The customer agenda is just as important as the exchange of best practice.
I will pick up on a couple of themes. On the change fund and ensuring some investment in preventative spending, John Downie has spoken about the feedback in relation to this year’s plans. In addition to that, we want to focus on the change fund process, in order to ensure that partnerships are locked in locally and, indeed, nationally, so that they are accountable and resources can travel in their direction. For example, we have specifically designed the change funds to require partnership sign-off, to ensure that the voluntary and, where relevant, the private sectors can work with and—if required—hold their statutory partners accountable on the preventative agenda.
We have similar partnership focus and scrutiny at national level—a process in which John Downie, as per his earlier comments, is obviously involved. We will advance that process over the next few weeks to ensure that we are satisfied that all the partners have submitted plans in a partnership-focused way that demonstrates that the resources are beginning to shift. The joint improvement team provides us with a mechanism to support partnerships that may face challenges in relation to the preventative agenda. I understand that the Scottish Government will evaluate the change fund—we may have to get back to the committee on that—but I am pretty confident that that has been commissioned.
Mark McAteer’s comments on the more general themes of innovation, best practice and evidence were really instructive. It is inevitable that we will have to live with an element of ambiguity. The more we focus just on doing things that have a strong evidence base, the less scope there will be for innovation and change but, equally, we do not want to innovate without assessing the impact that it would have. We have to take account of that creative tension.
Finally, Mark McAteer’s point about the customer agenda—or, as Elaine Murray put it, how we bring people with us—is extremely important and one on which we have not yet succeeded. For example, one of my elected members, who speaks eloquently about the shifting balance of the care agenda and is fully signed up to it, came under pressure in his locality to sign a petition against the closure of a community hospital. He eventually did so, because politically it was the right decision, but it was against everything for which he had argued for four years. We can attend to such challenges through political and other leadership.
To return to Mark McAteer’s point and that which John Downie made at the beginning of this meeting, if we can turn the whole agenda into an empowerment agenda in which there is community ownership whereby people understand the services that are available to them and have ownership of them—an assets-type approach—that would help us some way along this journey. That is the bit on which we have failed completely, as far as I can see.
It is 7 minutes to 1 and four people still wish to speak. Once they have done so, we will have to finish the meeting.
On Laurence Gruer’s point about the family-nurse partnerships, we have one in Tayside, where Dundee is predominant. I agree with Birmingham City Council’s view that it is the best tool in the box at present. I know that the process is at an early stage.
I visit primary schools in deprived areas—Mark McAteer’s point is relevant in this—and we must listen to what people in such communities have to say about what services they require. It is not often that we have an open debate about the subject, but we have started going to the pubs of Lochee to ask people not what services we are giving them—it is all too easy to do that—but what services they need.
We are taken by Harry Burns’s views on the early years—the earlier the intervention, the better—so we and health staff are focusing on pre-birth. On funding, when I pool my budget with the health board, I know that some of the benefits will not necessarily come back to the city council and the services that we provide, but we have to look at the community in its wider sense, and not just at the agencies that support it. There is a real culture change happening in the public sector and the voluntary sector in that respect.
Leadership is key. I am waiting for the May elections so that I will have an administration that will be in power for a long period. We then need political leadership and leadership from the senior officers. I do not like the national initiatives that come in because they are done as pilots, then we have to roll them out, someone has to look at how to fund them and they are not embedded in the communities that we spoke about.
I rather like the ground-up approach, in which we speak to communities, find out what has happened in other areas, present that to them—“Here are our options”—and find out what they would like to introduce in their area. There is a far better chance of that becoming embedded, and it will be sustainable—it will be there in four or five years.
My meetings with primary school teachers depressed me in a way, because the teachers said that what they need is more intensive family support. Parenting skills that we might have known a generation ago are just not there now. Intensive parenting support for families is needed within schools. That is real early intervention. We might not see the benefits in one year or two, but we will see them in the future. That is the level at which we must put in the change fund money.
I will keep it short because Mark McAteer has covered what I was going to say.
In response to Mr Mason’s point about tightening budgets and which comes first, the decision or the money, we find in a lot of the work that we do that the cost information that would help to inform decisions is not there.
I agree with Mark McAteer about performance information. A lot of individual projects or interventions do not necessarily know what outcomes they are trying to achieve in the first place. There are difficulties if they do not know their incomes, their current performance, how to measure their performance or the cost of what they are delivering or what they might deliver. We make a plea for that information to be available. We appreciate that it takes time to pull together, but it would help the cost-effectiveness and evaluation.
All this will take time; prevention is long term in nature. Laurence Gruer mentioned the keep well programme. Four years on, we still do not know whether the programme is effective or whether it is what we would have expected. Some things take a long time to show their impact. The issue is to stick with the interventions, projects and policies to see whether they make a difference in the longer term.
I want to pick up on something that Mark McAteer said. We have taken evidence on the national performance framework and the single outcome agreements and how those flow through. We are putting a lot of emphasis on the role of community planning partnerships. One of the things that stuck out like a sore thumb was the disconnect between the single outcome agreements, the national performance framework and the health improvement, efficiency, access and treatment targets, which seem to be a bit of a barrier to collaboration between local authorities and NHS boards. That is not to say that collaboration is not happening—we have heard that Highland Council is collaborating well with NHS Highland—but I just want to raise that concern. Do we have to do something quite fundamental to change the targets by which our health partners are being measured?
On a positive note, you might have seen in the press that the Evening Times Scotswoman of the year is Dr Mary Hepburn. She is a glowing example of the sort of thing that we are looking for. Over the past 20 years, she has run a service in Glasgow to help pregnant women who have drug or alcohol problems. The service is a tremendous example of collaboration between the health service and social services. It intervenes at an early point in pregnancy for women who probably have the most intense problems that we can imagine and helps them through in a very personalised way. The service works with the social work department to produce outcomes that are far better than would otherwise be the case.
That is the sort of example we are looking for here: leadership in the form of a person such as Mary Hepburn, and a carefully designed service that is working closely with the community, overcoming stigma, dealing with people who are most at risk and achieving highly commendable outcomes that are highly regarded throughout the world and are seen as best practice.
I thank everyone for their helpful participation and contributions.
Meeting closed at 13:00.