Health and Community Care Committee, 31 Oct 2001

Meeting date: Wednesday, October 31, 2001

Official Report 311KB pdf

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Community Care and Health (Scotland) Bill: Stage 1

Good morning, gentlemen, and thank you for joining us. I apologise that we are running a bit late, but that is due in no small part to the fact that information on the budget, which we should have received in advance of taking evidence from the Executive this morning, was received only last night. The information had not been circulated to members, so we had to spend more time in preparation this morning. I apologise to our witnesses for keeping them waiting.

Before we ask questions, do the witnesses want to make a verbal statement? We have already received a written submission. Are you happy that we just go into questions?

I am quite happy to go to questions. Our submission speaks for itself. A verbal statement would just take up more time.

Okay. Let me kick off. The committee's "Inquiry into the Delivery of Community Care in Scotland" highlighted our concern

"to ensure that principles of fairness and of equity underpin community care policy."

Does the bill uphold those principles?

My reading of the bill is that the answer to that is yes. Perhaps the pragmatic answer is that will we find out in more detail once we start to implement the bill and see where the warts are. At face value, however, we do not have any unease about the bill. The Executive seems to have tried to adhere to those principles.

I am conscious of the fact that the bill was published less than two weeks after the publication of the care development group's report. On the face of it, that suggests that the Scottish Executive did not have much time to absorb the care development group's recommendations before the bill was published. In the light of that, have health boards been adequately consulted about the main provisions of the bill? Would you have appreciated more time for consultation?

I would always appreciate more time for consultation. If we are potentially uneasy about anything, it would be the target date of 2002. Let me qualify that by saying that I personally am a believer in the principle that one does not make progress without setting targets. There is perhaps some unease around that date. Further discussion on the target date would have been good, but we need just to go for it and give it our best shot.

Is that the sort of thing that you were looking for?

I was going to ask about your concerns about the April 2002 introduction date. I have read your written submission. Will you expand a little on the difficulties that the introduction date gives you; on the steps that you are taking to meet that date; and on whether, notwithstanding any concerns that you might have, you are confident that you will meet it?

I should first point out that today I am representing not just Argyll and Clyde Health Board but perhaps all health boards. Furthermore, Douglas Philips is attending the meeting because he chairs an ad hoc group on community care that work with health board groups. Coincidentally, he also works in Argyll and Clyde Health Board. That is by way of a preface to my point that if more than one local authority is included in a health board area, the problem is not the intent or desire to meet the date, but the sheer work load involved in working with each of those local authorities. Where only one local authority is included in a health board area, the chances are that if people do not meet the April 2002 deadline, they will get extremely close to doing so. However, in cases where five local authorities might be involved—in Greater Glasgow Health Board's case, six local authorities are involved—one of the principles is "One size does not fit all". That implies that, although we could put a framework in place, individual points of detail will still require us to spend time, set up meetings and so on.

Douglas Philips will explain some of the more specific steps that we are taking in our health board area to address such work load issues.

Much depends on where we start from. Everyone started from a different baseline, which means that in a health board such as Argyll and Clyde, where there are five partners, different people are at different stages of working on the Scottish Executive's joint resourcing and joint management circular and the local outcome agreements circular. As we say in our submission, it would be quite easy to prepare planning agreements—or, if you like, to tick a box—and we want to ensure that our arrangements will make a difference on the ground to patients or clients who receive community care. As a result, we will be at different stages with different council partners by next year.

There is also a practical issue about how the NHS family—the boards and trusts—and social work departments can identify from existing funding streams precisely what funding is committed for care for older people. The way in which authorities collect such information is different. We cannot really find out the costs of care for older people without also considering the costs of care of older people with dementia, which in some places is included in the mental health spend instead of the spend on older people's services. As a result, even such seemingly simple issues become quite complicated and require a huge amount of work.

The Minister for Local Government and Finance has announced new allocations—£100 million in 2002-03 and a further £100 million in 2003-04—to fund the care development group's recommendations on the implementation of free personal care. Is that provision sufficient to implement free personal care for all elderly people?

As I have not worked out the calculations, I am not sure that I could give you anything other than a subjective opinion.

So no real work has been carried out on the likely costs of implementing free personal care in your area.

I am not aware that we have submitted any figures.

In paragraphs 2.6 and 2.7 of your submission, you mention work force issues, particularly the "intensive support and training" that staff will require, and indicate that there is no identifiable funding for such support and training. How much it will cost to provide them?

I feel uncomfortable having to say no to two questions in a row.

Any programme of change must involve staff at all levels as much as possible in the design so that they feel a sense of ownership and can input their ideas. When you do that, there will be a feeling of threat. Some people will think, "Is this going to affect my job? What does it mean to me? Could my job move 30 miles?" All those questions will be asked. Involvement is the basic principle, but beyond that, we have to think seriously about training. New skills will be required and identified, but other people potentially—and I stress potentially—will find themselves displaced. We do not want to lose people, so we have to think about whether we can retrain somebody to do a job, which will allow someone else to be trained to do another job that meets their needs as well as the needs of the situation and the people we are trying to look after.

We have to examine how we work with the work force to support people through a change programme that potentially will involve cultural changes from the organisations in which they work, and changes in the duties that they are asked to perform, and the way in which we approach the care that we provide. It is about being supportive to the work force, because if we are not, and we do not put enough thought and effort into that, that will be an obstacle, as opposed to a force for good. Those are the principles at which we are aiming.

Do existing training budgets cover the costs that are involved? Will there have to be an additional specific allocation?

On a base management principle, going into a programme like this we should identify a ring-fenced sum of money, because traditionally, as we all know, training budgets usually are among the first to get the push. The answer to your question is yes.

One of the elements in the costing package is how many more long-stay beds will be closed, because one of the recommendations is 100 per cent resource transfer. Do we have any idea, at national level, how many more beds will be closed, what the programme is for closure, and what funds will be released by that? The average cost of an NHS bed is £800, but with a package in the community it is £400-odd, even given the current negotiations, which is a substantial saving.

I have two points. First, how quickly can we move towards what you outline in paragraph 2.2 of your submission, which is about disinvestment and flexible reinvestment? Secondly, how much do health boards need to retain in order to ensure the adequate provision of medical and specialist nursing services, and health promotion and health prevention services, in the community care sector?

I do not have an added-up number. We have a number of beds that we should be aiming for. On the closure of beds, the principle that we are most comfortable with is that when money is released, and care is reprovided, what is left should be part of a pool. The partners should then discuss how to use the money to provide what is most needed and address the gaps.

In paragraph 2.3 we outline the principle of 100 per cent resource transfer. We are slightly concerned that as care is reprovided, people who require continuing NHS care are likely to be those who require the most intensive care, therefore the proportion of investment in them will go up, but as money leaves the system, we will lose flexibility in the pool to put intensive resources into those who are the most vulnerable. There must be discussion with partners on the ground about the appropriate balance and where resource transfer is used. Resource transfer is not an automatic balanced equation, because you have to examine those who are going to remain and require care, as well as those who are moving into alternative models of care.

Do you think—

Richard, I will have to cut you off there.

I wish to address joint working between the NHS and social work. You say in your paper that you are "up for it", but you also say:

"there is a question about the extent to which proper implementation can be achieved … by April 2002."

You raise concerns about planning and commissioning issues, as well as operational service matters. You also raise the question of delayed discharge. I am concerned about your references to culture and attitudes. You say that there are cultural differences between partner organisations and different attitudes and opinions. That does not inspire me with confidence, given that joint working is to be up and running in six months.

I would like to separate what you said into two parts. One can be up for it, but better prepared if obstacles that must be tackled to make changes are identified. I do not think that identifying challenges that we face indicates in any way that we do not want to get on with the job in the most aggressive fashion. I would be more worried if we said that we are up for it and that everything in the garden is wonderful and rosy. We would be accused of not paying sufficient attention to detail. I am happy to stick by that—we are up for it, but we know that there is work to do and we must get on with it.

What will you do to overcome cultural attitudes and differences?

I return to the issue of working together with staff and bringing staff together in the same room who come from different organisations and backgrounds, with different practices. There must be joint training and an approach whereby people have the opportunity to speak to each other so that they can begin to understand each other and where others are coming from. One cannot click a finger and say that everyone must think or behave in the same way because legislation says so. It is a matter of how training and working with staff is approached—it must be done on a mixed basis.

You have only six months. What have you done?

At a strategic level, for two or three years, there have been roughly quarterly meetings in Argyll and Clyde between the leaders and chief executives of the local authorities and the chairmen and chief executives of various NHS bodies. Those meetings have been facilitated by the Scottish local authorities management centre at the University of Strathclyde and have tried to eradicate the finger-pointing culture that says, "No, that belongs to the local authority," or "No, that belongs to the health board." I think that we have been successful.

Trying to work together and change cultures from the top is extremely important. That cannot happen without working with staff at all levels, and what I have described is an example of what we are doing. The provision of local councillors on unified boards will undoubtedly drive the process of working together to change culture and attitudes. Joint training of staff who provide services is a critical and positive element.

You talked at some length about joint working. Will you say more about what role there is for joint assessment?

We share the view of joint assessment set out by the care development group—single shared assessment is the only way forward. People at the operational level must adapt existing processes and move to the single shared assessment process as quickly as possible. By that means, the real, integrated care needs of individuals can best be planned and delivered.

That will not be without difficulties. What action is required to ensure that there is not simply a paper exercise of intention and that the process actually happens?

I am optimistic about that. People in that field to whom I speak are keen to ensure that the single shared assessment process works. Reluctance has been shown in one or two places where people have had their own local assessment processes—there has been some reluctance to give up something that they feel has worked well. However, people are getting used to the concept and can see how the new procedure will work. They can see the value and benefits to patients.

What mechanisms to improve joint monitoring and accountability might be put in place?

NHS health boards are keen to be able to measure the health outcomes and to ensure that the changes that the bill proposes will deliver something meaningful and tangible for individuals. Clearly, the performance management arrangements are crucial. In our paper, we set out some possible options for measuring performance. It is our view that we need both to manage the performance of the whole system and to have health outcome criteria by which we can judge whether the changes for individuals, as well as for the system, have been beneficial and can be shown to have been for the better.

Do you think that there are ways of involving the public in the process of planning joint service delivery and monitoring the progress that has been made?

In the paper, we say that service users and their families are fundamental. They must not only perceive a real difference, but be given evidence that a real difference has been made to the care that is being delivered to them.

Many documents say that the views and involvement of service users and carers are important. However, finding ways of involving those people in planning and monitoring is more difficult. What ideas do you have for ensuring that that happens?

In our health board area, we have over the past 15 months done an enormous amount of work to develop a strategy that we describe as new for old, which is a strategy for older people in our health board area. Older people were crucial participants in the process of developing that strategy. We ran a series of theatre company events, which enabled us to access in a more innovative way the views and opinions of older people on the level of service that they perceive is currently available from NHS and social care agencies and how they expect that to change to meet their needs better in the future.

In responding to Shona Robison's question, you seemed to confuse the accountability process with the performance management process. In your paper, you flag up different mechanisms that could be used for performance management, such as the clinical effectiveness strategy group. By its nature, that group would be totally alien to colleagues working in local authorities. Another issue that you discuss is self-regulation. Would that self-regulation be by local authorities, by health authorities or by an amalgam of the two? Could you expand on your ideas in that area?

I admit to finding it easier to envisage how accountability will run down the health line, because that is the line with which I am familiar. Under the performance assessment framework that has just been published, we will be held to account on an annual basis through the Scottish Executive. When we talk about joint management, we are talking about a new way of providing services. I accept that there is still a lack of clarity about whether people will be held to account for their contribution to joint management or for their performance inside their owner organisation. That is bound to be the case unless one sets up a completely new organisation that is held to account independently, instead of having a joint management arrangement in which people remain part of their original organisation. I can see how those working on the health side can easily be held to account through inclusion in the performance assessment framework for health. However, more thought needs to be given to how what we might call the joint management group will be held to account and by whom.

Did you discuss that issue with the colleagues whom you are representing here today? Was there a consensus among them about the road that we should go down?

I have not received a round-table response from colleagues on that issue.

I must now draw this question-and-answer session to a close. There are two or three issues on which we would like further clarification from our witnesses, such as health board lists, the points that Margaret Jamieson touched on and definitions. Unfortunately, we are running out of time rapidly, so I suggest that we follow up by asking those questions in writing. At that point, you can add any further comments that you want to make to the committee.

Could I make one quick comment?

Yes.

I am not sure whether this is a question or a comment; it is not easy to read bills. Our opening comments have been very much about the fact that this is not just about services but about how we provide all sorts of services before somebody gets to the point where they might require services for care of the elderly. One of the points that intrigued me was that, in regard to deferred payments and the potential for selling somebody's house after—I assume—death to pay for care, the bill does not make any reference to what that might mean to a partner who is also moving towards that situation. The stress might accelerate the need for care. Will the committee consider that point?

That is a good point. Thank you for raising it with us and thank you for your contribution this morning.

We will now question Unison. Good morning, gentlemen and welcome to the Health and Community Care Committee. First, I apologise for the time that we have kept you waiting. We have had to deal with information not being given to us in time to allow us to examine it yesterday, so we had to discuss it in private before this morning's meeting. That has had a knock-on effect on our timing.

We have received your written submission and we have a series of questions to ask you. I will kick off by saying that the committee was concerned that any policies on community care should be underpinned by the principles of fairness and equity. Do you believe that the provisions of the bill uphold those principles? Are you generally happy with the bill?

Thank you for the opportunity to address the issue. Joe Di Paola and I are members of the human resources group that has been set up to look at the HR issues that relate directly to the bill. In our submission, we have highlighted the three models that will become operational under the bill. Each of them causes us concern, because they are short-term models and there has not been medium-term and long-term thinking.

We are not convinced that the principle of fairness will be upheld. We made the point in the introduction to our submission that we need a protocol for discussions so that the trade unions are involved early on in partnership working, to ensure that the principles of fairness and equity that are highlighted in our document are upheld.

The other point that we highlighted in our submission is that this is a massive exercise. We think that it will involve almost 100,000 health and local government workers. Much enthusiasm exists in the service for delivering the type of care that the committee wants to see, but that enthusiasm will dissipate quickly when individuals are working on secondment beside colleagues from health and local government who might be on very different terms and conditions; there might be a difference of £4,000 or £5,000 in their pay. When somebody who is seconded leaves the service, they might be replaced by an individual who is on vastly inferior terms and conditions. Many HR issues are associated with the bill.

With respect, the point that I was trying to get at in my opening questions was about fairness and equity in the community care services that are delivered to the client, or the patient. We will return to staffing issues, which are obviously your main concern. We want to see an improvement in the delivery of community care services that is effective and is also fair and equitable. What you are saying is that although you might see that there is fairness and equity in the provision of better community care services, you have a problem with the fairness and equity of the way in which that will affect your members as the bill stands.

Absolutely.

I do not want to lead you, but would it be fair to say that you do not feel that there was adequate opportunity for consultation between the publication of the care development group report and the publication of the bill?

There is a problem with the initial care in the community group that was set up. Human resources was seen very much as a side issue. As a union, we are here to talk about HR issues. Equally, we have 150,000 members in Scotland. Some members of their families are carers who receive those services directly. We had no involvement whatsoever in that side of things in the working group that was set up.

I declare, as an interest, that I am a member of Unison.

Notwithstanding your comments and understandable interest in HR issues, will you comment on the powers that ministers have under the proposed bill for the regulation of social care, for the purpose of separating out the personal care element from the housing and living costs of residential care packages?

Do you think that a definition of personal care is required in the bill? That has been discussed, but there is not unanimous agreement across the board.

Personal care was defined south of the border along with nursing care. The bill is about getting away from asking what a social work bath is and what a health service bath is. It is about defining clearly what the arrangements and responsibilities are.

You might have to follow the lead that has been set south of the border and have a definition.

Would you like to see that in the bill as primary legislation?

Yes.

Leading on from that, we asked the previous group of witnesses about the timing of the introduction of free personal care. I note from your submission that you welcome that introduction. Do you think that the commitment that the Executive has given to introduce it by April 2003 is an appropriate and achievable time scale?

The six action points that we identified in our submission will be difficult to implement. There is enthusiasm, but there is a series of practical and cultural issues, which were discussed in the previous witnesses' contributions. I see real difficulties, but it is important to have that target because we want to ensure that it is on the agenda. As a union, we are ensuring that it is on every agenda—for our health committees, local government committees, management committees and branch committees. We are saying that it is a priority. The Executive needs to stick to that deadline. I have my doubts about whether it is achievable, but in the short term, it would provide a culture of togetherness. It would say that health and local government get together and would show that they do not all have horns.

You do not mention direct payments much in your submission. The bill will make it a duty for those to be provided and wants to encourage them. What are the staff implications of that because direct payments will allow the individual to purchase care services?

Direct payments will cause us difficulties, which is why we have gone on to talk about options of management. There is a lot of enthusiasm and commitment and many projects are taking place. However, there will be difficulties as bad practice and bad examples start to come through the system.

We were given a variety of promises and guarantees about the private finance initiative and what that would mean within the national health service. Privatised staff were working in Hairmyres hospital for £4.18 per hour, with no weekend money, overtime rates or pension. Our concern is that if the resources are dissipated—and I see the logic in that—we will have difficulties with the provision of service. We want to provide a quality care service.

You want accountability. When the minister was here earlier this morning, you said that if you are putting money into the service, you want to see the outcomes of that. We are not coming down in favour of any of the three management structures that we brought before the committee, but if you want to go down the road of direct payments, you will have to use one of those models.

COSLA's submission mentions considerable concerns in relation to local authorities being dragged in to authorise the services of staff over whom they have no control. What sort of mechanisms should we have beyond the registration under the Regulation of Care (Scotland) Act 2001? Will there need to be local agreements?

Each of the options that we have talked about in our submission involves the need for professional as well as managerial accountability. We all know the horror stories about the individuals who were recruited without appropriate checks or training and who were not the kind of people we would want to see providing care.

The Parliament should lay down minimum standards. Then we can debate how to provide those minimum standards; we have identified three options relating to training, recruitment policies and ensuring that the appropriate checks are made. I realise that going down that road conflicts with some of the proposals in the bill.

I want to move on to joint working. I should declare an interest in that I am a member of Unison. I was interested in some of Jim Devine's responses.

You emphasised trade union concerns about terms and conditions and the professionalism of staff. However, the Community Care and Health (Scotland) Bill is about delivering a service to the most vulnerable in our society. Your submission talks about professional accountability. Given that we have just passed the Regulation of Care (Scotland) Act 2001, which requires those professionals to meet certain criteria, similar to those expected of nurses and other professions, how does that square with what you have said about the individual's accountability to their professional accountability?

I do not really understand your question. We welcome the Regulation of Care (Scotland) Act 2001 as a positive step forward. As members know, we have argued that anyone who goes into any health care setting, whether in the private or public sector, should have some form of training and that there should be minimum standards. We welcome the developments in that area.

The element of accountability is crucial. However, as I said, I accept that that runs contrary to the idea that individuals should determine some of their own care. It is about how we square that circle.

Are you saying that individuals who are assessed as being in need should have a service imposed on them, by whatever authority, without a choice of what that service should be? They might wish to compensate a member of their family financially or they might wish to buy the services of Joe Bloggs down the road.

I accept that. That is the difficulty with the structure and the strategy that we are presenting. The benefit of the Scottish Parliament is that we can come and present our way forward, but say that we accept that it runs contrary to some proposals. We welcome individual choice, but if individuals have a choice in the exact way that Margaret Jamieson has outlined, there are potential difficulties.

Since the time when I was involved in Unison, there have been significant changes, particularly in the way in which services are delivered. Perhaps I should direct my question to Joe Di Paola. For years we had home helps, but very few individuals have that title any more. We talk about home care and a work force that has more skills and, in some instances, long-awaited increases in pay. Is this a further development of something that has been happening already, to fit in with the modern-day needs of the service?

You are absolutely right. This is probably one of the most radical and crucial developments that will take place in service delivery. Unison represents huge numbers of employees, both on Jim Devine's side in health and on my side in local government. We are committed to seamless delivery for people—that is what our members are employed to deliver. We must ensure that staff are properly trained, organised, managed and resourced to deliver care. We fear that the huge and rapid changes that the bill will occasion in the delivery of a whole range of personal care services have not been properly thought through and have not been properly consulted and agreed upon. I think that I heard the minister say earlier that 70 per cent of the budget will be on staffing. That applies to local authority staffing as well.

We are not here to defend entrenched positions in the health or local government sectors, or even to defend a Unison position. We are more than happy to give members whatever information we can to aid your deliberations, but members must be aware that the implications of the bill for the staff who will deliver the radically changed services are such that we will have to get things right and do so quickly. As Jim Devine has said, we are not pushing any particular model. We are happy to discuss with you and with health and local authority management ways of making progress; however, as trade union officials who represent Unison members, after the delivery of the services, our prime regard has to be the way in which the people who deliver those services are properly looked after, resourced, managed and paid.

I totally agree. However, we must accept that the bill is a move forward. There are many things in the past that none of us wants to remember—things that perhaps put us where we are today.

Joint working initiatives have been springing up; the Unison submission cites examples in Perth and Kinross and in Dumfries and Galloway—I am sure that you did not have enough paper to list all the examples. However, in a submission that was sent to the Local Government Committee by South Ayrshire Council, the council proposes

"that a single body is charged with monitoring effectiveness of joint working and providing an arbitration service where joint working is failing. It would be necessary for this body to be independent."

What is your view of that statement?

I think that that is almost an admission of failure. If you have to set up an arbitration body for the component parts of a joint working arrangement—in health, local government, the voluntary sector and wherever else—it is as if you are saying, right from the start, "This is not going to work. There will be real problems and we'll require a referee who is outwith the participant bodies." We are arguing for a clear protocol that will set out how all the agencies and their employees can get together to deal with any issues that arise.

Joint working is the way forward. It is the only way in which we can deliver proper services in the 21st century. Everyone must be committed to it and everyone must be inside the circle. Proposals for an arbitration service seem to me to be an admission of failure.

Fear is a big issue. Everyone is committed to citizenship issues and joint futures, and groups are setting up joint assessment schemes. However, if such initiatives are not pulled together by unified boards, what kind of message does that send to the health sector? Let us consider the situation in the Lothians, which has four different local authority providers and one unified board: is a physician at Edinburgh royal infirmary to learn four different assessment schemes?

We can get people together, although at the moment partnership working across the health sector is not happening. The drivers in our national health service are partnership and staff involvement. Elements of joint future working are now at the top, although sometimes it does not happen at all.

I am convinced that local authority and health authority professionals are concerned about charging for a nurse who assesses a client—a citizen—who requires that level of care. The funding can come from A rather than B. If the citizen does not get the funding, staff are compromised. Standards are set for them by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. It is likely that social services staff will have the same problem with their professional organisations. If we can pull them together using single assessment across almost all of Scotland, the time scale will be more manageable and achievable. That will allay a lot of fear. People, especially at senior management level, need to stop being precious about their budgets. Joe Di Paola and Jim Devine articulated that.

The Scottish Parliament is introducing a bill. We owe the older people of Scotland a better, seamless service. Our members do not fear the bill. I listened to the previous witnesses who said that they were up for it. So are we, although it will not be easy. We can implement single assessment across Scotland with scrutiny from the Scottish Parliament and other places. We must identify what the professional issues are. How do we ensure that nurses' registration is not compromised with the UKCC? I do not see that as a problem, but as a way of enhancing the service.

You are right. Citizens should be at the centre. They should not have to fit into health or local authority frameworks. If citizens require social care, that is what they require. Does the bill go far enough? Should we set up something similar to the situation in Northern Ireland where there is one united employer?

Given that I am the chair of Unison's Scottish health committee, and that my counterpart is unfortunately stuck in the outer islands—

I will take that as a no.

I would not survive a week if I said that.

We need to take things beyond saying "I work in health," or "I work in local government." Many issues that relate to human resources are thrown up when we examine those two areas.

In your submission, you do not expand on other areas of your membership. That may be an oversight on your part, which you might wish to correct today, as you have a significant number of Unison members in the voluntary sector who deliver social care.

In the paper, we are saying that we want to start a debate. The short-termism of joint funding will not stand up. That is for the reasons that we outline in the section about HR, in which we address issues including terms and conditions. We want to start a debate about where we will be in the medium and long long term—as does the Health and Community Care Committee.

We give three solutions. In one of the proposals that we are working on for health and local government, we are going to Northern Ireland. I do not know enough about the situation there and we receive mixed messages—

As we did when we took evidence.

You are right. The voluntary sector is a crucial issue. We want to move the game onward in exactly the way that Margaret Jamieson has described. We want to flag up the problems that exist with the present proposals and suggest solutions. Northern Ireland presents another model and there will be others.

In your paper, you mention the differences in the terms and conditions of local authority workers and health workers. I know the system; the conditions that apply are national sets of conditions. You then cover the provisions that exist for the voluntary sector. They involve thousands of sets of terms and conditions, yet you make no reference to that.

We are having discussions with Scottish Care, because of the bill and the way that—

That is the private sector. I am talking about the voluntary sector.

I accept what you are saying. We have membership in the voluntary sector, but our experience of some parts of the voluntary sector is that it is not what one might call a model employer. We have had some difficulties—difficulties that you will be aware of from your previous job. We are here to talk about what we would consider model employers and good practice. The convener mentioned fairness. The ethos of the Unison health committee is quality care, dignity and accountability for the staff, clients and patients.

I have to wrap things up at this point. We have many more questions, so will you indulge us by allowing us to put them in writing? We can then expand on any queries that we have about your written submission.

As you have stressed, we are talking about the long-term direction of care services in Scotland. I take Eddie Egan's point that as long as we are all positive about what is going on and realise that we are about improving services, and as long as people are in dialogue with one another, many of the issues that you have brought before us today can be addressed. However, we have to do that in partnership with the component parts, including the voluntary sector, the private care facilities, the statutory bodies, the Parliament and the Executive. Thank you for your contribution so far. We will be in touch.

Good morning to our next witnesses. I apologise for keeping you waiting. We have had a bit of an odd morning. You have given us a written submission on the bill, and we have a number of questions that we hope to get through today. The committee is concerned that the community care policies and services that we deliver in Scotland should be underpinned by principles of fairness and equity. Do you believe that the bill upholds those principles?

I think that it does. I do have a short opening statement.

I am sorry, but we have only about 20 or 25 minutes—I know that you have to be away by 12.45. If you read out your opening statement, we will have less time for questions, but if you provide us with a copy of the statement, we can pick things up in writing after the meeting. The most productive use of our time today is probably to ask the questions we want to ask, based on what you have given us so far.

That is fair enough. There are five members of the delegation—the various members will deal with different questions as they arise. This is only my third day as spokesperson, so please be gentle.

I wish you all the best in your new post.

You state in your submission that you would be unhappy if the Executive issued statutory guidance on charging, as you think that that would result in ill-defined and unresourced commitments being passed down to local government and that you would have to find money out of your already stretched social work budgets. Can you outline the progress of the work that COSLA has undertaken on charging guidance for local authorities and the proposed time scale for completion of that work?

A great deal of work has been done and COSLA has reached an interim position. The final details must be linked to the detailed proposals, guidance and regulations that will follow and to the completion of the progress of the bill. The starting point was difficult because, as members are aware, there are 32 different charging systems in Scotland. That reflects the position that central Government took until relatively recently. Now we recognise that a balance needs to be struck between having a completely open situation, in which every authority has its own system—people in neighbouring authorities would perceive inequities in such a system—and having a centrally prescribed position that ensures that everywhere the situation is the same. Local government should retain some flexibility to determine how it uses its resources to carry out its responsibilities.

In your submission you state that

"the issue of mandatory guidance on charging does not arise until an assessment of COSLA ‘s guidance has been undertaken".

Is that the current stay of play?

Yes.

You may have heard my next question being put to the previous witnesses. COSLA is one of the only organisations from which we have received evidence that it would be more appropriate for the definition of personal care to be included in regulations rather than for it to appear on the face of the bill. Can you explain how you reached that view?

This is a complex area, as the time that it has taken to produce a definition of personal care and the difficulty that the care development group has experienced in resolving the issue reflect. In our view, the definition of personal care that is agreed while the Parliament is considering the bill may not be the definition for all time. There must be some recognition that experience of implementing the bill, of providing care and of managing finances will lead to a changed understanding of personal care. If the definition is included in regulations, all the parties concerned will have more flexibility to review, adapt and fine-tune it over time. We regard the care development group's proposals as manageable, pragmatic and realistic. They provide us with a basis that will allow us to move forward.

I have a supplementary question on that issue. Is there not a danger that, if the definition does not appear in the bill, it could be watered down? If it were included in the bill, changes to it could be made in the future, but they would need to be considered by the Parliament and would be subject to scrutiny. The definition would not be set in tablets of stone, but any major changes to it would be made through the democratic process. Service users, carers and interested organisations have good reason for wanting the definition of personal care to be enshrined in the bill. It could not then be changed by a future Administration by the stroke of a pen

I doubt whether the definition could ever realistically be changed by an arbitrary decision by any of the parties. The nature of community care services is now such that decisions are taken largely by consensus. Services evolve and priorities are set by consensus. That is the reality on the ground. Increasingly, users and carers have a central position in the evolution, development and prioritisation of services. That is an important safeguard.

Given the capacity that parliamentary committees have for scrutinising the performance of the Executive and of care providers—the health service, local authorities and so on—there would be ample scope for them to review fairly closely the performance of the bill and of care providers on the ground. I do not envisage any great difficulty with that approach.

This is a complex field and it has been difficult to get to where we are. I am a wee bit anxious about setting everything in concrete at this stage, in case we have to revisit the whole process soon. There is scope for evolution and, given my experience on the ground with users and carers, my view is that they would recognise that degree of pragmatism.

Last week, we received a submission and oral evidence from representatives of the Royal College of Nursing, who suggested that nurses were reluctant to be employed by local authorities or other organisations that have not employed nurses before. Given that local authorities are to become major employers of nurses, I was shocked to hear that the RCN had not talked to COSLA and that, consequently, COSLA had not talked to the RCN. There is serious concern about the huge human relations issues that must be overcome, given the fact that the systems must be in place in six months.

I am not entirely sure that I agree that local authorities will become major employers of nurses. The provisions of the bill on joint working are enabling, to a large extent. They leave open the arrangements for managing and resourcing community care services, which are to be agreed at the local level between the health authorities and local authorities. I recognise that nurses are concerned that their professional status is being threatened and that they feel that they might have to move out of nursing into some other care sphere. I am sure that we can deal with the practical issues that exist within the constructive setting of the developing joint working relationships. I am not unduly concerned about that, although I take your point about the importance of the nursing profession talking to local authorities soon.

I do not share Mary Scanlon's view that nurses will have to change their employer base just because joint working is going to be introduced. For example, an individual might remain in one establishment, even if their needs change over the piece. They may need one type of nurse for a few years, after which they would move on to another type of nurse. If the local authority houses that individual, it would be wrong to specify that that local authority should have to provide that service. Am I correct to say that, if joint working is introduced, the local authority will buy in such services from health colleagues in the area?

Perhaps I can provide an illustration that is based on local experience and that I am sure is typical of the arrangements that exist in a number of areas. In the authority in which I work, we have what we call an intensive home care service, which co-locates home care staff, home care managers and community nurses, who are seconded in from the local primary care trust. The local nurse manager has access to other community nursing services, which can be accessed as and when required for the group of people with whom we work on the basis of an assessment. I do not suggest that that service is unique, but it is a model of how we might be able to move forward, as it allows the flexibility that Margaret Jamieson referred to. It is important that we recognise that people change over time and that we should not get stuck with a rigid prescription. We should be able to respond flexibly to people's needs.

It sounds as though many of the perceived threats could be overcome if people were simply to talk to one another.

The submission from COSLA says that

"no case has been made for the creation of a further power of ministerial direction which could have a perverse effect on joint working arrangements".

Could you explain what that means?

The stage that we have reached on joint working has been achieved through a lot of hard work. I take the point that previous witnesses have made about the different levels of joint working and its effectiveness throughout the country. That has been arrived at through commitment and effort. I firmly believe that the way forward is to construct the opportunities that I have just outlined to bring together people who deliver services and their line managers. The greater the confidence that they have in each other's judgment, performance and targeting of resources, the more feasible it is to think of joint working and integrated working as really meaningful.

It would be wrong to start by creating a superstructure—a new organisation—to take over responsibility for that. Such an organisation would pluck key elements out of the existing organisation, and that is a recipe for turbulence and disruption. We have had experience of that both in the health service and in local authorities over the past few years. That would not be the starting point for me. We may reach that stage at some point in the future, but it is far too early to say what will happen. The danger of providing for such a superstructure in the bill is that it would be seen as a threat. People instinctively react badly to threats. We are talking about building a culture and climate of confidence and collaboration. The suggestion seems unhelpful and unnecessary at this stage. The Executive and others have levers for monitoring and holding people to account so that we can be encouraged, pushed and cajoled without that specific step being necessary.

In your submission you are fairly forthright in your opposition to the ring fencing of resources. Indeed, you complain about the increase in ring fencing in recent years. However, the care development group pointed to a £43 million gap between grant-aided expenditure for community care services for the elderly and actual budgeted local authority expenditure on those services. Given that gap, how can we ensure that additional funding, such as the £100 million in each of the next two years for free personal care, will actually be spent on that unless it is ring-fenced?

That is a difficult issue. I am sure that you will be aware that local authorities have responsibility for the full range of social work services. Although there appears, according to one calculation, to be a deficit in the spend on community care services in relation to GAE, local authorities have overspent in other areas. Local authorities take those decisions at local level to deal with their responsibilities, and the process can be difficult and painful.

If the Parliament votes, as it will on the budget, for £100 million to be allocated to implement free personal care, why should local authorities be able to overturn that decision?

I am coming to that point. If that proposal is made explicit in the bill, it would be surprising if local authorities sought to thwart it.

If money for free personal care was ring-fenced, would not it be easier to pool budgets between local authorities and health boards?

I do not think that it would be any easier or any more difficult. The field that we are talking about requires a lot more pooling and joint management of resources than is constituted in the care development group's proposals. I expect that we will go beyond that in terms of the resources that we commit to joint activity.

The care development group has recommended that all the funding for older people's services should be the subject of clear outcome agreements that are closely monitored. Would COSLA support that?

Yes.

We are concerned about outcomes, as you have heard, but we are also concerned about inputs. The Scottish community care statistics for 2000 show that net expenditure by social work departments on all community care clients fell by £45 million between 1997 and 2000. What is the point of putting more money into the budget if we cannot measure the outcome and if spending over those three years fell by £45 million according to Government statistics?

Local outcome agreements are an important way of dealing with that issue. That approach deals with the outcomes of the activity that we are engaged in. It is a useful safeguard for how we approach the issue in future.

You are receiving more money from the Executive, but you are cutting community care funding by £45 million.

We also spend on other services substantially more than we receive from the Executive. Local authorities face a difficulty in balancing their resources with their responsibilities. On the care development group proposals in the bill, we are committed to working through a mechanism of local outcome agreements that will safeguard the investment that people want to make.

Richard Simpson will speak next. I ask him to talk about deferred payments and top-up costs.

I will ask about both. Delayed discharges are a big problem, but we cannot discuss that today. They relate to joint working. If the budget has been underspent by some £43 million and delayed discharge numbers have increased by 20 per cent or 25 per cent in the three years to which Mary Scanlon referred, the health service must pick up the tab, so joint working must start to show signs of success.

COSLA has clear concerns about deferred payments. Your submission says that there is no budget for dealing with them in the three-year local government settlements. Should deferred payments be covered by the bill? Should local government receive extra money for them?

This morning, we heard about how long an individual is likely to have before a local authority claims the capital involved, but partners are another matter. If there is a lien on a house, a local authority would not want to evict anyone from that house. The purpose of the arrangement is to prevent people from being evicted.

That is a clear misunderstanding of the arrangements. There is no question of eviction being an option. We were slightly surprised that that question was asked today. We understand people's concerns about that, but the reality is different. That is a public information issue. I am trying to remember your earlier question.

It was about your funding concerns.

A new responsibility is being placed on local authorities and they must construct a system to manage that new activity. I would be concerned to find ways to fund that that avoid impoverishment of people who require care, but we must also ensure that that is not a back door to discounted access to services. If people postpone payment and no provision for interest is made, local authorities will have to pick up the tab. That technical issue must be dealt with through the process, eligibility requirements and the financial arrangements. We will have to be careful about that. The responsibility is new and we must explore it.

We have set out our concerns about top-up costs. We must ensure that people's personal allowances are safeguarded from predatory demands, because it is important that people have a basic amount of money to use for personal purposes.

Do you think that that safeguard should be in the bill?

Yes.

Do you have any other suggestions on what it would be useful to include in the bill and do you think that anything has been omitted?

I thought that you were going to ask about carers.

Yes—the protection of carers. I had also planned to ask a question about the housing situation when someone dies, but that has been covered. How can we make progress on aid to carers generally?

The bill says that carers should have a right to an independent assessment from a local authority. What impact would assessments and any additional funding that they require have on local authority budgets?

We welcome the bill's provisions on carers. We were slightly disappointed that carers were not the subject of a separate bill, but we express some satisfaction about the fact that the bill will enhance their position.

It ought to be possible to address carers' proposed separate right to assessment with the additional resources that will be made available to us over the next few years. There is some speculation—nobody has a great deal of certainty—about the additional demand that might be made on authorities for that. At this point, it would be unrealistic to claim that we will be grossly under-resourced. We will have to suck it and see.

Crucially, the developing relationships with carers—their greater capacity for sticking up for themselves through local organisations—means that the position will become clearer quite quickly. We are fairly sanguine about the situation.

Do you include advocacy in that?

No, we regard that to be separate, additional and important. We certainly invest in that.

Margaret Jamieson has a small, final question on implementation.

In your submission, you indicated that implementation will have cost and staffing implications and that the time scale that has been set in the bill is not realistic. You also discussed the task of implementing such a complex scheme. However, you seem to be saying today that things are already in place on the ground. How do you back up your statement about complexity?

You mentioned in your submission that staff need to be trained in risk assessment. I sincerely hope that staff who deliver services assess the risk on a daily—perhaps even an hour-by-hour or minute-by-minute—basis. Brokerage and contract management requirements were also referred to. To me, that implied that you really did not like the bill and were throwing a spanner in the works so that you did not need to go down that road. That is not what you have said in your oral evidence today.

I certainly want to disabuse the committee of any notion that we have got the situation sorted. I heard some of the earlier witnesses talking about being up for it and I share that view. I suggested in my introductory comments that good work is going on, but that that work is not perfect and has not reached an end point. We are in a process of continuous improvement. I believe firmly that relationships on the ground and at senior level are getting better—people now understand each other's language much better.

However, it is impossible to legislate for changes to take place suddenly—on a particular day—six months from now. Hard work is necessary. Within the framework of the bill, the conditions are being created for moving further down that road. That is the message that I tried to give.

The bill contains some innovative elements about contracts and training. For example, the expansion of direct payments is an important area to which we are committed. Despite a lack of experience in that area, there is a common view that direct payments are a good thing and should be implemented. However, the system of operation will be complicated. Who will be hired to provide the care and where will they come from? In large part, those people do not exist at the moment. Businesses must be grown in the independent sector so that they can be engaged to provide those services. That takes time and requires the local authority—as the overseeing agency, so to speak—to be confident that the people working or managing those services are of an acceptable standard. Systems have to be set up to safeguard the interests of the people who are being empowered.

In my opinion, appetites for accessing direct payments vary across different care groups. Although there is considerably less enthusiasm among older people—which I understand—there is a massive demand for direct payments among younger people with physical disabilities. There will have to be a differentiated response. Different approaches are used to deal with the interests and welfare of those two groups. Direct payments are a good thing, but we must work at improving the system.

Given that you have clarified your position and maintain that the time scale is unrealistic, what in COSLA's view would be realistic?

It would be reasonable for the bill—complete with its provisions on direct payment—to be enacted on 1 April, but people should not expect that the whole show will be on the road immediately. It will take time to achieve wide-ranging implementation, which will involve local outcome agreements, performance targets and so on. We should be reasonable about that.

On joint working, the bill incorporates a lot of the joint future group recommendations. It is important to state what we want to happen, but we recognise that the implementation of that should be a process of continuous, gradual improvement. We do not want that to take for ever, but we need to negotiate and agree with each other on the milestones for progress. Not everything will happen on 1 April.

Personal care and nursing care issues seem to be a priority for everyone and it is important that we recognise that that aspect of the bill must be up and running quickly. The other bits will take a while.

Are you suggesting a rolling implementation?

Yes, that is right. We need to hold each other to account on that, which I think we can do.

Thank you very much for giving us evidence. I apologise again for keeping you—we have kept you five minutes longer than you requested. I hope that that is not too much of an inconvenience.

We would be grateful if you would accept other questions, which we might come up with as a result of examining your statement and your earlier submission. We will be happy to accept your comments about the bill—or about anything else.

I remind colleagues that we have a meeting about the draft report on organ donation this evening at 6.30 in room 5.14. I have requested sandwiches because it is a teatime meeting. I thank members.

Meeting closed at 12:52.

Members who would like a printed copy of the Official Report to be forwarded to them should give notice at the Document Supply Centre.