“Commissioning community care services for older people” and “Adapting to the future: Management of community equipment and adaptations”
We move to agenda item 4, which is to consider two reports, more or less one after the other. They are "Commissioning community care services for older people" and "Adapting to the future: Management of community equipment and adaptations". I invite the Auditor General to start by speaking about the first report.
Mr Robert Black (Auditor General for Scotland):
Over the summer, we published two reports, both of them published jointly by Audit Scotland and the Accounts Commission. One looks at commissioning community care services for older people and the second one looks at the specific service of managing community aids and adaptations.
The first report is a high-level examination of the services that are currently provided for older people. Back in 2000, a handbook for councils was published in the name of the Accounts Commission, which aimed to help councils to develop a best-value framework for such services. In the new report, we follow up some of the key issues that were identified in that handbook. The main part of the report looks at councils, because they have the lead role in planning community services. However, as joint working between councils and the health services increases, we also comment in the report on how councils are working with their local health partners.
I suggest that there are important issues about how the Scottish Executive monitors its major policies in this area. The report considers the performance of all 32 councils in three key areas: planning, commissioning and reviewing performance. We identify five areas that need to be addressed by the various bodies, including councils, the health service and, indeed, the Scottish Executive.
The first point that we identify is about planning. Councils and health partners need to do more to plan for the likely growth in demand for community care services for older people, and the expected shortage of carers, both paid and unpaid. As the committee knows, the number of people aged 65 and over is expected to grow by about 45 per cent over the next 20 years or so. We also expect the number of paid and unpaid carers to fall in line with the expected decrease in the working-age population.
Secondly, although councils and health partners collect a lot of information about the older population, they do not always use that information to inform their planning. We have considered the types of contracts that councils use, for example. We addressed that significant issue back in 2000. Different contracts are suited to different situations and we outline in the report the advantages and disadvantages of each. Strategic planning needs to be supported by a balance of contracts that ensures value for money and sustainable services. We recommend that councils review that balance regularly to ensure that those are being achieved.
The third point is that research shows that most people want to stay in their home for as long as they can. There has been a small shift in the balance of care for older people away from care homes towards more intensive care packages delivered at home. Care at home is also being delivered in a more flexible way, with an increase in the proportion of older people who get home care outside normal office hours. However, that focus on more intensive care packages might have affected the number of older people who get lower-level preventive services. I am sure that the committee will recall that we touched on that issue in our overview of national health service performance.
The fourth point is that the Scottish Executive needs to ensure that it collects information about the local implementation of key national policies so that it can analyse their impact and cost and establish whether quality services are being delivered. There are three examples relating to the implementation of national policy in the report.
The first example relates to the data provided by councils to the Executive about the uptake of free personal and nursing care. Gaps in the data make it difficult to assess the effect of that important policy and to forecast future expenditure in the area. Of course, free personal and nursing care is a major policy, and examining its implementation is only a small part of reviewing it. A much more detailed review will be needed in the future to examine the numbers receiving the service, how it affects their quality of life and the cost of the policy, and it will be difficult to conduct that review without proper information. We understand that the Scottish Executive will today produce national statistics on free personal and nursing care, and we are keen to find out whether that information base is more comprehensive than the data that were available to us when we were doing the support work.
There is also a problem with information about the implementation of the new duty on councils to offer direct payments to disabled and frailer older people. We suggest that there are some unanswered questions about changes in the pattern of service delivery where large numbers of older people opt for direct payments. We have also found that the estimated costs and take-up vary significantly between the nine councils that have made estimates. That is quite starkly evident in the report.
We touch on the implementation of rapid-response services in each council area. It appears that such services are helping to reduce unnecessary admissions to hospital and to achieve earlier discharge but, again, the information at a national level is incomplete, so it is difficult to advise the committee on exactly what is happening.
Our final main point is that our census of older people on waiting lists for care homes and home care, in 31 March 2003, showed that almost every council has a waiting list for care home places and almost two thirds have a waiting list for home care. Although information about how long people wait for services is extremely important in the health service, the same information in relation to community care services is patchy and inconsistent, because the monitoring systems differ between councils and there is a lack of standard data definitions. We think that, in parallel with the concern about waiting times in the health service, the Scottish Executive should consider how long people wait for care homes and home care and how that is monitored.
We will be happy to answer any questions that you have. Alternatively, Barbara Hurst can take you through the other report on the agenda today.
I see that Margaret Jamieson and George Lyon would like to ask questions.
I have concerns about the fact that the Scottish Executive does not seem to be collating information on certain policies as they are rolled out. I say that from my experience of dealing with the Community Care and Health (Scotland) Act 2002 in the Health and Community Care Committee. Is there any indication of the amount of bed blocking that is caused by old people who restrict the type of care home that they are willing to go into? In my constituency, people specify which home they want to go to, although they could be moved much more quickly if that stricture were removed, even if only on a temporary basis.
I know that some authorities pioneered direct payments before they were rolled out across all councils. If we do not have information, how can we gauge whether the council in a given constituency is good, bad or indifferent?
Barbara Hurst (Audit Scotland):
The issue around choice for care homes is key. Older people should be given a choice—that is paramount. Angela Canning will correct me if I am wrong, but I think that the stats that have been collected on delayed discharges include a category that would cover the issue that you raise, although it does not necessarily form the greatest category for delayed discharges.
We would agree with the committee that the data that are available for monitoring policy and service delivery have been weaker in the social care field than in the health field. We have picked that up over a number of years now, particularly as the evidence base for services in social care is so much weaker than it is for health. It is relatively easy to consider the outcomes of interventions in health—people either get better or not. The evidence base is more subjective for social care and is very much tied up with people's quality of life.
Without the core information, there is no way that we can get at the outcomes. We have been pushing strongly the point that we need not just information on services and choice; we need information on cost. If we are going to monitor the effect of a policy and a service, we need good information on cost and on quality, most importantly from the user end, and indicators for the management of the service. The report on community equipment tries to explore some of those themes.
The fact that you report that the measurement of outcomes in relation to care of the elderly is worse than it is in the health service is worrying, given some of the discussions that we have had recently on measuring outputs in the health service.
The lack of focus on outcomes is a recurring theme in our reports, especially those concerning health and community care—it seems to be prevalent throughout the Health Department and other areas of government. When you try to prod the Health Department on the subject of money being allocated for a given policy on the basis of it delivering the expected outcomes, do you encounter resistance?
I am not sure that we have encountered any resistance. I think that everybody subscribes to the approach that you describe as being the holy grail, as it were. It is hard to measure outcomes that concern the quality of an individual's life, but that does not mean that we should not try to do so. If we can get evidence of the difference that can be made for people, surely service providers can, too.
Even basic information about how many people are waiting for services would assist. It is not rocket science; you need basic information that will allow you to calculate how much more money needs to be put into the system and what value is being derived from the various types of care that are being offered. That is nuts-and-bolts stuff. For any system, the issue is to try to measure the effect of policies and the amount of money that might be required to deliver certain outcomes.
As George Lyon recognises, we have a recurrent concern that, in study after study, the information simply does not exist to allow resources to be managed well. That leads to an element of doubt about the quality of the management of programmes throughout Scotland. We are working on the development of indicators for some community planning issues. I ask Barbara Hurst to say something more about that.
It is probably safer for Angela Canning to say something about it.
Angela Canning (Audit Scotland):
We are working with the Health Department's joint future unit under its joint performance, information and assessment framework. Part of the work that the joint future unit is doing involves developing indicators for waiting times for community care services as a whole. The unit is in the process of developing definitions, which will enable us to have a national overview of waiting times for community care. The plan is to roll those out next year, so we hope that, over the next few years, there will be information at a national level about waiting times for community care services as a whole.
To emphasise the point that the Auditor General was making, we think that what is lacking at local level is the kind of information that would let managers who are involved in the services know how long people are waiting for home care and for community equipment and adaptations. If they could break down that type of information, they could have detailed knowledge of how their service is performing.
Where in the Executive does the responsibility for driving that agenda lie? Is it with accountable officers in each department? Does it lie with the Finance and Central Services Department? Given the modernising government agenda, one would think that that is where accountability should lie. Do you have a view?
I find it difficult to answer that question, because we are talking about a cross-cutting service area, so we have the sort of systemic problem that we came up against in youth justice, in that more than one accountable officer has a role. I would imagine that ministers are well aware of that, but the question would really have to be addressed to the accountable officers. If the committee were to take evidence, the chances are that it would be necessary for more than one accountable officer to be invited to appear, so it would then be possible to have a discussion that would tease out an answer to that fundamentally important question.
I would like to pick up on the question of accountability. Although this is not part of the Audit Committee's remit, should we not be thinking about the specific roles, responsibilities and accountability of local authorities? It strikes me that we are seeing only one side of the coin if we sit here talking about who in the Scottish Executive is accountable for driving the changes, when there are, in fact, 32 local authorities with their own democratic mandate and lines of accountability for doing that. Is that a fair point to factor into this specific area of consideration?
The answer to that has to be that the committee is primarily concerned with how the Scottish Executive uses resources, so questions must be put in the first instance to the accountable officers. On where local government fits into the picture, I would suggest that part of the answer is certainly in the best-value regime. It would be perfectly possible—and I am sure that this will happen—for the Accounts Commission to expect Audit Scotland to ask questions about the implementation of a major national policy such as personal care or direct payments, and for that to be challenged in a constructive way at the level of individual local authorities.
In the past, the committee has taken evidence from local authority interests in the round, to get a better understanding of some of the system problems that local authorities face in cross-cutting areas such as this. The committee might wish to think about taking some evidence on that.
That is helpful.
I have four specific questions. First, you recommend in your report on adaptations, "Adapting to the future", that updated national guidance is needed to support new ways of joint working between social work, housing and the national health service. Is more national guidance really what is needed? Will more of the traditional form of written national guidance emanating from the Executive necessarily be any more effective than all the guidance that has gone before? I wonder why you recommend that, rather than some other effort or measure at national level to aid implementation locally.
My second question relates to joint resourcing, which is mentioned in paragraph 81 of "Commissioning community care services for older people". That area jumped out at me because of the disparity in progress. It is some four or five years since both the Executive and the Parliament—Margaret Jamieson referred to the Health and Community Care Committee's work on this—made some clear recommendations and put in place mechanisms to support joint resourcing of those services. Some councils have followed those recommendations, but they are the minority and the fundamental question is why others have not. On the key question of implementation, beyond what is in paragraph 81—which strikes me as more of the same, in terms of the Executive process—are there any other suggestions that you might make at this stage for how progress could be accelerated across the board?
My third question relates specifically to the policy of free personal care. Paragraph 32 of "Commissioning community services for older people" states:
"Public perceptions are reported to have been that all aspects of care are ‘free' when in fact it is only the ‘personal' element of their care that is free."
From the anecdotal evidence that I have received, I think that you are right, but I wonder what the basis for your view is and whether you have any comments about the impact of that perception—if it exists—on demand for the service locally and the experiences of people throughout the country.
My fourth question is whether you have any plans to undertake—or whether you might consider undertaking—a more wide-ranging piece of work jointly with the registrar general for Scotland on the impact of demographic change on future planning for public services in Scotland. The work that the registrar general has done on that should be required reading for us all. It strikes me that the combined efforts of both agencies could be enormously powerful.
May I work from the back forwards?
Certainly.
As soon as I run out of my comfort zone, I shall pass the ball along the line.
As Beckenbauer recommends.
I heartily agree with what Susan Deacon says about joint working and the impact of demographic trends on services. That is clearly a major issue. Some good work has been done on it and more could be done. I would be prepared to consider undertaking such a piece of work if the committee, on behalf of the Parliament, felt that that was a helpful area for me to go into. Some people might argue that the role of the Auditor General is not to look forwards but only to look backwards; on the other hand, our skills in the analysis of systems, for example, might be helpful in that area. If the committee was of the view that that might be useful at some point, I would explore the possibility with the Scottish Executive and the registrar general for Scotland.
I look to members of my team to answer on free care and the issues round the joint future agenda, as they have much more detailed knowledge of those things. On the first point, concerning adaptations, it might be helpful to the committee if we gave you a brief outline of some of the key issues. Barbara Hurst will be able to pick that up, if that is acceptable to you.
We asked councils about the implementation of free personal care. We do not often report what councils tell us on the ground, but in this instance we felt that they made an interesting point. They told us that they are having some issues around the definitions of free personal care and what people expect. The 32 councils reported to us directly and that issue was flagged up fairly much across the board.
On the demand for free personal care, the policy was challenging to implement locally and it is to the credit of councils and the health service that they rolled it out. Unmet need in relation to private provision—where people who bought care privately in the past are now eligible for free personal care—is still an unknown factor. That matter came up at our most recent meeting. We are uncertain about the true scale of such need and councils need to get a better handle on it if they are to know how to plan for it in the future.
That is all that I can say on free personal care, but I will pick up on joint resourcing. A couple of years ago, we made a decision that the most effective way of working on the matter was to support the Executive's joint future unit in rolling out that approach. Angela Canning, in particular, has done a lot of work with the joint future team. There are clear differences across the country, but the joint planning framework assessment did not identify why those differences exist, as it was more or less a desk-based exercise. We probably need to go in underneath that work; a number of our local auditors are starting to examine the partnerships, particularly in relation to the accountability arrangements. If one has joint resources, one needs clear accountability arrangements. We are rolling out that work throughout the country in local audit; we need to pull it together in our headquarters and consider where to target the audit. That work is for the future, but we recognise that it is an issue.
Should I quickly run through the community equipment report and then pick up the point on guidance, or would you prefer me to pick up that point first?
It would be better to keep them separate, because we still have Rhona Brankin's question to take.
What is the role of the Scottish Commission for the Regulation of Care? How is the quality of care monitored? Is there a standard way of doing that, or are you saying that the work that is continuing just looks at indicators? When I have asked questions about staff qualifications and training and the monitoring of quality of care in the community of adults with learning disabilities, I have been told that the care commission has a role in that, but I am unclear about where it sits.
The care commission is, I think, a non-departmental public body and its role is to inspect all social care services and some independent health care services. It does that by setting standards for services, including quality standards or proxy quality standards around staff training. Its programme of inspections of care providers applies to all care homes and home care providers, although it does not go down to the level of the individual home carer.
The care commission has a key role to play in the quality of services. Last week, it published a report on care homes, which arose from its Scotland-wide inspections of the quality of services. On the back of that, we are in the early stages of discussion about doing some joint work. The care commission has the quality angle and we can bring the harder financial and management angles, so we could do a good joint piece of work. The care commission has a clear role in the quality of care that is provided.
Given the quality part of the best-value agenda, it strikes me that it is hugely important to work with the care commission on the issue.
At this point, it would be useful to move on and take up some of the issues arising from the report "Adapting to the future: Management of community equipment and adaptations". Barbara Hurst will cover that, after which we will take Susan Deacon's question and other questions from members.
The report complements the report on commissioning care services and examines in detail a specific service area. We drilled down to look at the management of the service and did a lot of work to get users' views on the services that they receive. The service is a low-expenditure one, relative to some other community care services, but it has such a big impact on people's lives that we felt that it was worth looking at. We also felt that, because community equipment had been around for a long time and health bodies and councils should have been working together for a long time, it would be a good area in which to examine joint-working initiatives.
Equipment and adaptations help people to live as independently as possible and so enhance the quality of their lives. Moreover, they can prevent more costly interventions, such as admissions to hospital, and they help people to get out of hospital sooner. The issue is not just about the £30-odd million that we identified.
Because we were interested in getting the views of users and carers, we did a Scotland-wide survey of just under 1,000 members of the general public and held five in-depth focus groups with users and carers. We used that information to illustrate points throughout the report, which adds a necessary dimension to our work in looking at community care services. The study was challenging for us, because it was difficult to track services through different agencies. For example, exhibit 6 on page 19 shows in a simplified form the complex route for service users.
I will highlight four key findings. First, the users told us that, from their perspective, it was not easy to find information on how to get hold of services, what they are eligible for, whom they go to for help and whether they need to pay. Clearly, there is an issue about providing better information to potential service users. It is fair to say that people were overwhelmingly positive about individual staff. Although users and carers highlighted a number of difficult issues for service providers, they focused on the system rather than on individuals, because they recognised what staff were trying to do for them individually.
The report also picks up on waiting times. We heard sad stories about how long people had to wait for services and what that meant for them on a day-to-day basis. Therefore, when we examined the management of the service, we wanted to know from the data how long people were waiting. Where we could obtain information—which was not everywhere, by any means—on, for example, the time taken from referral by a general practitioner through to assessment for the service, we found an average waiting time of three months. If we add on the time that it takes to get the equipment or the adaptation, that is a long period.
Secondly—this picks up the point that Susan Deacon raised—services are still fragmented, even though action has been taken in a number of areas to improve and co-ordinate them. There is an issue around guidance. We are not asking for more guidance; we are asking for clarity on the guidance. The joint future agenda, which promotes joint working, has come in, but some of the guidance is now out of date and is positively acting against joint working. Our recommendation is for clarifying some of the guidance to enable service providers to provide a more joined-up service. We can return to that, because Susan Deacon still looks sceptical.
The third issue, which is a kind of mantra in the report, is the lack of good performance information on every level—the cost of the service, how it is being managed and its quality. How on earth can a good, streamlined service be provided to users without such information?
Even given the increase in the older population, which the Auditor General has already picked up on, we found a lot of historical budget setting that takes no account of the growing demand for the services. We found an over-reliance on non-recurring funding in the health service in particular. The winter money is being used to boost provision of the service.
Finally, in considering the policies and procedures that are in place for the service, we found that there are some risk management issues for providers. For example, we found that only a third of the councils and half the NHS bodies that we considered had written procedures in place to recall faulty equipment; that could be serious if a recall notice needed to go out. Users told us that, because of the lack of clarity about where to get their equipment in the first place, they often did not know whom to approach about repairs and maintenance.
That is a quick run-through of a complicated and detailed piece of work. We are happy to answer any questions. I do not know whether I have answered Susan Deacon's question; perhaps she wants to come back on that.
It makes sense for Susan Deacon to follow that up before Robin Harper and Rhona Brankin ask questions.
Barbara Hurst has answered my question; whether she gave the answer that I wanted to hear is another matter. She has also aided my understanding of why the recommendation was made for yet more national guidance on joint working. Her answer served to compound my view that we need to think of a different way of taking forward such change, rather than rewriting yet more guidance and having carefully crafted words on a page emanating from within a department. As to whether the guidance is the most effective way of driving forward and implementing change in culture and practice in this area, I wonder whether we need to start saying, "The emperor has no clothes."
In both reports, a great deal of emphasis is put on the need to shift towards outcomes. Are we not at a stage where anything that could be said has been said about how to do some of this stuff? There is a case for drawing a line and saying, "Here are the outcomes that are required in relation to the delivery of the service." That is what will be tested to the limit by the various processes in place, be it through the monitoring systems in the joint future unit, through the Executive audit process or through Audit Scotland. My fear is that we or some future committee could be back here three or four years from now having exactly the same conversation.
In many ways you are right. We have evidence that, where local systems have pushed the boundaries and worked together, they have radically reduced waiting times for the service.
I want to come back to the guidance issue. I will talk about housing, because that is the one area that surprised me. The guidance firmly places the responsibility for major adaptations with a council's housing function. However, we know of authorities that are challenging that policy and have a co-ordinated, joined-up system based in the social work part of the organisation. They are going against the national guidance. Therefore, either we should get rid of the national guidance and say, "This is the outcome that you are aiming for, so go for it," or we should clarify the guidance.
Following on from Susan Deacon's question and what you have just said, do you want to draw attention to any particularly good examples of good practice? You are saying that that departure from guidance appears to be working towards a desired outcome. Are there any other departures from guidance that allow things to be done better or are there places that you could point to as examples of where an approach is being taken that should be considered?
We always try to pick up on good practice and we flag up several examples in the report. We do not say, "This is best practice," or that it can necessarily be applied across the country, because there might be different dimensions to take into account. However, there are several areas where innovative work that makes a difference is being done. I do not know how much local partnerships are using the guidance issue as an excuse for not getting on more or whether there really is a barrier. In one area, the guidance issue has been a barrier, but I do not want to say where, because I think that the authority is currently in dispute with the department about whether what it is doing is acceptable.
As someone who has been a user of the service on behalf of my daughter, I welcome the report. Absolutely everything that you say in it is something that I have found to be true over the years. The point about the difficulty of accessing information is absolutely right. From what I can see, there is no mechanism for reviewing whether the provision is appropriate and I am sure that, as you have said, provision varies a lot between local authorities. This is a hugely important area, despite its small budget. The report is also hugely important; it has the potential to make a huge difference to people's lives.
My point is not so much about the detail of the report as about the general theme of outcomes and the lack of good information to enable us to measure whether the local authorities or whoever is responsible are delivering the outcomes that we expect from the policy. What is the Auditor General's view on moving to a system of payment by results, as has been introduced in the health service south of the border. Could that be one way of dealing with the issue? There has been a lot of talk about guidance and trying to ensure that organisations go about things in a certain way. However, if the major driver is payment by results, the responsibility to deliver lies with the deliverers—it is up to them to figure out the best way of delivering—whereas it is our responsibility to fund the outcomes. What is your view of that?
Moving to payment by results would be a policy issue and not one on which we should comment. However, given that mechanisms for payment by results—to use that phrase loosely—are being introduced south of the border, there is an issue about gathering evidence on whether those mechanisms are making a difference.
That is important.
It seems to me that, generally, many of the presented problems that we come to you with, which are about poor information, lack of co-ordination and so on, relate to incentives and opportunities for staff locally to get on with things. There seem to be barriers in the way of that—not least some of the guidance, which is completely out of tune with where people want to go with their services.
I cannot give you a simple answer today in which I state that we have evidence that payment by results is the way to go; I think that some good solid work will be needed over the next few years to find out what seems to be working best. That does not necessarily simply mean considering a formal payment-by-results system but, as Barbara Hurst indicated, it involves examining more carefully the areas that seem to work best, by going round the restrictions.
I take it from that answer that you intend to investigate the subject in the next few years and to do some benchmarking.
I invite Barbara Hurst to remind me of what we are saying in that area.
Are you talking about benchmarking specifically against what is happening in England?
Yes. One could argue that such benchmarking should be done on health, given that there is starting to be quite a divergence in the way in which the systems north and south of the border are managed. Surely it would be useful to measure the impact of those different systems.
Yes. We have kicked off discussion with the health services management centre in Birmingham about our doing joint work on trying to bottom out some of those differences, but first we want to examine the evidence on what is happening. We must track that evidence and date it according to the time at which different initiatives have been introduced.
We have started that process, but I think that it will be more difficult than I initially thought that it would be. We had a very interesting discussion on payment by results. It is clear that the health services management centre feels that it is too early to say what is happening with that, so we might not be able to map the development of payment by results against changes in activity. However, we are certainly pursuing work on that.
Having read both reports, I am quite depressed in some respects, given what the policy outcomes of care in the community and free personal care, for example, were supposed to be. In some cases, things have not moved on or changed.
It is good that we introduced the single shared assessment, but thereafter things fall to bits. I am interested in the way in which housing seems to see itself as something separate that does not have an input. I think that we could all outline examples of cases in which we have dealt with constituents who have had a single shared assessment and who have had people out to measure them up for a motorised wheelchair, only to find that housing could not provide the ramp. It seems that no one is examining how that journey is progressing. Social work departments get to hear about such situations only when there is a further difficulty because the quality of life of the individual who needed the adaptation has been affected and they and their carer have said, "Look, we haven't been able to get out because we don't have that adaptation."
In the health service, we talk about the patient journey but, as far as I can see, the report contains no recommendations on how the client journey can be overseen, improved on and followed through. How do we measure that journey from the single shared assessment to the outcome that was agreed? Is there a timescale for that? Are there any measures that we can apply?
You are right. We could have—and perhaps should have—examined the single shared assessment and the impact that it is having. In our defence, that was such a detailed piece of work that it was hard to get a handle on.
In theory, the single shared assessment should help because it provides a single point of reference and, in the future, we will be able to measure whether it has had an impact on the whole system. I still have reservations about where housing sits. When we got some of the findings, I was surprised that that area was not pulled in closer, given the fact that 32 councils run both housing and social work departments. I would have expected the departments to be more integrated.
Angela Canning has had some involvement with work on the single shared assessment with the joint future unit. Are there plans properly to measure its impact?
As part of the joint performance information and assessment framework, the plans are to develop a tool that will be sent out for councils to use. That will be a way of measuring whether the single shared assessment has had a positive impact on the user—for example, how involved they were in the assessment process, how involved their carer was in the process and whether they were happy with the end result. That work is under way.
Will that work pick up on the situation in which an individual gets a single shared assessment that identifies that they require a motorised wheelchair, which is a health matter, and a ramp to get out of the house to use it, which comes under housing? How will such situations be charted effectively? It is all very well to say that single shared assessment worked, but that the other bits did not kick in. How do people feel about such assessments? What is the waiting time from an initial assessment to getting an assessment for a motorised wheelchair? What interface with other organisations takes place? Most local authorities have a small housing repair grant scheme, but there is nothing left in it by August. If someone gets their assessment in September, they might be lucky to get their wheelchair by the following summer. Sometimes, the client does not have that time to wait, but organisations are not responsive enough. I do not know whether the problem is professional barriers or a lack of understanding of the client's needs. At the end of the day, it is a question of how we measure quality of life.
Measuring quality of life is difficult. The information technology systems that the councils use are among the current barriers to our being able to collect all that information. There might be two different systems for housing and social work even within one council. That takes us back to the issue that we discussed earlier about how those areas should be managed. It would make sense for them to be managed together because that would bring them closer together. There are genuine barriers around the IT systems within councils, let alone around systems between councils and health partners. When a single shared assessment is carried out, there should be a record of all that information on an individual. The question is about how one aggregates the information to achieve a meaningful picture of what is going on in an area. That is not a very satisfactory answer, but the situation is difficult.
I will add a couple of thoughts, the first of which relates to resources. We summarise in paragraph 4.11 of "Adapting to the future" one of the many striking features in this area of work: the way in which moneys are allocated to primary care activities by the health service does not seem terribly clever. We say in the report that the budgets are way short of demand among those primary care trusts that were able to provide financial information. What seems to happen each year is that a budget line is allowed that falls far short of the expenditure required and then the tap is turned off or on during the year, depending on how the overall budget is going.
I am sure that members will recall that I have been concerned for some time about the movement to unified health boards. For example, if there is pressure on acute services, the tap will be turned off and on elsewhere in the system to do as much as possible to bring everything in on budget at the end of the year. I am not criticising managers who do that but, as far as the health service is concerned, the fact that the insufficient money that is allocated is drip-fed into the system adds to the complications in service delivery that Barbara Hurst has outlined and about which Margaret Jamieson has expressed concerns. How can one plan on a reasonable timescale when resources are being managed in such a way?
In her introduction, Barbara Hurst mentioned exhibit 6 on page 19, into which Margaret Jamieson's example of the electric wheelchair fits beautifully. One would go down one side of the diagram in question to identify the need for such a wheelchair and then go down the other side of it to work out whether it required a home adaptation. If a minor adaptation were required, the matter would go to the social work department; if a major adaptation were required, it would go to the housing department, but only if a council tenant were involved. If a council tenant were not involved, the matter might go elsewhere. The system is horrendously complicated; indeed, as Angela Canning keeps reminding me, the diagram in the report is a simplified version. As a result, the report highlights some very big issues about systems for which there are no easy answers.
I remind members that we will discuss our reaction to the report later in the meeting. I suggest that we move on, unless members have further questions that are meant to elicit information.
I want to ask one very brief question about information. Would the Auditor General or Barbara Hurst like to indicate where coterminosity features in the overall picture? Are the boundaries of health bodies and local authorities coterminous in the areas that are performing better? I do not think that you have touched on that matter.
We have not done a systematic match in that respect, but I can say that the good practice that we have identified tends to come from areas that have coterminous boundaries. However, that is not exclusively the case. The issue is important, because a health board or service provider could be working with up to six councils, all of which have different systems. Indeed, that became quite clear once we tried to map the partnerships, which we found to be an incredibly complicated task. When we drew up a boundary map of Scotland to get a feel for the number of potential partnerships, we found that there could be a huge number of them. Obviously, things are easier if boundaries are coterminous, but that does not mean that there is no good practice where there is no coterminosity. It is just that the matter is more complicated.
I should point out that as boards do not have the strategic resources to cope with issues such as planning capacity, it gets extremely difficult to work one's way through such a complicated system.
That completes our discussion under new agenda item 2, which was agenda item 4. I am sorry if that confuses anyone.
I now intend to move on to what were agenda items 1 and 2, on declaration of interests and choice of deputy convener, after which I will take the item on a committee debate in Parliament. After that, we can have our discussion on the SPCB accounts, the management of the Holyrood building project and subsequent items from which Andrew Welsh will absent himself. That will make the meeting flow better.
I also intend to take an aural break just as we go into private session to give members some respite from the background noise. [Interruption.] For those who did not quite catch that, I said "aural" not "oral".