Adult Health and Social Care (Integration)
The next item of business is a debate on motion S4M-05838, in the name of Alex Neil, on the integration of adult health and social care.
I remind members to speak through the chair by referring to other members by their full names and not as “you”.
14:45
I hope that today’s debate will be slightly more consensual than yesterday’s debate was, but one never knows.
I am very pleased to open this debate on integrating adult health and social care in Scotland. We will introduce a bill in Parliament on that important area of public service reform by the end of this parliamentary year. During the debate, I will restate our commitment to integration and outline our priorities for the bill.
I thank partner organisations in health and local government, stakeholders across the professional organisations, the third and independent sectors, and patient, service-user, carer and staff representatives for their contributions. I also thank the Parliament’s Health and Sport Committee for its contribution in the very productive period that has led up to where we are.
Since I became Cabinet Secretary for Health and Wellbeing, it has been clear to me that the Scottish Government is by no means alone in recognising that, as society’s needs change, so, too, must the nature and form of public services. It is also abundantly clear to me that the successful delivery of integrated health and social care services depends on effective partnership working across both the statutory and non-statutory sectors. Getting that right is a priority for Scottish society as a whole, and it requires leadership, engagement and involvement across the health and social care landscape.
I was pleased to receive 315 written responses to last year’s consultation. Those responses have added considerably to our collective stock of thinking on the matter.
As part of last summer’s consultation process, the Scottish Government ran nine public and practitioner events, which approximately 900 people attended. At those events, my officials heard from health and social care professionals, statutory and non-statutory organisations, carers, users of health and social care services, and members of the public more widely, and all the contributions were immensely valuable. On top of that, my officials were involved in around 50 local events, including focus groups, local forums and seminars. In total, around 2,000 people were directly involved in those discussions.
That shows two things: that we have gone to some lengths to ensure that the matter is thoroughly consulted on, and that the challenges that are being discussed really are important and matter very much to many people in Scotland.
Following the consultation, we published an analytical report that reflects the consultation responses, and our response to the consultation responses has also been published. That approach is consistent with our priority to continue the invaluable on-going partnership work involving the national health service in Scotland, local government, the third and independent sectors and professional bodies, including allied health professionals. We are committed to ensuring that effective integration is informed by the knowledge and experience of those in the public sector and beyond who have a key interest in health and social care. We must continue to work together to ensure that public services evolve effectively, so that people receive the support that they need both quantitatively and qualitatively, and that we use all our resources to best effect to achieve the best possible outcomes. That is why the integration of adult health and social care is a key part of the Scottish Government’s commitment to public service reform in Scotland, and why what we achieve with that programme of reform matters so much.
What do I mean when I refer to the changing shape of Scottish society? The 2011 census showed us that for the first time there are more people aged over 65 in Scotland than there are people under 15. It is great that more people are living longer, healthier lives, but for us, as for the rest of the developed world, an ageing population means that we must look carefully at how we plan and deliver services. Recent research shows that one fifth of all girls born in Scotland today will live until they are 100. As well as the ageing of the population, we have also had the increase, to record numbers, in the population of Scotland. That is a welcome development, but one that presents another challenge that we need to rise to.
However, this is about more than just older people and longevity; it is about improving outcomes for people who have a range of complex support needs and for their carers and families. Too often people in those circumstances are admitted to hospital or to a care home, when a package of care and support in the community could deliver better outcomes for them and would be more their choice. When people are admitted to hospital or a care home, the costs are human and financial, and the consequences are not just personal but felt across the whole system and by other people as resources are tied up inappropriately in care that is not best suited to the individual.
This is also about putting the leadership of clinicians and care professionals at the heart of service delivery for people with health and social care needs. Perhaps most ambitiously, it is also about establishing a public service landscape in which different public bodies are required to work together and with their partners in the third and independent sectors, removing unhelpful boundaries and using their combined resources to achieve maximum benefit for patients, service users, carers and families.
Like other areas in Scotland, West Lothian has developed a universal reablement service, which responds to all hospital discharges, where needed. Staff come from different agencies and organisations but work in an integrated way to deliver what is a truly personalised service for the individual. Early indications are that that service has saved West Lothian more than 800 care hours per week and resulted in individuals being able to complete everyday tasks for themselves again. That is a very good example of health and social care partnership working, leadership, engagement and involvement in action.
In many ways, it was no surprise to me that the response to the consultation was so thoughtful and thorough. We have an excellent record of partnership working over many years in Scotland. Nevertheless, we all recognise that our current health and social care system still incorporates barriers relating to structures, professional territories and silos, governance arrangements and financial management. Often those have no helpful bearing on the needs of the large and growing group of service users, many of whom have multiple health and social care needs. Many barriers also work against the general aspirations of efficiency and clinical and care quality.
Our forthcoming bill will reform the system to enable delivery of care that is better joined up within health and between health and social care and which, as a consequence, will deliver better outcomes, as I have said.
Indeed, the hospital at home programme in North Lanarkshire is a very good example of joined-up working between a health board and a local authority, enabling more people to be treated in their local community. The project, which involves a team of nurses, allied health professionals, healthcare support workers, social care staff, general practitioners and consultants caring for patients at home, is to be adapted for use and rolled out across Scotland. The programme has enabled 80 per cent of patients to stay in their home rather than be admitted to hospital. That is an example of what integration can achieve.
The bill will start from the principle of person-centred care, focusing on the importance of prevention and anticipation. That is in line with our ambitions as a Government for community planning and for the reform of children’s services, and it recognises the findings of the Christie commission. It is also based on the wealth of evidence that tells us that a person-centred approach delivers the best outcomes.
Therefore, the starting principle of the bill will be a requirement on health boards and local authorities to deliver, jointly, a set of nationally agreed outcomes that are focused on improving the individual’s experience of care. We will remove from the statute community health partnerships and establish health and social care partnerships to provide an environment of joint governance, joint accountability and integrated oversight of service delivery.
Each health and social care partnership will be accountable to its council and health board for the delivery of nationally agreed outcomes and any other appropriate outcomes agreed locally, using an integrated budget covering adult social care, community healthcare and aspects of secondary healthcare.
We will legislate to require health boards and local authorities to integrate those services, but we will leave to local agreement decisions on whether to include children’s services within the scope of the partnership. The proposals will allow for local agreement of the range of areas of service provision to be integrated.
Two possible models of integration have been agreed with the Convention of Scottish Local Authorities. One is similar to the Highland model, which is a single agency model, and the other is a corporate model, involving a partnership between the health board and the council, with a joint accountable officer in charge of the day-to-day running of the partnership. We believe that that is the most effective way to ensure that our objectives are met by the legislation.
It is also extremely important that we totally involve other key stakeholders, such as the patients, the end users, the third sector and the independent sector, to ensure that, in every area, the design and architecture as well as the delivery of services are up to the standard that we demand.
This is a revolution in the delivery of health and social care in Scotland. It is a positive, radical step to improve the quality and quantity of service provision throughout health and social care. We believe that it is a major step forward and we look forward to taking the legislation through to the statute book, in collaboration with others in the chamber.
I spoke at the COSLA conference this morning, and my loud and clear message to every health board, council and stakeholder in Scotland was that there is no need to wait for the legislation to pass before we get moving. Already, many parts of Scotland have their foot on the accelerator. We must encourage everyone to move on this as quickly as possible, get the partnerships established and, most important of all, ensure that we are delivering the quality of provision that our people deserve.
I move,
That the Parliament acknowledges the importance of assuring successful integration of health and social care services, on which the Scottish Government will soon introduce a bill for the Parliament’s consideration; agrees that a key aim of the legislation should be to improve outcomes for people using these services; notes that the foundation of reform should be based on nationally agreed outcomes and joint and equal accountability for the delivery of outcomes by the statutory partners, and notes the importance of integrated budgets and a strengthened role for clinicians and care professionals along with the third and independent sectors in the planning and delivery of person-centred services.
I should make it clear that there is some time available at this point for interventions.
14:58
In what has been a busy time for the respective health teams, I am pleased to bring the parliamentary week to a close debating the integration of health and social care.
I do not think that there is a more pressing social policy concern than the care of our older people. Nobody in this chamber doubts the scale of the demographic challenge that we face, whether it is the 40 per cent increase in those who are aged 65 to 74 in the next 20 years—which includes many of the people in this room—or the staggering 83 per cent increase in those who are aged over 75. Scotland’s population is getting older and people are living longer. Earlier, the cabinet secretary said that a girl who is born today is likely to live to be 100. It strikes me that, on the basis of that statistic, the cabinet secretary is going to see an awful lot of me for an awful long time.
Although the statistics are a cause for celebration, they also raise challenges. Experts suggest that we would need 6,000 more beds in the NHS and that the health budget would need to double to simply stand still if we are to meet the likely demand. Doing nothing is clearly not an option. Our aim must be to provide the very best quality health and social care to enable people to live their lives in their local community, enriched by family and friends.
Scottish Labour set out our policy intentions almost three years ago and we followed that up with an expert group chaired by Sir John Arbuthnott that drew in members with expertise in health and social care. Their work has helped to shape the agenda, and I thank them for that.
We recognised at the time that older people were falling through the gaps in services. They were ending up in emergency care because of a lack of integration on the ground. Although we all talk the language of prevention, the assessment frameworks that are used by local government have to prioritise those who are in most need and ration services. Also, there remains a postcode lottery in care. Costs are shunted between different public organisations and there are differential charging regimes.
Our vision of the future is to have integrated, locally delivered, locally accountable services that are based on radically reformed community health partnerships and involve GPs much more in the design and commissioning of services, and to have a national framework that ends the postcode lottery of care, drives up standards and delivers better quality care with much better outcomes for older people. We need a single budget to stop health and local government playing pass the parcel with people’s care, and a charter that sets out what is expected in terms of outcomes, equity and quality.
The member says that the Labour vision is to create more integrated services at the local level. I wonder how she squares that with the decision by her colleagues in Aberdeen City Council to establish a local authority trading company for social care, which the chief executive of NHS Grampian says will put at risk some of the benefits that could be realised from the integration of health and social care.
I have to say that, when funding for local government is squeezed such that the SNP Government passes on 83 per cent of all the cuts that it receives, it is no wonder that local authorities have to be creative in order to continue providing lifeline services to their communities.
At the time of our previous debate on the subject, we had a different cabinet secretary. Her approach was remarkably similar to ours, and at the time I made reference to imitation being the sincerest form of flattery. I confess that I was slightly disappointed by the consultation document and the Government’s response. The document was light on vision and ambition and it was all about structures and governance. The focus on older people and adults appeared to be a secondary consideration in the tussle for control. In short, although it is, regrettably, a pale imitation of the Government’s earlier ambition, we will work with it to try to get this right. I welcome the cabinet secretary’s comments today about the principles and the vision that will underlie the bill. They were worth hearing.
The stakes could not be higher. We need a radical vision of how to achieve integration, and not backroom deals that balance competing interests. If we start from what we need to achieve for service users and their carers and design the service around that, we are much more likely to get it right.
Before I turn to governance, there is a key issue that I hope the cabinet secretary and the Scottish Government will consider. The NHS and local government have very different cultures. The NHS assesses people based on need and then provides treatment free of charge. In local government, need is also assessed, but then priorities are determined, services are rationed, and in many cases people are required to contribute financially. How will we bring those two competing cultures together?
Equally, a number of services are outsourced to the private sector, such as home care. Will that use of the private sector continue as it is? Will it in some way spread? How and from which sectors will the Government commission services? Those are key and fundamental questions that the Government needs to consider and discuss with the Parliament. The model of governance that the Government suggests concedes the fact that there should be more elected representatives on the board—that is welcome—but that that should be balanced by health board members.
I invite the cabinet secretary to be even more radical. Virtually every submission that we have received asks for representation and voting rights on the board. I am sympathetic to many of those calls, as I am sure the cabinet secretary is. If we take allied health professionals, occupational therapists and physiotherapists as examples, many of those people are the bridge between health and social care services. They help in practical ways to sustain people in their own homes, and of course they should have a voice and a seat at the table. For that matter, we should consider the myriad voluntary sector organisations that operate at a community level, building capacity as well as providing services. They, too, should have a voice and a seat at the table. However, it will become an incredibly crowded table.
Will the member take an intervention?
Not at this point.
All too often, the voluntary sector acts as the glue between health and social care. Many voluntary organisations operate at a neighbourhood level in a way that other services find difficult. I am a fan, but not because I have some kind of romantic notion of what voluntary organisations do. I know that we get added value when the voluntary sector delivers services—we get a bigger bang for our buck—and I know that, in many cases, the quality of the services delivered is second to none. Therefore, let us ensure that the voluntary sector has a key role in integration.
However, I want to draw a distinction between local authorities and health boards that might chime with the experiences of many members in the chamber. In my 13 years as an MSP, I have found health boards to be wholly unaccountable to everyone other than the cabinet secretary—and he would surely concede that, even then, there are challenges. I have watched executive directors, as employees of the health board, engaged in payroll votes where, no matter the issue under discussion, all the hands go up simply to follow the chief executive.
On the subject of officers, we really do not need another set of accountable officers. We already have accountable officers in local government and health. Is there genuinely a need for more institutional clutter and confusion?
I appreciate the point about including the voluntary sector, but on the issue of local authorities and health boards working together I have found that local authorities tend to be worse because, unlike health boards, they can get politically defensive. Does Jackie Baillie accept that the key strength in health and social care integration will be having a single accountable officer, who is equally accountable to both the health board and the local authority, so that there is absolutely no passing the buck?
I have more faith in local authorities than Bob Doris has. I will come on to develop how I think that that accountability is best deployed.
I want the new health and social care body to be accountable and to be answerable to the people of the area. We live in a democracy, thankfully, where we elect councillors to deal with matters in our local communities. Our councillors have a wealth of knowledge and experience and they are tenacious in representing their communities, and I believe that they should be in charge. The model that is operated by local government allows for officers and expert advisers to influence and shape the agenda, to have their seat at the table and to provide the professional input that is essential to good decision making. That is a model that works. I invite Bob Doris to think about that. What is wrong with that?
On the day that the Convention of Scottish Local Authorities president, Councillor David O’Neill, has set out his vision for further devolution of powers to local government, let me encourage the cabinet secretary to be radical. The debate should be about not who holds the balance of power, but who provides the best vehicle for delivery. Democratic accountability may be an alien creature in the NHS, but it is alive and well in local government where it is such a driver for change. I trust councillors—does the cabinet secretary?
I thank the member for taking an intervention, as I am genuinely interested to get a clarification from her. Is she suggesting that councils alone should run these partnerships? Does she believe that councils should take over the work of health boards?
I am very clear that this should be a partnership, and I want to bring democratic accountability to that partnership. Increasingly, what we are talking about is ensuring that services are effectively knitted together and delivered on the ground. I see councillors very much as providing the democratic accountability, but the local government model also involves professionals from across the sector and provides a way of including the voluntary sector, allied health professionals and the whole working partnership. I think that there is merit in that, and I hope that the cabinet secretary will consider it.
On finance, I see that the cabinet secretary will retain an annual focus of tension: agreeing the budget. However, if the two sides do not agree, do not worry—he will have the powers to force them to do so. Frankly, that sounds like a recipe for more bean counters rather than a focus on older people or adults. A more radical alternative would be to allocate the money centrally using an Arbuthnott-type formula that recognises need in much the same way as the Scottish Government already does for health boards. Unfortunately, that does not filter beyond health boards. However, if the formula works for health boards, why cannot it work for integrated health and social care bodies?
On the subject of money, local government is woefully underfunded for social care. As I said earlier, the SNP passed on to local government 83 per cent of all the cuts made. Is it any wonder, then, that costs of care are rising and people in neighbouring areas are being charged different rates under different eligibility criteria? The SNP must ensure that there are adequate resources for local government to meet its responsibilities or it will destine the integration of health and social care to the worst possible start.
The Government must consider the impact of welfare reform. Many people who are in receipt of the disability living allowance use it to pay for services. If they fail to qualify for a personal independence payment, there will be a black hole. I have asked the Government many times to address that.
Matters are pressing. Members on the Labour benches will help to deliver a fair and robust system of health and social care, but the Scottish Government must do more. It must be more ambitious and visionary. The cabinet secretary spoke about a revolution; I look forward to seeing it.
I move amendment S4M-05838.1, to leave out from “joint” to end and insert:
“strengthened accountability for local service delivery, with a strong role for local authorities; notes the importance of truly integrated budgets that avoid conflict between local authorities and NHS boards as well as a strong role for clinicians and care professionals along with the third and independent sectors in the planning and delivery of person-centred services; notes with concern both the increases in care charges and the postcode lottery in charging experienced across Scotland as local authorities are forced to react to Scottish Government cuts to their budgets, and calls on the Scottish Government to use the integration of health and social care to create a truly integrated health and social care service that improves care across Scotland.”
15:10
I welcome the debate. It is another milestone along the journey towards achieving better integration of adult health and social care, and I look forward to seeing the Government’s legislative proposals to assist in the process when its bill is introduced in Parliament in the near future.
From the evidence that was taken by the Health and Sport Committee ahead of the Government’s consultation, the responses to the consultation and the Government’s response to them, the unanimous view is that the focus must be on achieving better outcomes for people who require health and social care services by improving the quality and consistency of the care that they receive to support them in their daily lives and enabling them to live as full a life as possible within their capabilities, whatever their age.
Although the legislation will be restricted to the integration of health and social care for adults, those who responded to the consultation demanded that the legislation be extended to children’s services, and to a broader range of services, such as housing provision.
The Government justifies its stance by stating the view that health boards and councils are best placed to make decisions on service integration for children. We have seen that in Highland, where the NHS is providing services for adults, and the council is looking after children’s services. With regard to other services, the Government’s view is that, because many joint and collaborative services work well and can be left to local partners to work out, it sees no need to legislate for the integration of services such as housing, whereas there is an immediate need to address the health and social care needs of people with multiple support needs. I agree. It is often the case that people do not get the joined-up care that they need to keep them safe and well in their homes for as long as possible.
As was pointed out in one of the briefing papers for members, by proactively embracing the role of housing in developing integrated housing and care services, both central Government and local authorities could make substantial savings in the long run without compromising on quality. That is a fair point, given the demographics of an increasing number of elderly people with multiple physical problems and increasingly complex care needs because that will inevitably lead to growing demand during the next decade for very sheltered housing and extra-care housing.
There is broad support for the Government’s proposals to base its reforms on nationally agreed outcomes, with locally determined priorities. Local circumstances vary widely and must be considered in the planning of integrated local services. Circumstances also change over time and, to be meaningful, there must be scope for both nationally agreed outcomes and local priorities to evolve, while assuming that the focus will be on the wellbeing and independence of service users, giving them control over their lives.
A barrier to integration—it has been hinted at this afternoon—has been the cultural differences between health professionals and social workers, illustrated by segregated training, rivalries between the two groups and a perception of medical dominance. If integration is to proceed successfully, ingrained organisational cultures must be overcome. The Government’s view is that by placing a statutory duty on health boards and local authorities to work together, and in collaboration with key stakeholders, it will ensure that competing rivalries and difficulties can be overcome. I hope that that will be the case, because I do not see how health and social care integration will work without such cultural change. The consultees feel, nonetheless, that there should be a mechanism in place to resolve disputes, should they arise.
On the composition of the health and social care partnerships and the Government’s proposal to legislate for HSCPs to include a single health board and one local authority, there was some demand for partnerships to include more than one council, where appropriate. For example, the British Medical Association’s view is that that facility must be in place if integration is to be successful.
Nanette Milne makes a fair point about cases in which there is a desire for the partnership to cover more than one local authority area. I intend to make provision in the bill that, where there is a local desire and agreement for that to happen, it can be achieved. There are areas in which we have three local authority areas within one health board area. If the three local authorities and the health board agree that they should have one partnership instead of three, the bill will allow that to happen.
The cabinet secretary has taken a paragraph out of my speech, but I will still say it.
The BMA feels that, because of the current lack of coterminosity in some areas—where health boards cover more than one local authority area—that facility must be in place if integration is to be successful. The BMA gives as an example the NHS Greater Glasgow and Clyde area, but the same applies in my region, where NHS Grampian covers the Aberdeen City Council, Aberdeenshire Council and Moray Council areas.
The Government’s decision to allow in the legislation for ministers to consider applications where more than one council wishes to join a partnership is to be welcomed. It would also allow for any future changes in health board or local authority boundaries.
It is proposed that the legislation will allow voting rights only to statutory members of local health and care partnership committees and for councils and health boards to have parity of voting power. That is fine, but some consultees were unhappy with those proposals. The Health and Social Care Alliance Scotland and third sector organisations made a case for service users and carer representatives to be voting members as well. That issue can be probed further when the bill comes before committee, and I have no doubt that we will receive further representations then.
The legislation will ensure that health and social care partnerships are accountable to full councils and health boards, not only council leaders and board chairmen, which should satisfy a number of concerns.
The committee membership of HSCPs is of significant concern to the BMA and the clinicians whom it represents, particularly GPs, who have an enormous role to play in ensuring proper integrated care for patients. The BMA feels that membership of the HSCP committees, as set out in the consultation, is significantly management oriented, and its membership would welcome a stronger role for doctors who are appointed to positions on those committees.
GPs and consultants shied away from community health partnerships because they were largely management run and bureaucratic. I recall my GP husband saying that they were too large and too management focused to make primary care professionals feel that their contribution would be heeded and valued. That issue must be addressed if the new HSCPs are to get the support of clinicians, which is important to the success of integration.
I am content with the general principles that underlie the Government’s motion for the debate as a foundation on which the forthcoming legislation will be built. I look forward to seeing how they are translated into the bill, which will soon be introduced to the Parliament.
15:18
I welcome the opportunity to speak in the debate on a policy area that will be important to the way in which we deliver health and social care in the future. I also look forward to the detailed scrutiny of the bill by the Parliament, particularly as I am a member of the Health and Sport Committee.
The cabinet secretary has already outlined some of the demographic challenges that face Scotland. There are areas of the country, such as Dumfries and Galloway, where the demographic trends towards a rising population of older people and a falling population of people of working age and children already outstrip the national figures. When those challenges are combined with the challenges of delivering high-quality health and social care in a largely rural environment, with many remote settlements, it is clear that change in the way in which we plan and deliver care is needed.
Of course, the agenda is not only about delivering integrated care for our older people, although that is a worthy prize. Integration will also bring benefits for adults with multiple or complex conditions, as well as for those who live with long-term conditions.
The system has become complicated and sometimes disjointed. It needs to be fully integrated, and the needs of the patient, rather than concerns about operational or corporate demarcation lines, need to be put first.
I think that it is fair to emphasise that professionals who provide front-line care are already trying to carry out as much integration as they can. I recently visited Kirkcudbright community hospital, which occupies the same building as the GP surgery. The hospital deals primarily with discharges from the regional general hospital in Dumfries, and the local GPs—who are often the patients’ own family doctors—work closely with social services to smooth the transition from hospital back home and to put in place any continuing support that may be required. To me, that is an example of integration working already.
Last week, I visited the Galloway community hospital in Stranraer, which is an altogether larger facility. Both hospitals have renal units, which enable patients to benefit from the three sessions of dialysis that they need every week without having to make the very lengthy journeys that they previously had to make to Dumfries. Both hospitals also provide services that match the specific needs and priorities of the local communities that they serve.
In my view, the delivery of services closest to where people need them will be crucial to the success of integration. On both visits, I was struck by the enthusiasm that NHS staff and GPs have for the policy, which is a logical extension of the clinical practices that I have described. I believe that firm foundations already exist in Dumfries and Galloway. The forthcoming bill is intended to build on those firm foundations and to strengthen good practice by empowering front-line staff to deliver the better health outcomes that we seek.
Prevention and anticipation must be at the heart of the integration policy. Integration is as much about helping people to avoid being admitted to hospital as it is about managing their return home. The Christie commission demonstrated that although everyone understood the importance of preventative spending, as a country we had not come to grips with the changes that that agenda demands.
The Government has made it clear that its approach to legislation will be permissive rather than restrictive and that it will enable organisations to work together to take down barriers and build on the good practice that already exists. In my view, that collaborative approach must include the third and independent sectors in the design and planning of services.
I know that, this morning, Dumfries and Galloway’s community health and social care partnership board took important decisions to move the integration agenda forward for the region. The willingness to embrace integration that I have seen on the front line is shared by the senior management and elected members of Dumfries and Galloway Council and the local NHS board. Those decisions include the decision to include representatives of the third and independent sectors on the project board that will take forward the detailed work on integration.
I believe that the participation of the third and independent sectors in the development and implementation of integration is important. Both are delivery partners with the public sector and sources of experience and expertise that will add materially to the quality of the eventual outcome. I hope that the bill will make clear the role that the third and independent sectors will play in shaping the whole process.
I believe that the integration of adult health and social care is an exciting and important policy that has the capacity to dramatically improve the way in which we provide adult health and social care. It has the potential to deliver meaningful preventative measures and to support older people and those with complex or multiple conditions to live well in their own homes. Although I accept that there will be challenges ahead in delivering such an ambitious agenda, I believe that working together locally, nationally, professionally and politically will enable us to improve the health and wellbeing of our nation and will help us to tackle the health inequalities that exist in our local communities.
I support Alex Neil’s Government motion.
15:23
I should begin by declaring an interest: I am an elected member of Fife Council where—the cabinet secretary will be pleased to hear—we have had a health and social care partnership for a number of years. It is already delivering a number of co-located and co-ordinated services for the benefit of the people of Fife.
Excuse me. I am sorry, but would you move your microphone round slightly?
Is that better?
That is great, thank you.
The integration of health and social care services is a priority for the Scottish Labour Party and has been for some time. Although opinions vary across the chamber about how the integration will work, I am pleased that we are discussing a principle in which we all believe. I hope that the debate will be constructive, that the cabinet secretary will listen to what is said and that we can work together to produce legislation that we can all be proud of and which will deliver for Scottish people.
What is the debate about if it is not about the power of working together to deliver meaningful outcomes? It is crucial that the legislation goes beyond the headline, the superficial and the superstructure. It must deliver long-term and fundamental change. When we talk about change, we must recognise that we are talking not only about organisational change but about an enormous change in the culture of the delivery of health and social care services.
The delivery of care should not be a tug-of-war between health boards and councils, but the proposals simply do not address that issue. Integration goes beyond co-operation and co-ordination of autonomous bodies. True integration is about softening boundaries and the emergence of a new work unit. That is possible only when we recognise how tensions arise and when boundaries become lines of defence.
The lines of accountability need to be local and clear. That leaves local authorities well placed to take a lead role in health and social care partnerships. The cabinet secretary already monitors local authority delivery of single outcome agreements, and Healthcare Improvement Scotland and Social Care and Social Work Improvement Scotland should have a continuing role.
Health boards and councils face increasingly difficult financial conditions, which must be addressed before legislation is implemented. By its nature, any budget places limits on a service, so it is essential that all parties work together as part of an integrated care service to solve local problems. We must ensure that the right framework is in place to allow them to do that as equal partners.
The proposals as they stand will inevitably create tensions and pressures between health boards and councils. We have seen examples of that in Fife, where unseemly and undignified arguments have taken place between the health board and the council about who should fund the care places that will free up hospital beds. That is why we support direct Scottish Government funding for health and social care partnerships, for service users’ needs should be at the core of the reorganisation. We must start with the service user and work upwards to provide a framework that supports them best. My worry is that the proposals focus too much on formulating a superstructure at the macro level and not enough on the individual user’s needs. That has serious implications for delivery at the service level.
People need accountable, clear and truly integrated care services. They need responsive services in which the professionals who support them work together to build local networks, knowledge and continuity of care. It is critical that, through integration, the emphasis is on health and wellbeing, not sickness.
Most healthcare is delivered outside the hospital setting, so I am pleased that the proposals provide scope for local partners to ensure that we approach health and care holistically. That recognises that health and care are not just about acute services and treatment but about life circumstances, prevention and early intervention.
In addition to broadening out integration to all adults and other groups, the proposals allow local partners to ensure that policy areas such as housing and transport are part of the bigger picture. I hope that we can ensure that such holistic thinking is part of the new culture of care. The time of compartmentalised service provision must end. I know that that will take years and will go beyond our tenure in Parliament. However, it is important that we get the legislative framework right, right now.
General practitioners, third sector organisations, allied health professionals, front-line staff, patients and service users must be part of the decision making for integration to work, and decision making must be clear and coherent. Beyond ensuring that we get the structural aspects of integration right, the difficulty of merging cultures lingers. It will take strong leadership and a secure framework that provides the right environment to engender a new work culture. I am not convinced that the proposals will deliver that for the Scottish people. I repeat my hope that we can work with the Government to improve the legislation.
I have concerns about the proposals, but I remain hopeful that we can get them right. We have the opportunity to offer the Scottish people true integration that is properly and constructively financed, clearly managed and fully accountable at a local level. I hope that we take it.
I am not keen to interrupt members’ speeches, so if everyone who is to speak in the debate could ensure that their microphone is pointing in the right direction, I would be most grateful.
15:29
This week has been a health week in the Parliament—there was another health debate yesterday. That is good, because health is an important matter. I would like to see this happening more frequently—perhaps we could put it in the calendar annually. As a member of the Health and Sport Committee, I welcome the opportunity to speak in the debate.
It is taken as read that both health and social care are of immense importance to the Scottish Government and the Scottish Parliament and that, in their own ways, they both provide vital services for communities across the country. As regards the present operational delivery of services to the community, we cannot say either that health and social care are working completely separately from each other or that they are working completely together. It would be wrong to say either, so the Government’s attempt to bring together health and social care to deliver even better outcomes for our people is to be welcomed.
With budgets under pressure, there is an added incentive to find ways to do a better job for more people with the same resources. It is a goal worth striving for. To achieve that goal, we need everyone to pull together and, in my view, third sector involvement is key to bringing about that success.
There is a high level of experience in the third and private sectors when dealing with health and social care and we must do everything we can to learn from that experience and put it to good use. As well as experience, the third sector brings a different perspective on health and social care. It is able to look at those services from a user’s viewpoint, which is of fundamental importance when mapping out how best to offer best practice for patients and families alike.
Without third sector participation, integration will not work as we want it to, at the highest level, so I commend the Scottish Government for its continued dialogue with the organisations that are at the coalface. The integration of health and social care is of the utmost importance and I am pleased that the Scottish Government is showing the leadership that is required to achieve it.
That leadership is shown when we look at the policy of single budgets. It is the norm for any organisation, private or otherwise, no matter the size, to be precious about its budget and to spend it only in areas over which it has direct influence or responsibility. A unified budget means that there are no artificial barriers either practically or in people’s minds. That is the single biggest initiative in the proposal that leads to me to believe that this integration will be a success, as it gives each sector equal responsibility.
As our people live longer, the services that they require will become more complex; having two separate systems will not meet their expectations or provide the services that they require. A larger, combined budget—in contrast to two smaller budgets—will allow clinicians, care professionals and health managers to rise to those challenges with the necessary funding. It will also lead to achieving agreed health and social care outcomes while putting an end to the practice of cost shunting between the NHS and local government.
Away from the financial aspects, it makes sense for health and social care to be integrated. I am pleased that this is about integration of services and that the Government is clear that it is not about structural changes—staff in both sectors will be able to continue to use their expertise. I am also pleased that a massive transfer of staff between employers is neither sought nor desired, which will be of great comfort to those involved and ensure a smooth transition.
Where there is an overlap between health and social care, integration is the most practical way to deliver a service that has people at its centre. Individuals, their carers and family members will benefit most from that integration, which is the basis for the change. Ensuring a successful integration will be hugely challenging but greatly rewarding.
I feel that we have the right leadership and that we will carry out the changes. Those who use the services will benefit the most. I am also sure that there will be tough decisions to be made in future, for health and for social care. I look forward to the Government introducing the proposed bill for Parliament’s consideration, as a way of making the number of tough decisions that bit smaller. I commend the motion in the name of Alex Neil to the Parliament.
I call Duncan McNeil, to be followed by Bob Doris. I draw members’ attention to the fact that there is adequate time for interventions, and even loquaciousness.
15:35
The good news is that we are living longer; the bad news is that old age does not come alone and those extra years are not always healthy ones. Men and women can commonly expect to spend, respectively, about seven and nine years in poor health. Scotland’s national dementia strategy tells us that approximately 71,000 people in Scotland have dementia and that the figure is likely to double in the next 25 years. On Tuesday, the Finance Committee was the latest parliamentary committee to highlight the significant demographic change, which the Office for Budget Responsibility has identified as the key source of long-term pressure on public finances.
Local authorities, which are contending with increased demand and less money, and health services, which are having to deal with and manage unplanned admissions, clearly need no reminding of the task or the situation that we face. Despite the recognition of the challenge of delivering health and care services at a time of rising demand and reduced finances, despite the work of committees of the Parliament—through my convenership of the former Local Government and Communities Committee and the Health and Sport Committee I, like others, have been on the case for a considerable time—and despite the work of Beveridge and Christie, and the Government and others, progress has been slow and patchy.
It is good that we have arrived at the current point, because we cannot continue as we are. It is important that we move forward and instigate significant cultural change in the delivery of services. If we are to address the huge challenges that are to come, as the cabinet secretary recognises, the integration of health and social care must be at the heart of that change. However, as he knows and has referred to today, the barriers are significant. Reform of public services is difficult. If it were easy, we would have done it.
It is worth recognising that sustained cultural change can be achieved best through working in co-operation, however difficult that can sometimes be. If we are to achieve change, it cannot be seen to be done simply because of financial pressures. The truth is that we should have been doing this many years ago when there was more money. The objective is to improve services, and we must be careful not to lose the focus on that. As we have seen with self-directed support, change cannot be perceived as a cheap option. If the major budget holders—the Government, the health service and local authorities—are still wrestling with one another and do not trust one another to share or shift budgets, is it any wonder that the minor parties in the process, the third and independent sectors, feel put upon, as my Health and Sport Committee colleague Aileen McLeod referred to?
That tension seeps into the workforce and into public perception. People are sometimes fearful about change and think that the process will lead to a decline in standards or working conditions. Although the Health and Sport Committee of course wants the focus to be on putting the person first—we all agree on that—we need to address such fears and concerns.
We have had the current national care standards for 10 years. Before the bill is introduced, we need to produce a new set of national care standards, which has human rights at its heart, to reassure all the people who use and work in the health service that the main objective of the integration process and the bill is to maintain and improve the services that we provide.
We need to ensure that we have good regulation when those rights are established. If we are to ensure that rights and standards are properly implemented, maintained and monitored, it is essential that we bring together and properly resource and fund the care inspectorate and Healthcare Improvement Scotland.
We must deal honestly with a commissioning and procurement process that is predatory and causes great mistrust and pain in the third sector, where we see people shuffling along their problems. It is unfortunate that the process is often regarded not as improving services and efficiency but as a crude attempt to drive down costs at the expense of quality. Committees of the Parliament have dealt with some of the worst excesses during the past few years.
If we are saying that the integration of health and social care is the most important issue, we cannot ignore workforce planning in the area. The people who work in the area deserve and must have our respect. The status of the existing and newly emerging workforce, which is essential to delivery, must be recognised, and the sector must be offered training and at least the living wage.
Only if we address those issues can we have a successful process that improves efficiency and quality of delivery of public services to our most vulnerable people. If we address some of the issues before we introduce the bill or alongside it, the process will be easier. If the cabinet secretary is up for revolutionary change and wants to be radical, he will have my support.
15:43
I commend Duncan McNeil for his speech, which was thoughtful. I did not agree with everything that he said, but I absolutely agree with much of what he said, which was testament to the work that we did in the Local Government and Communities Committee in the previous session of the Parliament and the work that we are currently doing in the Health and Sport Committee. Committees have served the Parliament well in taking things forward in conjunction with the Government.
I am delighted to speak in a debate that ain’t the debate that we had yesterday. Many members who are here took part in yesterday’s debate, which did not cover the Parliament in glory—I see that Jackie Baillie is muttering, and perhaps we should both reflect on the tone of that debate. The tone of today’s debate is much better and the Parliament is the better served for that.
There are, however, strong links between the two debates. Why are accident and emergency units getting busier? Why do more people need a hospital procedure? Part of the answer is about demographic change, but it is also about getting things right in the community, through preventative spend. There are things that can be done quite easily in communities to reduce slips, trips and falls among older people, for example, which would drastically reduce the number of people who turn up at A and E or who need a hospital stay. We need to integrate and co-ordinate strategy for matters such as care at home and prevention work, to reduce presentations to hospital and ensure that people can be treated in the community.
We also need appropriate discharges from hospital. I do not like to use the terms “delayed discharge” or “bed blocking”, because I do not want discharges to be quick or slow. I want people to be discharged from hospital at a time that suits their care and medical needs—their discharge should be neither fast nor slow, but appropriate. We all need to reflect on that.
That approach needs a single accountable officer, so that the buck cannot be passed on getting the strategy right, and there have to be clear lines of accountability. There is of course a core role for local authorities in that. However, some of Ms Baillie’s comments make it sound as if local authorities should have a dominant role, which would be the wrong approach.
Will the member take an intervention?
I will make this point first. I will let Ms Baillie in, assuming that I get a little bit of additional time, which would be welcome, Presiding Officer.
In our report on this subject, the Health and Sport Committee said:
“The Committee acknowledges the findings of Audit Scotland that governance and accountability arrangements for CHPs have been ‘complex’ and ‘not always clear’. The Committee therefore welcomes the Scottish Government’s proposal for a clear line of accountability to rest with a single individual for each health and social care partnership. The Committee also considers it essential that the governance arrangements for each local partnership should retain strong links with local government through representation of councillors on partnership boards.”
Local authorities should have a clear core role, but not a dominant one. Of course, local authorities are democratically elected bodies, but I say gently to some of my Labour colleagues that saying, “Just leave it to the cooncil,” results in a shiver of fear running through Glaswegians, given what is happening in Glasgow, particularly regarding protecting the most vulnerable. Just yesterday, three day care centres were earmarked for closure without there having been any proper consultation with the community. I needed to raise that point; had I not done so, vulnerable people in Glasgow would think that I had betrayed them.
We have heard a lot about national care standards and Duncan McNeil made some important points. I ask the Labour Party to reflect on the use of expressions such as “postcode lottery”. In its report, the committee said that it
“welcomes the intention of the Scottish Government to provide flexibility within a legislative framework which will prescribe minimum standards.”
We absolutely need core minimum enforceable standards, but we must ensure that minimum standards do not become the extent of our aspirations. We must ensure that local health boards and local authorities can, if they decide, invest more money and go beyond a basic minimum standard. That is my issue with the Labour Party wanting to take local democracy away from the system and leave minimum standards as the only standards that people receive. There is a threat to local democracy in that.
Taking forward this agenda will need significant service redesign. I agree with Duncan McNeil that we should do that to improve the outcomes for all people in society, irrespective of the demographic challenges and the financial situation. However, those two things are clearly drivers for change.
The point has been made that when we redesign services, the voluntary and third sector should be seen as an equal partner. There is a fear that if local authorities and health boards come to the table with millions and millions of pounds, the third sector will find itself squeezed out of service redesign and the commissioning process, which often looks at what parties can bring to the table, rather than what they can do for the people most in need in our society.
I will use some of the time that I have left to mention a couple of excellent projects. The good morning project in Glasgow—sorry, Presiding Officer, do I have time to let Ms Baillie in?
No.
I apologise for not having time to let Ms Baillie in, but she will find that it is far more important that we talk about the good morning project in north Glasgow. It gives hundreds of older people in the community a friendly telephone call in the morning, to provide them with the support and reassurance they need to sustain their tenancy and place in society. The call is also to make sure that they are not lonely or isolated and that they can live happy, healthy and productive lives. It is an innovative way to keep our older people happy.
There is also South Lanarkshire’s hands-on project in Cambuslang, which the minister and I visited, and which includes a handyman service and a befriending service. Those are innovative ways of redesigning services to support older people within the community.
Rather than the good morning project, the hands-on project and the hundreds of projects around the country looking to a fragmented funding system to keep their projects going from one year to the next, it would be good if, with health and social care integration, they had a seat at the table and got some secure core funding, and a core, secure, long-term strategy for health and social care provision. It is a shame that we need the forthcoming bill to deliver that, but we do, and I thoroughly welcome it.
15:50
Last year, the then outgoing Auditor General for Scotland, Bob Black, audited the joint commissioning of social care by the NHS and local government. He called it one of the most significant performance audits that he had ever prepared, for two reasons. The first was the demographic change to which many members have referred. Bob Black pointed to a projected 147 per cent rise in the number of people aged over 85 in the next 25 years. The second reason was that it was because he had audited those services six times in 12 years and could find little evidence of any significant improvement. Of 32 councils, only 11 had any strategy at all for the joint commissioning of social care. Only four even considered demographic change and only one strategy was more than short term. Audit Scotland struggled to find any good joint planning underpinned by an understanding of the shared resources available.
The report also showed that, for the first time, the majority of care at home and in residential settings is now delivered by neither the NHS nor councils but by myriad private, independent or third sector providers. So what? So, an elderly lady, struggling to stay home, has daily care assessed by the council, but delivered by an agency that sends different carers every week. Her bath is provided by an NHS service, but not the GP surgery that she knows well. Meanwhile, her shopping service comes from a different department of the council. The highlight of her week is when someone visits her to take her out for a short walk, which is the responsibility of a local voluntary organisation. When one of them fails to turn up, she does not know who to call. Whoever she does call knows nothing. When she goes into hospital, as happens every so often, all those services are removed and every one of them has to be reinstated when she comes out. Sometimes that takes weeks or months, dozens of phone calls and a bewildering array of highly paid professionals. Some basic needs, such as nail cutting, turn out to be no one’s responsibility.
That is my family’s lived experience of the care system for an elderly aunt, but it is not unique and it is why we need integration. I have seen the capacity of the NHS and local councils to agree the need but resist the change. It is 13 years since, as a health minister, I got them to promise that they would pool budgets through joint future committees. Thirteen years on, the joint future committees are still there and so are the separate budgets. I hope that I can be forgiven if I am a little more sceptical than some colleagues about the willingness to change. It is informed by experience.
The Government’s proposals are in danger of becoming as complex and convoluted as the care system that they seek to reform. We are to have
“body corporate models of financial integration”
unless there is an agreed “delegation between partners” arrangement. There will be integrated resource frameworks and a non-hierarchical relationship between community planning partnerships and HSCPs. I do not know what that means. Accountability will be to NHS boards and local authorities—because that is working really well—and we can have confidence in all that because of single outcome agreements, which is nice; most of us had assumed that they had died a death a long time ago.
That adds up to a committee in which the NHS and the councils will argue forever about how much of their budgets they are willing to share. The consultation shows that they are already arguing about their voting rights and dispute resolution procedures. For all that I know, they are arguing over where they will sit and whose turn it is to bring the biscuits; they are not arguing about the care standards that we need.
We are in danger of paying senior professionals serious salaries to sit in endless meetings looking after their own budgets while the looking after of people is being done by a minimum-wage workforce in 10-minute care visits, with no time allowed between clients and with orders not to waste time speaking to them. Even that parody of care will be available only to those who are assessed as being in critical need.
I believe that the cabinet secretary is absolutely sincere in his desire for the integration revolution that he described. Like him, I think it is a revolution that we need. It is not too late to use this opportunity to deliver it. He can create a proper, formula-based, local, integrated budget so that the local negotiation is about delivery and not the share of budgets. He can legislate for a clear single line of accountability through democratically elected councillors who are answerable to their communities. He can insist on clear basic standards such as giving users and carers a single point of contact to manage all their care. What could be simpler?
The cabinet secretary can do those things if he is willing to show the leadership that he talked about and to call time on the vested interests on all sides of this debate. He can then create a care service on which our elderly and disabled citizens can depend and of which we can all be proud. If we do not do that, our successors will be back here in 13 years’ time, doing this all over again.
15:57
I welcome this debate and the serious, constructive tone of the speeches so far. The subject is too important for us not to treat it with such respect.
I welcome the proposed bill, given the need for the integration of health and social care. I believe that a society is judged on how it cares for, helps and supports its older people, the vulnerable and those with long-term conditions. The bill focuses on that.
I appreciate the cabinet secretary’s explanation of the lengths to which the Scottish Government has gone regarding engagement with health and social care professionals and users, given that we must get the bill on this important issue correct first time.
The changing shape of Scotland’s society, with an ageing population, is a challenge that we have all had to face for a number of years. When I was a member of the scrutiny board on Renfrewshire Council, one of the first things that we discussed was the challenge of demographic change and how we could deliver services. I know that other local authorities have looked at that as well.
As the cabinet secretary quite rightly said, many councils and other organisations are working together towards the joint goal of ensuring that they can deliver for people in our communities.
The most important part of the bill is the focus on improving outcomes for families and carers in our community. At the end of the day, we are dealing with people’s lives. As elected members, we have all heard stories of situations in which the system has not worked. We have to make sure that the system is seamless.
The cabinet secretary is correct that public agencies and organisations must share the challenge, work together and move away from silos in their management ideas. I have experienced that in relation to my wife with her long-term conditions and in relation to constituents who have had difficulties accessing the services that they need.
During my time in local government, I developed a great belief in the work that social workers do in our communities. As a councillor, I saw what social workers did, particularly with older people, but also with the other groups that they deal with.
One of the stories that I was involved with simply involved an older man who was, in effect, going home to die. He and his wife were both in their 80s. We could not get the care package in place to get the elderly gentleman home and his wife was extremely worried about that. It took a phone call from me to the social work services to get that done. For me, that is the difference with social work at a local level. As an elected member, I can contact the council’s social work department and get something done, whereas it can be rather difficult to get the health boards to do something similar. If I asked the local health board, things would be even more difficult.
One in 12 people uses social work services at some point in their life. The social work departments in our councils protect children and support people with mental health issues, addictions and learning disabilities. Let us not forget the role of social work departments and their accountability to local communities. The successes of the services that social care staff offer and their commitment in working in very challenging situations must be recognised. Many social care staff are driven to help and work beyond the call of duty to protect and care for vulnerable people in our communities. Integration must take all that into account. Front-line staff will be the key to making integrated services a practical reality and it is the skilled staff in health and social care who will deliver the results that we all want.
Leadership and management will be needed. Effective, robust and innovative leadership at all levels will be central to the success of the transformation programme. In particular, it will be crucial to have a clear focus on putting leadership by social workers, care professionals and clinicians at the heart of all integrated health service delivery.
As the cabinet secretary said, we must move away from organisational silos, but we must retain the services that work. I welcome the idea that the bill will deliver outcomes for the individual, the family or the client. The local delivery of integration is extremely important, and ensuring that there is accountability is equally important—a jointly accountable officer will help that. Obviously, they will work with the health board and social work services in local councils and bridge the gap between the health board and the local authority. NHS and social care staff have to deliver the integration, and we must ensure that they buy in and work with us on that, and that we use all their talents.
Change is not new to people in local government and social work. Social work services have operated in an integrated manner across the range of needs in our communities, and integration has been a particular strength for Scottish social services over the past 40 years. We need to tap into the practical professionalism and expertise that exist. The integration of health and social care is a radical new way of working for our health and social care professionals, but we need to ensure that the expertise of local social work departments and health experts across Scotland is not forgotten. As the cabinet secretary said, many partner organisations are working in that way already. We must ensure that they continue to work in that way.
Let us hope, as Iain Gray has said, that we do not come back here in 20 years’ time and have the same conversation.
16:03
The need to integrate health and social care in Scotland has been on the agenda for some time. I welcome the consultation results, and note that the Government intends to introduce a bill this year. I remind everyone that that was also in the Liberal Democrat manifesto. Indeed, we could argue that the bill should have been introduced long ago, when beds were reduced for more care at home, because it could have been argued that systems for caring at home were not fully in place for that step change.
Without doubt, the existing system contains overlaps in the responsibilities of health boards, local authorities and, of course, care services. It is also worth noting that the organisations have different ways of working, different cultures and, almost, different languages, so there may be barriers to integrating. However, we want outcomes, and I am sure that the forthcoming bill will have the potential to iron out any differences in organisations’ methods. I hope that it will address those differences, bridge the gaps and lead to even better provision for patients and service users who require the services, and to more individuals staying in their homes for treatment—when that is appropriate, of course.
Once the bill is introduced, if it does what it says on the tin it will get our support. That support will be conditional of course, and I shall keep a close eye on whether local decision making is protected. We would oppose any centralisation in the form of a national care service. To make integration work, we need local accountability. In fact, I would go further: it is essential that throughout the bill’s progress and in the changes that it will make for our constituents, patients are treated as equal and active partners in decision making and planning.
Integration of health and social care will not be easy; the representations that we have received echo that point. It is important to note that housing associations have an important role to play, given that 85 per cent of very sheltered and extra-care homes are run by housing associations, and that it is estimated that the demand for that service will increase. As I have said, keeping people in their homes when that is appropriate has great benefits, and the use of adaptations is essential for that to happen. Research shows that adaptations are good value for public money, too, with an estimated £4 saved for every £1 spent. They are an excellent example of preventative spend, on which we need to focus more.
The consultation reported on the role of a jointly accountable officer. Some people believe that that responsibility should lie jointly with local authority chief executives, health boards and health partnerships. The cabinet secretary referred to the matter, but it is worth noting again that there are often several local authorities within one health board area. I am glad that the cabinet secretary acknowledged that point; it will be interesting to see how he addresses it in the future. Governance in that regard can be cumbersome, so we will keep an eye on it.
The consultation highlighted general agreement that the jointly accountable officer must have gravitas and a wide skills base. The person who will have overall responsibility for delivery of integrating health and social care must have a good skills base, so we should look to deliver the changes with the help of people who have experience of joint working. I am thinking particularly of allied health professionals, who have a track record on medical versus social views on different ways of delivering joint services, are experts on rehabilitation and reablement, with knowledge from around 12 professions, and are already in post. As part of his deliberations, I would like the cabinet secretary’s view on representation from allied health professions as part of the development of national policy and regulation in the integration of health and social care services.
There is no doubt that there will be increased demand on our health and social care services, given that we have an ageing population and limited public resources. We shall all call on those services in the not-too-distant future unfortunately, and we all know of family and friends who have already done so. We must ensure that the services can meet needs in the 21st century.
There are good examples of partnership working across Scotland, mainly at organisation level. We now need to concentrate more on delivery of first-class services for our patients and users. We need a system in which people do not fall between different organisations’ responsibilities—for example, clearing a bed in hospital only places the burden of responsibility for a person on a local authority or extra-care home. Addressing such issues must be part of the joined-up thinking of the future.
I welcome the results of the consultation. The Liberal Democrats will follow the bill’s progress and hope for better integration of services, with local accountability protected.
I call James Dornan, to be followed by John Pentland. There is time for extensive debate and interventions, should members wish it.
16:08
I thank you for that reminder, Presiding Officer, just before I got up to speak.
Like most others, I welcome the Government’s plans to integrate health and social care. I am confident that the bill will help bring together the best that the NHS and local authorities, along with third sector and independent bodies, have to offer to make life that bit better and to make treatment much more streamlined for those of us who will need it at some time in our lives. I suspect that, as Jim Hume just said, that time is nearer for some of us than it is for others.
It is great to see the support from organisations such as the independent living movement, which speaks on behalf of the independent living in Scotland project, the Scottish Government’s self-directed support Scotland initiative, and Inclusion Scotland and agrees that disabled people must be at the heart of the decision-making process. I am delighted that there will be a strengthened role for the third and independent sectors in planning and delivery of services.
The movement’s five asks are that the bill should support independent living, citizenship and human rights; that disabled people be considered and supported as key stakeholders and co-producers in the delivery and development of the bill; that disabled people should be involved in leading on principles and on how money is spent; that the bill should support and promote self-directed support in the community on leaving hospital; and that the bill should not entrench existing inequalities. Those are all reasonable requests and it is clear from the cabinet secretary’s opening remarks that careful consideration is already being given to them.
I agree with the British Medical Association that effective health and social care partnerships have the potential to reduce duplication, to ensure that appropriate care is delivered at the right time to the right people in the right place, and genuinely to break down some of the unhelpful barriers that exist between health and social care. I cannot see how we can do that without the integration that is envisaged in the bill.
I have experience of working in an environment that is similar to what is envisaged in the bill, so I have seen the benefits of such a structure. In my time as a councillor, one of my most fulfilling roles was as a member of the Glasgow south-east community health and care partnership, which covered Glasgow Cathcart and Glasgow Govan constituencies, both of which include areas where there are huge problems and challenges.
I will not deny that there were, when I joined the partnership, tensions between people from the health board and people from the local authority at committee level and—as we heard from practitioners and other front-line staff—in offices across the city. That was understandable; after all, we were asking people to rethink how they worked and to take into their consideration people from other services who had different work practices and, to some extent, different priorities.
However, there was a commitment among most members of the CHCP to make it a success, and through hard work and commitment—driven by the human dynamo that is Cathy Cowan, whom many members know—things started to turn around. There were a number of staff away days—or greeting sessions, as they were called—at which people got to quiz directors about the reasoning and direction of the CHCP, and to voice general concerns, and at which they got straight answers from the directors who were present. There was great interaction with representatives of the users of the service and meetings were held in public.
Things were turning around, and we began to see a real change in attitude. That was not so much on the part of the board—its attitude was already correct, in the main—but on the parts of the workforce and the users. Staff began to see the benefits of having someone from a related service across the room from them, or just down the hall, and users could see that the system was working with regard to, for example, home care for the elderly. Some of the work to alleviate bedblocking was really encouraging and the work on addictions was showing particularly good outcomes.
However, as soon as the suggestion of devolving powers and, in particular, funds to the CHCP reared its ugly head, the shutters came up and all the head honchos moved into their silos. That is why I am supportive of the bill and why I think that it is—unfortunately, as Bob Doris said—necessary. Intentions might be good and results on the ground might be great, but when it comes to institutions sharing some of their power, none of that seems to account for anything. Therefore, legislation is undoubtedly required.
That is also why I am disappointed with Labour’s amendment. I had to go and rewrite my speech today because I was going to speak about positive outcomes from the eventual bill and my experiences in the CHCP, but I do not think that we can let the amendment go by unnoticed. We should expect an attack on the Scottish Government in an amendment, no matter what the subject is that is being debated. That is fine; that is politics. However, the amendment is more than that. It is clear that, again, instead of looking for what is best for the people of Scotland, Labour is doing the work of what it considers to be its last bulwark of support: Labour-run local authorities. In this case, as it is so often, the authority in question is Glasgow City Council.
I was there when Labour-run Glasgow City Council reneged on commitments to devolve funds to the CHCP, and it was that intransigence that eventually brought about the demise of the regional model in favour of a Glasgow-wide, Labour-controlled version, which was disbanded before it even got started. That was my shortest membership of any committee: I eventually got on it, but it was disbanded before its next meeting. That was quite an achievement.
I am clearly missing something with regard to Mr Dornan’s interpretation of our amendment. I suggest to him that the issue is not just for Labour councils, but is for SNP councils and every other council across Scotland.
Would Mr Dornan care to comment on the suggestion that executive directors of health boards should somehow be on the new integrated partnerships? Does he support a payroll vote?
Having been a councillor in Glasgow City Council, I have seen a payroll vote at work. I suggest that we have a jointly accountable officer, as per the proposals.
Labour’s amendment mentions
“a strong role for local authorities”,
but the main thrust of Jackie Baillie’s opening speech was that it is important that local authorities have control. I have seen what happens in the biggest city in Scotland when the local authority has control of something that should be under joint control, and the people of Glasgow suffered for it. The CHCP that I was a part of was a huge success and would have gone on to much greater things. It was supported by everybody except Labour Glasgow councillors and executive directors, and they brought it to an end. Those are the facts. It was very unfortunate, and it is a shame that I am having to describe it in this debate, when we should be discussing the merits of CHCPs and not how to ensure that power stays with local authorities.
If members think that I am exaggerating—for the sake of the successful CHCP—about Labour’s unwillingness to part with control, they should listen to the following comments in Glasgow City Council’s response to the consultation. It states:
“The proposals are overly prescriptive on organisational arrangements.”
That means, “We want to stay in control.” It states:
“we consider the proposals as going too far in prescribing arrangements for partnerships”.
That means, “We want to stay in control.” It states:
“we would assert that the mechanisms for how these outcomes are met should be agreed locally.”
This is what happened in Glasgow last time: nothing got done. As soon as we hit the slightest bump, Labour went into its silo and the whole thing fell apart.
In response to the question,
“Will joint accountability to Ministers and Local Authority Leaders provide the right balance of local democratic accountability and accountability to central government, for health and social care services?”,
the council stated:
“No, councils are accountable to the electorate.”
It is saying, “Within the five year period”—as it is just now—“we can let the CHCP go, close down daycare centres and do whatever else we want in the hope that people have forgotten about it by the time the election comes round.” That is not in the best interests of the most vulnerable people in our society.
There is much at stake; some really good work was going on. George Adam talked about the work that the social workers were doing, and the amount of great close work between social workers and health board workers was fantastic. The problem lies not on the ground, but higher up. It is vital that we ensure that the forthcoming bill is passed.
As an aside, I know a doctor who works in Glasgow who says that she is terrified of what will happen if the local authority gets control, because she remembers what happened last time. She says that the money will end up going to pay for something else—something that is favoured by Glasgow City Council. It is vital that the work be taken out of the control of local authorities and that we have a jointly accountable officer. I look forward to the eventual bill being passed.
16:17
The arguments for integration of health and social care have always been strong. Over the past 20-odd years there have been successive, but not uniformly successful, attempts to move services in that direction, and each fresh attempt has encountered fresh obstacles. Too often, reforms are seen as an opportunity to pass on responsibility while retaining funding, which is always more tempting in an era of shrinking budgets. Partners have signed up to integration, but it is too easy for initiatives to be seen as solutions for one partner’s immediate problems, such as bedblocking, without their being too concerned about how the solution works in practice.
It makes good financial sense to support people in the community—I have been told that it costs four times as much to support an in-patient—but financial gains should not come at the expense of the overall quality of services and support. That is difficult to avoid when local government is severely cash constrained. With real-terms cuts in central Government funding, an underfunded council tax freeze and few other sources of income for local government, something has to give, and it appears to me that the most vulnerable are among the biggest givers. They are faced with either losing services or paying for them.
As freedom of information evidence has shown, income generation does not come only from car parking and leisure charges. It is clear that social care charges have increased, and that the pattern of cuts and charges is uneven. We could even call it a postcode lottery. I congratulate councillors who have done their best to protect services while keeping charges down, and I lay the responsibility for their dilemma firmly and squarely with the Scottish Government.
That said, this is not just about budgets. The postcode lottery that is faced by Scotland’s elderly and disabled people is exacerbated by the lack of a coherent and consistent strategy for care. We need clearer plans from the Scottish Government to address the demographic challenge that we face. We also need better funding for health and social care to meet the needs of the increasing numbers of service users.
We need to build consensus, which is difficult when the current situation pits partners against each other. We need to avoid service developments being held back by the people in power taking a narrow view of a service in a particular location, rather than recognising the best interests of the service users across an area. Cross-party support for better joined-up health and social care services is undermined by the current set-up, which fosters annual conflict.
However, by concentrating on structural reform at senior level in the organisations and by focusing on who controls budgets, the Scottish Government is neglecting questions about how to improve services on the ground—that is what I am told by the people on the ground. Change should happen, but it needs to be driven by reviewing at local level what works well and what can be improved by integrating health and social care services. Local delivery needs a strengthened role for local authorities, not a diluted one. A fully integrated delivery structure should be led by local authorities and underpinned by legislation.
There should also be straightforward and direct Scottish Government funding to health and social care partnerships using an allocation system that is sensitive to local needs. It is significant that much of the current agenda is being driven by an attempt to prevent bedblocking, but bedblocking is not an issue in all areas so not all councils or health boards will start from the same base. The proposals as they stand are focused on structure, on which budgets are to be included and on who controls those budgets; they say little about the outcomes that need to be delivered.
Let me come to a conclusion. The cabinet secretary has said that this is a revolution, and Iain Gray has said that we must not wait for another 20 years. Let us provide the care that people expect to receive in an open and transparent system that supports delivery, with local health and social work organisations that can locally determine the best way to deliver outcomes. Let us get away from the current divide-and-rule tactics, which I do not think the cabinet secretary is trying to recreate. Instead, let us concentrate on creating a national care service that truly integrates health and social care services.
I now call Mark McDonald, to whom I can give a generous seven minutes. This is a time for verbal virtuosity.
16:22
Gosh, Presiding Officer. How many times have I found myself being told at the end of a debate that I have three and a half minutes or two minutes or four minutes? Finally, there is a reward for patience. [Interruption.] Do not worry—this will be worth it.
One phrase in the Labour amendment really stuck out at me, about the need to
“avoid conflict between local authorities and NHS boards”.
That interests me, because in my speech I want to explore one example of what is happening in practice where the Labour Party has some control.
Yesterday, Aberdeen City Council voted to establish a local authority trading company for social care. Following previous votes on the business case at the full council, yesterday the council voted to take things one step further. That will involve the transfer of 750 staff, three care homes and occupational therapy and rehabilitation services to the new arm’s-length company, Bon Accord Care Ltd.
Indeed, the council has also found within itself funding for the new trading company. Although it was interesting to hear Jackie Baillie talk about the need for tough choices being driven by budgetary pressure, the leader of Aberdeen City Council announced at the budget-setting meeting in February that there would be no cuts in the council’s budget. Clearly, that is due to, for example, a strong funding settlement from the Scottish Government and good stewardship of the council’s finances by the previous administration.
It is interesting that a consultant has been hired as part of the establishment of the local authority trading company. The consultant will form part of the management team. Indeed, he is named as a director and sole shareholder in Bon Accord Care. The council will pay £42,800 for 12 weeks’ work—a pro rata salary of £170,000 a year, which is more than the chief executive of Aberdeen City Council is paid.
When challenged about the expenditure, Len Ironside, the social care convener, said:
“These are the experts—they have set up these types of companies before.”
In effect, he is saying that it is because they are worth it. Many people in Aberdeen city would question whether the council should be spending that amount of money on a consultant to deliver social care services.
However, there are not only concerns there. Indeed, the chief executive of NHS Grampian, Richard Carey, has stated his concerns that the
“creation of the LATC does not prevent integration ... It does, however, restrict the range and nature of the partnership ... we have expressed concern to the council that the opportunities for integration to deliver best value through changing service delivery may be restricted. It is therefore not integration that is potentially at risk, but the ability of the eventual partnership to deliver the changes as required in reshaping care for older people ... The opportunity to look at innovative staffing models on a joint basis is severely restricted ... the LATC was described by the council as remaining ‘100% under council control but would compete in the marketplace, effectively selling services to people who can afford it and are willing to pay’. If there is an inability to recruit home care staff, the available hours of care should be directed towards those in most need, not those who can pay ... The ability to pool the budget and use resources flexibly across health and social care is impacted upon as the LATC plan involves issuing a 5-year contract for £26 million ... This will restrict the ability and flexibility of the partnership to reallocate resource to match the assessed needs of the population as described in the joint strategic commissioning plan. The flexibility normally associated with a contracting model of procurement is restricted ... Savings made or profits generated by the LATC shall either be redirected by the LATC to create other services ... or result in profits returned to the council ... It is difficult to visualise how this will enable the integrated partnership to make the savings necessary to generate additional capacity to support the increasing number of older people in the local population ... integrated partnership will be required to create a strong ethos of partnership not only between the NHS and social work service but also with the third and independent care sectors. We are very aware of the concerns being expressed by both the third and independent care sectors of the competitive nature of the LATC, and this may have implications for the partnership.”
Mark McDonald promised that the extra time that he was given would be worth it. When will the member stop reading out the minutes of Aberdeen City Council and get to the good part of his speech?
That was not worth it.
I am not reading out the minutes of Aberdeen City Council; I am reading out the deep concerns that the chief executive of NHS Grampian has about the behaviour of Duncan McNeil’s colleagues in administration in Aberdeen and the policies that they are pursuing. He would perhaps do well to pay attention to what Mr Carey has to say. In particular, let us listen to the response that was given by Willie Young, the finance convener of Aberdeen City Council, in response to Mr Carey’s concerns, who said:
“I would say get off our lawn—I promise not to interfere with his business if he won’t interfere in ours ... They are actively undermining us at each and every opportunity”.
However, the only thing that is being undermined is the ability of health and social care integration in Aberdeen to deliver the best results for the people of Aberdeen.
Will the member take an intervention?
No, no, no.
It is not only NHS Grampian that has concerns. Unison has said that it has
“grave concerns that this will result in an erosion in the terms, conditions and pension entitlements of our members, and a two tier workforce.”
There are other examples of local authority trading companies but, unfortunately, we must look outwith Scotland, because the only example that exists in Scotland is the one in Aberdeen. Perhaps that ought to be instructive.
We can look at the situation in Barnet. A press release from Barnet Unison on 1 March said that despite the fact that staff were transferred under the Transfer of Undertakings (Protection of Employment) Regulations, just more than one year on
“170 staff will be presented with a redundancy consultation document”.
That underlines what Unison in Aberdeen is saying about the situation leading to significant challenges and potential risks for staff in the future.
However, that is not the only area in which there are issues in Aberdeen. My colleague Kevin Stewart wrote to the cabinet secretary in February about the emerging care crisis in the city, with 66 elderly and disabled who were assessed as requiring essential care but who were still on the waiting list for care from the council. The chief executive herself had to intervene in some cases.
SNP group councillors made attempts to get the council to convene a care summit, including through a motion from my colleague Councillor Jim Kiddie that the Labour-led council would not even consider.
Those developments are not a result of budgetary pressures, as Jackie Baillie claims; they are all about the political dogma of the Labour-led council. Labour in Aberdeen is using social care users as guinea pigs in a bizarre political experiment. It ought to think again.
16:30
What an exhilarating, zinging, thrilling extravaganza of an afternoon it has proved to be. Season ticket holders to such consensual events will know that my appreciation of the spectacle knows no bounds.
On Tuesday, we had a three-hour debate on the ageing demographic. This afternoon, we had the two-and-a-quarter-hour debate on the consequences of it. We have had five and a half hours about an ageing Scotland and, I have to say, in those five and a half hours, most of us aged ever so slightly in consequence.
When Jackie Baillie opened by saying that she was bringing the parliamentary week to a close with her speech, I wondered whether she knew something about proceedings that the rest of us did not and whether we would all be released immediately afterwards, but no—the debate continued. That is not to take away from its importance and the many speeches of note that were made during it.
We start from a policy to which all four major parties’ manifestoes were committed at the previous Scottish election. It is genuinely a path forward to which we are all committed and that we all wish to succeed.
I wondered how Alex Neil would fill his 13 minutes. I do not know if even he was aware of what I am about to say but, while he was speaking, I thought that I would just glance over the Scottish Government’s response to the consultation only to find that I was following his speech verbatim because large parts of it were printed in the document.
It is consistency.
Well, I look to his civil servants to inject more flair and originality into his performances in the chamber, rather than having him read out documents that are in the public domain. That is not to take away from the importance and sense of all that was said.
Alex Neil referred to the 315 written responses, the public meetings and the participation in the consultation. He talked about a revolution. I looked around at the revolutionaries; “Hardly ‘Les Misérables’,” I thought but, nonetheless, there is commitment around the chamber and beyond to the huge effort of will that integration will require.
I will come to Iain Gray shortly because his speech was, for me, the key contribution of the afternoon. However, I was struck by the language in the early speeches: “radical”, “inclusive”, “delivery”, “service users”, “carers”, “governance”, “culture”, “vision” and “ambition”. That is the sort of corporate language that sometimes drowns out the good intentions that we are all trying to achieve.
Jackie Baillie talked about an ageing Scotland. I mentioned in Tuesday’s debate—some members who are present were not there, so it is worth saying—that the Parliament is a reflection of that because, when it first met in 1999, only eight members were 60 or older. By the end of this parliamentary session, 46 will be. That is a considerable change in the demographic of the Parliament—eight members in the first session, 15 in the second, 22 in the third and 46 in this session. Many of them were keen to contribute this afternoon.
We are dealing with an ageing Scotland. It was Bob Doris, I think, who said that most of us will be part of that within the next 20 years. However, it is not only in the next 20 years; today—here and now—the issue is pertinent.
Jackie Baillie made an important point about the fact that there are competing practices that must be merged. That is a theme throughout the debate. There will be a battle for somebody’s current practice and culture to prevail but, in fact, nobody’s culture and practice can be allowed to prevail if integration is to be successful.
I thought that Nanette Milne was correct when she talked about the importance of local priorities. Jim Hume touched on that. I will have to read his speech carefully, because I lost the plot at one point during it. I promise so to do. I think that he said that Scotland could sleep easy, because he would keep an eye on ensuring that local priorities were respected. That will be fundamental to what happens.
Two speeches struck me, the first of which was Duncan McNeil’s. In it, he made two significant points. The first was a highly impassioned plea that we all remember that an improvement in services is at the heart of what we are trying to achieve and that that objective should not be lost. I think that he was advocating a charter of sorts to underpin that. His emphasis on the fact that an improvement in services was necessary is key. His second point was about workforce planning, and it leaked slightly into what Iain Gray talked about subsequently. It is terribly important that the people who are part of the workforce that deliver the integration that we are talking about are the right people in the right jobs who carry out the right functions at the right time and are suitably motivated to do that.
In between the speeches of Duncan McNeil and Iain Gray, we had a speech from Bob Doris. To borrow an old phrase, he did the crime, but didn’t do the time, in the sense that he took the extra minutes that were offered to him, but then did not give way as he had promised to do in return for the award of those extra minutes, and poor Jackie Baillie was left floundering. [Laughter.] That might not be the right description.
For me, the key speech was Iain Gray’s. I think that he illuminated the experience that we are all trying to legislate to change. I like the phrase
“agree the need but resist the change.”
In Tuesday’s debate on an ageing population, when I noted in the Finance Committee’s report the phrase
“dependent on significant cultural change”,
I said that I was not optimistic without being pessimistic, because the exigencies of today often get in the way of and stand against the radical and comprehensive change that is needed to prepare for the future. I am concerned about that.
I thought that Iain Gray made a powerful point when he talked about the language becoming corporate and complicated. We could get to a point at which the language is all-inclusive, in the sense that we are all included in not understanding what it is trying to say to us as efforts are made to deliver the change. Those pitfalls must be avoided. Iain Gray’s point that the discussions should be about delivery and not about the share of the budget was also a powerful one that registered with me.
Thereafter, we had some of the usual have-a-bit-of-a-bash-at-one-another contributions. I do not think that they were necessary. Notwithstanding that, the quote of the afternoon came from James Dornan. I took it down. He said:
“Having been a councillor in Glasgow City Council, I have seen a payroll vote at work.”
I enjoyed that. As someone who has lived in Glasgow but who has never served there—I am a Conservative, after all—I have seen the payroll vote at work as well.
Let me get back to the point of the debate. It has been a debate on the response of the Government to the consultation. I hope that the Government is still open to listening even now that it has given its response. I was grateful to the cabinet secretary for his response to Nanette Milne on councils potentially coming together to work within a single partnership. I think that there are other areas in which, if we are to make the integration process a success and avoid the problem that Iain Gray identified of another generation of politicians—given that 46 members will be 60 or over by the end of the session, it will probably not be the same generation of politicians—confronting the same issues in another 13 years, the consensual approach must continue through a partnership of all the political parties here and of all the organisations beyond that we have talked about.
16:38
As Jackson Carlaw indicated, this discussion goes back a long way. It goes back even before devolution. In 1979, the Mitchell report talked about liaison—that was the word that was used at the time—between social work and healthcare. We have been considering the issue for a long time.
As many members have said, and as Tuesday’s debate indicated, the challenge of demographic change is now upon us. As Duncan McNeil said, that challenge will intensify, as people experience longer periods of not-such-good health, chronic disability and long-term conditions. The challenge is intensifying year by year.
The Parliament has previously supported very similar attempts in debates in which almost exactly the same speeches have been made. The speeches that we have had this afternoon—with the exception of the three or four from SNP members that simply attacked Labour councils—have, on the whole, been exactly the same. The desire, the ambition and the aspiration are there.
In 2000 to 2001, we established the joint future programme, which Iain Gray referred to. We started with an ambitious pilot in Perth and Kinross to amalgamate social care and healthcare. People spent two years wrangling about staff terms and conditions, but then they finally got going. Two and a half years later, the pilot collapsed, because the leadership withdrew its support. The lesson that I take from that—we should take lessons from our failures—is that, without strong commitment and strong leadership from the Government, local authorities and health boards, we are doomed to another 13 years of talking about integration but seeing only a small amount of reasonably good practice.
How did Labour respond? In 2004, we legislated for the CHPs, which were intended to build on 85 local healthcare co-operatives—groupings of primary care practices—and to link social work teams to the co-operatives. In fact, the CHPs destroyed the co-operatives. Very few local healthcare co-operatives are left. GPs and primary care staff disengaged from the process. Far from integration, what we achieved was disintegration. We need to learn that lesson, too. If primary care staff disengage, we will be in trouble.
A number of speakers have raised a fundamentally important point. The world is changing, and the third sector is now providing an increasing volume of the services that are vital to integrated health and social care, so it must have a strong place at the table.
Since the CHPs were established, we have had Crerar, Christie and Beveridge. In a thoughtful speech, Duncan McNeil showed us that reform will be more difficult in a period of austerity than it would have been when considerable additional funding was available. It will be difficult for us not to portray reform as cost cutting.
Labour foresaw the problem and the need for change, so it established a commission under Sir John Arbuthnott. Far from what was portrayed by the SNP—with its usual knockabout party politics, which we on all sides love—we did not seek the establishment of a new national quango; we sought national standards to underpin local democratic revisions of the CHPs. Duncan McNeil referred to those standards—which we need now, before the bill is introduced. They will underpin how we go forward. As a number of speakers have said, it is outcomes that will matter.
In his eloquent speech, Iain Gray described the reality for individuals. All the services are being provided but, if something goes wrong, people have no idea who to turn to. That is not satisfactory.
The Association of Directors of Social Work has tended to welcome integration, but it does not want structural change. It is not right about that; we need to revise the structures. However, ADSW is right in saying that we need to ensure that we do not do what happened previously. We must not destroy the existing good practice. Flexibility on that in the bill is welcome, but other aspects are not.
We need a mapping exercise to see whether more than the 11 councils that Audit Scotland found are engaged in the process. We need to build on that work and ensure that it is not destroyed.
Resources will be important and we believe that they will have to be determined centrally. We have tried aligning budgets. In an otherwise pretty awful speech, James Dornan was right about one thing: there was disintegration in Glasgow. However, that was caused by two partners, not one. The two partners could not agree—that was the important point.
In his speech, which was entirely about Aberdeen, Mark McDonald referred to an Aberdeen City Council project. That was started under the SNP, not Labour—Labour might have carried it through, but your party started it. Both parties are simply trying to solve a difficult problem that needs a huge resource. As you said, 65 people are waiting. How do you deal with that in your funding envelope? The Aberdeen approach provides one possible solution.
In Sandwell, care was outsourced 16 years ago, and I commend this example to the cabinet secretary. It has been a phenomenal success—the Sandwell model has grown from an initial 82 employees to 500 employees, who provide a fantastic service that gets a superb report from the users, which is critical.
As regards the Aberdeen project, the SNP said that we would look at the business case. The business case came back and it did not stack up, and so the project was opposed. It is a great pity that the Labour Party did not join us in opposing it and did not listen to the concerns that were expressed, not just by politicians but by trade unions as well.
I call Richard Simpson—please speak through the chair.
I say to Mark McDonald that that illustrates the confrontational nature of the relationship between health and local authorities, which is exactly what we have to get rid of. If he thinks that the system that is being proposed by the Government in the bill will do that, I am afraid that he will be disappointed.
I said that leadership and culture are important and the last part of the discussion reflects that. There are two different cultures involved, and marrying them has never been considered as anything other than extremely difficult. However, unless we achieve that integration, things will be very difficult indeed.
Accountability is critical. I was disappointed that James Dornan does not appear to think that local democratic control is in any way appropriate. I wonder if he believes in local democracy—maybe he does if his party is in charge, but not if ours is.
It is important that local democracy is involved. We have tried health board elections, which have been expensive and have not worked particularly well. I do not think that there has been any word of those elections continuing. Democratising the local system through councillors being in a majority or being in control of the community health and social care partnerships will be a mechanism for democratising health.
This is not about medicalising social care; it is about socialising medical care. That reflects what Duncan McNeil was saying—there are individuals who need their care to be fully integrated.
We will vote for the motion even if the SNP does not accept our amendment because we agree with the principles of the bill; we will work with the Government. However, we disagree as regards the question of joint and equal accountability. There is a need for single democratic accountability and we will continue to argue that case.
I call Alex Neil to wind up the debate. Mr Neil, you have until 4.58—so you have 10 minutes.
16:48
As this is my own production, I will try to be as loquacious as possible.
Integration is not new—there are examples of successful integration in Scotland. I have used the example of West Lothian many times. The West Lothian integration project has been running successfully for eight years. It started as the integration of adult health and social care; it then incorporated children’s services; and it is now quite rightly incorporating acute services. The West Lothian example clearly shows that integration can work and that many of the problems that have been identified are not necessarily endemic in every local authority area across the country.
West Lothian is not the only area in Scotland to have successful integration. I was up in Turriff on Monday and I visited Turriff hospital. As Nanette Milne will be aware, Turriff hospital has a totally integrated operation, with a health centre, a hospital, and social care workers from the local authority who work side by side with the health workers in the health centre. Aileen McLeod mentioned the example in the Dumfries and Galloway area. We have good examples of successful integration across Scotland as well as down south.
We have also seen that, where there is successful integration, we achieve the outcomes that we are trying to achieve through this bill. Having said that, I recognise many of the points that have been made, very fairly, by Iain Gray. That is precisely why we need legislation; it is precisely why, in the bill, I will take reserved powers to deal with either a recalcitrant health board or local authority and to ensure that integration happens. That will include powers, if necessary, in relation to budgets and other matters, because we are not prepared to sit back and allow integration not to happen in any part in Scotland.
Iain Gray raised valid points, which are obviously based on his experience of trying to make integration work—an experience that many of us have had.
Mr Neil makes a fair point. If I was asked what our key mistake was in 2000 and 2001, I would say that it was that we did not legislate. We should have done that, which is why, as I said, the proposed bill is a real opportunity. However, the legislation should sweep away the negotiation about pooling budgets, because that is the greatest barrier to moving forward.
Without being specific about that, I am open to suggestions from other parties, particularly from somebody such as Iain Gray, who as a minister had direct experience of trying to make integration work. I am happy to meet individual members and talk through some of the issues.
We have been in sustained negotiation with COSLA and other stakeholders, and we have a bill advisory committee. I have agreed that any proposals or amendments will go through the bill advisory committee to ensure that we take as many stakeholders with us as possible. The other parties in the Parliament are also stakeholders. My door is open to suggestions on how we might improve our proposals and the bill once it is published.
The integrated resources framework provides the cabinet secretary with the opportunity to look at the financial situation in a way that was not available to Labour in 2001. The Government has a great advantage in being able to look at the budgets in an integrated form and to compare between different authorities.
Absolutely. I intend to use that framework as and when it is necessary.
The irony is that just the knowledge that legislation with those reserved powers is coming will in itself, I hope, force people in many areas to work together and reach agreement, rather than continually wrangle about issues that, at the end of the day, are not the most important aspects of the exercise.
The issue of national standards was initially raised by Duncan McNeil and came up a couple of times. I can confirm that we will publish our consultation paper on the national standards prior to the publication and introduction of the bill. I absolutely accept that the national standards are a vital part—a linchpin—in the success that we are trying to achieve, as are the outcomes that we have included in our response to the responses.
Will the consultation be completed and the national care standards put in place in order to inform those who set the outcomes? That seems a natural process.
We will synchronise the standards and outcomes and all the other decisions to ensure that there is a logical flow. I anticipate that it will be well after the summer recess before the bill gets properly into the committee stages. By that time, I hope to have reached decisions on the national standards and have agreement on them. We have already indicated the high-level outcomes that we expect and that we must ensure that we get from the integrated partnerships. That is absolutely right.
I will turn to some other points that have been raised. I share the concerns about the arm’s-length external organisation in Aberdeen. It is fair to put that on the record, although I will not get into the internal politics in Aberdeen.
I do not accept that it would be right to have a majority of local authority representation on the partnership committees. The reasons that were given for that were that it would make the process more democratic. This is not a party-political point but, believe you me, some of the practices in North Lanarkshire Council in the area that I represent are anything but democratic.
Will the member take an intervention?
I will in a minute, and I will do it this time—I will keep my promise to you, Jackie.
I will not concede on the principle of equal representation between the health board and the local authority.
Presiding Officer, I should have said, “I will keep my promise to Jackie Baillie,” which I now do.
Thank you. I remind all members that they should refer to other members by their full names. I call Jackie Baillie.
Thank you, Presiding Officer. This is the first time that the cabinet secretary has kept a promise to me. [Laughter.]
Will the cabinet secretary specifically exclude executive directors from the new bodies?
My view is that health board representation will be up to each health board, and it will primarily be the non-executives who are the representatives on the new bodies.
It would not be right to have the executives of the health board as members of the board of the partnership. First, I do not think that that is right in principle. Secondly, the health board needs to ensure—and most have done this—that the places that it has on the committee are taken not just by non-executive directors but by patient representatives. I want to see end users on the board, because no one is better placed to drive up standards than the people who use the services. That will be crucial.
There is an issue in that respect, and we are still in discussion about it with COSLA and other stakeholders in the third sector and the independent sector. We have to be clear about two separate functions. There is a precedent for that. When I was convener of the Enterprise and Lifelong Learning Committee in the first session of the Parliament and Jack McConnell, now Lord McConnell, was education minister, we had the crisis at the Scottish Qualifications Authority. A reason for the crisis was that the SQA’s board was made up of people who were primarily there not to run the organisation on the basis of what the organisation needed at the time but to represent their own interests. I suggested and Jack McConnell accepted that we needed to separate the two functions: the management and running of the organisation, which should be done by a fairly tight, reasonably small and manageable management board; and the separate issue of the involvement of stakeholders.
In each area, there are tens if not hundreds of stakeholders who want an input into service design, architecture, delivery and so on—and they should have an input. What I am saying is that the management board must be of a manageable size, so that it manages the organisation, looks after the money and ensures that the outcomes are achieved. That is not necessarily the same as a wide-ranging stakeholder group, for which there is also a role. It will be important to get those two things right in each area.
There will have to be a close relationship between the partnership boards and the community planning partnerships. The logical place for the board to report locally will be the community planning partnership, because all the other relevant services will be represented round that table. One member quite rightly made the point that we need better involvement of housing services. Council housing services and housing associations will be much more involved in community planning partnerships, which, when they have been reformed by my friend Mr Swinney, will be the logical platform through which the partnership boards should report to wider stakeholders and the wider community.
Finally, on culture, I have heard it said many times that there are two cultures: the local authority culture and the health board culture. That is a gross underestimate. In each health board there are many cultures. There is the culture of GPs; there is the culture of almost every allied health professional organisation; and there is the culture of secondary care. As for local authorities, I can tell members that in North Lanarkshire Council, which is a good example, there are a lot of sub-cultures.
The point is that we must develop one culture, one organisation, one integration, one delivery and one set of budgets for each area, so that there is one set of outcomes and standards and, I hope, one big success in each area, which delivers for the people of Scotland.