Integration of Health and Social Care
Good morning. The first item of business is a debate on motion S4M-01585, in the name of Nicola Sturgeon, on the integration of health and social care.
09:15
I am pleased to open the debate on the integration of adult health and social care. During the debate I will set out the Government’s clear commitment to improving health and social care outcomes and outline the proposals for reform that will assist us in achieving those outcomes.
First, let me be clear about the objectives of this programme of reform. We want to ensure that adult health and social care services are firmly integrated around the needs of individuals, their carers and other family members; that the providers of those services are held to account jointly and effectively for improved delivery; that services are underpinned by flexible, sustainable financial mechanisms that give priority to the needs of the people they serve rather than the needs of the organisations through which they are delivered; and that those arrangements are characterised by strong and consistent clinical and professional leadership.
Our next step as a Government will be to continue the invaluable partnership work that we have already begun with NHS Scotland, local government, the third and independent sectors and professional bodies to develop detailed consultation material for public discussion and scrutiny. I believe that that approach will help us to ensure that integration is informed at each and every step of the way by the knowledge and experience of those in the public sector and beyond who have a key interest in health and social care.
We are not starting from scratch or with a blank sheet of paper. There is already a great deal to be proud of in Scotland in health and social care provision. There have been significant improvements in recent years in standards and outcomes, with improvements in waiting times, patient safety and delayed discharges from hospital.
Our healthcare quality strategy underpins our commitment to delivering the highest quality healthcare services. Our introduction of a dementia strategy, the continuing commitment of us all to free personal and nursing care, and our reshaping care for older people programme, supported by the change fund, all demonstrate our commitment to ensuring innovative, high-quality services that improve people’s lives. Our carers strategy supports unpaid carers, who, we must remember, are essential providers of health and social care. Just this week, we published our refreshed national performance framework, which includes a specific commitment to the wellbeing of older people. Much is being done, but we must go further.
There is now a consensus around the contention that separate and—all too often—disjointed systems of health and social care can no longer adequately meet the needs and expectations of the increasing number of people who are living longer into old age, often with multiple, complex, long-term conditions and who, as a result, need joined-up, integrated services.
It is important to stress at this stage that our ambition is not limited to improving older people’s services. People can and do experience complex care and health support requirements at any age, and we need to ensure that our health and social care services apply the principles of integration to any area of service provision that needs them.
However, there is no getting away from the fact that the factors driving closer integration are particularly relevant to care and support for older people. We know that, too often, older people can be admitted to institutional care for long periods of time when a package of assessment, treatment, rehabilitation and support in the community, or indeed more support to their carers, might have served their needs and maintained their independence much better. Of course, more people are living longer and therefore, just like every other developed country, we must plan now for the needs of a growing older population.
It is against that backdrop that we have embarked on this programme of reform. The preliminary work that we carried out over the summer and autumn, with statutory and non-statutory partners and with professional bodies, has confirmed a number of issues that the integration of adult health and social care—along with other measures—must address. First, there is too much inconsistency in the quality of care for adults and older people across Scotland. Secondly, there is too much variation in the level of resources invested in care locally by health boards and local authorities and in the outcomes that those resources then achieve. Thirdly, too many people are unnecessarily admitted to hospital or are delayed there when they are clinically ready to leave. Fourthly, for too many people, the experience of moving between health and social care services as their care needs change is not smooth enough.
Another key message that emerged from work over the summer was that wholesale, nationally driven, structural reorganisation of current statutory bodies was not the best way to address the challenges. Evidence shows that that is not the way to achieve better outcomes for people, and it is therefore not the route that we are choosing. However, I make it clear that we are determined to tackle the aspects of current structures that stand in the way of effective integration.
The approach that we intend to take is as follows. We will introduce legislation to bring about a radical transformation of community health partnerships. Community health partnerships—currently sub-committees of national health service boards—will be replaced by health and social care partnerships that are the joint and equal responsibility of the NHS and local government.
We will focus squarely on improving outcomes. A nationally agreed set of outcomes will apply across health and social care, and—through the new partnerships—we will hold the NHS and local government jointly to account for the delivery of those outcomes.
We will require statutory partners to integrate budgets, starting with budgets for services for older people. Within those integrated budgets—and, for me, this is a key point—where money comes from, be it health or social care, will no longer be of consequence. All that will matter is that partnerships can and do use the integrated budgets to achieve the maximum possible benefit for service users or patients, and to deliver the shared and agreed national outcomes.
As an MSP for the Highlands and Islands, I am aware of the significant structural change between NHS Highland and Highland Council. I believe that the change is on the way to success, and I had thought that the Government supported and favoured it. From what the cabinet secretary has just said, do I take it that the model is not one that she would support now?
No, the member cannot take that from what I have said. I have said that nationally driven, structural change is not the way to go. I will talk about Highland a little later, but what the two bodies are doing there—the result of local agreement—is absolutely legitimate and I support it whole-heartedly.
I will finish my outline of the model that we propose. I have spoken about integrated budgets, and it is also important to talk about the role of a single, senior, locally accountable officer to ensure that partners’ joint objectives are delivered. It will no longer be necessary, or indeed legitimate, always to refer back up separate lines of governance within health boards or councils when what would serve the needs of local people is a well-integrated approach, jointly led by both partners after they have engaged effectively with people in the communities that they serve. There will be a direct line of accountability for the performance of health and social care partnerships, via the chief executives of the health board and local authority to ministers and the council leader, and partnerships will be expected to publish regular progress reports for public scrutiny.
We will have to ensure that service planning and provision for older people is professionally led by clinicians and social workers, with appropriate input from the third and independent sectors. Again, I feel that that is a crucial point, because it concerns an issue that has got in the way of the success of community health partnerships.
Locality-based service planning and decision making will be key to such reforms. Within that local service planning, primary care will have an absolutely vital role. Primary care clinicians are at the heart of the NHS and will be central to the successful delivery of the improvements. More and more general practitioner practices are already working together in groups to consider local budgets and local options for improvement.
The cabinet secretary is making a particularly important point, and the concept of networked primary care is supported by the Royal College of General Practitioners. Local healthcare co-operatives are the embodiment of what the cabinet secretary is saying. There were 85 in 1999 but there are only 40 now, and there has been a critical disengagement of primary care and community staff.
I think that there is a point of agreement here. Richard Simpson will appreciate that at this stage I will not get into the number of locality-based groups that we might see, but I agree with him as I believe that the involvement, engagement and meaningful input of clinicians, particularly primary care clinicians, are crucial to the success of the reforms. That is why they are such a key part of our proposals.
It is fair to say that, in keeping with overall Government policy, our focus is on achieving a decisive shift towards preventative and anticipatory care. Our clear intention is that over time a smaller proportion of resources will need to be directed towards institutional care, with more resources instead being directed towards community provision and capacity building. That will mean creating new and different job opportunities in the community to serve people where they want to be.
By making more flexible use of resources across health and social care, we can and will ensure that funding shifts to support that change. We will need to build on the work that we have already taken forward under the integrated resource framework to develop a fuller understanding of local patterns of resource allocation and use.
I have already referred to transformation. I want to be clear that there should be no mistake about the extent and ambition of the changes that we seek. We are determined to work with local leaders to shine a spotlight as never before on outcomes for patients and service users across the spectrum of adult health and social care.
We will, of course, take forward those improvements in the context of public sector reform more widely. For reasons that will be understood, I have talked a great deal about the central role of the NHS and local government, but the important role of other services in meeting the objectives cannot be overstated, whether they are housing services or the range of different services provided by the voluntary and independent sectors.
I have set out some very important principles. Another important point that I want to stress, which comes back to the issue that Mary Scanlon raised, is that our framework for integration is exactly that: it is a framework within which local professionals and managers will have and must have the room to make the decisions, choices and changes that best serve local people in their own areas.
In Highland the council and NHS already have ambitious plans for implementation of lead agency arrangements. I welcome that development, which is one example of the kind of delivery arrangements that can be used to improve integration across health and social care and, crucially, thereby improve outcomes.
There are other examples of work around the country, much of it now done with the support of the change fund, that demonstrate real innovation and strong leadership, whether that is from housing services and the third and independent sectors or from health and social care. Those are examples of innovation and leadership of the type that we need to drive forward the improvements successfully.
Taking forward the integration of health and social care as a priority was, of course, a specific recommendation to the Government by the Christie commission. We are focusing on the priorities identified by the Christie commission more generally, as we are legislating in favour of preventative action, putting in place funding regimes that support integrated provision, applying commissioning standards more consistently and transparently across health and social care, and building public services around the needs of people and communities. The needs of people must always take precedence and priority over the needs of the organisations that provide services.
The reform that I have outlined today sits squarely within our wider approach to public service reform as set out at the time of the spending review. I am sure that all members agree that change on this scale and of this significance must be taken forward carefully and thoughtfully. We must do it in consultation and partnership with the NHS, local government, the third and independent sectors, and professional bodies. We are determined that, as we move forward into more detailed discussion and scrutiny of the proposals, the partnership approach that has characterised our work so far will continue.
We are a small country with a history of social co-operation and we are building this ambitious programme of improvement on an unrivalled foundation of professionalism, commitment and expertise. We will use all those advantages to ensure that our proposals make best use of all that expertise, experience and insight.
We are determined to put in place a system of health and social care that is robust, efficient and effective, that is fit for the 21st century, and that will reliably and sustainably ensure that the high quality of support and care that is right for the people of Scotland is delivered for the people of Scotland. I look forward to the debate.
I move,
That the Parliament recognises the improvements achieved in terms of adult health and social care services since it was established; further recognises, particularly with regard to the needs of Scotland’s older people, that the integration of services needs to be improved to deliver better health and social care services; notes that the cornerstone of reform should be nationally agreed outcomes and that these reforms will be judged by the delivery of specific goals, such as reducing the number of delayed discharges, which directly impact on the health and care experience of older citizens; notes that services should be characterised by strong and committed clinical and care professional leadership; notes that NHS boards and local authorities will work together to produce integrated budgets that will bring to an end the cost-shunting between the NHS and local authorities that currently occurs, and notes that the Scottish Government will continue to work with partners in the NHS, local government, the third and independent sectors and professional bodies to take these reforms forward.
09:30
This debate on the integration of health and social care is extremely welcome, albeit long overdue. I believe that the cabinet secretary’s view of what the objectives should be in providing better—and better integrated—health and social care is shared across the chamber. We also agree on the important role to be played by all the stakeholders: not just the NHS and the local authorities, but the third and independent sectors and the many community groups such as those that operate in my local area to support older people in their community.
I do not think that anyone would disagree that the care of our older people is probably the most pressing social policy concern in this session of Parliament. No one can doubt the scale of the challenge that we face or the significance of the demographic change that we are experiencing.
We will undoubtedly trade our favourite statistics during the course of the debate, but it is worth repeating some of them. There will be an increase of 40 per cent in the number of people aged 65 to 74 in the next 20 years, and a staggering 83 per cent increase in the number of those over 75. Scotland’s population is getting older, and people are living longer. We are thankful for the advances in medicine that have contributed to that trend, but it also creates a different set of challenges for us. I recall reading somewhere that, if we did nothing in the face of those changes, we would need at least 6,000 more NHS beds and about double the existing budget simply to stand still and meet the likely demand. Doing nothing is clearly not an option.
Let me digress for a minute, because it is important to make it clear that not all our older people need care. About 90 per cent of them are sustained in their own homes and communities, with very limited input from care services. We should therefore think about older people in the context not only of their care but of the contribution that they make to our communities, through their experience, time and knowledge. Many of them are the volunteers who make our communities strong, but they need to know that, should the time come when they need care, it will be there for them.
Scottish Labour started thinking seriously about the challenges more than 18 months ago. We set out our policy intentions last October, and followed that up with an expert group chaired by Sir John Arbuthnott and drawing in members with expertise in health and adult social care. I am grateful to them for their contribution in helping to shape the agenda before us today.
At the outset, we recognised that older people were falling through the gaps between health and social care. They were ending up in emergency care unnecessarily, often because of a lack of integrated care on the ground. We need look no further than our constituency postbags to find evidence of that. We have seen a postcode lottery of care, costs shunted between different public organisations, differential charging and an emerging lack of fairness and equity.
In an early Labour-led debate on Scotland’s older people, we set out our view of the future. We said that the way to cope with the demographic change in relation to the care of older people was to integrate health and social care by having local services and local accountability. Based on reformed community health partnerships, and involving general practitioners much more in the design and commissioning of local services, delivery would be focused on the needs of the older person.
We suggested the need for a national framework, ending the postcode lottery of care and delivering better quality and better outcomes for older people. We also said that there needed to be one budget in order to stop health and local government playing pass the parcel with people’s care. We went further, advocating a charter for care in Scotland to set out what an individual could expect in terms of outcome, equity and quality. I commend that to the cabinet secretary.
Members might be forgiven for thinking that that is all remarkably similar to the newly published Scottish National Party proposals. Let me reprise some of them. They include a national framework with agreed outcomes, an end to cost shunting, reform of CHPs, and clinical leadership. People say that imitation is the sincerest form of flattery, so I am flattered. However, in the spirit of consensus, I say that I am pleased that the Scottish Government has taken much of our approach forward. We will work with it to ensure that any future system of social care is fair and robust.
We would have gone further because our vision was for a national care service as radical as the creation of the NHS, bringing fairness and raising standards in the provision of care. The SNP would have members believe that we were creating another quango or bureaucratic monolith, but that deliberately misunderstands the proposal. There would be no new body and no more civil servants; it would be about having national care standards for services that are delivered locally, which is a model that is currently used in the health service. It might suit the Government politically to rubbish Labour’s proposal, but there is no doubt that key elements of what we proposed previously are before us today, and I welcome that.
The devil, of course, will be in the detail and we stand ready to engage positively in the debate. As I said earlier, we suggested a national framework because of the inconsistency of service provision. We have 32 local authorities, different eligibility criteria and different costs—in short, we have 32 different ways of doing things. We have seen the cost shunting that goes on between local authorities and health boards, whereby officials will openly say that they are cutting a social care budget because health will pick up the costs. Both are public sector bodies that use taxpayers’ money, but in many areas they are fundamentally unable to work together. Where is the focus on prevention, never mind on the person needing care? All that has to stop. We cannot afford to play pass the parcel any longer.
I know that local authorities are struggling financially. For the first time, many of them are making substantial cuts and introducing charges for services, which are resulting in some older people cancelling services such as community alarms because they are worried about whether they will be able to afford the cost.
Neighbouring local authorities are taking different approaches to charging. I am bored raising the fact that a service costs £30 in one area but right next door the same service is £300. I first raised that point almost three years ago, but it is as true today as it was then. The Learning Disability Alliance Scotland provided us with illustrations for a previous debate as evidence. The criteria for charging vary widely. For example, Argyll and Bute considers 100 per cent of somebody’s income, but across the water in Inverclyde only 25 per cent of their income is considered. How about the hourly rates for home care, which is just one social care service? The picture is one of different costs. In West Lothian, home care is £7.76 per hour, but in Angus it is £22 per hour, which is three times the amount. Clearly, that is not fair.
It would therefore be useful to know whether the cabinet secretary envisages the framework dealing with those inconsistencies and considering matters of eligibility, charging and outcomes. I agree with her that Scotland is not such a vast country that we should experience such wide variations and injustice in the provision of social care. Whether someone lives in my constituency in Dumbarton or in Dunbar, Dingwall or Dumfries, they deserve a care system that supports them to live as independently as possible and which offers access to the best-quality care possible. The basis of the system and how much people pay for it must be fair.
That brings me to the next point. When we access the NHS, we are provided with publicly delivered services that are based on need and free at the point of delivery. However, the culture in social care is different. Social care is rationed, prioritised, charged for and often delivered by the independent sector. Clearly, those different approaches and cultures need to be thought through. There is the need for a wider debate about how we afford and pay for care in the future. I wonder whether the cabinet secretary has considered the outcome of the Dilnot inquiry. What approach does she believe that we need to adopt in the future to ensure the sustainability of care?
Preventing older people from requiring care in the first place is of course the real prize. I hope that that will feature explicitly in the outcomes in the national framework. It is the case that current eligibility is increasingly determined by the severity of need. That is understandable, but there are swathes of people with lower-level needs who will not be provided with a service because budgets are too tight. Even though we know that prevention is cost effective and that it is much better for the individual to be sustained in their own homes and community without the need for more formal care, we also know that cuts are being made to some community-based services that do not cost a lot of money but have such a huge impact on the potential for long-term savings. It is a matter of regret that such early intervention work and upstream activity, which is key to prevention, remains an aspiration rather than a reality. I hope that the cabinet secretary will use the national framework to change that.
I want to explore with the cabinet secretary how accountability will be delivered. We were clear that clinicians have to have greater involvement in the planning and commissioning of services, and we envisaged a system of local democratic accountability in which councillors would be given oversight in a context of reformed CHPs and reporting to ministers. Given that much of what the cabinet secretary has outlined relates to delivery by local agreement, how will she monitor progress towards achieving outcomes? Concern has already been expressed that single outcome agreements are not sufficiently robust to deal with the issue, lack independent scrutiny and contain little sanction for failure. What power does the cabinet secretary have to ensure that all areas make the progress that we want them to make?
On a different note, I understand that integration of health and social care is to be focused on older people. I agree with that move and welcome the cabinet secretary’s commitment to the principle of applying that approach more generally to adult social care.
In the final moments remaining to me, I want to welcome the fact that, 10 months on and with a change of minister and a more robust approach from the cabinet secretary, it has been recognised that legislative underpinning is needed. That conversion from the position outlined in Shona Robison’s press release on 2 February is very welcome; indeed, such a move is necessary if we are to make the proposals work.
The issue is too important for us to fail. After all, the debate is ultimately all about people. It is about supporting and caring for our older people, providing that care, involving older people in shaping it, driving up standards and ensuring that we have care of the very best possible quality. Our social care system needs to be overhauled and today we are taking some welcome steps in that direction. However, we must continue to focus on the delivery of fairness, certainty and top-quality care for all Scotland’s people.
I move amendment S4M-01585.1, to insert at end:
“, and welcomes the Scottish Government’s acceptance of the need for legislative underpinning following the conclusions of the Expert Group on Future Options for Social Care established by Scottish Labour.”
09:41
I am pleased to take part in this debate following the Scottish Government's announcement earlier this week of its plans to integrate adult health and social care. We welcome that move as an important step towards improving care services for older people and having services that are developed locally in partnership with Government, the NHS, local authorities and others, led by clinical and social care professionals and tailored to meet the needs of local people and their families and carers.
We all know about the problems of securing quality and consistency in care for older people and the difficulties in finding them appropriate community provision after discharge from hospital, often as a result of the failure to sort out funding between local authorities and the NHS—the so-called cost shunting that goes on. Although things have undoubtedly improved in recent years, there is no room for complacency. Delayed discharge is creeping up again and the demand for care for older people is set to rise steadily as the number of frail elderly people increases.
In these difficult times, we have to make the best possible use of resources, human and financial, and all parties have come to realise that that can be achieved only through effective integration between the NHS and local authorities. This year, all parties had an election manifesto commitment to that effect, although each set out a different approach to achieving that goal. My party went into the election seeking to merge the health and social care budgets and integrate social care for older people into the general health budget under NHS control. Although that goes a step further than the current Government proposals, the decision in Highland to give adult social care powers to the NHS, with councils having responsibility for child community services, chimes well with our manifesto proposals.
As we know, the integrated resource framework model chosen by the SNP to develop systems for resources to follow the patient between partner organisations, with the intention of delivering care in the most appropriate setting for the patient, is being trialled in four different health board areas. We await the assessment of those trials with interest. The Scottish Government and Lord Sutherland favour the Highland model of lead commissioning, but the Royal College of Nursing, in particular, is flagging up difficulties in fully implementing it by the target date of next April. As she is much closer to the trial than I am, my colleague Mary Scanlon will deal with it in her speech.
Whatever model is used to achieve the integration of health and social care, the aim has to be better outcomes for patients, with improved local services that provide patient-centred care based on an assessment of individual needs and focused on helping more of them to live in their own homes rather than in a care home or hospital. However, in order to achieve that, we will need more input from social care professionals and clinicians into local service planning, and NHS boards and councils will have to be required to produce integrated budgets for older people's services, as proposed by the Government. Indeed, we are pleased with the proposals in that respect.
Attitudes have to change, too. We need strong leadership and co-operation between clinicians and social care professionals, who must put aside cultural differences and overcome the ingrained organisational practices that often get in the way of integrating and sharing services, such as segregated training and professional rivalry. I found the briefing paper from the Association of Directors of Social Work unhelpful in that regard. Such problems will need to be overcome by effective transition management if better integration is to be achieved.
The change fund has allowed the shift to community provision to begin. I agree that legislation will be needed to ensure the development of better local services for local people. The existing CHPs have become overly bureaucratic, and from their inception they have failed to engage clinicians, particularly at primary care level, as the cabinet secretary said, but also at secondary care level. They have also failed to bridge the gap between health and social care.
A radical overhaul is overdue—the British Medical Association made the point forcefully in its briefing paper. I welcome the proposed health and social care partnerships, which will be jointly accountable to the NHS and councils, as well as to the cabinet secretary, the local council leader and the public, for the delivery at local level of nationally agreed outcomes.
There is enormous enthusiasm for greater integration of health and social care for older people—from the RCN, carers organisations and Macmillan Cancer Support, for example. All those organisations are eager to become involved in helping to shape the change process and the new legislation, and it is important that such organisations are involved from the outset. I hope and am confident that the Government will welcome their input.
There is a fair wind behind the Government’s proposals for shifting the balance of care. I hope that the framework that is proposed for the delivery of nationally agreed outcomes will allow delivery mechanisms and structures that best suit local needs and priorities to be developed locally.
We are at the beginning of what could become an exciting journey of achievement in patient care, but a great deal remains to be done to change attitudes and working practices. It is very much work in progress, which we will follow with interest. We support the motion in the cabinet secretary’s name and the Labour Party’s amendment.
09:47
The final sentence of the Health and Sport Committee’s report to the Finance Committee on the health budget this year reads:
“The settlement for Health and Sport has been generous: it is beholden on all involved in these two sectors to demonstrate that in return they have placed quality and efficiency at the heart of their thinking.”
I am glad that that statement received unanimous, cross-party support at the Health and Sport Committee. It acknowledges not just the generous settlement but the more important point that how much money is put in does not necessarily dictate the quality of the outcomes. Today’s debate is all about ensuring that we get the quality outcomes that are essential.
Despite the generous settlement, we face financial and demographic challenges. By 2031, the number of people over 65 in Scottish society will have increased by 62 per cent, and every year over the next 10 years there will be an additional 10,000 people who are 75 or older, so it is clear that the Scottish Government is right to have a focus—although not an exclusive focus—on integration of health and social care for the elderly as we go forward.
If someone is to have the best possible life journey as they get older, they need to be supported in their own home, with community health interventions as appropriate. The worst journey would involve unplanned admissions to hospital, prolonged hospital stays, delayed discharge and admission to residential care at an earlier stage than might otherwise have been necessary. We can all agree on that.
As we drive change, we are right to acknowledge that structural change as an end in itself will not achieve what we want and will be a costly distraction. What we need is cultural transformation in health and social care, underpinned by structural change where appropriate.
That is why I welcome the statutory reform of community health partnerships, changing them into health and social care partnerships. We can see that that underpinning is necessary if we look at the Glasgow experience, where a pilot project did not work because people would not get out of their cultural silos. I am therefore glad that we are taking that direction.
We have talked about pooling budgets, but I hope that that actually happens. It is easy to talk about pooling and sharing budgets, but we must insist that it happens. I believe that the mechanism that we have will help to achieve that. In the change fund for older people, which is £300 million over four years, the mechanism is that not one penny can be spent unless it is agreed by local authorities, the NHS and the third sector. That is an excellent model to ensure that change is driven.
Ahead of the debate, we received various submissions from voluntary sector organisations. The Princess Royal Trust for Carers stated:
“We ask for your support to ensure that the impact of these changes for Scotland’s unpaid carers is fully recognised and that the needs of carers are a central focus in the development of the new integrated structures and the legislation which underpins this work.”
The trust wants to ensure that it is “directly involved” in the formation of the new legislation and the guidelines that will help to underpin it. I am sure that the cabinet secretary will be able to give reassurances on that. Given that 20 per cent of the change fund will be specifically for carers, it is clear that the Scottish Government is mindful of that issue.
In future, the environment for carers will become more challenging. I am delighted that the Government is tackling the challenge of self-directed support, which will change the cultural landscape of care at home. The changes will affect the individual’s choice and how money is spent to support them in their homes. The issue is how we ensure that there are quality care standards at home and how that approach fits into the Scottish Social Services Council’s qualifications framework. We are mindful of those challenges.
We are mindful of the issue of self-directed support, too. Does the member believe that self-directed support can apply to health services as well as to social care, given that some people who receive that support will enjoy services from both areas?
That is a reasonable point. People cannot work in silos in relation to self-directed support. We are talking about integration of services. We must tease out that issue as we make progress on the legislation, although we cannot take it as a given—we must test the evidence.
We have heard about cost-shunting issues. I believe that, in years to come, the fact that different institutions are being precious over their budgets will be seen as foolishly myopic. To understand that, we need only think about the elderly person who is at risk and who is not suitably supported in the community. It leads to greater overall costs if that person has an unplanned admission to, and a prolonged stay in, hospital. That is not the best use of our money or the best outcome for our elderly population.
My final point is on inspecting the care pathway and having an integrated care pathway for elderly people as they go through the care system. Perhaps in future, the health inspectorate and the care inspectorate will investigate not only care in hospitals at home and in residential accommodation, but—jointly, or perhaps as one organisation—the care pathway as people go through an integrated service. That might drive further change and reform.
09:53
Those who usually come to the chamber on a Thursday morning for a Donnybrook will be disappointed this morning, because there is a great deal of consensus. I certainly welcome the Scottish Government’s moves. I will repeat some of the themes that my deputy convener on the Health and Sport Committee, Bob Doris, has just spoken about. It must be recognised that the Government is trying to address an imposing and complicated problem. I believe that it is an extremely worthwhile cause.
Jackie Baillie referred to cost-shunting issues, as did the cabinet secretary earlier this week. As Jackie Baillie described it, there is pass the parcel between the national health service and local authorities. That is a good example of a serious failure of the current separated system, which all too often leaves elderly people with the short end of the stick.
Delaying elderly people in hospital beds at a cost of £2,000 a week when residential and nursing home services can cost a fraction of that is not only a blatant waste of funds but offensive to the high standards to which we hold our health service.
The integration of health and social care is a way in which to spend precious funding more effectively, and it should also be a way in which to provide higher-quality services to the elderly. As I said, it is an extremely worthwhile cause, but we all understand that it is not a cure-all for the issues that face the health and social care system as it applies to the elderly.
In 2002, the Parliament made the bold decision to provide free personal care for the elderly men and women of Scotland, and for nearly 10 years the Scottish Government, in one way or another, has paid the health and social care bills for nearly every Scot over the age of 65. However, as has been mentioned, much has changed in those 10 years. Scotland’s demographic has been ageing and the cost of providing people with that healthcare has nearly doubled to a staggering £370 million a year. At the same time, we have seen the economy crumble around us. Budgets across the board are on the chopping block and the personal care funding gap has grown to about £40 million a year.
So far, the Scottish Government has stepped in to plug the gap, but the reality of Scotland’s ageing population and the Government’s diminishing funds in these difficult economic times have put the sustainability of the system under question. Experts challenge us with warnings to Government. The Convention of Scottish Local Authorities, the independent budget review group, the Association of Directors of Social Work, the Centre for Public Policy for Regions and Lord Sutherland, who was the architect of free personal care, have all called into question the sustainability of the policy. Against that stark backdrop, those of us who support affordable, good-quality care for the elderly recognise that progress must be made and that the status quo is not an option. We also recognise that the integration of budgets is a step in a long but necessary journey, but that is not the only area in which we need integration in order to improve services.
The Health and Sport Committee recently produced our “Report on Inquiry into the Regulation of Care for Older People”, in which we welcome moves towards greater integration of health and social care, and with it, the integration of the regulatory regimes that oversee those services. In recommending a review of the national care standards, we believe that there is an opportunity to include
“the introduction of joint inspections of care pathways”,
which Bob Doris mentioned,
“including clinical care in the community and the inspection of social care for older people in ... acute services.”
The committee also recommends that the Scottish Government should consider establishing
“a single point of entry”
into the complaints procedure,
“with a view to greater integration in future.”
We all want to ensure the best outcomes for elderly people, but the integration and securing of care will be easier said than done. That is the challenge that the policy presents. However, I am sure that I speak for all members of the Health and Sport Committee when I say that we look forward to working with the Scottish Government to make progress in this challenging area and, through that, to keeping our focus on improving care for our elderly people in Scotland.
09:59
I thank the cabinet secretary for her speech and welcome the measures that she outlined. I was particularly pleased to hear her talk about giving people priority over organisations.
As has already been stated, Scotland faces huge demographic changes over the coming years, particularly with the 38 per cent increase in the 65 to 74-year-old population by 2031.
Already, £1.4 billion is spent on unplanned emergency admissions to hospital. Indeed, we know from clinicians, care managers and older people themselves that unplanned emergency admission to hospital is often distressing and leads to poorer health outcomes than might have been achieved by a package of primary and social care in the community, and lead commissioning can help us achieve that.
Will the member give way?
Already?
The member makes a very important point at the beginning of his speech when he asks what we can do at the moment to prevent emergency admissions, which cost us £1.4 billion. Does he agree that emergency planning for individuals who are receiving care is absolutely vital and that, without that, emergency admission is almost inevitable?
Some work is already being done to ensure that the number of emergency admissions is lowered.
Clearly, we should be focusing more on outcomes than on processes and looking for creative ways in which different levels of government can work together.
As a great man once said, we have “no monopoly on wisdom”, and that is why we should listen to what others have to say about the proposals. The chair of NHS Highland, Garry Coutts, said:
“I am convinced that staff will be much more able to organise services that best meet the needs of the people they are caring for if the artificial barriers between health and social care are broken down.”
The chief executive of NHS Tayside, Gerry Marr, said:
“The closer integration of social care and healthcare is the next step that we must take to ensure we can provide the best care for our older people into the future.”
Although the Association of Directors of Social Work has concerns about the move, its president, Andrew Lowe, said:
“We consider the announcement represents significant progress and we support the clear emphasis on making better use of joint resources.”
I know that there appears to be cross-party consensus about where we are heading—I will deal with the differences later on.
The ADSW already works closely with the NHS on many fronts and the approach is something that it can build on. As it says, it is the norm across Scotland for joint teams to operate in learning disability, mental health and addictions services. Joint service approaches in older people’s services are now being developed further as the result of the implementation of the change fund.
I am a former member of the south-east Glasgow community health and care partnership. I thoroughly enjoyed being a part of the partnership before its unfortunate and untimely demise. As the cabinet secretary knows, although there were difficulties, it managed to do to the best of its abilities what it was tasked with doing, and it enabled politicians, medical practitioners, social workers and, most important, members of the community to work together to deliver better outcomes for the people of the south-east of Glasgow. So, what happened to it? I believe that, although those at the ground level were keen and worked co-operatively, after initial difficulties and a lot of effort and commitment, the desire to hold on to power—and budgets—was too great for those higher up the food chain. I am not making a political attack; my comments are based on my experiences. As I was part of the executive committee that discussed the matter, I know that Glasgow City Council was not willing to devolve money to the CHCP to deliver services and was much more interested in protecting its social work silos. I doubt that that was untypical of councils and health boards across the country. Members should not just take my word for it, though. The BMA says that resource transfer to community health partnerships
“has been a source of tension between the NHS and councils.”
It has also said that
“the barriers that exist within and between health and social care need to be broken down and replaced with greater collaboration, both financial and cultural.”
I was delighted to hear the cabinet secretary say that what is important is not where the money comes from but how it is used. If that approach had been taken with regard to the practical application of the CHCPs, we would not be in our current situation.
At this stage in the process, there are a number of questions. Bob Doris mentioned the issues around carers. I congratulate the cabinet secretary on her positive comments on the third sector and carers in particular. Where do carers fit into the policy, and how will the Government ensure that carers and carers organisations are directly involved in the planning and delivery of the legislation and the new partnerships from the outset? As has been said, if we do not ensure that the carers are on board, it is hard to see how the approach will work.
The challenge for the Scottish Government, local authorities and health boards is to ensure that we deliver the changes that are needed to meet the challenges that we face now and in the years ahead. However, those changes need to be flexible in order to accommodate the differing needs of communities across the country. Close co-operation is vital, and joined up thinking is crucial, but a one-size-fits-all approach would be wrong. We need to get local authorities and health boards to work together and then give them the space to meet the needs of their patients or clients. That is why, faced with all the evidence and statements welcoming the integration of health and social care and a joined-up approach across all sectors of local government and stressing the need for flexibility, I do not support the Labour amendment. In my view, a national care service is not the answer to Scotland’s care challenges.
However, it is coming up to Christmas, so I will be more charitable than I normally am. I am honestly in no doubt that all members sincerely want Scotland to have a first-class health and social care system that is fit for the 21st century, that has the people at its heart, that is publicly accountable, that involves partnerships across all areas and levels of government—where that makes sense—and, most important, that delivers for the people of Scotland. It would be a very good sign if the Parliament sent a message as one, and I therefore ask the Labour Party to support the motion.
10:05
We have heard talk of consensus and working together. I understand why Jackie Baillie made the point that much of what is being looked at came from recommendations that were made in work that the Labour Party asked for, and why the cabinet secretary wants to take credit for what she proposes. However, fundamentally, the issue is how we can work together to make a lasting change that will benefit the people whom we represent. We all want to get in our own particular points about who said what, but I was disappointed by James Dornan’s conclusion, as he distorted what Jackie Baillie said. He said that the SNP would not support the Labour Party’s amendment because it looks for a statutory national service. I suggest that James Dornan should read Jackie Baillie’s amendment again, as that is not what it says.
One of the problems that we have with how the public sector works in Scotland is the length of time that it takes to change anything. In the Public Audit Committee, I have seen some of the problems that relate to entrenched attitudes and the difficulty of getting change. In listening to some of the speeches in the debate, I have reflected on the fact that it was 10 years ago that Malcolm Chisholm and I were appointed as health ministers, and one of the first things that we had to look at in our portfolio was how to get health and social work budgets to work together to bring forward a common agenda. We are still talking about the same problem 10 years later. That is not because the ministers in the previous Labour-led Administration had a lack of political will, and it is not a reflection of a lack of will by the ministers who have served since 2007; rather, it is a fact that there is a bureaucracy and there are vested interests that are very often resistant to change. We need to think about how we can think outside the box and beyond our own safety and comfort zones about how we will force change.
We can talk about delayed discharge statistics and statistics on how much things cost, but at the end of the day, it is human stories that count: the distress and anxiety that families feel when they see a loved one kept in hospital for longer than they have to be; families’ worries when they know that someone is relying on a vital care service and costs are shooting through the roof; and families’ worries about what will happen when the length of time for carers is cut.
Hugh Henry is quite right: this is about the direct human experience. However, he mentioned delayed discharges. We have to monitor outcomes somehow. Does he believe that it is reasonable to measure unplanned admissions and delayed discharges to see whether the approach is having an impact?
By all means. They are among a number of factors that have to be taken into account, but at the end of the day, we need to force the pace of change. That is why I support what the cabinet secretary said. Legislative underpinning is vital in achieving that.
Bob Doris referred to the Princess Royal Trust for Carers. It is not only the trust that has talked about what needs to be done—Macmillan Cancer Support and others have also done so.
The change fund is to be welcomed, and I seek a guarantee that it will be protected and will not be sliced in other directions as other pressures emerge. Bob Doris mentioned that 20 per cent of the fund is for carers, and I seek a guarantee that that element will be protected and will not be taken in other directions.
Change comes slowly—
Will the member take an intervention?
No, thank you—I have a couple of points to make before I finish.
The cabinet secretary made her announcement at the magnificent new Barrhead health and care centre in my constituency, which leads me to reflect on how long that welcome project has taken. The money for it was signed off in 2006, when Andy Kerr—who is no longer in the Parliament—was a minister. It was driven by local councillors Roy Garscadden and Danny Collins, who are no longer councillors in East Renfrewshire. That is how long it takes to deliver vital services, and we must find a way to change that and make things happen more quickly.
What we have discussed today is welcome, and it would be petty of the SNP to reject Jackie Baillie’s amendment at this stage.
Strathclyde Regional Council was much derided, but it delivered fantastic initiatives in health and social care and education. That Labour-dominated authority had officer/member working groups that brought together politicians from all parties with council officers and outside experts to come up with a range of reports on poverty, education, early years, social care and so on. We could consider replicating that model if we want change that everyone will buy into over the longer term: change that does not just come from the Government, but which has the support of every member in the Parliament.
10:12
I thank the cabinet secretary for bringing the debate to the chamber, and I declare an interest as a sitting Renfrewshire councillor. As many members who have been elected councillors will know, we are effectively at the coal face. As MSPs, we receive letters in our mailbags about social work cases, but as councillors, we receive all the information.
There is much that can be done, and nine times out of 10 I can find a solution to the situation with which I am presented. However, there are inevitably cases in which I feel that I just have to deal with the issue to the best of my abilities.
Hugh Henry is right to say that we must work together. I have enjoyed the consensus in the debate, because I know that, outside the chamber, people are concerned only about the service and its delivery, and what that means for their families and friends. The professionals who work in health and social care are also concerned about how they can deliver—there are many motivated professionals out there who want to make a difference and who want to deliver.
I like the idea that health and social care partnerships will be integrated and accountable, and it is important that we involve the public and the third sector. It would be good if there was a way in which service users could feed into the partnerships, perhaps through community planning groups. If someone uses a service, they will get involved and engaged only if they are gaining from that process and having some input from the other side.
We must look at the accountability of local authorities and elected members. It is very important that there is an accountable officer in the partnerships, but it is also important for the leader of the council to take an active role. When I was working in my own area for Renfrewshire Council, it was ably led by Councillor Derek Mackay. He is now Minister Mackay, and I wish my good friend all the best for the future. I am extremely proud of everything that he has achieved, and I know that he is the man for the job. I will go on to a best man speech in a minute.
As council leader, Derek Mackay was very motivated by the idea of getting involved with the community health partnerships. The CHPs in our area worked because of focus and direction, which came from a political level as well.
The current social work model works well. Nationally, social work deals with a diverse group of 650,000 adults, who feel that they are treated with dignity and respect. We need to remember that social work is based locally, in local authorities, which deal with cases day to day. Authorities also deal with housing and other issues for adults and young people. Social work deals with difficult and challenging cases and it is important for us to move things forward.
Social work works well, but does George Adam agree that it could do better? I do not support the tone of the ADSW’s briefing, but I think that the ADSW recognises that, although social work does a good job, it could and should do better.
I agree that everyone should challenge themselves and do better all the time. All that I add is that a lot of good, radical work is being done in social work departments the length and breadth of the country. It is important that we keep focused and remember that, but I agree that social work departments can achieve a lot more, as we all can in day-to-day life, too.
It is important that older people in our communities are supported to remain in our communities. In my time as an elected member, I have noticed that it is better for families and individuals to be together in their areas. Our area has had various housing schemes such as high flats with social areas where older people can congregate, so that people can stay together all the time. That has been good and successful, to the extent that people have become almost clannish and allow into their own wee area no one other than people in their own block.
The agreed national outcomes are important and involve local authorities and the NHS working together in a focused partnership. In relation to partnership, no one will be surprised that I will talk about carers. I emphasise that we must ensure that carers are equal partners in the new organisations. We must not lose sight of the fact that husbands and wives look after their life partners in older years as time moves on.
The cabinet secretary is correct to say that much has been achieved, but we must go much further. As elected members, we all know people in our communities who use the services that we are discussing. They are the important people in the debate. Health and social work professionals throughout Scotland must deliver the agreed national outcomes, and all elected members must remain focused on that. That will be difficult, but nothing that is worth while is not difficult. It is important to get the system correct.
The debate has been consensual and is extremely important to me and other members. All that we have to do now is stay focused and deliver what is needed.
10:18
I welcome the opportunity to discuss and support integrated health and social care. As Nanette Milne said, we support the Government’s motion and Labour’s amendment. Until James Dornan stood up, I had planned to say that, unusually, I agreed with all the speeches, but he spoiled that line.
Jackie Baillie outlined Labour’s approach, which we have supported. The one inconsistency that she did not mention is that the cost of self-funded residential care can vary from £460 a week to more than £900 a week, depending on where somebody lives. I feel strongly about that issue, which we could go on about.
It is worth looking at how integrated care has been dealt with in the Parliament’s lifetime and particularly at the attitude that Hugh Henry highlighted. In the Parliament’s first eight years, the Labour-Liberal Scottish Executive introduced several initiatives—all of which we supported—including the joint future group.
I found a letter to all health boards, councils, the Convention of Scottish Local Authorities, directors of social work and many more from Malcolm Chisholm when he was the Minister for Health and Community Care in July 2002. He wrote to promote community health partnerships and said that they would
“seek to bridge the divide that has existed for too long between primary and secondary care and between health and social care.”
Today, nine and a half years later, we have a Government motion—which we support—which states that
“the integration of services needs to be improved to deliver better health and social care services.”
I acknowledge that some progress has been made since 2002, but it is not enough. The evidence that the Health and Community Care Committee took on the Community Care and Health (Scotland) Bill in the first session of Parliament was overwhelmingly in favour of having one organisation and one budget for care for the elderly, although there was no unanimity on what that single authority should be. At that time, up to 3,000 people were waiting in hospitals for councils to fund home care or residential care. Those people had delayed discharges or were bedblockers through no fault of their own.
There are also examples, which Richard Simpson mentions quite often, of health and social care working together that have had to be abandoned.
Millions of pounds have been spent over the years on initiatives to tackle bedblocking, and we also supported those initiatives.
In 2004, we got the community health partnerships, whose main purpose was to integrate NHS and social care. Audit Scotland criticised the CHPs for their “duplication” of
“existing health and social care partnership arrangements.”
Not only did they not achieve integration, but it was found that any attempt to integrate often resulted in a duplication of existing services.
That brings me to the £70 million change fund, which, again, we support, some of which will be used for health and social care partnerships to implement local plans for better integration of their services. Today, we hear that the community health partnerships are being replaced by new health and social care partnerships that will be jointly accountable to NHS boards and local authorities. The CHPs should have been doing that work since 2004. Excuse my frustration, but we have been here before.
The Audit Scotland report “Overview of the NHS in Scotland’s performance 2010-112”, which was published today, states:
“Improvements in partnership working are needed to deliver more efficient and effective services. ... joint working could be improved by tackling differences in organisational cultures”—
which Hugh Henry mentioned—and
“planning and performance and financial management arrangements.”
That was highlighted in evidence as far back as 1999-2000, yet today we have an Audit Scotland report highlighting the same problem.
I trust that, within the programme for improvement outlined by the cabinet secretary, organisational cultures will no longer stand in the way of patient care and support. I agree with Nanette Milne—I think that Dennis Robertson alluded to this, too—that some of the briefing papers for the debate have been considerably unhelpful.
Against that background, I commend NHS Highland for taking the courageous step of becoming the lead agency for care of the elderly, working with Highland Council, which will become the lead agency for children’s services. I have already found that the single-agency model is very helpful for my constituents.
Why do we need the integration of health and social work? As Malcolm Chisholm said back in 2002, it will
“enable health and social care ... to look at the whole picture”.
In a country of 5 million, it is unacceptable to have people working in silos, allowing patients and others to be marginalised behind bureaucracy, budgets and a dogged refusal to put the needs of ordinary people before organisational cultures.
I support the Highland lead-agency model to integrate home carers into the NHS. I hope that the home care workforce to be redeployed from the council to the NHS will be given more training and support and will be better co-ordinated with other health professionals in their team.
The Highland process of change has faced many challenges along the way, with NHS staff moving to council employment and council staff moving to the NHS. There are challenges ahead, but we should all commend what Highland Council and NHS Highland are doing.
10:24
It is always a pleasure to follow my good friend Mary Scanlon. [Interruption.] Anything George Adam can do, I can do better.
I welcome this debate on the integration of health and social care. Social care is pivotal to the care of all who require the service. A social work department in any council deals with the range of needs across a wide remit and must react to meet those needs. Many improvements have been achieved in adult health and social care services, but I agree that the integration of services to Scotland’s older people needs to be improved to deliver better health and social care services. We need to continue to reduce the number of delayed discharges because that impacts directly on the health and care experience of older citizens.
For too long, there has been a silo mentality in social work and the health service. Each blames the other for the delays that they both cause, and each watches its own budget too closely. They now have to learn to work together to release the potential that has always been there to improve the quality of care for our elderly citizens. I read with interest the parliamentary briefing on social care and health integration from the Association of Directors of Social Work. It says:
“We acknowledge that there are things we could do better and there are issues that politicians are concerned about and we are keen to assist Government in addressing this.”
It then goes on to say why social work should stay in its silo. Frankly, like Nanette Milne, I was not impressed by the submission, which continually states “We must keep”. Yes, social work can keep, but it must also work with other agencies to improve the quality of care in our society. We must put an end to cost shunting between the NHS and local authorities. Too often, that ends up with older people being delayed in hospital longer than they should be and not getting the standards of care that they deserve.
Like many others, I have personal experience of the delay that can arise when a family member is unable to go home because they have to wait for the hospital and local social work to agree on the best action. I will not go into that case because it is personal. However, I will talk about the case of one of my constituents, who was stuck in hospital in my region. We all have such cases and Jackie Baillie mentioned one. My constituent’s relation, Mr John Love, who stays in Motherwell, contacted me to gain my support. Mr Love had tried without success to resolve his relation’s problem. Mr Love was going between the hospital and social work and getting nowhere. I was lucky enough to know who to phone in the social work department and, within a few hours, Mr Love was able to talk to the people who could really help him. I was happy with the outcome.
If we can use common sense and working together to solve one constituent’s problem, we can solve most of the problems that face social work in local hospitals. We cannot go on any longer suggesting that the problem cannot be solved. We cannot hide in our local silos and suggest that another department should bear the costs. I therefore welcome the health and social care partnerships that will replace the community health partnerships. The new partnerships should be accountable to ministers, leaders of local authorities, MSPs, councillors and the public for delivering new nationally agreed outcomes. Reform is vital to ensure the long-term sustainability of adult care in Scotland. We need closer working.
I welcome the comments of the Princess Royal Trust for Carers about the proposal. I agree with it that
“Carers play a crucial role in the delivery of health and social care in Scotland.”
I note that the Princess Royal Trust for Carers has tabled a number of questions in its submission. I am sure that the cabinet secretary will respond to them in due course.
I also pay tribute to the work that is done by various organisations that deal with patients who have cancer. The submission from Macmillan Cancer Support details what we can do to help people who have cancer and to improve services if we start to come out of our silos: we can reduce avoidable emergency admissions to hospital and the length of stay in hospital, improve follow-up, support patients to return to or stay in work, and support patients to die at home rather than in hospital.
I welcome also most of the comments from the Royal College of Nursing, which looks forward to working with the Government to progress the proposal. I welcome the proposal.
10:30
The cabinet secretary is to be commended for her determination to bring about transformational change in the delivery of health and social care. I have listened with interest to the detail that she has presented this morning.
The contributions from Hugh Henry and Mary Scanlon served to remind us all just how difficult it is to achieve change. There seems to be so much inertia in the system. Leadership nationally and locally will be essential to taking the proposal forward.
I am pleased that the cabinet secretary has decided not to create a new statutory organisation, separate from the NHS and local authorities, and her acknowledgement that that approach would have created further barriers to integration. Her decision instead to build on community health partnerships is a commonsense approach to the reform that is needed.
Who actually suggested that separate super-quango? It was not the Labour Party.
The Labour Party is on shifting ground on that matter.
Only the Lib Dems portrayed it as such.
All along we have advocated that sort of commonsense approach to the reform that is needed. We have opposed the centralisation of care into a single national care service.
As an aside, I draw Kenny MacAskill’s attention to what Nicola Sturgeon said earlier this week:
“We are keen to avoid the pitfalls that can accompany centrally directed, large-scale structural reorganisation”.
It is not too late for Kenny MacAskill to ditch his centrally directed, large-scale reorganisation of the police service, but that is for another day.
As Scotland’s population ages, it becomes increasingly important to ensure that care is provided in a joined-up and personalised way that can respond effectively to local needs. Liberal Democrats are committed to enabling older and disabled people to live independently and with dignity in their own homes for as long as possible. Bridging the gap between health and social care is essential if we are to make that a reality. This is an opportunity to put people not process at the heart of health and social care services.
Liberal Democrats believe that health care should be delivered as locally as possible. Despite much rhetoric on shifting the balance of care, most spending is still directed towards acute services. Often, people are being cared for in hospitals miles from their homes when they would receive better and more cost-effective care closer to home in the community.
More than 60 per cent of Scottish Government spending on care for older people is still on care in hospitals and care homes and almost a third is spent on emergency or non-elective hospital admissions. Only 6.7 per cent of the budget is allocated to providing care at home. Earlier this year, NHS Grampian’s medical director warned that, unless health services, local authorities and individuals work together, we would have to build a new, 600-bed hospital in Scotland every year from now to be able to cope. In addition, he reckoned that every person leaving school would have to find a job in the NHS in order for us to provide enough care for the elderly.
As well as being better for the individual, supporting an older person to retain their independence is much cheaper. Reducing delayed discharge and unplanned admissions to hospital and increasing the number of older people who live at home rather than in a care home or hospital are not new ideas, but it is proving difficult to achieve the switch in resource. The reality of what has happened with the change fund demonstrates that good intentions are not enough.
Will the member give way?
I have quite a lot to get through.
We believe that the principle behind the creation of community health partnerships remains sound and that the CHPs are the correct vehicle to integrate the provision of health and social care in the community. They can deliver improved health outcomes locally. However, as we all know from experience and of course from the Audit Scotland report, the outcomes for patients across Scotland are too varied at the moment. CHPs are extremely variable in quality. Some are little more than large and unwieldy talking shops and, in other areas, the relevant health boards and local authorities have failed to co-operate. In many areas, that has led to general practitioners completely disengaging from CHPs.
I share the cabinet secretary’s ambition that the reform should be transformational and I agree that nationally agreed outcomes, integrated budgets and leadership are the foundations for change. However, it is important that local responsiveness is not lost, and I welcome the Government’s recognition of that point, too. We need to treat people as partners in their care. Social care services should build people’s capabilities and wellness in older age rather than react to crisis when it is reached.
The RCN is right to point out the need for shared purpose and mutual respect as the reform rolls out.
Only a couple of weeks ago, we debated the role of carers. Much in that debate should inform the cabinet secretary’s work on the reform that we are discussing now.
The Princess Royal Trust for Carers has asked that, from the outset, carers and carers organisations be directly involved in shaping the proposed new care bill and any supporting guidance. It rightly points out that we cannot focus on tackling challenges such as delayed discharge and shifting the balance of care without ensuring that the needs and contribution of unpaid carers sit at the heart of plans to bring services closer together. Carers organisations have a crucial role to play in the process.
How do we ensure that GPs are returned to the heart of local healthcare delivery? They have largely turned their backs on the CHPs—the BMA called them “bureaucratic monoliths”—but, if health and care in the community are to be joined up properly, it is vital that the biggest providers of healthcare in the community be fully involved.
Will the Scottish Government include carer-specific outcomes in the national outcomes for the new partnerships and, through those, in single outcome agreements? Are single outcome agreements the best way to measure progress? How do the reforms fit with the proposed bill for self-directed care?
There are many questions to be answered. This is simply the start of a long process. It is essential that we get it right. Scottish Liberal Democrats will work with the Government on this essential reform to get the best possible outcome.
10:36
I congratulate the cabinet secretary on her positive comments on the integration of health and social care. She said that we were not starting off with a blank sheet. That is correct, because there are already many examples in our communities of positive integrated approaches to health and social care. I will come back to that point in a minute.
I also congratulate the convener and deputy convener of the Health and Sport Committee on the tone of their comments on integrated services. They are to be welcomed.
While I am in a congratulatory spirit, I thank Jackie Baillie for highlighting the fact that the majority of our older people—I think that she said 90 per cent of them—do not require care. However, we must ensure that, when they require care, the facilities and resources are available to provide it.
I welcome the briefing from the Princess Royal Trust for Carers and the questions that it poses to the cabinet secretary. I am sure that she is listening to the questions that are being asked and to the other briefings that we have received. Macmillan Cancer Support provides an example of an existing joint approach to the provision of care between the health service, local authorities and the third sector. It provided some excellent examples in its briefing.
I commend the ADSW for the good work that it does. Being a former social worker and having spent 32 years in the social care sector, I am well aware of the complexity of the work in social work departments. However, the tone of the ADSW briefing was less than desirable for this debate.
I agree with Nanette Milne, Richard Lyle and Mary Scanlon that, if we are going to work in partnership, we need to be more positive. We cannot afford to remain in our silos and try to be autonomous.
I will give a good example of what I consider to be integration that works. It concerns the work that Optometry Scotland does with the Royal National Institute of Blind People and the third and independent sectors. The SNP Government provided money from the Scottish eye care fund to enable community optometrists to start to deliver much improved services in the community. They now have the facility in their community optometry practices to take electronic images to send direct to ophthalmic services, thereby obviating the need for the patient to go to an ophthalmology out-patient appointment. That approach is welcome. I commend that model, because it encourages patients, when they have a sensory problem, to go to their local optometry practice rather than to their GP or to opthalmic services in hospitals. That is definitely the right approach, as early intervention and prevention are the way forward in an integrated service.
The debate has been consensual and it has been welcome to hear everyone’s comments. I am sure that when the cabinet secretary dips her hand into her Christmas stocking this year, she will pull out the Official Report, which will probably just say, “Consensual.”
10:40
This week, the Cabinet Secretary for Health, Wellbeing and Cities Strategy announced a radical rebranding of community health partnerships, which will now be health and social care partnerships, on a visit to open Barrhead’s new health and care centre. In the minister’s words, the reforms
“will deliver a system that is effectively integrated, leading to better outcomes for older people and better use of resources.”
How will that suddenly be achieved through health and social care partnerships, and why could it not be achieved through community health partnerships?
Ms Sturgeon’s announcement on Monday indicates that the key elements of the new system will make health and social care partnerships accountable to local authorities and ministers, will create new or different job opportunities in the community—at a time when the SNP Government is cutting nurses from the NHS—and will ensure that NHS boards and local authorities will be required to produce integrated budgets, which will bring an end to the cost shunting that currently takes place.
Accountability has always been an issue in the integration of health and social care. Who will be responsible when staff, service users or the public make a complaint about the service?
Another aspect of accountability is the regulation of health and social care professionals. Will that be in the remit of the care inspectorate or that of health boards? There also needs to be accountability for the finances of health and social care partnerships. If integrated budgets are to end cost shunting, will the resources come from the change fund, local authorities or health boards? What will be the contribution from each body involved?
As local authorities and health boards have had their budgets cut, can the minister assure the Parliament that the change fund will not be used to plug the gaps that have been created by underfunding by the Government? I have raised that issue previously.
In recent months, care homes have closed after the parent company has entered administration, leaving many of our elderly people unsure about how they will be looked after. Therefore, not only must we regulate the financial accountability of health and social care partnerships, but there must be greater financial regulation of all social care organisations.
The integration of health and social care cannot be fully achieved without input from the third sector and carers. What measures will be in place to engage fully with the third sector on how to maximise the integration most effectively? When legislation is brought before the Parliament on integration, I hope and have no doubt that Ms Sturgeon and the Government will fully consult the third sector.
A recent survey shows that senior executives in local authorities believe that the third sector should be more involved in delivering services, with 86 per cent believing that the third sector could provide services as effectively as councils. That shows how important a role the third sector can play in shaping our services and our legislation.
It is also vital that carers be given a greater say in how services are run locally and nationally. We all agree that Scotland could not survive without those selfless people and that our NHS would be bankrupt without the fantastic care and support that they provide, so we must utilise their experience and ideas to help to deliver more integrated services that join up the dots between health and social care.
A key element of the health and social care bill that is to be introduced will be to strengthen the role of clinicians and social care professionals in the planning of services for our elderly. That can be achieved only through competent leadership from the Government, local authorities and health boards that creates a shared purpose between the professionals, as well as mutual trust and respect.
One of the biggest criticisms of CHPs came from health and social care professionals who found that they could not work together or that their skills were seen as less important than those of others. In other words, there was a lack of respect between the professions, even though their purposes are very connected.
In fact, that criticism has been highlighted by GPs since the inception of CHPs. Brian Keighley, the chairman of BMA Scotland, recently said:
“The failure of CHPs has been highlighted by GPs since their introduction in Scotland in 2004 and more recently by Audit Scotland. They have become bureaucratic structures, caught up in their own internal processes rather than influencing planning, funding and development of local services to meet patient needs. It has been widely accepted that they have failed to bridge the gap between health and social care.”
Dr Keighley added that, for the reforms to succeed, it was essential to involve clinicians from secondary and primary care.
I would like to highlight two final issues. The first is the variation in charges for services implemented by local authorities, and the fact that that adds to the many existing barriers to integration that the health secretary wishes to remove. The other relates to the comments made by the Royal College of Nursing on self-directed support. It has expressed concern that self-directed support will be introduced in advance of a national debate on whether that is the best way of allocating health services.
10:46
It was all going so well! Before I was elected, I used to coach school debating teams. The kids used to say to me, “I want to turn up at the debate with a pre-written speech.” I offered them two pieces of advice. The first was, “Don’t.” The second was, “If you do, be flexible enough to change the tone of your speech if the tone of the debate does not match what you prepared for.” I now extend that advice to Mary Fee.
The submission from the Association of Directors of Social Work was unfortunate. The message that we should send back to the ADSW is that the proposals represent an opportunity, not a threat, and that it can work with us to deliver an integrated service. I hope that it will choose to do so.
I welcome the framework’s focus on outcomes. All too often, in politics in general, we get hung up on input measures. I have an example of that from my experience as a councillor in Aberdeen. The learning disability budgets there were focused on what was spent on the packages, and people were being provided with very expensive packages of support that were not necessarily appropriate to their needs. Indeed, it was pointed out to us that if Birmingham City Council, which had a learning disability budget of £50 million, had spent the same amount per head as Aberdeen City Council was doing, its budget would have been £85 million. The crucial factor, however, was that the outcomes were not up to standard. Change and reform were therefore necessary. We must ensure that we reform and transform services.
Mr McDonald has given us a good example. Some bureaucrats prefer to focus on packages rather than on outcomes. Does he agree that some of the new learning disability packages being delivered in Aberdeen by organisations such as Cornerstone are much more outcome based?
Indeed I do. The third sector will have a crucial role to play in the integration of social care and health, and I shall say more about that later.
I have said before that it is incumbent on us to highlight best practice where it exists and bring examples of it to the chamber. It is all very well for us to talk about what is going wrong and what could be done better—we might hear more of that later—but we also have a duty to highlight examples of good practice. I have spoken here in the past about Rosewell house and Smithfield court in Aberdeen. They are good examples of places in which the health service and the social care department are working closely together to deliver services for elderly people.
Another example of good practice in Aberdeenshire is the Old Mart community resource centre in Maud, which provides a multi-agency support network involving health, council and third sector services. A range of services is delivered by health visitors, community nurses, physiotherapists, mental health teams and home care support, and the GP practice delivers a twice-weekly surgery. That is an example of a number of sectors coming together to deliver. I believe that the framework that will be established will enhance provision and provide opportunities to roll it out further.
I welcome the fact that the debate and the Government’s agenda will address some of the issues that the audit of community health partnerships identified. Although I am soon to be a former member of the Public Audit Committee, depending on how the vote goes at decision time today, I took part in committee discussions on the community health partnership audit that made it clear that issues needed to be addressed. Indeed, one of the first recommendations of that audit is that the Scottish Government should
“work with NHS boards and councils to undertake a fundamental review of the various partnership arrangements for health and social care in Scotland to ensure that they are efficient and effective and add value”.
I welcome the fact that the Government has clearly grasped that thistle and will introduce legislation, as outlined by the cabinet secretary.
We should be aware, however, that there are often gaps in provision. One of the glaring gaps in the Grampian area is around advocacy, particularly mental health advocacy. My colleague Councillor Jim Kiddie, the chair of social care and wellbeing in Aberdeen City Council, has pushed very hard over many years to get NHS Grampian to advance advocacy services. Some funding has been unlocked—£75,000 over a three-year period—but the problem is that that is non-recurring expenditure and it will not necessarily lead to properly planned and resourced advocacy. One of the key points about such advocacy for mental health sufferers is that it can save substantial amounts of money in other areas. I hope that when the cabinet secretary looks at the framework in general she will take a look at how advocacy services can fit within it to ensure that we deliver appropriate advocacy across the nation, particularly for people who have mental health problems.
10:52
I will start by putting on my hat as convener of the cross-party group on older people, which I think is the longest running cross-party group. As members can imagine, the subject of integrated care comes up constantly at our meetings and has much exercised us in our discussions, so I welcome the debate. The group had a meeting yesterday at which there was excellent discussion of the issue, as others who were there have said.
Although it is unfortunate that Mary Fee referred to supposed cutbacks in the number of nurses, the debate has otherwise been constructive and members have focused on improvements and reform, regardless of our political differences. As Jackie Baillie said, the issue is people and we should not forget that.
I have long questioned the community health partnership situation in Glasgow, and other Glasgow MSPs have referred to it, too. My concerns in that regard are well documented, so I will not reiterate them, but I will give an example of what happened to one of my constituents. I am sure that other members can talk about similar examples from their constituencies. An elderly gentleman was taken into hospital and it was decided while he was there that, because care services could not be provided for him, he could not go back to his home and should go into a care home. The family and others duly rallied round and looked for a suitable care home near them that met the gentleman’s needs, but it took months to find a suitable one. Not even a letter from the doctor, stating that the man’s health was deteriorating while he was in hospital, helped in getting the local authority to reach a decision on finding him a place in a care home.
Last week, Richard Simpson referred to a charter for whistleblowers. I found out that Glasgow City Council had a moratorium—or, I should say, ran a quota—on admissions to care homes every month only because someone in the health service told me about it. It is really important that we look at integrated care services and I entirely agree with Hugh Henry, who made an excellent speech, and other members that the biggest challenge that we face with the proposed health and social care partnerships is getting rid of the attitudes at the top. People at the bottom desperately want to help and integrate social care and hospital services but the problem lies with those at the top. The various partners have to work together because we simply cannot allow people to languish in hospital; that is costing the health board a fortune and it is happening only because some local authority wants to save money from its budget. Who is suffering in all this?
I am sure that the member agrees that the issue with earlier discharges is not just the cost of keeping patients in hospital, but the quality of care for individuals when they go back into the community.
Absolutely. Indeed, in the case that I highlighted, the doctor wrote a letter saying that the health of the man in question was deteriorating in hospital. However, if we can bring budgets together, we can secure the best for patients and older people. Far too much empire building is going on in the NHS, local authorities, social work and so on and, as Hugh Henry and others have pointed out, the people at the bottom are suffering as a result. I have cited one particular case, but I am sure that members can mention many others.
I agree with most of those who have spoken that the Association of Directors of Social Work’s briefing is most unhelpful. I hope that the ADSW will get round the table and share its concerns. I am sure that the cabinet secretary has met its representatives and that it will come to the table and work in partnership.
As others have pointed out, we need legislation to ensure that the reforms are carried out. That will not happen overnight—this is not some magic wand—but, although it might take some time, we desperately need to make the approach work, not just for the people whom we represent but for all our sakes. We should give our all to ensure that people such as the gentleman I mentioned do not languish in hospital; that doctors do not have to keep writing letters to local authorities or social work or social care departments; and that what we do in here is for the good of the people we represent, not for social work departments, local authorities or health boards.
I am pleased to have been involved in this debate on the reforms. I congratulate the cabinet secretary on what she has done and look forward to seeing what she—and indeed all of us—can achieve with this. The job will be hard but we have to get it done for everyone’s sake.
10:58
One of the great strengths of the Scottish NHS compared with the English health service this century has been its tendency to progress through evolution instead of structural upheaval and we have another fine example of that before us. I welcome the proposed development of CHPs into health and social care partnerships and the focus on “nationally agreed outcomes”,
“clinical and care professional leadership”
and integration, especially the integration of budgets.
As other speakers have emphasised, the prize in all this is achieving the shift in the balance of care required by demographics as well as improving the quality of care. The prerequisite in that respect is better working together, not only between health and social care without the perverse incentives and “cost-shunting” referred to in the motion but—and we must not forget this—between community clinicians and specialist hospital clinicians. After all, that was part of the drive behind the establishment of the CHPs in the first place.
I am very well aware that I and others were making many of these comments seven years ago when CHPs were set up—and, indeed, nine years ago, when the Community Care and Health (Scotland) Act 2002 was being considered. I thank Mary Scanlon for reminding us of that, although I am sorry to say that I was not in the chamber at that moment.
There has been progress since then but, in retrospect and having watched developments over the past few years, I make three observations. First, there was not enough prescription on pooled budgets in the legislation. Secondly, I do not think that there was enough autonomy, including budgetary autonomy, for community health partnerships. Thirdly, I do not think that there was enough clinical leadership in practice in community health partnerships, although when CHPs were set up it was certainly the intention that there should be clinical leadership.
Budgets will be central to what is proposed. As some members will remember, there was provision in the Community Care and Health (Scotland) Act 2002 for facilitated pooled budgets, but in practice very few areas have taken them up. I assume that the forthcoming legislation will require pooled budgets to be set up. There are a lot of questions about how the budgets will operate in practice. A difference between what is proposed today and what the Arbuthnott report proposed is that budgets will be subject to local decision making; I understand that Arbuthnott suggested that they should be distributed centrally, on the basis of a funding formula that is similar to the one that applies to health boards—or indeed the one that applies to local authorities. I do not have particularly strong views one way or another, but if we are to have local decision making it is clear that questions will be asked about how that works in practice, because if local authorities or health boards can adjust their contributions each year there could still be cost shunting. I presume that the matter can be sorted, through legislation or guidance.
We must ensure that we get as much of older people’s services as possible into the community health and social care partnerships. Indeed, as far as possible, we should get all older people’s services into the new partnerships, including geriatric beds in NHS hospitals—I am not sure that that is still the correct terminology. I accept that the intention is to start with older people, but it is clear that the more that we can get other care-group budgets and perhaps specific disease budgets into the health and social care partnerships the better, in terms of shifting the balance of care.
As I said, and as the BMA briefing reminded us, greater integration of community and hospital services is crucial for the health and social care partnerships, as it was in the context of the setting up of CHPs in the first place. In preparation for my speech, I looked into the archives last night and found a speech that I made to the NHS Confederation, which is a United Kingdom body, on 25 June 2003. I was speaking to mainly English health leaders, who thought that Scotland was in the stone age at the time, and I had to explain what we were trying to do. I said:
“Tomorrow in our Health Reform Bill we shall be establishing Community Health Partnerships, which will empower frontline staff in the community and give them the resources and flexibility to deliver services in new ways and bring community and specialist hospital staff together to design services for patients in a way which ensures their journey of care across the NHS is smooth, integrated and effectively managed.”
I am sure that that is still our objective, even though it has not entirely worked out in that way—although as we look across the border to the NHS in England I suppose that we might ask who is in the stone age now.
As the motion emphasised, clinical and care professional leadership is fundamental. That was the intention behind CHPs in the first place, but mechanisms must be established to ensure that such leadership happens in practice.
The focus on national outcomes is absolutely right, but along with that there must be local flexibility and local empowerment, so the forthcoming legislation will have to establish the balance. I remember debates on the issue when community health partnerships were set up. In general, the cabinet secretary has got the balance right and I commend her proposals.
11:04
I have worked in the NHS and in social care, so the question of how to achieve closer working between health and local authority social work is familiar to me, as it must be to everyone who has worked in the sectors in the past 20-odd years.
I share Malcolm Chisholm’s and Mary Scanlon’s frustration. We have been discussing the issue for at least 20 years, right back to the introduction of care in the community. From joint futures through to local healthcare co-operatives and community health partnerships, there have been many names for the approach and a variety of structural arrangements, but the common hope has always been that in one way or another the differences and separations between agencies could be overcome sufficiently to enable service users to access the much-wished-for seamless service. The fact that we are still talking about the issue is enough to tell us that that ambition has never quite been achieved.
That is not to say that there has not been progress. There are superb examples of integration that has delivered significant improvements for service users. We have heard several examples of that already, and I add one from my area—the integrated learning disability service that is delivered jointly by NHS Lanarkshire and South Lanarkshire Council. However, the reality is that the examples of excellence are often driven by enthusiastic and committed individuals and teams, rather than emerging from an organisational culture that prioritises consistent integration across the full range of services.
Without a clear statutory underpinning, genuinely integrated services have remained an option rather than an essential. That means that the good examples are too often isolated rather than mainstreamed and that service users still end up on the receiving end of failures in communication, knowledge and understanding between agencies that fall far below the exemplar standards of integration that we all want. We have heard several examples of that. That is why, although I am happy to praise the council and the NHS board in my constituency when they work together as they should, my constituency case load contains plenty of examples of people who have been let down by services on which they rely because staff in one agency have not spoken to or shared information with staff in another or—worse—because staff in different departments of the same organisation have not communicated properly. I am sure that members will be familiar with that scenario. I can see lots of heads nodding.
Do not get me wrong—I do not blame staff. When there is a lack of a clear and shared understanding within and between organisations about what integration means and what it is intended to achieve, it is all the harder for individual staff to fully meet service users’ needs. I therefore believe that the Scottish Government’s plans, as set out by the cabinet secretary, will be welcomed by not only service users and their representatives across Scotland, but people working in health and social care, notwithstanding the ADSW briefing.
I pay tribute to my constituent Robert Anderson, who runs the Lanarkshire Carers Network and whom most members from Lanarkshire will know. He has been a formidable campaigner for carers and, in turn, has changed policy and informed me in my quest to support my constituents, as he has done for other members. Campaigners such as Robert Anderson deserve our thanks and, importantly, our support.
The proposals achieve a good balance between setting down the specifics of principles, structure, resources and accountability and enabling local health and social care partnerships to respond flexibly to local circumstances and needs. From my experience of having been a member of staff in the NHS and in local authority social care, I believe that staff will welcome that firmness and clarity of purpose, which will empower them to do what it takes to achieve the best outcomes for their patients and clients. Setting out clear requirements and duties, far from constraining individual staff, frees them to use their professional skills creatively in the context of that clear vision for integrated care.
The proposals on structural change also achieve a good balance. We are neither throwing the baby out with the bath water nor inventing brand new organisations; we are keeping what works in the existing structures and making the changes that need to happen now to make the vision a reality and to deliver genuinely integrated care once and for all.
We have already heard that the growing number of older people in the Scottish population means that we can delay changes no longer. We need to ensure that genuinely integrated care happens properly and happens now. Older people will not be the only ones who benefit from the improvements that the agenda will bring about. Everyone who, for whatever reason, relies on NHS or social care services, or a combination of the two, to help them in their daily lives needs us to make the changes and will be better off as a result. That is why I support the cabinet secretary and the Scottish Government in their aspirations for a quality service.
We turn to the closing speeches. I remind all members that, if they participated in the debate, they should be in the chamber for the closing speeches. We have a little time in hand for interventions if members want to take them. I call Jackson Carlaw, who has approximately six minutes.
11:10
Thank you, Presiding Officer. If you had told me that I had a little time in hand in any other debate, I would have been delighted, but I am bewildered as to how I will fill in the time with my summation this morning, because to a large extent I am inclined to say, “Much of all of the above”, and then sit down.
I start on a consensual note by entirely agreeing with Malcolm Chisholm, who said that, after 13 years of Labour, the NHS in England is struggling to emerge from the stone age. At least, I think that that is the import of what he was trying to say.
As the member well knows, I was referring to the current proposals of the current Government in London.
Oh dear. There was me being consensual, too. However, let me also note the blushing pride with which Malcolm Chisholm acknowledged all the progress that has been made by the SNP in the past few years. I am sure that there is a consensus on that.
I come bearing gifts, because I can say to Jackie Baillie that, being the season that it is, I am happy to support her amendment. I know that that will come as a terrible surprise to her.
I will pick out a couple of themes that emerged from the debate. Jackie Baillie started by talking about the ageing population, but I think that we sometimes forget that that is her and me. [Interruption.]
I think that the member would be well advised to change his last comment. [Laughter.]
Well, we are all getting older. Even the younger members of the Parliament are getting older.
Jackie Baillie picked out in particular the increasing incidence of older folk falling between health and social care, and the inappropriate admissions to emergency departments.
I want to digress slightly on a theme that I developed when I held the health brief previously, and which I moved forward. We know that there is an ageing demographic, and when we talk about cultural change, one of the cultural changes that we, as politicians, must achieve is a greater understanding of the responsibility of everybody in society for their own health. We all cherish and admire the health service. We all want the best for it in the future, and we recognise that there are emotional, human issues that have to be dealt with, but if it is not to find itself under an intolerable strain, there is a need for everybody in society to recognise that they have a responsibility for their own health, too.
I am trying to help the member out with his time allocation. Does he agree that that is the essential part of a person-centred approach to the integration of the services?
Yes. It has a lot to do with the preventative agenda to which we are all committed in the development of health.
Hugh Henry touched on the key issue of the ability to influence change. Mary Scanlon detailed at some length the history of all the good intentions in the Parliament. As someone who came to the Parliament from a business background where business acquisitions, mergers and changes of culture were always prevalent, I have seen for myself how difficult it often is for people who have come from different work experience, possibly even nominally wearing the same hat but in a different area or a different authority, to translate change into practical action, and that was in the private sector, where to some extent—I mean this in the nicest possible way—people can be quite dictatorial in trying to drive things forward. In the public sector, the problems are even more manifest. It is easy for us to be naive about our ability to make change happen.
We should absorb the lessons of what was intended for community health partnerships and what actually happened. The cabinet secretary mentioned the need for planning to be professionally led and for the CHPs to have effective budgetary control, but if we look back, what happens in the absence of clinical leadership is that the good intentions become a set of dry rules on a sheet of paper and people adhere to them in a bureaucratic fashion. Interest, enthusiasm and motivation are lost and all the intentions that underpinned what was originally planned somehow dissolve and are not realised. It is fundamental that the opportunities that exist, the cabinet secretary’s emphasis on the spotlight on outcomes and the requests that there have been for consultation and engagement are embraced and remain the focus of attention. That is what is needed if we are not continually to have this debate.
James Dornan reminded us that a “great man” once said that the SNP has “no monopoly on wisdom”. When I heard that, I reflected that, if only that great man believed anything he said or acted on it, how much better off we would all be.
Richard Lyle made a blunt contribution, and talked with candour about some of the vested interests that exist and the opportunities that we have to address the situation.
Alison McInnes reminded us that, as they are fewer in number now, the Liberal Democrats have to multi-task in their contributions to debates, and gave us something of a polemic against Kenny MacAskill on police reform, which left some of us a bit bewildered. However, I am sure that the front bench will send a billet doux to him to ensure that he is kept up to speed on that.
Dennis Robertson gave us one of his characteristically stylish contributions.
With regard to Mary Fee’s speech, I say to the SNP members that they should not be unduly sensitive if a member poops on their parade. It is part of the responsibility of members occasionally to say in the chamber things that are slightly awkward.
I hope that that phrase was not too indiscreet, Presiding Officer.
It is said now.
I offered it in the general, not in the specific.
I enjoyed the speeches of Mark McDonald, Christina McKelvie and Sandra White.
This is one of those debates in which we are all agreed. We are all determined that there should be progress. We must translate the will of this chamber to a will among those who are going to have to deliver the objective that we seek.
11:17
I always enjoy Jackson Carlaw’s speeches, although his remarks about my colleague should more properly be addressed to me, as I am the second-oldest member.
I draw members’ attention to my various declarations of interest with regard to my membership of a variety of colleges, which have some of the vested interests that we are trying to tackle.
It was at a time of even greater austerity than that which we face today, when deficits were not 60 per cent to 80 per cent of gross domestic product but 250 per cent, that the post-war Labour Government implemented the Beveridge reforms to bring about the NHS, an institution that, despite its minor failings, has embodied principles that are embraced by all but a few Britons. It has delivered healthcare free at the point of need for more than 60 years. Moreover, notwithstanding the massive changes that have been proposed in England, about which I have huge concerns, it is to remain free.
The integration of health and social care as delivered to individuals in need is the pre-eminent challenge of this generation. It must be done within a national framework—not a national super-quango, which is how the Liberal Democrats constantly try to portray Labour’s position—with a national set of standards and outcomes.
I am taken aback by Richard Simpson’s loss of memory, because I sat with Labour candidates on hustings across my region, and they all proposed a new national organisation.
No, they did not. As I have just indicated, they proposed a national framework and national standards. Why do we propose that? Because, as Jackie Baillie has just said, our freedom of information inquiry found a tenfold variation in charges for the same services across local authorities. I am not saying that variations should be eliminated, but the costs should be managed within a national framework, so that we do not have such gross differences.
I acknowledge that progress has been made on delayed discharges, an issue that was the big challenge in 2001-02.
Many members have quoted the figures on the growing size of our elderly population. We have been told by Audit Scotland that, without a radical change, we will need many more hospital beds, reversing the trend of the past 25 years to reduce their number. As Duncan McNeil said, the associated costs will overwhelm our budget—whether Scotland has devolution or is independent. We must change or face being overwhelmed by the situation.
Many members, including Nanette Milne, Richard Lyle and Mary Scanlon, have indicated a certain disappointment with the briefing from the Association of Directors of Social Work. A briefing that starts by saying that the Kilbrandon report separated us and that that is where we want to remain indicates that there has been a certain lack of thinking, but the ADSW makes the important point that institutional change alone will not deliver what we want. That said, there is legislation in many areas—I refer to the requirement to provide emergency planning for carers, for example—that the ADSW has not implemented. Even some of the basics that would prevent unnecessary admissions have not been followed through by those in social care and social work. Therefore, even in the current situation, things need to be addressed.
Many members have said that if health services are not to be overwhelmed, a shift in the balance of care is needed. We have talked about that for many years, but we know again from Audit Scotland that addressing of the matter has been minimal. If the ADSW understands the changes that all four parties in the Parliament now propose as being a means for the medical model to overtake the social care model, I say to it that nothing could be further from the truth. This is about engaging the social care model and reducing the medical care model and making it more effective.
Mary Scanlon made an excellent speech that was redolent with institutional memory. Like Malcolm Chisholm, she reminded us that we have had good intentions for 10 years. A pilot was established in Perth and Kinross that included a shared budget and staff on shared terms and conditions, but it failed. We must start with a resolve not to repeat the mistakes of previous attempts—I fear that that may be being done in Highland. I urge the Scottish Government to talk to the joint futures group and everyone involved in that failure to ascertain why it occurred. I have already done so. There was a lack of consensus on what constitutes a model of care and the desired outcomes, and there was a failure to build on the micro examples of existing good co-operation and practice in the area. Many members, including Dennis Robertson and Mark McDonald, have referred to good local examples. They must not be destroyed by any institutional change that we create; rather, they must be enhanced.
I hear what the member is saying, but does he agree that the proposed changes would enhance many of those current examples? Indeed, in the conversations that I have had with NHS Grampian, it has welcomed what the Government is bringing forward, as it sees it very much as an enhancement of the work that is being done locally, not a threat to it.
Like Mark McDonald, I hope that that will occur. I am merely saying that ministers’ intentions were the same in the first parliamentary session, but the pilot failed.
There was a lack of adherence to the key worker principle in the pilot. There was competition between nurses and social workers. As an elderly person, it does not matter to me whether my key worker is a social worker or a nurse, but I want a key worker who is responsible and accountable and can determine the budget for the care package that will come to me. We need to recognise that the pilot fell apart. Worse than that, the process undermined the effective micro joint working that existed.
The CHPs have been subject to an Audit Scotland review, which confirmed that they have largely become creatures of the health boards and that many of them have poor governance and lack transparency. There is little evidence of resource transfer either from the acute sector to the community or between health boards and social care. Perhaps the worst failure is the failure to enhance preventive services. Those sub-health board structures should have grown organically from the local health care co-operatives, of which there were 85. The Royal College of General Practitioners has recommended the networking of primary care groups and their engagement. Contrary to the good intentions of ministers to involve professionals and have them leading, in practice the professionals have withdrawn from the community health partnerships and are totally disengaged. Therefore, whatever legal structure comes forward must seek to re-engage them, as the cabinet secretary said. To go further, it must engage patients, carer groups and voluntary organisations, and it must ensure that there is accountability.
In my view, elections to health boards have not delivered in the way that we would have liked. Engaging local councils through the reformed community health partnerships will produce the degree of strengthened local accountability that—along with an accountable officer—is necessary.
Do I have a little more time, Presiding Officer?
You do indeed, as you took two interventions.
Thank you.
Unison and the RCN have already indicated the hurdles that they will face in transferring staff between the local authorities and the NHS, and we should not underestimate the difficulty of that process. However, there are situations in which that type of joint approach has worked well—in Lothian, for example, where Peter Gabbitas was given a joint appointment between NHS Lothian and the City of Edinburgh Council.
In future, we cannot have an opt-in and opt-out approach. Some members have referred to the CHPs in Glasgow, where the system just fell apart. It must not fall apart because the people at the top decide that they do not want it to work and undermine local efforts. We need a legal underpinning, which is what our amendment says—it does not call for a national group, but simply mentions legal underpinning, which the SNP now accepts is necessary. The Government specifically said in February that legislative change should not happen and is not required, but it now says that we need legislation. I very much welcome that change.
Bob Doris reminded us of the importance of self-directed support as a means of rebalancing power between the institution and the individual.
This issue is the biggest challenge that we face. There is a measure of consensus across the chamber, the likes of which we have rarely seen. The opportunity is there for the Government to engage with Opposition party spokespersons in the post-consultation and pre-legislative phase to ensure that we get something lasting and sustainable, which delivers the good intentions that each previous Parliament and Administration—including this one—has had with regard to integration.
11:27
The debate has been very positive. There are occasions on which the Parliament comes together to develop a consensus on an issue, and this has been one such debate. It is clear that greater integration of health and social care is supported by members from each of the different political parties.
I have no doubt that the dialogue will continue as the consultation takes place and we move towards progressing legislation to enact some of the changes that we wish to introduce. As a Government, we will be open to dialogue with representatives of the different political parties in the chamber and with other stakeholders.
Hugh Henry, in his contribution, hit the nail on the head. He made an important point about past attempts to bring about greater integration of health and social care. I acknowledge the previous Administration’s actions to try to bring about greater integration, but I say to Hugh Henry that the issue goes back further than 10 years. It goes back—as I have said in the chamber on a number of occasions—to the National Health Service and Community Care Act 1990. That legislation was intended to bring about greater joint working and integration of services, but over the years that has failed to happen consistently and effectively.
I acknowledge the minister’s point. Will he consider setting up a group—as I suggested—along the lines of the Strathclyde Regional Council officer/member working groups, so that we can embed joint co-operation between every member in the Parliament?
Our consultation will involve looking at how we can ensure that health and community care partnerships are working effectively at a local level, and at how local engagement operates within that. I have no doubt that Hugh Henry will wish to express his view during that process. We are open to considering how we can ensure that there is effective engagement with local officers, healthcare professionals, the third sector and those in the various statutory organisations.
It is important to recognise that there have been attempts in the past to bring about greater integration of services. There have been successes and examples of integration working well in parts of the country, but often in a limited way or in the provision of a specific service. Malcolm Chisholm made the good point that some errors of the past involving not being direct enough about how pooled budgets should be used might have contributed to the lack of further integration.
Some integration has taken place, but aligning services has at times been a mistake for integration. Some local authorities and health boards have tried to align services more closely but have not integrated them effectively so that they are joined up for the individuals who receive them. It is clear that the change that the Government proposes can address that fundamentally.
We as a Government do not underestimate the challenge in taking forward integration. Part of the challenge is to move beyond the organisational and professional interests that can often act as barriers to creating the necessary integration. Nanette Milne, Bob Doris and Mary Scanlon referred to the need for attitudinal and cultural reform in how some of our community health services and social work services are provided in communities.
Dr Simpson rose—
I give way to Dr Simpson. [Interruption.]
I ask for Dr Simpson’s microphone to be switched on.
The responsibility for that was mine and not officials’.
An important point that I failed to make in my speech is that neither undergraduate training nor continuing professional development is undertaken jointly. I lectured in social work for 19 years and when I attempted such joint training, I found it extraordinarily difficult. Serious leadership from the top will be required to ensure that it happens, so will the minister invite NHS Education for Scotland and the appropriate social work groups to get together as soon as possible?
The professional bodies, along with higher education institutions, have a good opportunity to look at how they arrange their training and how they can embed more joint training. When I trained as an occupational therapist, I had no joint lectures with physiotherapists or speech therapists, although they were in the department next to me and were often in the lecture room next to me for lectures on anatomy or whatever they were learning about. We need to look at how we can embed greater joint working in training where possible. Professional bodies and higher education institutions could give that further thought. I have no doubt that NES will want to discuss that with higher education institutions.
Attitudinal and cultural reform will present one of the most significant challenges in taking integration forward. We as a Government are keen to ensure that that reform occurs.
A number of members highlighted the demographic challenge. I will not point the finger at any particular person in the chamber who might be contributing more to that than anyone else, but I will say that the cabinet secretary and I do not consider ourselves to be part of that challenge yet. This is not change for change’s sake; it is change because we as a nation face a demographic challenge. The number of over-65s will rise by 62 per cent by 2031 and, to add another item to the growing list of demographic changes that we have been presented with in recent months, the registrar general for Scotland projects that the number of people who are aged over 75 will grow by about 10,000 every year in the next decade.
A big part of the agenda is ensuring that services are sustainable and shifting the balance of care more from the acute end to the community setting. It is fortunate that people are living longer, but many will have a long-term condition. Part of the challenge is in supporting people to self-manage their condition in the community. Shifting the balance of care will assist us in achieving that objective.
From the speeches this morning, it is fair to say that our approach to CHP reform and the national framework strikes the right balance. That is about setting a course nationally and accommodating local flexibility to allow health boards and local authorities to determine how they translate the national approach into local action on the ground.
On the points that Nanette Milne and Mary Scanlon made about the lead commissioning approach that Highland is taking, which I support, it is important to have flexibility, because the approach in Highland would not necessarily be suitable for greater Glasgow, given the rurality and the way that services are delivered in Highland.
We as a Government are trying to ensure that we get a level of consistency in the outcomes from services that people will receive, as well as allowing flexibility for services to be delivered and planned in a way that recognises local needs.
Nanette Milne raised concerns around delayed discharges. A number of members referred to cost shunting, which can contribute to that, and local authorities either taking responsibility or leaving it with the health board. The only point of correction that I would make is to tell Nanette Milne that delayed discharges are down; they are not rising at the moment and we as a Government are keen to continue to make progress on that. Our approach, with integrated budgets, allows us to get away from the cost shunting to which a number of members referred, so that there is no debate around where the budget should come from for arranging care for someone who is ready to be discharged from hospital into the community. It is not about where the money comes from; it is about where it is used.
On delayed discharge, I note that the Government motion refers to working with the independent and third sector. Will the Government consider using the up to 5,000 empty beds in the independent care home sector for respite care and to allow earlier discharge from hospital?
Mary Scanlon refers to the use of independent care home beds. An important aspect of this is enabling services to support people to live as independent a life as possible. We should not get drawn into the narrow view that if someone gets discharged from hospital, the next port of call for them is to go into a care home.
I was talking about rehab.
Yes. It is extremely important that we look at how we can plan enabling and rehabilitation services to help to support people within the community as effectively as possible. As we take this agenda forward, we will have a good opportunity to plan services in that way.
A number of members referred to self-directed support. The approach that we are taking will help self-directed support. The bill that we are planning to introduce next year will embed the existing strategy in legislation.
Jackie Baillie said that part of the difficulty is that those with complex care packages can at times be funded by the NHS board and might not be able to access individual payments under the present arrangements. One of the benefits of the integrated budgets approach is that we no longer have to worry about whether the money is coming from the health board or the local authority; it is a single budget, so it is not about where the money is coming from but about what it does. The approach that we intend to take, with integrated budgets, will allow us to take away the type of difficulty that some people with a complex care package might experience at present.
A number of members referred to the important role that carers play. We had a debate on carers recently and this Government recognises the very valuable role that carers play in Scottish society in supporting people within their own home.
Will the minister guarantee to protect the change fund and the carers element of it?
We have made very clear our commitment on that. As of next year, for the following three years, 20 per cent—not up to 20 per cent—of the change fund will be for the purposes of carers services. We must look at how we can take that forward. The guidance that has been issued to local authorities and health boards makes it very clear that the money should be used to help to support the development of carers services and to work with other services in supporting carers’ needs.
In recognising the role of carers, Richard Simpson made a point about emergency admissions. It is fair to say that emergency admissions are down at present, but support to carers can play an important role in helping to avoid such admissions. Some of the work that we are taking forward—with funding—with Enable will allow us to look at how we can make more of emergency planning for carers, to avoid unnecessary emergency admissions within the NHS. That in itself will help to embed that practice across local authorities. There is further work to take forward in that area.
It is clear that the message from this chamber and this Government is that change is going to happen in how we deliver health and social care in the community.
Notwithstanding some members’ concerns about the ADSW’s views on the issue, it has been helpful to the Government in our dialogue in recent months and weeks and I have no doubt that it will play a constructive part in the future.
The debate is not about whose proposal is better or whether Labour proposed a national care agency or not; it is about getting this right and making sure that we focus more on outcomes. It is about delivering services that are in people’s best interests. On that basis, I ask members to support the motion and the amendment and to recognise Parliament’s commitment to the proposal.