Public Bodies (Joint Working) (Scotland) Bill
The next item of business is a debate on motion S4M-09115, in the name of Alex Neil, on the Public Bodies (Joint Working) (Scotland) Bill.
16:20
It gives me considerable pleasure to open the stage 3 debate on the Public Bodies (Joint Working) (Scotland) Bill, which brings together health and social care services in Scotland. It is particularly appropriate that the bill’s development has been characterised by strong, committed effort—joined-up teamwork, in other words—by members across the chamber and in committee. If I may quote myself, I think that we have all been on the same page and trying to achieve the same things, even when we have disagreed about wording.
I particularly thank Duncan McNeil and the Health and Sport Committee, which was the lead committee, for their careful consideration of the bill. I also thank the Local Government and Regeneration Committee, the Finance Committee and the Delegated Powers and Law Reform Committee for their careful scrutiny, input and support. I pay tribute to the work of my team in the civil service, which has provided me, as it always does, with first-class support at every stage.
We have heard before today that it is much to the benefit of the bill that it draws on the commitment, co-operation and inspiration of a broad and deep range of partners and stakeholders across all sectors. Local government, the national health service, the third and independent sectors, professional groups and representatives of patients, carers, service users and families have all, in different and complementary ways, lent us their expertise, experience, ambitions and aspirations.
Our consultation on the proposals that underpin the bill received more than 300 responses, and the information sessions that we ran during the consultation exercise attracted roughly 900 attendees to the discussion and debate.
The bill as introduced in May last year yielded 85 written responses during stage 1, and the interests of many of our stakeholders and partners were represented during committee sessions at stage 2.
Last, but by no means least, our various working groups—particularly our bill advisory group and the ministerial strategic group on health and community care, both of which I chair—have been active participants in the development process right up until today.
I signal my sincere thanks to everyone who has been involved so far—but the job is not yet finished, of course. I look forward to continuing to work with everybody as we develop regulations and guidance to support the bill and—most important—as we put integrated arrangements into place.
The whole point—indeed, the only point—of integrating health and social care is to improve people’s lives. Even as we debate the bill, our focus is on improving outcomes for people who currently use health and social care services across Scotland.
The Public Bodies (Joint Working) (Scotland) Bill—perhaps that is not the sexiest name for a piece of legislation, albeit one that is very important—provides a legislative framework for integrating health and social care services. I remember that, at the start of the process, a former Labour minister advised me that we should stick to our guns to make joint working a statutory requirement for local authorities and health boards, because there have been many attempts in the past to integrate health and social care services with varying degrees of success—or lack of success. The statutory underpinning that we will provide is essential to ensuring that such integration works, and does so within a timeous period.
One thing that we can learn is that many of the advances that have been made where I live in West Lothian have been made without legislation. Much of the challenge is perhaps not so much about statutory change but about the cultural change in health and social care.
Absolutely. West Lothian is a very good example of an area where integration has worked successfully under successive administrations. Unfortunately, I could give many examples of other local authority areas where that has not been the case. We need to put integration on a statutory basis so that the experience of West Lothian can be rolled out across the country.
The bill also sits very well alongside the Social Care (Self-directed Support) (Scotland) Act 2013, which was piloted through Parliament last year by my colleague Michael Matheson, and other policies, such as that in the Children and Young People (Scotland) Bill, which we passed last week, that drive forward our commitment to personalising care. By focusing on person-centred planning and delivery, the Public Bodies (Joint Working) (Scotland) Bill will help to ensure joined-up, seamless health and social care provision that will improve people’s lives. It will support our commitments to ensure that people get the right care in the right place at the right time and to support people to stay in their own home or another homely setting as independently as possible for as long as possible.
I will take a moment to remind members of the foundations of our approach. We are legislating for national health and wellbeing outcomes and we will underpin the requirement for health boards and local authorities to plan effectively together to deliver quality sustainable care services for the people whom they serve. We are bringing together the very substantial resources that we commit to health and social care in Scotland, to make it easier for local systems to deliver joined-up, effective and efficient services that meet the needs of increasing numbers of people with long-term and often complex conditions. Many of those people are older, but not all of them are, and an important feature of our approach is that local systems must integrate for all adults. In addition, those systems are free to choose locally to integrate children’s services as well.
We are bringing together accountability for results across health and social care. Too often in the past, people have found themselves between systems when there is no division in their lives between what we have categorised historically as health needs and social care needs. The bill focuses on the whole person and the needs of the community in which they live. It places on statutory organisations co-ordinated planning and delivery requirements that radiate from people’s needs, rather than expecting people to fit into historical patterns of service planning and delivery.
The bill is a response to the findings of the report of the Christie commission on the future delivery of public services that effective services must be designed with and for people and communities—and I believe that they should be designed by people and communities as well—not delivered on a top-down basis for administrative convenience. Also—and this is key—the bill will ensure a full and proper role for clinicians and other professionals in planning and delivering services. We have listened to concerns that that role has been lost or diluted in recent years, and we have responded. We recognise that the expertise and sharp-end experience of the professions and of people who use services must together guide the shape of services in future.
Locality planning arrangements under the bill provide the locus and opportunity for effective professional leadership of integration. We know from the evidence on integrated care that it is all about successful co-production: people working together to tackle challenges in innovative ways.
When it comes to health and social care support, our emphasis in Government is on prevention. We know that a concerted effort to anticipate people’s needs and prevent problems from arising in the first place is the way to improve outcomes.
The challenges are difficult. As we have worked with partners and stakeholders to develop the bill, we have not always agreed with one another. What is important, though, is that we have a shared goal: we know what our destination is and we have worked together to agree the route.
That work goes on. We have today released updated data on delayed discharges, which shows us clearly that although we have made great strides in recent years, we have more work to do to ensure that people receive the quality of care that we all want to be proud of in Scotland. Of course, we are not starting from scratch. We can already see many examples—we have just referred to some of them—of good partnership working across Scotland. I saw one this morning. Cowan Court in Penicuik in Midlothian is a brilliant example of an innovative approach to integrating housing, social care and healthcare. We need to build on and develop that good practice and increase the pace at which such facilities are rolled out across Scotland.
The bill provides the right foundation for those improvements, and it provides the imperative that I believe is needed to ensure consistent progress across the country. The bill offers a good and careful balance. It sets out the framework for integration and makes it a necessary requirement of health boards and local authorities to deliver effective integrated care. At the same time, it provides flexibility to allow local arrangements to respond to local needs and to encourage and enhance local innovation and leadership. I welcome this opportunity to provide further clarity on the bill, and to discuss the stage 3 amendments, which we have just completed.
When we pass the bill, we will significantly enhance both the health and the social care of the people of Scotland.
I move,
That the Parliament agrees that the Public Bodies (Joint Working) (Scotland) Bill be passed.
16:30
The issue of social care should be at the top of the political agenda in Scotland. As politicians discuss the intricacies of currency unions, European Union membership and all the rest of it, our elderly and vulnerable people are experiencing a care system that is in crisis as a direct result of cuts to local government.
We know that most people want to remain in their own homes when appropriate, among familiar people and surroundings for as long as possible. We also know that, over the next decade, the elderly population will increase significantly as we live longer lives—or as some of us live longer lives, depending on where we live and how rich or poor we are. We have to be careful when we speak about the issue. Increasing life expectancy is all too often spoken of in negative terms, with phrases such as “time bomb” and “burden” bandied about, but living longer also throws up tremendous work, leisure, travel and community opportunities for the older population. More people should have more time to enjoy a more fulfilling life and contribute to our society. We should all be careful about how we refer to our ageing population.
We cannot, however, get away from the fact that there will be financial and practical implications. Politicians and policy makers have to address those matters and plan for the situation now, not when it becomes a reality, although it is a reality at the moment. The bill will move us a bit down that road, but it has missed the real issues that are facing social care in the here and now. My frustration at the way in which the bill has progressed is that it has failed to address the deep-seated problems in the care system.
One of those is an issue that many of us perhaps want to avoid, which is money. The savings that the Christie commission identified that are supposed to be achieved by freeing up NHS beds through people remaining at home do not have a cat in hell’s chance of being achieved under the current social care system. Organisation after organisation that I have met and spoken to has said, when asked the question, that the social care system is in a state of crisis.
In the care home sector in Edinburgh, 15 per cent of private care home places are out of commission, and the figure is 20 per cent in Glasgow and 15 per cent in Highland. All those places are out of commission because of concerns about standards. In Edinburgh alone, more than 100 NHS beds are blocked because there is no safe place for people to be discharged to, and I understand that there was further bad news on that today. A few weeks ago, a care home in Fife got top marks from an inspector one week and then, the next week, appalling levels of care were identified, and the same inspector regraded the home at a much lower level.
In home care, we have a social care system that is based on the minimum wage, with working conditions being driven down to the lowest common denominator, contract prices being forced down, training budgets being cut, a recruitment crisis and staff morale on the floor. One carer told me recently:
“People only go into home care because they can’t get another job and only stay long enough until another one is found.”
Last week, Unison Scotland published the very disturbing report, “Scotland—It’s time to care. A survey of Scotland’s homecare workers”. The report said that 56 per cent of staff surveyed said that they were on time-limited visits to their clients and that, although the visits normally lasted 15 minutes, some were as short as seven minutes. One worker said that it is
“Rush, rush, rush, I think they forget we are dealing with human beings, old ones at that.”
Another said:
“Clients are anxious they don’t know which carer is coming from day to day”,
while another said:
“Clients are losing out, care is not given properly, clients are missed out or forgotten about, no one cares or listens to staff or our clients.”
Fifty per cent of care staff said that they do not get paid for the time taken to travel between clients, some said that they have to pay for their uniforms, others said that they have to pay for phone calls to their employer, and many said that they do not get breaks.
Another member of care staff said that the
“Service is not able to retain staff due to terrible wages, my work load has increased and I’m getting paid less.”
Another said:
“Before Christmas I ended up 2 weeks on sick leave, because I was doing 16-18 visits during long day and my body couldn’t cope any more, I had to work although I was sick, and when I asked my manager to take half a day off I was told there is no one to cover my shift. My breaks were reduced to minimum and there was not even time for having hot meal during day.”
The report highlights that care visits are missed out, staff are asked to administer medication with almost no training and corners are cut at every turn. In short, it is a system in crisis at a time when the Scottish Government’s white paper, “Scotland’s Future: Your Guide to an Independent Scotland”, claims that we have “world-leading ... social care”. I ask the minister to come into the real world, speak to the people who are delivering care services and ask them whether the social care system in Scotland is world leading. I ask him to read the report and then reflect on that statement in the white paper.
We need to change how social care is procured and delivered. I support moves in the Procurement Reform (Scotland) Bill to omit the need for social care contracts to be advertised and for organisations to compete. If contracts are awarded to the private sector or the third sector, that should be based not on price but on what added value can be offered. People who work in social care do a vital job that should have a career structure, a training regime and pay and status to match.
I hope that the bill will begin to move matters forward, but I fear that we have missed an opportunity to address the very real and deep-seated problems that exist in the here and now. Good practice takes place across Scotland, but if we do not get the basics right, the system will continue to fail our vulnerable people.
16:37
I confirm that the Scottish Conservatives will support the bill at decision time. It is a better bill following the amendments that have been agreed to at stages 2 and 3—many of them from the Government—and I am pleased that the cabinet secretary has taken on board a number of stakeholders’ and Opposition members’ suggestions.
There is no doubt that, across the board, we have been seeking to achieve the best possible outcomes for adults who require health and social care services. However, there have been differences of opinion along the way on how best to reach that goal. Those have centred mainly on what should be in the bill and what should be in guidance and statutory regulation.
As I said at stage 1, I fully accept the necessity for the legislation because, despite many initiatives in recent years—some of them very successful—to secure better integration of health and social care, joint working between partners to bridge the gap between primary and secondary healthcare and between health and social care is still at best patchy across the country.
The bill is fairly technical. Basically, it sets the framework for the changes that are needed to achieve the joined-up services that are required by many adults in Scotland today and in the future if they are to remain in their local communities living a fulfilled and dignified life within their capabilities for as long as possible. That particularly applies to the increasing number of elderly people with multiple health problems, both physical and cognitive, who have complex care needs that require significant support from social services.
However, the legislation will be successful only if its fundamental aim of improving the wellbeing of care recipients is at the forefront of its implementation. That will require a change of culture and attitudes, and will depend on strong leadership at the local level and the full co-operation of people across many disciplines, with everyone focused on achieving the best possible outcomes for those in their care. That is not a cheap option and it will involve some innovative thinking in service provision in an environment of ever-scarce resources. Neil Findlay makes a fair point about resources. In my city of Aberdeen, it is difficult to get home carers because of the competing high salaries in the oil industry.
Many people have been involved, at stakeholder and government levels, in the development of the bill, and all are to be congratulated on bringing it thus far, although much more co-operative work will be required to develop the statutory regulation and guidance that will determine the effectiveness of integration.
Much is already going on in different parts of the country to integrate health and social care services at the local level. Health and Sport Committee members have seen the enthusiastic commitment of staff in Highland and in West Lothian as they work to that end under the two different models in the bill. The work is on-going, but the commitment in Highland and West Lothian to person-centred care and the development of services that are focused on securing the best possible outcomes for people is encouraging. Different parts of Scotland are at different stages in the development of integrated services, and many areas are awaiting the statutory regulation and guidance, so it will be important to get that right.
There is no doubt that concerns remain about how the legislation will work on the ground. I mention three concerns, which the British Medical Association set out in its briefing for stage 3. First, there is a lack of clarity about the detail of the implementation of integration and there is a need for the Scottish Government to engage with organisations such as the BMA in the development of regulations and guidelines. Secondly, there is a lack of clarity on how the third sector will interface with the statutory bodies, to ensure a closer working relationship. The sector has a crucial role, at the strategic and local levels, in the planning, design and delivery of care. Thirdly, it is vital that general practitioners are embedded as key stakeholders in the reshaping of services, as the health secretary has promised and as I have said in the past. If that does not happen, GPs will walk away and the new system will be no more successful than the discredited community health partnerships that it replaces.
At the local level, all interested parties must be closely involved in planning the care services that are required. GPs, specialists in secondary care, nurses, allied health professionals, social workers, the third sector, service users and carers must all have an input into planning services so that they properly meet the needs of and achieve the best outcomes for people who require health and social care and so that those people are able to live a life that is as fulfilled as possible in their local communities.
As I said, we will support the bill, but key to its success will be the guidance and regulation that underpin it. We will keep a careful watch on how that develops, and we will ask the cabinet secretary for updates on progress towards achieving the integrated services that our older population throughout Scotland deserves, now and into the future.
16:42
I am delighted to speak in support of the bill, which will implement substantial and wide-ranging reforms to how we deliver adult health and social care.
The Health and Sport Committee benefited from a wealth of collective experience and expertise from a wide range of stakeholders, including local government, the NHS, housing, allied health professionals and the third and independent sectors. Representatives provided invaluable written and oral evidence to the committee throughout our scrutiny of the bill, and we are grateful for their efforts.
I sincerely hope that those representatives feel, as I do, that their contribution helped us to reach a stage at which we have the legislative framework that will achieve the aim that the cabinet secretary set out when we first debated integrating health and social care services throughout Scotland: to improve outcomes for the growing number of people who need health and social care support, most of whom have multiple complex needs, some of whom are older and all of whom should have access to the right care, at the right time, in the right place.
I very much welcome the Government’s recognition of the key role that housing has to play in improving the health and wellbeing outcomes of our citizens, not least given the policy commitment and 2020 vision of enabling people to be cared for
“at home, or in a homely setting”
for as long as possible, and in a way that enables them to be as independent as possible, as the cabinet secretary said. I am therefore glad that housing stakeholders have been added to the list of persons whom the Scottish ministers must consult before they prescribe national outcomes for health and wellbeing.
Many members can point to good examples of integrated care in our areas. I recently visited the Crossroads Newton Stewart & Machars Care Attendant Scheme in Wigtown, in Dumfries and Galloway, which provides a range of services, including respite care, personal care, palliative care and assistance with transport and shopping. The staff do a fantastic job in enabling more people to live independently, through close partnership working with social work services, the NHS, the community hospital in Newton Stewart, Marie Curie Cancer Care nurses, occupational therapists and other health professionals. Their services help to integrate the care that an individual receives. They already deliver care in a person-centred way, but of course they are working in one area of a large rural region.
The local council and the health board in Dumfries and Galloway have recognised the inherent strengths of existing arrangements, which already deliver measurable benefits. They also recognise that the locality is where we can make a big difference to people’s outcomes. It is very much at the local level where service provision in the community is critical.
I have reflected before, as has the cabinet secretary, that the localities are where the action will happen and where important decisions will be made. The model that Dumfries and Galloway has chosen—of four localities that are based on the areas of the current area partnership committees—very much reflects that. There is broad agreement across the region that integration will produce a radical improvement at all levels of health and social care.
That is our ultimate aim. This evening’s vote represents the culmination of a lengthy process of engagement, debate, scrutiny and amendment. I am confident that it will produce an outcome that we can all be proud of—an approach to adult health and social care that is genuinely seamless and responsive, with services that are firmly integrated around the needs of individuals, their carers and their families and which place people at the centre of service planning and delivery. That was the message that the Christie commission gave, and I believe that the bill will enable us to change how we deliver public services to meet the needs of people in our communities better.
I hope that members across the chamber will support the bill.
16:46
I welcome the bill and the changes that the cabinet secretary was willing to make at stages 2 and 3. For example, although he did not go as far today as I, disability organisations and other third sector organisations wished, he incorporated to some extent the language of rights into the bill.
At stage 2, the cabinet secretary addressed some of the problems that I and others highlighted at stage 1 in relation to the financial arrangements. For example, the bill originally said:
“The Health Board must make a payment to the integration joint board”.
The fear was that that would reintroduce contracting arrangements, which we in Scotland put behind us several years ago. He changed the arrangement at stage 2 by introducing a reference to money being set aside. I welcome the changes that he made.
However, in welcoming the bill, we must not overstate the difference that it will make per se. It is a necessary but not a sufficient condition for making progress on better integrated care. As Alison Petch—perhaps the leading Scottish academic on community care—said to the committee a few months ago,
“legislation is not really what drives day-to-day delivery.”—[Official Report, Health and Sport Committee, 10 September 2013; c 4205-6.]
We can look at that from two points of view. As Neil Findlay said at various times today, wider issues must be addressed, such as the length of care visits. The other point is that what really drives change is culture change—that phrase has been used today and at other times—as well as leadership and bringing teams together on the ground.
The words “on the ground” are fundamental. In its briefing, which Nanette Milne just mentioned, the BMA uses that phrase when it expresses concern about
“the lack of clarity of what integration will actually ‘look’ like on the ground.”
It also says that
“the success or failure of integration will be the result of the effectiveness of the locality partnerships.”
In the committee, I expressed concern that the bill does not contain more on the locality arrangements. There is only one reference, in section 23, which says that the local authority area will be divided
“into two or more localities”.
We had quite a long debate about that in the committee, and it was reassuring to hear from the cabinet secretary that he will produce statutory guidance on localities. However, given that that is where the bill’s success or failure is to be determined, I think—like many others—that it is somewhat surprising that the bill does not contain more on the subject.
When I mentioned the issue at stage 1, I said that
“I would like it to be included in negotiations on the GP contract.”—[Official Report, 26 November 2013; c 24890.]
The fact that GPs were not involved sufficiently in community health partnerships was one of the fundamental reasons why they failed. I must take responsibility for that, although it is partly because of that experience that I am saying that more should be included in the bill.
Community health partnerships did not turn out exactly as I had envisaged them in terms of the locality arrangements, and I hope that things will be different this time. In the past few weeks, I have read that something was incorporated into the renegotiated Scottish GP contract about GPs’ role in the integration locality arrangement. If the cabinet secretary could say something about that in his winding-up speech, that would be appreciated.
The issue is not just about GPs, though, as secondary care clinicians must be involved on the ground as well. The bill is about integration that should be vertical as well as horizontal. The third sector—including disability organisations, which we should remember have a particular contribution to make—also needs to be involved on the ground, and it is on the ground where the bill will succeed or fail.
Yes, the bill is necessary, and we all agree that it is a step forward and we all hope that it will lead to the improvements that we want. However, as a final word, let us have the statutory guidance and regulations as quickly as possible. Processes must obviously be gone through, but one of the issues that I raised in committee was about regulations on what could not be handed over to the integration authority, as I heard concerns that local authorities and NHS boards will have to wait to see what they can put into the plans. Let us at least know as quickly as possible what is ruled out, and let us then leave it to health boards and local authorities to get on with the delivery on the ground.
16:51
As the deputy convener of the Health and Sport Committee, I thank all stakeholders who were involved in the bill process. I also thank the Scottish Government, which has been very willing to adapt and change the bill on the basis of representations that have been made to it.
I thought that an earlier speech was going to be about project fear but, to be fair to Mr Findlay, the member went on to talk about project care. I would like to stress that it is actually project health and social care. We have heard a lot about social care without hearing about the other side of the coin, and it is important to get that balance. Nevertheless, there is a meeting of minds and political will on the issue across all the political parties. I am reminded of what Malcolm Chisholm said about what is going to happen at the coalface—I hope that I will have time to speak about that.
The bill—shortly to be an act—is not the change in itself but is designed to facilitate change. The change will be an end to cost shunting at a local level with the development of single budgets, so that, for example, the bed blocking that perhaps happened for financial reasons will no longer take place. The change will be the strategic commissioning or the co-production of integrated services. The change will be building on existing best practice and, just as important, redesigning services in every local area in a way that improves the health and social care outcomes of the people we represent.
Some of that change is happening right now through the change fund for older people, which is providing £300 million over four years or so to promote such change. Importantly, that money is to be spent only if it is agreed by both councils and health boards. They can and do work jointly when they are instructed to do so, and I am sure that there is a will to go further in addition to the statutory basis that the bill will introduce. It is also significant that the change fund requires sign-off by the third sector.
With the statutory underpinning of health and social care integration, a far larger single budget will come into play in the innovative service redesign right across health and social care. Although the third sector, as non-statutory bodies, will not have sign-off over that larger budget, I expect it at a local level to be directly involved in the co-production and, where appropriate, the co-commissioning of services and in looking at new ways of service delivery right across Scotland. Likewise, I expect our communities to have a direct say about what they want services to look like, and I expect other stakeholder professionals, whether allied health professionals or our GPs, to have a strong say as well.
With that in mind, I think that some of the points that the BMA has made are a bit oxymoronic. As soon as we start dictating what a local plan should look like, it is not truly a local plan. There has to be a degree of flexibility to allow the new body corporates that are coming online and all the stakeholders at local and strategic level to have their say, and to avoid their being presented with a fait accompli on the ground locally, which would not serve anyone’s interests.
As Aileen McLeod did, I will finish by mentioning a good local project as an example of the good work that we want to see: the good morning project in Glasgow, which I know that the cabinet secretary has been to visit. As part of that project, older people get a daily telephone call from a volunteer caller—who is called “a friend on the phone”—to ensure that they are okay, that they are not lonely and that they have no health needs that are going unmet.
I have no doubt that such innovative services keep older people safe, secure, happy and content in their own homes for longer and prevent them from presenting elsewhere, which would be a poorer outcome for them and a more expensive one, too. I want to see such initiatives on health and social care integration being implemented on the ground right across the country.
16:56
Liberal Democrats have long called for the delivery of a commonsense approach of having health boards, local authorities and the third sector work more closely together to provide more joined-up care and better outcomes for patients. All sectors agree that the integration of health and social care is a move in the right direction that is needed if integrated, person-centred care is to be achieved.
We know that the incidence of emergency admissions has increased in the past few years and that the largest increase has been among the over-75 age group. That contributed to a 7 per cent increase between June 2012 and June 2013 in the number of bed days associated with delayed discharge patients. The fact that we have an ageing population and an increasing incidence of patients who present with multiple conditions makes such figures inevitable. They exist in a climate in which the number of staffed beds in the NHS has reduced dramatically over the past six years, which makes the problems of an ageing population and bed blocking all the more acute for the NHS.
The number of geriatric beds dropped from 7,500 in 2012 to 7,229 in 2013. In 2007, there were more than 9,000 geriatric beds. The number of staffed geriatric beds is the lowest in more than 10 years, while the number of emergency admissions of older people is at its highest level in that period. The Government is failing to meet the national indicator to reduce emergency admissions to hospital, and an Audit Scotland report found that at least 90 per cent of the patients who experienced a delay of more than three days were aged 65 or over. It is against that backdrop of the pressures and challenges that the NHS faces that integration is necessary.
In supporting the bill at stage 1, Liberal Democrats had some concerns that we felt needed further attention. It is critical that proper engagement is entered into with the NHS, local authorities and the third sector so that a truly integrated pathway delivers for the patient. Health and social care partnerships must work with GPs, carers, the voluntary sector and the independent sector in a locality planning framework.
GPs talk about the fact that they very much welcome the bill but, worryingly, they are still unclear about what it will mean for them on the ground on a day-to-day basis. Therefore, we need to involve and engage GPs in the new integrated arrangements. One of the reasons why community health partnerships were not successful was that GPs were not engaged. In its submission, Glasgow City Council stated:
“without effective GP engagement, attempts to keep people in the community as opposed to within a hospital setting will be hindered. It cannot be stressed enough that the inclusion of GPs within the legislation is vital if the overall objectives of the Bill are to be achieved.”
The proportion of the NHS budget that goes to general practice fell from 9.47 per cent in 2004-05 to 7.78 per cent in 2011-12. If GPs are to play a more central role in a person’s care by engaging with the new health and social care framework, the Government needs to acknowledge the demands that are being placed on their time against a backdrop of constricting budgets.
The legislation will mean nothing if it cannot be tailored to best fit the needs of the local population, using the knowledge of health and social care professionals working in communities. Indeed, the Convention of Scottish Local Authorities has argued that the bill’s provisions are at times too prescriptive and detailed and that they should allow more flexibility at a local level to determine the shape and governance of the proposed partnership arrangements—hence my earlier concerns regarding ministerial powers versus local accountability.
I am glad that the minister stated in his opening remarks that the job has not finished and will continue. We shall therefore support the bill today.
We move to closing speeches. I call Cameron Buchanan, who has four minutes, please.
17:00
I am pleased to contribute to this afternoon’s stage 3 debate and to support the Public Bodies (Joint Working) (Scotland) Bill, which perhaps does not have a sexy title, but is about removing barriers to better working between our public bodies. Given the potential that it holds for improved and more efficient services, it is indeed a welcome move by the Scottish Government.
However, I find it to be a bill of two halves. If I may, I will address the latter half first. Part 2 and onwards largely concerns barriers to existing working. There are already moves towards joint commissioning of facilities—for example, with the hub initiatives—and large-scale procurement through National Services Scotland. However, ambition in this regard has been restricted in scope or blocked altogether due to the limitations of existing legislation. The bill is straightforward and adopts a commonsense approach by removing such restrictions for the future.
Part 1 of the bill is, however, another matter entirely, in that it is designed to deliver momentum towards integrated working and the statutory basis to facilitate it, which is a far more complex and ambitious proposition. As the cabinet secretary and my colleague Nanette Milne have pointed out, the bill provides a framework and an initial push.
However, it is widely accepted that there is also a need for a culture change. Already there are local authorities and health boards that are well down the road to integration, including NHS Lothian and the City of Edinburgh Council, West Lothian Council and Midlothian Council in my region. However, the picture is very different elsewhere, so the Government will have to maintain pressure if we are to see change and overcome the resistance to that change that undoubtedly exists.
That was borne out by the evidence of Professor Alison Petch to the Health and Sport Committee. She warned of the ignorance about one another’s working that exists between the various professional groups. With so much of the detail still to be consulted on and confirmed, in particular around financial accountability and conflict resolution, the Government must ensure that no momentum is lost later, and it must press local authorities and health boards to commit to the integration process and, beyond that, to begin their strategic planning.
Even assuming that there is that vital impetus and the bill achieves better integration between health and social work, we already have evidence that that will not, in itself, be enough. I have learned quickly that with every new bill or subject in the Scottish Parliament there comes a complete set of new buzzwords and accompanying jargon. With this bill we have the word “disconnect”; the bill highlights the key disconnect in co-ordination between health and social care agencies. However, as Glasgow City Council pointed out in its evidence to the Health and Sport Committee, there is as much of a problem with co-ordination and working between primary healthcare professionals and those in acute care—that is, within the health profession. The bill does not directly address that, but it is vital to delivery of the type of change that we are looking for. Working within agencies is as important as working between agencies, especially if we are to achieve the reduction in spending on hospital visits, and to focus more on community-based care.
There has been a good deal of comment from Malcolm Chisholm and others on how demographic changes—in particular the challenges of an ageing population—make the bill necessary. I think that we all agree that we must be smarter in our public spending; a co-ordinated focus on preventative spending is central to that. However, if we are to deliver a genuinely integrated, joined-up and person-centred approach, the bill must be the start of the process, and not the end. The real test of the legislation will be in the experiences of those who use our health and social care services. The overarching goals must be improved delivery, fewer delays, reduced waiting times and fewer non-scheduled hospital admissions. Those are the standards by which reform will be judged; the bill, though welcome, is just one step towards achieving them. However, we shall support the bill.
17:04
I thank all the stakeholders who gave evidence to the Health and Sport Committee when we were scrutinising the bill. I also thank the committee clerks and the support staff for their assistance, and the Scottish Parliament information centre, which helped us very much. I give special thanks to the bill team, who helped us all to draft amendments for the bill. Without that help, we would have been in an even more difficult situation today in respect of lodging our amendments. I thank all the people who made it possible to do that.
We in the Labour Party support the general principles of the bill. We want a seamless service for users, who must be at the heart of the service in planning their own care to fit their needs and their life chances. I agree with Malcolm Chisholm about the bill being necessary but insufficient to make the change that we need. We need to go much further to properly integrate health and social care, and I agree with the cabinet secretary that there is much unfinished business in the area.
The catchphrase that the minister has used all the time as we have gone through the bill process is that we are “on the same page”. Some of us had hoped that the script on that page would be a little bolder, so we will continue to push for a bolder vision of integration of health and social care.
We need a change of culture. Nanette Milne mentioned that in her speech today, but it has run through the whole debate. The culture needs to change, but we cannot legislate for that.
We have to embrace co-production. The bill will improve that to an extent, but we have a huge distance to go to ensure that the person is at the very centre of care—that they are at the heart of the legislation and how we deliver care. We provide services to allow people to go out and live their lives, so we cannot dictate to them how they should do that. They need to be at the centre of it, and that is where the culture change comes. It involves our recognising that their needs are much more important than the needs of the organisations and the people who deliver the care.
We have all heard stories of people being told what they can and cannot eat, what time they must eat, what time they need to get out of bed and when they have to go to bed. I have heard heartbreaking stories about situations in which parents are not even allowed to sit up with their teenage children of an evening because the parents have to go to bed long before they would put their children to bed. How can they parent their children under those circumstances? We need to look at how we deliver services in order to ensure that the needs of service users, their carers and families are met, and that their ambitions are met.
Neil Findlay talked about the Unison survey. I read it, and it makes stark reading, covering—as it does—what the people who deliver care services feel. They are underpaid and undervalued and they are not given enough time to care. They see what needs to be done, but they are not given the time to deliver it. We need to involve and value all workers who deliver care. Many members talked about GPs, including Jim Hume and Malcolm Chisholm, and we heard about the third sector and those who represent service users, but we must also consider care providers. Bob Doris mentioned allied health professionals. All those people are crucial. We have to remember that they are involved in delivering care and we need to respect their views and pay them accordingly. Caring should not be a Cinderella service. If we really value the people for whom we care, we need to ensure that we also value the people who deliver that care.
As I said, I agree with the cabinet secretary that there is much unfinished business; inspection is one area that falls into that category. The inspection landscape is cluttered, with different regimes for health and social care. We need them to be integrated. We recommend that there be a new independent body that would be available to both staff and patients, because it is important that we have protection for whistleblowers. Many of the complaints about how care is delivered have come from staff who work for inadequate providers. They need to be able to raise their concerns, and the inspection regime needs teeth—it needs to be able to take steps to right the wrongs.
The inspection regime also needs to be transparent. One of the big challenges that we have learned of while considering the bill is in respect of inspection of home care. How do we get into a person’s home to inspect the care that they receive, especially when they are so dependent on the person who delivers the care to them? We need to look at all those things and see how we can tighten up services.
We heard today from Neil Findlay that social care is in crisis; he talked about the number of care homes that are out of commission due to poor standards. Surely we should find out about that sooner and steps should be taken sooner to try to bring them up to standard. We are seeing bed blocking increasing and people are not receiving care that is appropriate to their needs because it is not available in the community. We need to look at how we can improve standards throughout the care sector.
We all understand that shifting the balance of care from acute hospitals to communities is what we desire. It keeps people out of hospital, and allows them to be independent and enabled. It is what we would want in that situation, and it is also more cost effective. However, we cannot shift the balance of care out of acute care altogether. Neil Findlay raised concerns about the savings that were highlighted by the Christie commission and how we can possibly achieve them. People will still need acute care and that has to be delivered in hospital settings, but if we want to keep people well for longer, we also have to provide high-quality care in the community. That care will also have to deal with multiple conditions. As people live for longer, they will have more conditions that need to be dealt with, so we need all workers to be working towards that.
Integration of health and social care is really necessary. I hope that the bill will start the process. Legislation will not change everything; it will not change the culture, so we need to take the lead in order that we can do that. I hope that the bill helps us to do that.
Thank you Ms Grant. Alex Neil will wind up the debate. Cabinet secretary, I would appreciate it if you would continue until 5.20.
17:11
Thank you, Presiding Officer, I shall do my best to continue until 5.20.
First, I will respond to a number of the important points that have been made by members from all sides of the chamber.
On the question about where we go from here the bill gets royal assent, the next step is to move on secondary legislation, regulations, and guidance. I am very keen to do that as soon as possible because we want the integration boards to be fully operational from April 2015. It is also important that we continue, as we have throughout this exercise, to take the key stakeholders with us. We have agreement from the members of the stakeholder groups and the bill advisory group, which has been advising the Government on the bill throughout the entire process, that they will continue to advise the Government about discussions on secondary legislation, regulations, guidance and all the rest of it. Continuing with that group and the stakeholders is the right way to proceed. The more consensus we get, the more buy-in we will get throughout the process, and the more success we will have in implementing the provisions of the legislation.
On general practitioners’ involvement, I could not agree more that they have an absolutely vital role to play. The entire primary care sector has a vital role to play—although I should say that I expect consultants from the hospitals to play a much bigger role in the community, as well. I agree about the importance of GP involvement, particularly in localities and partnerships themselves.
Having said that, I should also emphasise to members something that they probably already know. In the guidance that I have issued for local delivery plans being submitted by boards to the Scottish Government for approval, I have stated very clearly that I expect every local delivery plan from every health board in Scotland to show a significant increase in spend in the primary care sector from April 2014 onwards. That will not mean a cut in acute services, because there will be a real increase in every board’s future budgets. It means that a bigger share of the growth should be allocated to primary care services in order to allow us to increase the resources that are available to primary care while simultaneously ensuring that there are not cuts in the acute services that are—as Rhoda Grant said—absolutely essential.
The cabinet secretary will be aware that one of the major growth areas in health board budgets is the cost of medicines. One person told me that that cost is now ahead of staff costs in healthcare budgets. Will he factor that in when he is looking at increases to health board budgets?
As far as I am concerned, we account for the prescriptions budget separately from the budget for primary care services, although much of it is paid through primary care. For example, if Rhoda Grant looks at the accounts that we present to Parliament, she will see that we have a specific line item on the cost of prescriptions, which is running at roughly £1.3 billion a year.
When I talk about additional spend in the primary care sector, I am not talking about the prescription element of it—I am talking about the services element. That includes primarily GP services, because there is no doubt at all in my mind that in order for us to achieve our health outcomes—including a reduction in unnecessary admissions to hospital—we have to improve and expand primary care services as part of the integration process. Primary care services must be absolutely integral to commissioning and strategic planning of the integrated authorities. I agree that speed is of the essence.
I also agree with Malcolm Chisholm about the importance of involving disability organisations. Clearly, although integrated services are for the entire adult population, the main users of the services are older people and disabled people. They and their stakeholder groups need to be involved in discussions nationally and locally.
The cultural issues that have been referred to by a number of members are also important. I believe that the bill itself will be a major tool in changing the culture—in particular, in changing it from one that delivers services to people to one that delivers services with people and for people, in agreement with them. It will be a change to a culture in which people are involved in designing delivery of services.
The role of users and user groups in the design and delivery of services is also crucial. Again, in particular at locality level, that will be an essential prerequisite to success.
I emphasise that although the bill is largely about the financial and organisational arrangements for integration, we should never lose sight of the purpose of the bill, which is to improve dramatically service provision for people who use the services. It is not just about delayed discharges; I believe that experience shows that where there is integration, the problem of delayed discharges is much easier to deal with. I believe that, over time, we can eliminate delayed discharges, as has largely been done, for example, in West Lothian. The bill is also about, for example, ensuring that people can be treated much more in the community, either at home or in a homely setting in the community—both in terms of their healthcare and social care. That is a key element in improving the health outcomes of the population.
The minister has spoken at length and I have yet to hear him mention anything about the two fundamental problems that we have: the poor pay and conditions of the staff who deliver the care, and the time-limited appointments that are made for clients. I have yet to hear him mention those problems.
On the latter point, there are already two or three investigations on issues related to social care outcomes. The time element is being looked at as part of those investigations. Neil Findlay should know that because the Association of Directors of Social Work and the Care Inspectorate are looking at those specific issues.
I said earlier that terms and conditions in the social care sector need to be addressed and that we need to do that with our local authority colleagues. It is a bit rich for Neil Findlay of the Labour Party to be complaining about how the workers are treated when we have seen what has happened in Glasgow City Council, where the workers have been treated with total contempt by the Labour administration—[Interruption.]
Mr Findlay—enough.
—so much so that they have been forced into industrial action. I do not think that we will be taking any lessons from Mr Findlay or from any of his Labour colleagues on how to treat workers.
I will not mention Aberdeen, where there has been what has been described by some people as a disastrous move in transferring services to an arms-length external organisation—Bon Accord Care Ltd. That is hardly the model that we want. Again, we will certainly not be taking any lessons from the Labour administration in Aberdeen or from the Labour spokesperson on how to treat workers or how to treat service users.
Can you bring your remarks to a close, cabinet secretary?
The passage of the bill, which—with the exception of Neil Findlay’s contribution—has happened on a consensual basis, is a significant landmark in health and social care in Scotland. I believe that its passage will do a great deal to improve both healthcare and social care in Scotland. I hope that every member will vote for it.